So currently I've, I've mentioned that in Europe and the UK for patients with relapsed refractory peripheral T cell lymphoma, whether it's TFH derived or not, or NOS, really we are relatively limited in what we can uh access. It's largely chemotherapy based and then potentially. as I say, renttuximab vodotin anti CD30 or uh immunomodulatory drugs such as lenalidomide. Uh, in the US, uh, treatment decisions are often informed on the basis of the NCCN guidelines. So even if a drug is not licensed, Uh, if the NCCN guideline has, uh, a recommendation for that drug, then insurance companies will often, I'm told not always, but often, uh, reimburse that drug, and clinicians will be able to use it. Now Duvalii is on the NCCN guidelines, both as monotherapy and in combination. Uh, now, the combination data is interesting, so the combination data suggests that when duvaliip is used in combination with certain agents such as HTA inhibitors, the response rates might be increased, but also some of the specific toxicities may actually be decreased, and that is a fascinating observation and not something you see very often in combination studies. You usually expect more toxicities all around because you've got the two specific agents contributing toxicity, and there may even be a sort of synergism of toxicity. Uh, however, to see some of the toxicity in my memory is that it was the liver function test, particularly. Uh, derangements that were abrogated, uh, is a very fascinating observation. So the NCCN guidelines do include some of those combinations, such as with HDAC inhibitors. However, in Europe and the UK we don't have access to, unfortunately, HDAC inhibitors, um, in relapsed refractory PTCL. I would say, however, one thing about HDAC inhibitors, they're an interesting, uh, group of drugs. They do seem to be slightly more active in the TFH derived T cell lymphomas. The response rates are very modest, which is why they never really got a license, well, they didn't, uh, get a license or reimbursement in Europe or the UK. But for those patients that do respond, and they're not very common, but they do happen, the responses can be surprisingly durable. Um, and certainly I've been involved in trials in the UK of HDTAC inhibitors in T cell lymphoma, and I've had one or two patients who have benefited hugely. It's just not very many of them, uh, had that benefit. So, You know, going forward, when we think about HTA inhibitors, one of the holy grails really in, um, peripheral T cell lymphoma research is trying to increase that response rate, um, in the HDTAC inhibitors, so that hopefully more people can benefit from those prolonged responses. And combinations such as with duvaicip uh may be one way to achieve that.
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