Low serum albumin is an independent risk factor in elderly patients with aggressive B-cell lymphoma: Results from prospective trials of the German High-Grade Non-Hodgkin's Lymphoma Study Group

Appropriate Treatment Intensity for Diffuse Large B-Cell Lymphoma in the Older Population: A Review of the Literature

Most patients with diffuse large B-cell lymphoma (DLBCL) are >65 years of age, with the number of patients expected to increase in the coming years. A comprehensive geriatric assessment that carefully evaluates fitness status and comorbidities is essential for selecting the appropriate treatment intensity. Although generally healthy patients or those <80 years of age may benefit from standard immunochemotherapy, unfit/frail patients or patients >80 years old may require reduced-intensity chemotherapy or less-toxic drugs. Some new drugs are currently being tested as single or combined agents for first-line treatment, aiming to improve the outcomes of conventional chemotherapy. This review systematically collates and discusses the outcomes associated with the use of immunochemotherapy in older patients with DLBCL, as well as considering the impact of full-dose immunochemotherapy on quality of life in older and frail patients, summarizing the rationale for reduced dosing in the older population, and presenting recommendations for selecting patients likely to benefit from reduced dosing. If preliminary efficacy and safety data are confirmed in future clinical trials, non-chemotherapy-based immunotherapy approaches could become an alternative potentially curative option in frail patients and those >80 years of age with DLBCL.

Reduced-Intensity Anthracycline-Free Chemoimmunotherapy in Elderly Patients With Newly Diagnosed or Relapsed Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL); it has a cure rate of approximately 50% with standard anthracycline-based chemoimmunotherapy. However, the clinical outcomes of elderly unfit/frail DLBCL patients remain suboptimal due to poor tolerance of anthracycline-containing regimens. Herein, we report a series of seven elderly unfit patients with DLBCL who were treated with a reduced-intensity anthracycline-free chemoimmunotherapy (rituximab, cyclophosphamide, vincristine, and prednisone) regimen combined with lenalidomide (R2-COP). Five patients received R2-COP as first-line therapy, and two patients were treated for relapsed DLBCL. Four patients with newly diagnosed DLBCL and two with relapsed disease achieved complete remission. The R2-COP regimen was well tolerated. Interim positron emission tomography (PET) scans in four patients after two to three cycles showed a complete metabolic response. At a median follow-up of 24 months, six patients remain in complete remission. R2-COP is an effective anthracycline-free regimen with encouraging clinical activity in elderly DLBCL patients who are unfit for standard anthracycline-containing regimens.

The prognostic role of red cell distribution width on all-cause and cause-specific outcomes in peripheral T-cell lymphoma: a retrospective cohort study

Readily accessible biomarkers for risk stratification in settings with limited resources are lacking. We evaluated the effect of high red distribution width-coefficient of variation (RDW-CV) values (>14%) on all-cause and lymphoma-specific mortality outcomes among 118 patients with peripheral T-cell lymphoma (PTCL) who received systemic treatment at two tertiary centers between 2010 and 2019. With a median follow-up of 45 months, patients with a high RDW-CV had a lower 4-year overall survival rate (34% vs. 45%, p = 0.015) and higher cumulative incidence of lymphoma mortality (54% vs. 34%, p = 0.007). RDW-CV >14% was associated with all-cause (adjusted Hazard Ratio [aHR] 1.98, 95% confidence interval [CI] 1.10-3.56) and lymphoma-specific mortality (aHR 2.64, 95% CI 1.32-5.29). In our study, RDW-CV emerges as an easily accessible and complementary prognostic biomarker for risk stratification among treated patients with de novo PTCL. Further research should validate the predictive role of RDW-CV in prospective cohorts.

Insights from a pharmacometric analysis of HDMTX in adults with cancer: Clinically relevant covariates for application in precision dosing

AIMS

High-dose methotrexate (HDMTX) is an essential part of the treatment of several adult and paediatric malignancies. Despite meticulous supportive care during HDMTX administration, severe toxicities, including acute kidney injury (AKI), may occur contributing to patient morbidity. Population pharmacokinetics provide a powerful tool to predict time to clear HDMTX and adjust subsequent doses. We sought to develop and validate pharmacokinetic models for HDMTX in adults with diverse malignancies and to relate systemic exposure with the occurrence of severe toxicity.

METHODS

Anonymized, de-identified data were provided from 101 US oncology practices that participate in the Guardian Research Network, a non-profit clinical research consortium. Modelled variables included clinical, laboratory, demographic and pharmacological data. Population pharmacokinetic analysis was performed by means of nonlinear mixed effects modelling using MonolixSuite.

RESULTS

A total of 693 HDMTX courses from 243 adults were analysed, of which 62 courses (8.8%) were associated with stage 2/3 acute kidney injury (43 stage 2, 19 stage 3). A three-compartment model adequately fitted the data. Time-dependent serum creatinine, baseline serum albumin and allometrically scaled bodyweight were clinically significant covariates related to methotrexate clearance. External evaluation confirmed a satisfactory predictive performance of the model in adults receiving HDMTX. Dose-normalized methotrexate concentration at 24 and 48 hours correlated with AKI incidence.

CONCLUSION

We developed a population pharmacometric model that considers weight, albumin and time-dependent creatinine that can be used to guide supportive care in adult patients with delayed HDMTX elimination.

Geriatric assessment in older adults with non-Hodgkin lymphoma: A Young International Society of Geriatric Oncology (YSIOG) review paper

Non-Hodgkin lymphoma (NHL) is a disease of older adults, with a median age at diagnosis of 67 years. Treatment in older adults with NHL is challenging. The aging process is associated with a decline in functional reserve that varies among individuals, and results in an increasing risk of treatment-related toxicity and mortality. Chronological age and performance status fail to capture the multidimensional and heterogeneous nature of the aging process. A geriatric assessment (GA) screens multiple geriatric domains and provides a more accurate assessment of functional reserve. Several abbreviated GA tools have been developed for use in oncology clinics and help identify patients at high risk for chemotherapy-related toxicity and mortality. In this review, we explore GA tools validated for use in patients with NHL. We discuss the evidence behind GA-guided treatment in NHL and present a suggested approach to assessing frailty in this patient population.

Clinical, inflammatory and immunohistochemical features in a cohort of Peruvian patients with diffuse large B-cell lymphoma

Data on response and survival outcomes of Latin American patients with diffuse Large B- cell lymphoma (DLBCL) are limited. We describe the clinical, inflammatory and immunohistochemical features of a cohort of DLBCL Peruvian patients treated with chemoimmunotherapy between 2010 and 2015. Logistic models were fitted for complete response (CR), and Cox proportional-hazard regression for progression-free survival (PFS) and overall survival (OS). Seventy-three patients were included in this analysis, 41 % had high/high-intermediate IPI and 48 % had high/high-intermediate NCCN-IPI scores, 41 % had non-germinal center (NGC) profile and 36 % were double expressors. CR was attained in 63 % of patients, median PFS was 53 months and median OS was 80 months. Both IPI and NCCN-IPI scores were statistically associated with PFS and OS. Neutrophil/lymphocyte ratio (NLR) ≥4 was associated with lower odds of CR (OR 0.19, p = 0.007), worse PFS (HR 2.67, p = 0.02) and worse OS (HR 2.77, p = 0.02). NLR ≥ 4 remained significant after adjusting for the IPI score and had a trend towards significance when adjusted for the NCCN-IPI score. Albumin <3.5 g/dl was associated with worse OS when adjusted for the NCCN-IPI score (HR 2.96, p = 0.04). NGC profile and double expressors were not prognostic. Our study identified NLR ≥ 4 and albumin <3.5 g/dl as potential adverse factors in DLBCL patients and could add to the prognostic value of the IPI or the NCCN-IPI scores.