Equitoxicity of bolus and infusional etoposide: results of a multicenter randomised trial of the German High-Grade Non-Hodgkins Lymphoma Study Group (DSHNHL) in elderly patients with refractory or relapsing aggressive non-Hodgkin lymphoma using the CEMP regimen (cisplatinum, etoposide, mitoxantrone and prednisone)

[Current therapeutic strategies for diffuse large B‑cell lymphoma]

Diffuse large B‑cell lymphoma (DLBCL) is the most common form of non-Hodgkin's lymphoma. The incorporation of the CD20 antibody rituximab into CHOP polychemotherapy at the beginning of this century has considerably improved the outcome of all patients with DLBCL. Nowadays, depending on the prognostic subgroup less than one half to one third of patients die from DLBCL compared to the pre-rituximab era. Treatment is usually tailored to the individual risk profile of DLBCL patients according to the international prognostic index (IPI). Assignment of a DLBCL according to the gene expression profile to a DLBLC originating from a germinal center B‑cell (GC type) or from an activated B‑cell (ABC type) has provided novel insights into the pathogenesis of the respective DLBCL and identified molecules which are indispensable for the formation and growth of a DLBCL, thus providing targets for novel targeted therapies. Incorporating these new drugs into the current internationally recognized combination immunochemotherapy R‑CHOP or substituting single drugs in the R‑CHOP combination will result in even higher survival rates and reduction of therapeutic side effects in patients with DLBCL in the coming years.

Barriers to inclusion of older adults in randomised controlled clinical trials on Non-Hodgkin's lymphoma: a systematic review

BACKGROUND

The majority of Non-Hodgkin's lymphoma (NHL) patients are over 65 years. Management is challenging, especially for aggressive lymphoma, and appropriate assessment of efficacy and tolerance specific to this population is crucial.

OBJECTIVES

To assess the representation of older patients in randomised controlled trials (RCT) in NHL, examining whether trial eligibility criteria prevent participation, and whether appropriate primary endpoints such as toxicity, quality of life, or geriatric assessment scores are used.

METHODS

We searched Medline for articles published in English or French between 1 January 2005 and 31 December 2011 reporting on phase II/III RCT evaluating therapeutic strategies for NHL. Articles were categorised as including or excluding (directly or indirectly) older adults, and features of RCT that included or excluded older patients are compared.

RESULTS

We identified 87 relevant RCT: 9 (10.3%) focussed exclusively on patients >65 years, 22 (25.3%) directly excluded patients >65 years, 47 (54.0%) indirectly excluded older adults through selective inclusion criteria (ECOG status, liver or kidney function, and comorbidities), and 9 (10.3%) did not directly or indirectly exclude patients >65 years (although two excluded patients >70 years). Proportions of older patients included do not reflect incidence. Trials including older adults were published in journals with lower impact factors and few RCT used appropriate endpoints for older adults.

CONCLUSIONS

Older adults are poorly represented in NHL RCT both due to direct age-based exclusion and restrictive inclusion criteria. This situation needs rapid correction to better represent older patients and thus improve cancer management in this highly prevalent population.

Role of conventional salvage multiple-drug chemotherapy in relapsed and refractory aggressive non-Hodgkin lymphomas

Autologous stem cell transplantation is the standard care for patients with relapsed or refractory aggressive non-Hodgkin lymphomas. Of the patients who are sensitive to second-line chemotherapy, approximately 40-50% are likely to be cured using this approach. The optimal salvage regimen for pre-transplant debulking is controversial and these second-line chemotherapies are particularly important for patients who cannot undergo transplantation for various reasons including age, comorbidity and insufficient stem cell collection. Numerous reports regarding this topic are available. This study evaluated reports published in the last 5 years, focusing on conventional multiple-drug second-line chemotherapies (with or without rituximab), and disregarding single-agent investigational phase-II trials. Results are encouraging, particularly when considering that the more recent and less toxic combinations appear to be equivalent to or even more favourable than previous, more aggressive approaches. Previous results obtained using a combination of mitoxantrone, carboplatin, cytarabine and methylprednisolone, are further updated and included in this study. In conclusion, the most effective conventional chemotherapy currently available for patients with relapsed or refractory non-Hodgkin lymphomas obtains complete remission rates of up to 50-70%; the achievement of a complete remission is the most important factor associated with a better outcome. Although the addition of rituximab is beneficial and safe, it is more effective in patients who have previously not been exposed to this monoclonal antibody. The addition of cycles of salvage chemotherapy to those strictly required for mobilization of peripheral blood stem cells ultimately improves the response rate.