A systematic review and meta-analysis of rituximab-based immunochemotherapy for subtypes of diffuse large B cell lymphoma

Adding rituximab to chemotherapy for diffuse large B-cell lymphoma patients in Indonesia: a cost utility and budget impact analysis

Background

Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) has been used to treat patients with diffuse large B-cell lymphoma (DLBCL) under National Health Insurance (NHI) scheme in Indonesia. This study aims to estimate its cost-effectiveness and budget impact.

Methods

We conducted a cost utility analysis using Markov model over a lifetime horizon, from a societal perspective. Clinical evidence was derived from published clinical trials. Direct medical costs were gathered from hospital data. Direct non-medical costs, indirect costs, and utility data were primarily gathered by interviewing the patients. We applied 3% discount rate for both costs and effect. All monetary data are converted into USD (1 USD = IDR 14,000, 2019). Probabilistic sensitivity analysis was performed. In addition, from a payer perspective, budget impact analysis was estimated using price reduction scenarios.

Results

The incremental cost-effectiveness ratio (ICER) of R-CHOP was USD 4674/LYG and 9280/QALY. If we refer to the threshold three times the GDP per capita (USD 11,538), R-CHOP could thus be determined as a cost-effective therapy. Its significant health benefit has contributed to the considerable ICER result. Although the R-CHOP has been considered a cost-effective intervention, the financial consequence of R-CHOP if remain in benefit package under National Health Insurance (NHI) system in Indonesia is considerably substantial, approximately USD 35.00 million with 75% price reduction scenario.

Conclusions

As a favorable treatment for DLBCL, R-CHOP ensures value for money in Indonesia. Budget impact analysis provides results which can be used as further consideration for decision-makers in matters related to benefit packages.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07956-w.

5-Hydroxymethylcytosine profiles of cfDNA are highly predictive of R-CHOP treatment response in diffuse large B cell lymphoma patients

Background

Although R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) remains the standard chemotherapy regimen for diffuse large B cell lymphoma (DLBCL) patients, not all patients are responsive to the scheme, and there is no effective method to predict treatment response.

Methods

We utilized 5hmC-Seal to generate genome-wide 5hmC profiles in plasma cell-free DNA (cfDNA) from 86 DLBCL patients before they received R-CHOP chemotherapy. To investigate the correlation between 5hmC modifications and curative effectiveness, we separated patients into training (n = 56) and validation (n = 30) cohorts and developed a 5hmC-based logistic regression model from the training cohort to predict the treatment response in the validation cohort.

Results

In this study, we identified thirteen 5hmC markers associated with treatment response. The prediction performance of the logistic regression model, achieving 0.82 sensitivity and 0.75 specificity (AUC = 0.78), was superior to existing clinical indicators, such as LDH and stage.

Conclusions

Our findings suggest that the 5hmC modifications in cfDNA at the time before R-CHOP treatment are associated with treatment response and that 5hmC-Seal may potentially serve as a clinical-applicable, minimally invasive approach to predict R-CHOP treatment response for DLBCL patients.

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.

Discriminant analysis and machine learning approach for evaluating and improving the performance of immunohistochemical algorithms for COO classification of DLBCL

Background

Diffuse large B-cell lymphoma (DLBCL) is classified into germinal center-like (GCB) and non-germinal center-like (non-GCB) cell-of-origin groups, entities driven by different oncogenic pathways with different clinical outcomes. DLBCL classification by immunohistochemistry (IHC)-based decision tree algorithms is a simpler reported technique than gene expression profiling (GEP). There is a significant discrepancy between IHC-decision tree algorithms when they are compared to GEP.

Methods

To address these inconsistencies, we applied the machine learning approach considering the same combinations of antibodies as in IHC-decision tree algorithms. Immunohistochemistry data from a public DLBCL database was used to perform comparisons among IHC-decision tree algorithms, and the machine learning structures based on Bayesian, Bayesian simple, Naïve Bayesian, artificial neural networks, and support vector machine to show the best diagnostic model. We implemented the linear discriminant analysis over the complete database, detecting a higher influence of BCL6 antibody for GCB classification and MUM1 for non-GCB classification.

Results

The classifier with the highest metrics was the four antibody-based Perfecto–Villela (PV) algorithm with 0.94 accuracy, 0.93 specificity, and 0.95 sensitivity, with a perfect agreement with GEP (κ = 0.88, P < 0.001). After training, a sample of 49 Mexican-mestizo DLBCL patient data was classified by COO for the first time in a testing trial.

Conclusions

Harnessing all the available immunohistochemical data without reliance on the order of examination or cut-off value, we conclude that our PV machine learning algorithm outperforms Hans and other IHC-decision tree algorithms currently in use and represents an affordable and time-saving alternative for DLBCL cell-of-origin identification.

Electronic supplementary material

The online version of this article (10.1186/s12967-019-1951-y) contains supplementary material, which is available to authorized users.

Prognostic impact of germinal center B-cell-like and non-germinal center B-cell-like subtypes of bone marrow involvement in patients with diffuse large B-cell lymphoma treated with R-CHOP

The prognostic significances of the germinal center B-cell-like (GCB) and non-germinal center B-cell-like (non-GCB) types of diffuse large B-cell lymphoma (DLBCL) have been reported to be different. We analyzed the effect of the cell of origin (COO) of bone marrow (BM) involvement in patients with DLBCL who were treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in a single institute.The subtype of BM involvement was evaluated in 633 patients who were diagnosed with primary DLBCL and had been treated with R-CHOP. BM trephine biopsies were analyzed, and immunohistochemical staining of CD20, CD79a, and CD3 was performed. Additional staining of CD10, Bcl-6, and MUM1 was performed to determine the COO based on a previously reported algorithm.BM involvement was present in 81 patients (12.8%). Among them, 30 patients (37.0%) had GCB-type BM involvement and 51 (63.0%) showed non-GCB-type involvement. Kaplan-Meier survival analysis showed that the non-GCB type had the worst progression-free survival (PFS) and overall survival (OS) (P <.001). In multivariate analysis controlled for the International Prognostic Index (IPI) score, non-GCB type was an independent predictor of PFS (P <.004) and OS (P =.042), whereas GCB type was not a prognostic factor independent of the IPI score.Further prognostication based on the COO of BM involvement is a useful indicator of PFS, independent of IPI score. Accurate staging based on the COO should be included in the examination of BM in DLBCL.

Misdiagnosis of primary pleural DLBCL as tuberculosis: A case report and literature review

Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL). DLBCL presents with pleural involvement at an advanced stage; however, primary pleural lymphomas without any other site of involvement are rare, and the possibility of misdiagnosis is high, particularly in developing countries, where tuberculosis or other severe pulmonary infections remain a major health concern. Furthermore, lymphoma and tuberculosis share a number of common clinical characteristics, such as fever, night sweats, feeling of satiety after a small meal, fatigue and unexplained weight loss, among others. We herein describe a case of misdiagnosis of primary pleural lymphoma as tuberculosis in a 49-year-old male patient who presented with pleural effusion and high adenosine deaminase (ADA) level in the pleural fluid. Anti-tuberculosis treatment was administered for 1 month, but the patient's condition deteriorated. A surgical biopsy was performed and was diagnostic of DLBCL. CHOP chemotherapy was administered with a significant delay due to the misdiagnosis, and it was not efficient, as rituximab was not added to the regimen. The therapeutic efficacy was monitored by computed tomography scans, which revealed that the lesion had shrunk slightly. The overall survival of the patient was ~1 year and he eventually succumbed to severe thoracic infection and pleural effusion. Suspicion should be raised when a patient presents with pleural effusion and extremely high ADA levels, as ADA activity of >250 U/L should raise the suspicion of empyema or lymphoma rather than tuberculosis.

A Case of Rituximab-Induced Necrotizing Fasciitis and a Review of the Literature

Necrotizing fasciitis is a fulminant soft tissue infection characterized by rapid progression and high mortality. Rituximab is a generally well-tolerated immunosuppresive medication used for B-cell malignancies and some rheumatological disorders. We report a case of a 69-year-old male with chronic lymphocytic leukemia who suffered necrotizing fasciitis of his left lower extremity secondary to Clostridium septicum 7 weeks after treatment with rituximab. Despite immediate intravenous antimicrobial therapy and emergent fasciotomy with extensive debridement, his hospital course was complicated by septic shock and he required an above-the-knee amputation. Physicians need to be aware of the possibility of necrotizing fasciitis in patients presenting with skin infections after rituximab therapy.

Phase 2 study of CHOP-R-14 followed by 90Y-ibritumomab tiuxetan in patients with previously untreated diffuse large B-cell lymphoma

The aim of this open-label, single-center, phase 2 study was to assess the efficacy and safety of dose-dense CHOP-R-14 followed by ⁹⁰Y-ibritumomab radioimmunotherapy (RIT) in patients with previously untreated diffuse large B-cell lymphoma (DLBCL). A total of 20 patients, the majority presenting with high-risk characteristics, were enrolled to receive dose-dense cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab every 14 days (CHOP-R-14), followed by ⁹⁰Y-ibritumomab tiuxetan consolidation. Sixteen patients completed RIT consolidation (rituximab 250 mg/m² on day 1 and day 7, 8, or 9, followed by a single injection of ⁹⁰Y-ibritumomab). Complete response (CR) rates of 75 and 95% were observed after treatment with CHOP-R-14 and RIT, respectively; 4 of the 5 patients who achieved a partial response after CHOP-R-14 converted to CR following treatment with RIT. With a median follow-up of 89.7 months, the progression-free and overall survival rates for the cohort were 75 and 85%, respectively. Hematological adverse events were common following CHOP-R-14 and RIT, but they were manageable with treatment interruption. Therefore, this regimen achieved promising survival outcomes in high-risk DLBCL on long term follow-up, with manageable toxicity.

PIK3CD promoted proliferation in diffuse large B cell lymphoma through upregulation of c-myc

Despite PIK3CD has been extensively reported in cancers, however, little evidence has been available regarding its role in the setting of diffuse large B cell lymphoma (DLBCL). In the present study, to investigate the role of PIK3CD in DLBCL, relevant experiments were carried out on both in vivo clinical tissue level and in vitro cell line level. Prognostic and clinicopathological significance were analyzed after immunohistochemical assay of PIK3CD expression on DLBCL tissue microarray. MTT assay and flow cytometry were employed to evaluate the proliferative variation, cell cycle, and apoptosis. Athymic nude mice xenografted with DLBCL cell line were employed to confirm the role of PIK3CD. It was found that there was a significant difference between expression of PIK3CD and international prognosis index (IPI), performance state (PS), and inferior overall prognosis. Furthermore, PIK3CD can promote proliferation and prevent apoptosis in DLBCL cells in vitro through upregulation of c-myc and p-AKT and in contrast downregulation of p21 and p27. In nude mice model, knock-down of PIK3CD was shown to be able to suppress the proliferation of DLBCL but not significantly compared with control group. Taken together, our study showed that PIK3CD can promote proliferation of DLBCL cells both in vitro and in vivo, suggesting that PIK3CD could be druggable in the therapy of DLBCL.

Comparative gene expression profiling identifies common molecular signatures of NF-κB activation in canine and human diffuse large B cell lymphoma (DLBCL)

We present the first comparison of global transcriptional changes in canine and human diffuse large B-cell lymphoma (DLBCL), with particular reference to the nuclear factor-kappa B (NF-κB) pathway. Microarray data generated from canine DLBCL and normal lymph nodes were used for differential expression, co-expression and pathway analyses, and compared with analysis of microarray data from human healthy and DLBCL lymph nodes. The comparisons at gene level were performed by mapping the probesets in canine microarrays to orthologous genes in humans and vice versa. A considerable number of differentially expressed genes between canine lymphoma and healthy lymph node samples were also found differentially expressed between human DLBCL and healthy lymph node samples. Principal component analysis using a literature-derived NF-κB target gene set mapped to orthologous canine array probesets and human array probesets clearly separated the healthy and cancer samples in both datasets. The analysis demonstrated that for both human and canine DLBCL there is activation of the NF-κB/p65 canonical pathway, indicating that canine lymphoma could be used as a model to study NF-κB-targeted therapeutics for human lymphoma. To validate this, tissue arrays were generated for canine and human NHL and immunohistochemistry was employed to assess NF-κB activation status. In addition, human and canine B-cell lymphoma lines were assessed for NF-κB activity and the effects of NF-κB inhibition.

Activity and complexes of mTOR in diffuse large B-cell lymphomas--a tissue microarray study

Diffuse large B-cell lymphoma is a heterogeneous group of diseases with different responses to therapy. Targeting mTOR (mammalian target of rapamycin) offers a new approach to improve the treatment. mTOR inhibitors are being developed and are in clinical use in mantle cell lymphoma therapy and clinical trials are ongoing in other high-grade lymphomas as well. However, there is limited data about mTOR activity and the expression of its different complexes in diffuse large B-cell lymphomas. Tissue microarray blocks were constructed from paraffin-embedded biopsy specimens. More than 700 immunohistochemical stainings (mTOR signaling-related proteins and phosphoproteins, markers for lymphoma classification) were evaluated from 68 diffuse large B-cell lymphoma biopsies from conventionally treated and followed patients. Approximately 30% of cases were characterized as germinal center-derived diffuse large B-cell lymphomas, which showed virtually no mTOR activity, as determined by phospho-ribosomal S6 expression, the most sensitive marker of mTOR activity. In about 80% of non-germinal center-derived diffuse large B-cell lymphoma cases, positivity of mTOR-related phosphoproteins was observed, denoting mTOR activity. Moreover, Rictor (a characteristic protein of the mTOR complex2) was overexpressed in 43% of all diffuse large B-cell lymphomas and in 63% of mTOR-active non-germinal center diffuse large B-cell lymphoma samples. Rictor overexpression with mTOR activity indicated significantly worse survival for patients than mTOR inactivity or mTOR activity with low Rictor expression. These results suggest that mTOR activity is characteristic in most non-germinal center-derived diffuse large B-cell lymphomas with potentially variable mTOR-inhibitor sensitivity. Taken together, mTOR inhibitors may be useful in addition to regular therapy in diffuse large B-cell lymphomas, however, patient and inhibitor selection criteria must be carefully considered.

Are we ready to stratify treatment for diffuse large B-cell lymphoma using molecular hallmarks?

The division of the heterogeneous entity of diffuse large B-cell lymphoma (DLBCL) into the ontogenic phenotypes of germinal center B-cell-like (GCB) and activated B-cell-like (ABC) is optimally determined by gene expression profiling (GEP), although simpler immunohistochemistry (IHC) algorithms are alternatively being used. The cell-of-origin (COO) classification assists in prognostication and may be predictive of response to therapy. Mounting data suggests that IHC methods of classifying COO may be inaccurate. GEP categorization of COO is superior in defining prognostically and biologically distinct DLBCL subtypes, but current barriers to its widescale use include inaccessibility, cost, and lack of methodological standardization and prospective validation. The poorer prognosis of ABC-DLBCL is frequently associated with constitutive activity in the NF-κB pathway and aberrations in upstream or downstream regulators of this pathway. The molecular mechanisms underlying lymphomagenesis in GCB-DLBCL are arguably less well defined, but C-REL amplification and mutations in BCL-2 and EZH2 are common. New technologies, such as next-generation sequencing, are rapidly revealing novel pathogenic genetic aberrations, and DLBCL treatment strategies are increasingly being designed focusing on distinctive pathogenic drivers within ontogenic phenotypes. This review examines emerging molecular targets and novel therapeutic agents in DLBCL, and discusses whether stratifying therapy for DLBCL using molecular features is merited by current preclinical and clinical evidence.

CD99 expression and newly diagnosed diffuse large B-cell lymphoma treated with rituximab-CHOP immunochemotherapy

In order to evaluate prognostic value of CD99 expression in patients with diffuse large B-cell lymphoma (DLBCL) who underwent treatment with rituximab-CHOP immunochemotherapy, immunohistochemistry for CD99/CD10/BCL-2/BCL-6/MUM-1 was performed on nodal DLBCL specimens from 70 patients. Patients were classified as either germinal center B-cell (GCB) subtype or non-GCB subtype according to the Muris algorithm. A superior 2-year event-free survival (EFS) was observed in patients with the GCB subgroup, compared to those with the non-GCB subgroup (p = 0.034). The distribution of CD99 expression (29 patients; 41.4 %) did not show deviation according to subtype and was not prognostic for survival in the entire patient population. Among patients with the GCB subgroup, better EFS and overall survival (OS) were observed in CD99+ patients, compared to CD99- patients. Conversely, among patients with the non-GCB subgroup, inferior EFS and OS were reported in CD99+ patients. Superior 2-year EFS (p = 0.004) and 2-year OS (p = 0.003) were observed in patients with GCB/CD99+ and non-GCB/CD99- compared to the others, and the combination classification was found to be an independent prognostic factor.

The Hans algorithm is not prognostic in patients with diffuse large B-cell lymphoma treated with R-CHOP

Our objective was to evaluate the non-germinal center (GC) profile as a marker for response and survival in DLBCL and to compare the characteristics of patients with GC and non-GC DLBCL treated with rituximab-containing regimens. In this patient-level meta-analysis, retrospective data from 712 newly diagnosed DLBCL patients treated with chemoimmunotherapy from 7 centers were analyzed. GC and non-GC profiles were defined according to the Hans algorithm. Although the non-GC profile showed a trend towards worse overall survival (HR 1.24, 95% CI 0.92-1.66; p=0.15) and progression-free survival (HR 1.29, 95% CI 0.96-1.73; p=0.09), it did not retain its value in the multivariate survival analysis. Additionally, the non-GC profile was independently associated with worse complete response rates (OR 0.55, 95% CI 0.37-0.83; p<0.01) in the multivariate logistic regression analysis. Interestingly, Asian patients had higher proportion of GC DLBCL (p=0.01).

Serum neuron-specific enolase is correlated with clinical outcome of patients with non-germinal center B cell-like subtype of diffuse large B-cell lymphoma treated with rituximab-based immunochemotherapy

The present study examines the clinical significance of serum neuron-specific enolase (NSE) in patients with non-germinal center B-cell type (non-GCB) of diffuse large B-cell lymphoma (DLBCL) that received rituximab chemotherapy. Serum NSE values were measured using electrochemiluminescence assay in 53 patients. About 54.7% of the DLBCL patients had positive expression of serum NSE (>15.20 ng/ml), which closely correlated with performance status, serum LDH level, B symptoms, IPI scores, and Ann-Arbor stages (P < 0.05). The mean serum NSE value in patients with non-GCB subtype of DLBCL was significantly higher than that of GCB subtype of DLBCL (P = 0.001), and among patients in non-GCB subtype group, there was significant difference in the 5-year OS rate between NSE-positive group and negative group (28.3% vs. 81.6%, P < 0.001). Furthermore, serum NSE level was found to be an independent prognostic factor in patients with non-GCB subtype. Serum NSE may be a novel marker of disease aggressiveness as well as a prognostic factor for non-GCB subtype of DLBCL in the era of rituximab.

Risk of infection in patients with lymphoma receiving rituximab: systematic review and meta-analysis

BACKGROUND

The addition of Rituximab (R) to standard chemotherapy (C) has been reported to improve the end of treatment outcome in patients affected by CD-20 positive malignant lymphomas (CD20+ ML). Nevertheless, given the profound and prolonged immunosuppression produced by R there are concerns that severe infections may arise. A systematic review and meta-analysis were performed to determine whether or not the addition of R to C may increase the risk of severe infections in adults undergoing induction therapy for CD20+ ML.

METHODS

Only randomised controlled trials comparing R-C to C standard alone in adult patients with CD20+ ML were included. Meta-analysis was performed on overall incidence of severe infection, risk of dying as the consequence of infection, risk of febrile neutropenia, risk of severe leucopenia, risk of severe granulocytopenia and overall response assuming a fixed effect model. Heterogeneity was investigated, if present and I2 >20%, according to several predefined baseline characteristics of the study populations.

RESULTS

Several relevant results have emerged. First, the addition of R to standard C does not increase the overall risk of severe infections (RR = 1.00; 95% CI 0.87 to 1.14) nor does it increase the risk of dying as a consequence of infection (RR = 1.60; 95% CI 0.68 to 3.75). Second, we confirmed that the addition of R to standard C increases the proportion of overall response (RR = 1.12; 95% CI 1.09 to 1.15), but it also increases the risk of severe leucopenia (RR = 1.24; 95% CI 1.12 to 1.37) and granulocytopenia (RR = 1.07; 95% CI 1.02 to 1.12).

CONCLUSIONS

R-C is superior to standard C in terms of overall response and it does not increase the overall incidence of severe infection. However, data on special groups of patients (for example, HIV positive subjects and HBV carriers) are lacking. In our opinion more studies are needed to explore the potential effect of R on silent and chronic viral infections.

Clinicopathological features of 171 cases of primary thyroid lymphoma: a long-term study involving 24553 patients with Hashimoto's disease

There are few large-scale reports of primary thyroid lymphoma (PTL). This study clinically and pathologically reviewed 171 patients with PTL and 24,553 patients with Hashimoto's disease at Ito Hospital between January 1990 and December 2004, to investigate the clinical features and the treatment outcomes of PTL. The median age of the patients with PTL was 67 years (range, 27-90 years). The pathological diagnosis of PTL patients included diffuse large B-cell lymphoma (DLBCL) (n=74), DLBCL with mucosa-associated lymphoid tissue (MALT) lymphoma (n=13), MALT lymphoma (n=80) and others (n=4). Of the 167 patients with B-cell lymphoma, treatment included combined modality therapy (CMT) (n=95), radiation therapy (RT) alone (n=60) and chemotherapy alone (n=6). Information on treatment was not available in six patients. Information on treatment response was available in 154 patients; 149 patients (97%) responded to treatment. According to the institutional treatment strategy of Ito Hospital, 45 of 54 patients with stage IE disease received RT alone, and 87 of 113 stage IIE patients received CMT. The 5-year overall survival rate was 85% (95% confidence interval, 79-91%). This study demonstrated that PTL showed good response to radiotherapy and chemotherapy and had a favourable prognosis.