Retrospective Study of Pegaspargase, Gemicitabine, Oxaliplatin and Dexamethasone (Peg-GemOD) as a First-Line Therapy for Advanced-Stage Extranodal NK/T Cell Lymphoma

The Clinical Features and Survival Outcome of 107 Newly Diagnosed Advanced Stage Extranodal NK/T-Cell Lymphoma Cases: A Triple-Center Study

Objective

Advanced stage extranodal natural killer/T-cell lymphoma (ENKTL) is a distinct type of non-Hodgkin lymphoma and the prognosis of ENKTL is poor with current treatment. This study aimed to investigate the clinical features, treatment strategy and survival outcome in patients with advanced stage ENKTL.

Patients and Methods

A total of 107 patients with newly diagnosed advanced stage ENKTL between January 2010 and December 2014 were reviewed from three cancer centers. Survival probability was calculated using Kaplan-Meier and the survival curves were compared by Log rank test. Cox regression analyses was performed to investigate the prognostic factors in ENKTL.

Results

The median patient age in our cohort was 42.0 years, with a male to female ratio of around 2.3:1. Over half of the patients had B symptoms (n = 61), high IPI scores (≥ 2, n = 60) and high Prognostic Index of Natural Killer Lymphoma (PINK) scores (≥ 3, n = 69). Elevated LDH level was present in around half of the patients (44/91). Most patients (n = 88) in our cohort originated in upper aerodigestive tract and the remaining 19 cases presented with non-upper aerodigestive tract involvement at first diagnosis. Chemotherapy regimens used in our study mainly include CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) (n = 26), L-asparaginase (L-asp) containing chemotherapy (GELOXD (gemcitabine, l-asparaginase, oxaliplatin and dexamethasone) and SMILE (L-asparaginase, methotrexate, ifosfamide, etoposide, and dexamethasone)) (n = 66). No significant difference between the baseline clinical characteristics was found between the L-asp and CHOP group. The CR rate after treatment was 39.3% (42/107) for the whole cohort. The 3-year progression-free survival (PFS) and 3-year overall survival (OS) rate was 41.0% and 41.5%, respectively. The 3-year PFS (49.2% vs 26.5%, P = 0.048) and 3-year OS (49.4% vs 26.0%, P = 0.030) was significantly higher in the L-asp group than the CHOP group. Patient CR status and PINK score were proved to be significant independent factors affecting OS and PFS by multivariate analysis. The grade 3/4 hematologic toxicity (P = 0.0003) and non-hematologic toxicity (P = 0.0002) occurred more frequently in the SMILE group than the GELOXD group.

Conclusion

Our results demonstrated that L-asp containing chemotherapy could provide favorable survival outcomes in patients with advanced stage ENKTL.

Defining the toxicity of current regimens for extranodal NK/T cell lymphoma: a systematic review and metaproportion

Objectives: The aim of this study is to compare the toxicity profiles of SMILE versus less intense L-asparaginase-containing regimens, CCRT or "sandwich" RT+CT regimens. Methods: PRISMA protocol was used to search Pubmed and Embase for studies of treatment regimens for extranodal NK/T-cell lymphoma, nasal type (ENKTL) in English published before March 2018. Pooled data were grouped into five categories: A) CHOP-like regimens; B) Gemcitabine-based regimens; C) SMILE-like regimens; D) Concurrent and "sandwich" RT + CT; and E) Methotrexate-based combinations. We pooled prevalence of selected adverse events from each study to calculate the weighted overall prevalence using meta-proportion in Stata. Results: Group C was the most toxic with the pooled neutropenia 72% (95 CI 64;80) and thrombocytopenia 48% (95% CI 40;55) prevalence. The use of Group D treatment regimens was associated with the lowest anemia (10% (95% CI 1;19)) prevalence. Group E was the least toxic with regard to thrombocytopenia (6% (95% CI 1;11). Conclusion: Our analysis confirms that SMILE regimen, which is current standard to treat advanced-stage ENKTL may be associated with more severe hematological toxicity compared to other L-asparaginase combinations, including methotrexate-based (AspaMetDex, MESA and MEDA) or gemcitabine-based (GELOX, PGEMOX, DDGP, GDL, GOLD, GLIDE) or CCRT-based regimens.

L-Asparaginase for newly diagnosed extra-nodal NK/T-cell lymphoma: systematic review and meta-analysis

OBJECTIVES

The aim of this review was to compare the efficacy of asparaginase (ASP)-containing vs ASP-absent regimens in the first-line treatment of ENKTL patients.

METHODS

The PRISMA protocol was used to search PubMed and Embase for both controlled and uncontrolled studies of ASP or alternative chemotherapy (CT) for newly diagnosed ENKTL, published in English by March 2017. The regimens were compared to calculate relative risk (RR) with 95% confidence interval (CI) of the overall response rate (ORR), complete response (CR) or partial response (PR).

RESULTS

Out of 38 studies included, eight were controlled trials, with the pooled RR of ORR in stage I-II 1.54 (95% CI 1.34-1.77); stage I-IV 1.34 (95% CI 1.09-1.64). In stage III-IV CT combined with radiotherapy (RT), RR of ORR was 2.30 (95% CI 1.66-3.18). ASP was also superior in achieving CR. When all single arms combined, RR of ORR after CT with ASP was 1.52 (95% CI 1.38-1.67) in stage I-II (15 studies); 1.44 (95% CI 1.32-1.57) in all stages (29 studies); 1.31 (95% CI 1.24-1.38) and 1.66 (95% CI 1.18-2.34) in stages I-II and III-IV combined with RT, correspondingly.

CONCLUSIONS

ASP-based CT significantly improved ORR and CR in patients with newly diagnosed both early-stage and advanced-stage ENKTL.