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Maybury BD, James L, Phillips N, Venkatadasari I, Qureshi I, Riley J, Talbot G, Moosai S, Giles H, Chadderton N, Dowds J, Rakesh P, Crosland H, Haslam A, Lane S, Vega Gonzalez M, Davies D, Cherian G, Shenouda A, Kaudlay P, Starczynski J, Rudzki Z, Chaganti S. Testing for t(3;8) in MYC/BCL6-rearranged large B-cell lymphoma identifies a high-risk subgroup with inferior survival. Blood 2024; 144:113-117. [PMID: 38648564 DOI: 10.1182/blood.2024024048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/25/2024] Open
Abstract
ABSTRACT A reciprocal t(3;8) BCL6::MYC fusion is common in large B-cell lymphoma (LBCL) with MYC and BCL6 disruption. These pseudo-double-hit cases are not adverse, whereas t(3;8)-MYC/BCL6 lymphoma has an inferior prognosis relative to other MYC-rearranged LBCL.
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Affiliation(s)
- Bernard D Maybury
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Lisa James
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Neil Phillips
- Department of Haematology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Indrani Venkatadasari
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Iman Qureshi
- Department of Haematology, Worcestershire Acute Hospitals NHS Trust, Worcester, United Kingdom
| | - James Riley
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Georgina Talbot
- Department of Haematology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Shivir Moosai
- Department of Haematology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
- Department of Haematology, University Hospitals Coventry and Warwickshire, Coventry, United Kingdom
| | - Hannah Giles
- Department of Haematology, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, United Kingdom
| | - Nicola Chadderton
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - James Dowds
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Pallav Rakesh
- Department of Haematology, The Dudley Group NHS Foundation Trust, Dudley, United Kingdom
| | - Henry Crosland
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Aidan Haslam
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sarah Lane
- Department of Haematology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Monica Vega Gonzalez
- Department of Haematology, Walsall Healthcare NHS Trust, Walsall, United Kingdom
| | - David Davies
- Department of Haematology, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, United Kingdom
| | - George Cherian
- Department of Haematology, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, United Kingdom
| | - Amir Shenouda
- Department of Haematology, The Dudley Group NHS Foundation Trust, Dudley, United Kingdom
| | - Praveen Kaudlay
- Department of Haematology, The Royal Wolverhampton NHS Trust, Wolverhampton, United Kingdom
| | - Jane Starczynski
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Zbigniew Rudzki
- Department of Histopathology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Sridhar Chaganti
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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Fan ZM, Wu DL, Xu NW, Ye L, Yan LP, Li LJ, Zhang JY. Transformation of marginal zone lymphoma into high-grade B-cell lymphoma expressing terminal deoxynucleotidyl transferase: A case report. World J Clin Cases 2024; 12:2655-2663. [PMID: 38817237 PMCID: PMC11135448 DOI: 10.12998/wjcc.v12.i15.2655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/15/2024] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND High-grade B-cell lymphoma (HGBL) is an unusual malignancy that includes myelocytomatosis viral oncogene (MYC), B-cell lymphoma-2 (BCL-2), and/or BCL-6 rearrangements, termed double-hit or triple-hit lymphomas, and HGBL-not otherwise specific (HGBL-NOS), which are morphologically characteristic of HGBL but lack MYC, BCL-2, or BCL-6 rearrangements. HGBL is partially transformed by follicular lymphoma and other indolent lymphoma, with few cases of marginal zone lymphoma (MZL) transformation. HGBL often has a poor prognosis and intensive therapy is currently mainly advocated, but there is no good treatment for these patients who cannot tolerate chemotherapy. CASE SUMMARY We reported a case of MZL transformed into HGBL-NOS with TP53 mutation and terminal deoxynucleotidyl transferase expression. Gene analysis revealed the gene expression profile was identical in the pre- and post-transformed tissues, suggesting that the two diseases are homologous, not secondary tumors. The chemotherapy was ineffective and the side effect was severe, so we tried combination therapy including venetoclax and obinutuzumab. The patient tolerated treatment well, and reached partial response. The patient had recurrence of hepatocellular carcinoma and died of multifunctional organ failure. He survived for 12 months after diagnosis. CONCLUSION Venetoclax combined with obinutuzumab might improve the survival in some HGBL patients, who are unsuitable for chemotherapy.
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Affiliation(s)
- Zhi-Min Fan
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Dao-Lei Wu
- Department of Ophthalmology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Neng-Wen Xu
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Li Ye
- Department of General Practice, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Li-Ping Yan
- Department of Pathology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Lin-Jie Li
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
| | - Jun-Yu Zhang
- Department of Hematology, Lishui Municipal Central Hospital, Lishui 323000, Zhejiang Province, China
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3
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Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol 2024; 204:1178-1192. [PMID: 38247115 DOI: 10.1111/bjh.19273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Graham McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sally F Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Cathy Burton
- Department of Haematology, The Leeds Teaching Hospitals, Leeds, UK
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, UK
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, UK
| | - Timothy Illidge
- Division of Cancer Sciences, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Nagesh Kalakonda
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Andrea Kuhnl
- Department of Haematology, King's College Hospital, London, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Andrew J Davies
- Cancer Sciences Division, Centre for Cancer Immunology, University of Southampton, Southampton, UK
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4
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Lewis KL, Jakobsen LH, Villa D, Smedby KE, Savage KJ, Eyre TA, Cwynarski K, Bishton MJ, Fox CP, Hawkes EA, Maurer MJ, El-Galaly TC, Cheah CY. High-Dose Methotrexate as CNS Prophylaxis in High-Risk Aggressive B-Cell Lymphoma. J Clin Oncol 2023; 41:5376-5387. [PMID: 37797284 DOI: 10.1200/jco.23.00365] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 07/01/2023] [Accepted: 07/28/2023] [Indexed: 10/07/2023] Open
Abstract
PURPOSE CNS progression or relapse is an uncommon but devastating complication of aggressive B-cell lymphoma. There is no consensus regarding the optimal approach to CNS prophylaxis. This study was designed to determine whether high-dose methotrexate (HD-MTX) is effective at preventing CNS progression in patients at high risk of this complication. PATIENTS AND METHODS Patients age 18-80 years with aggressive B-cell lymphoma and high risk of CNS progression, treated with curative-intent anti-CD20-based chemoimmunotherapy, were included in this international, retrospective, observational study. Cause-specific hazard ratios (HRs) and cumulative risks of CNS progression were calculated according to use of HD-MTX, with time to CNS progression calculated from diagnosis for all patients (all-pts) and from completion of frontline systemic lymphoma induction therapy, for patients in complete response at completion of chemoimmunotherapy (CR-pts). RESULTS Two thousand four hundred eighteen all-pts (HD-MTX; n = 425) and 1,616 CR-pts (HD-MTX; n = 356) were included. CNS International Prognostic Index was 4-6 in 83.4% all-pts. Patients treated with HD-MTX had a lower risk of CNS progression (adjusted HR, 0.59 [95% CI, 0.38 to 0.90]; P = .014), but significance was not retained when confined to CR-pts (adjusted HR, 0.74 [95% CI, 0.42 to 1.30]; P = .29), with 5-year adjusted risk difference of 1.6% (95% CI, -1.5 to 4.4; all-pts) and 1.4% (95% CI, -1.5 to 4.1; CR-pts). Subgroups were underpowered to draw definitive conclusions regarding the efficacy of HD-MTX in individual high-risk clinical scenarios; however, there was no clear reduction in CNS progression risk with HD-MTX in any high-risk subgroup. CONCLUSION In this large study, high-risk patients receiving HD-MTX had a 7.2% 2-year risk of CNS progression, consistent with the progression risk in previously reported high-risk cohorts. Use of HD-MTX was not associated with a clinically meaningful reduction in risk of CNS progression.
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Affiliation(s)
- Katharine L Lewis
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
| | - Lasse H Jakobsen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Diego Villa
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Karin E Smedby
- Department of Medicine Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Kerry J Savage
- BC Cancer Centre for Lymphoid Cancer, The University of British Columbia, Vancouver, BC, Canada
| | - Toby A Eyre
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Kate Cwynarski
- University College London Hospital NHS Foundation Trust, London, United Kingdom
| | - Mark J Bishton
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Christopher P Fox
- Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
- University of Nottingham, Nottingham, United Kingdom
| | - Eliza A Hawkes
- Olivia Newton-John Cancer Research & Wellness Centre at Austin Health, Heidelberg, VIC, Australia
- Monash University School of Public Health and Preventive Medicine, Melbourne, VIC, Australia
| | - Matthew J Maurer
- Division of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, MN
| | - Tarec C El-Galaly
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Chan Y Cheah
- Linear Clinical Research, Nedlands, WA, Australia
- Division of Haematology, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
- Division of Internal Medicine, Medical School, University of Western Australia, Perth, WA, Australia
- Department of Haematology, PathWest, Nedlands, WA, Australia
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5
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Alderuccio JP, Nayak L, Cwynarski K. How I treat secondary CNS involvement by aggressive lymphomas. Blood 2023; 142:1771-1783. [PMID: 37702537 PMCID: PMC10862244 DOI: 10.1182/blood.2023020168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/14/2023] [Accepted: 08/17/2023] [Indexed: 09/14/2023] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is a rare but clinically challenging scenario with historically disappointing outcomes. SCNSL refers to lymphoma that has spread into the CNS concurrently with systemic disease or CNS relapse during or after frontline immunochemotherapy, presenting with or without systemic lymphoma. Diffuse large B-cell lymphoma (DLBCL) denotes the most common entity, but an increased incidence is observed in other histologies, such as Burkitt lymphoma and mantle-cell lymphoma. The incidence, timing in disease course, location, evidence supporting the use of CNS prophylaxis, and treatment pathways vary according to histology. No randomized data exist to delineate the best treatment approaches with current recommendations based on retrospective and single-arm studies. However, a regimen comprising immunochemotherapy, incorporating agents that cross the blood-brain barrier, followed by thiotepa-containing conditioning and autologous stem-cell transplant outlined in the international MARIETTA study demonstrated improvement in outcomes, representing a major accomplishment in the care of patients with DLBCL with SCNSL. Anti-CD19 chimeric antigen receptor T cell denotes a paradigm shift in the treatment of patients with systemic aggressive lymphomas, with emerging data also demonstrating efficacy without higher neurotoxicity in those with SCNSL. In this manuscript we discuss 5 clinical scenarios and review the evidence supporting our recommendations.
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Affiliation(s)
- Juan Pablo Alderuccio
- Division of Hematology, Department of Medicine, Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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6
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Zayac AS, Landsburg DJ, Hughes ME, Bock AM, Nowakowski GS, Ayers EC, Girton M, Hu M, Beckman AK, Li S, Medeiros LJ, Chang JE, Stepanovic A, Kurt H, Sandoval-Sus J, Ansari-Lari MA, Kothari SK, Kress A, Xu ML, Torka P, Sundaram S, Smith SD, Naresh KN, Karimi YH, Epperla N, Bond DA, Farooq U, Saad M, Evens AM, Pandya K, Naik SG, Kamdar M, Haverkos B, Karmali R, Oh TS, Vose JM, Nutsch H, Rubinstein PG, Chaudhry A, Olszewski AJ. High-grade B-cell lymphoma, not otherwise specified: a multi-institutional retrospective study. Blood Adv 2023; 7:6381-6394. [PMID: 37171397 PMCID: PMC10598493 DOI: 10.1182/bloodadvances.2023009731] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/24/2023] [Accepted: 04/25/2023] [Indexed: 05/13/2023] Open
Abstract
In this multi-institutional retrospective study, we examined the characteristics and outcomes of 160 patients with high-grade B-cell lymphoma, not otherwise specified (HGBL-NOS)-a rare category defined by high-grade morphologic features and lack of MYC rearrangements with BCL2 and/or BCL6 rearrangements ("double hit"). Our results show that HGBL-NOS tumors are heterogeneous: 83% of patients had a germinal center B-cell immunophenotype, 37% a dual-expressor immunophenotype (MYC and BCL2 expression), 28% MYC rearrangement, 13% BCL2 rearrangement, and 11% BCL6 rearrangement. Most patients presented with stage IV disease, a high serum lactate dehydrogenase, and other high-risk clinical factors. Most frequent first-line regimens included dose-adjusted cyclophosphamide, doxorubicin, vincristine, and etoposide, with rituximab and prednisone (DA-EPOCH-R; 43%); rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; 33%); or other intensive chemotherapy programs. We found no significant differences in the rates of complete response (CR), progression-free survival (PFS), or overall survival (OS) between these chemotherapy regimens. CR was attained by 69% of patients. PFS at 2 years was 55.2% and OS was 68.1%. In a multivariable model, the main prognostic factors for PFS and OS were poor performance status, lactate dehydrogenase >3 × upper limit of normal, and a dual-expressor immunophenotype. Age >60 years or presence of MYC rearrangement were not prognostic, but patients with TP53 alterations had a dismal PFS. Presence of MYC rearrangement was not predictive of better PFS in patients treated with DA-EPOCH-R vs R-CHOP. Improvements in the diagnostic criteria and therapeutic approaches beyond dose-intense chemotherapy are needed to overcome the unfavorable prognosis of patients with HGBL-NOS.
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Affiliation(s)
- Adam S. Zayac
- Division of Hematology/Oncology, The Warren Alpert Medical School Medical School of Brown University, Providence, RI
| | | | | | | | | | - Emily C. Ayers
- Division of Hematology/Oncology, University of Virginia, Charlottesville, VA
| | - Mark Girton
- Department of Pathology, University of Virginia School of Medicine, Charlottesville, VA
| | - Marie Hu
- Division of Hematology, Oncology, and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Amy K. Beckman
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN
| | - Shaoying Li
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - L. Jeffrey Medeiros
- Division of Pathology and Laboratory Medicine, Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Julie E. Chang
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Adam Stepanovic
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Habibe Kurt
- Department of Pathology and Laboratory Medicine, The Warren Alpert Medical School of Brown University, Providence, RI
| | - Jose Sandoval-Sus
- Department of Malignant Hematology and Cellular Therapy, Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | | | - Shalin K. Kothari
- Division of Hematology, Yale University School of Medicine, New Haven, CT
| | - Anna Kress
- Division of Hematology, Yale University School of Medicine, New Haven, CT
| | - Mina L. Xu
- Department of Pathology and Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT
| | - Pallawi Torka
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Suchitra Sundaram
- Department of Medicine, Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Stephen D. Smith
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
- Division of Medical Oncology, University of Washington, Seattle, WA
| | | | - Yasmin H. Karimi
- Division of Hematology-Oncology, University of Michigan Health, Ann Arbor, MI
| | | | - David A. Bond
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Umar Farooq
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Mahak Saad
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | - Andrew M. Evens
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Karan Pandya
- Department of Medicine, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ
| | - Seema G. Naik
- Penn State Cancer Institute, Penn State Hershey Medical Center, Hershey, PA
| | - Manali Kamdar
- Division of Hematology, Hematologic Malignancies and Stem Cell Transplantation, University of Colorado, Denver, CO
| | - Bradley Haverkos
- Division of Hematology, Hematologic Malignancies and Stem Cell Transplantation, University of Colorado, Denver, CO
| | - Reem Karmali
- Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Timothy S. Oh
- Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Julie M. Vose
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Heather Nutsch
- Department of Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Paul G. Rubinstein
- Department of Medicine, Section of Hematology-Oncology, University of Illinois, Chicago, IL
| | - Amina Chaudhry
- Department of Medicine, Section of Hematology-Oncology, University of Illinois, Chicago, IL
| | - Adam J. Olszewski
- Division of Hematology/Oncology, The Warren Alpert Medical School Medical School of Brown University, Providence, RI
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7
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Khwaja J, Nayak L, Cwynarski K. Evidence-based management of primary and secondary CNS lymphoma. Semin Hematol 2023; 60:313-321. [PMID: 38135609 DOI: 10.1053/j.seminhematol.2023.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023]
Abstract
Central nervous system (CNS) lymphoma has traditionally had very poor outcomes however advances in management have resulted in dramatic improvements and long-term survival of patients. We describe the evidence for treatment strategies for these aggressive disorders. In primary CNS lymphoma there are randomized trial data to inform treatment decisions but these are lacking to guide management in secondary CNS lymphoma. Dynamic assessment of patient fitness and frailty is key throughout treatment, alongside delivery of CNS-bioavailable therapy and enrolment in clinical trials, at each stage of the disease. Intensive high-dose methotrexate-containing induction followed by consolidation with autologous stem cell transplantation with thiotepa-based conditioning is recommended for patients who are fit. Less intensive chemoimmunotherapy, novel agents (including Bruton tyrosine kinase inhibitors, cereblon targeting immunomodulatory agents, and checkpoint inhibitors in the context of clinical trials), and whole brain radiotherapy may be reserved for less fit patients or disease which is chemoresistant. Data regarding the efficacy of chimeric antigen receptor T-cells therapy is emerging, and concerns regarding greater toxicity have not been realized. Future areas of prospective studies include the identification of those at high risk of developing CNS lymphoma, management in elderly or frail patients as well as incorporating novel agents into regimens, particularly for those with chemoresistant disease.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospital, London, United Kingdom.
| | - Lakshmi Nayak
- Center for Neuro-Oncology, Dana-Farber Cancer Institute, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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8
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Perry C, Greenberg O, Haberman S, Herskovitz N, Gazy I, Avinoam A, Paz-Yaacov N, Hershkovitz D, Avivi I. Image-Based Deep Learning Detection of High-Grade B-Cell Lymphomas Directly from Hematoxylin and Eosin Images. Cancers (Basel) 2023; 15:5205. [PMID: 37958379 PMCID: PMC10650414 DOI: 10.3390/cancers15215205] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/04/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
Deep learning applications are emerging as promising new tools that can support the diagnosis and classification of different cancer types. While such solutions hold great potential for hematological malignancies, there have been limited studies describing the use of such applications in this field. The rapid diagnosis of double/triple-hit lymphomas (DHLs/THLs) involving MYC, BCL2 and/or BCL6 rearrangements is obligatory for optimal patient care. Here, we present a novel deep learning tool for diagnosing DHLs/THLs directly from scanned images of biopsy slides. A total of 57 biopsies, including 32 in a training set (including five DH lymphoma cases) and 25 in a validation set (including 10 DH/TH cases), were included. The DHL-classifier demonstrated a sensitivity of 100%, a specificity of 87% and an AUC of 0.95, with only two false positive cases, compared to FISH. The DHL-classifier showed a 92% predictive value as a screening tool for performing conventional FISH analysis, over-performing currently used criteria. The work presented here provides the proof of concept for the potential use of an AI tool for the identification of DH/TH events. However, more extensive follow-up studies are required to assess the robustness of this tool and achieve high performances in a diverse population.
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Affiliation(s)
- Chava Perry
- Hematology Division, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Orli Greenberg
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Pathology Department, Tel Aviv Sourasky Medical Center, Tel Aviv 6492601, Israel
| | - Shira Haberman
- Hematology Division, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Neta Herskovitz
- Hematology Division, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Inbal Gazy
- Imagene AI Ltd., Tel Aviv 6721409, Israel (N.P.-Y.)
| | | | | | - Dov Hershkovitz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- Pathology Department, Tel Aviv Sourasky Medical Center, Tel Aviv 6492601, Israel
| | - Irit Avivi
- Hematology Division, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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9
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Zeremski V, McPhail ED, Habermann TM, Schieppati F, Gebauer N, Vassilakopoulos TP, Mougiakakos D. Treatment intensification might not improve survival in high-grade B-cell lymphoma with a concurrent MYC and BCL2 and/or BCL6 rearrangement: A retrospective, multicenter, pooled analysis. Hematol Oncol 2023; 41:776-780. [PMID: 36945194 DOI: 10.1002/hon.3130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Affiliation(s)
- Vanja Zeremski
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Ellen D McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas M Habermann
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Niklas Gebauer
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Theodoros P Vassilakopoulos
- Department of Hematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, Athens, Greece
| | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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10
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Bobillo S, Wilson MR, Cwynarski K. Controversies in central nervous system prophylaxis of high-risk diffuse large B-cell lymphoma. Curr Opin Oncol 2023; 35:382-388. [PMID: 37551947 DOI: 10.1097/cco.0000000000000973] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) relapse in patients with diffuse large B-cell lymphoma (DLBCL) is an uncommon but devastating complication with an overall survival of less than 6 months. This article will review the recent updates on CNS prophylaxis including new potential advances in the identification of high-risk patients. RECENT FINDINGS The identification of patients at a high risk of CNS relapse is based on clinical and biological features has improved over recent years; however, the of different CNS prophylaxis strategies including intrathecal chemotherapy and high-dose methotrexate have been recently questioned in several large retrospective studies. The analysis of cell-free circulating tumor DNA (ctDNA) in the cerebrospinal fluid has been shown to identify patients with a high risk of CNS involvement and work is ongoing to identify how this can be used as a prognostic biomarker. SUMMARY Recent clinical retrospective data have questioned the effectiveness of intrathecal and high-dose methotrexate in the prevention of CNS relapse in high-risk DLBCL patients. The role of more sensitive methods to detect CNS involvement and the benefit of novel therapies in CNS relapse prevention are currently under evaluation.
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Affiliation(s)
- Sabela Bobillo
- Department of Haematology, Vall d'Hebron Institute of Oncology, University Hospital Vall d'Hebron, Barcelona, Spain
| | - Matthew R Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, UK
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11
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Zeremski V, Kropf S, Koehler M, Gebauer N, McPhail ED, Habermann T, Schieppati F, Mougiakakos D. Induction treatment in high-grade B-cell lymphoma with a concurrent MYC and BCL2 and/or BCL6 rearrangement: a systematic review and meta-analysis. Front Oncol 2023; 13:1188478. [PMID: 37546419 PMCID: PMC10399221 DOI: 10.3389/fonc.2023.1188478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background and aim High-grade B cell lymphomas with concomitant MYC and BCL2 and/or BCL6 rearrangements (HGBCL-DH/TH) have a poor prognosis when treated with the standard R-CHOP-like chemoimmunotherapy protocol. Whether this can be improved using intensified regimens is still under debate. However, due to the rarity of HGBCL-DH/TH there are no prospective, randomized controlled trials (RCT) available. Thus, with this systematic review and meta-analysis we attempted to compare survival in HGBCL-DH/TH patients receiving intensified vs. R-CHOP(-like) regimens. Methods The PubMed and Web of Science databases were searched for original studies reporting on first-line treatment in HGBCL-DH/TH patients from 08/2014 until 04/2022. Studies with only localized stage disease, ≤10 patients, single-arm, non-full peer-reviewed publications, and preclinical studies were excluded. The quality of literature and the risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) and National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Random-effect models were used to compare R-CHOP-(like) and intensified regimens regarding 2-year overall survival (2y-OS) and 2-year progression-free survival (2y-PFS). Results Altogether, 11 retrospective studies, but no RCT, with 891 patients were included. Only four studies were of good quality based on aforementioned criteria. Intensified treatment could improve 2y-OS (hazard ratio [HR]=0.78 [95% confidence interval [CI] 0.63-0.96]; p=0.02) as well as 2y-PFS (HR=0.66 [95% CI 0.44-0.99]; p=0.045). Conclusions This meta-analysis indicates that intensified regimens could possibly improve 2y-OS and 2y-PFS in HGBCL-DH/TH patients. However, the significance of these results is mainly limited by data quality, data robustness, and its retrospective nature. There is still a need for innovative controlled clinical trials in this difficult to treat patient population. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42022313234.
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Affiliation(s)
- Vanja Zeremski
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Siegfried Kropf
- Department for Biometry and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Koehler
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Specialty Practice for Psycho-Oncology, Magdeburg, Germany
| | - Niklas Gebauer
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Ellen D. McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Thomas Habermann
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | | | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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12
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Chan JY, Somasundaram N, Grigoropoulos N, Lim F, Poon ML, Jeyasekharan A, Yeoh KW, Tan D, Lenz G, Ong CK, Lim ST. Evolving therapeutic landscape of diffuse large B-cell lymphoma: challenges and aspirations. Discov Oncol 2023; 14:132. [PMID: 37466782 PMCID: PMC10361453 DOI: 10.1007/s12672-023-00754-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/13/2023] [Indexed: 07/20/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) represents the commonest subtype of non-Hodgkin lymphoma and encompasses a group of diverse disease entities, each harboring unique molecular and clinico-pathological features. The understanding of the molecular landscape of DLBCL has improved significantly over the past decade, highlighting unique genomic subtypes with implications on targeted therapy. At the same time, several new treatment modalities have been recently approved both in the frontline and relapsed settings, ending a dearth of negative clinical trials that plagued the past decade. Despite that, in the real-world setting, issues like drug accessibility, reimbursement policies, physician and patient preference, as well as questions regarding optimal sequencing of treatment options present difficulties and challenges in day-to-day oncology practice. Here, we review the recent advances in the therapeutic armamentarium of DLBCL and discuss implications on the practice landscape, with a particular emphasis on the context of the healthcare system in Singapore.
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Affiliation(s)
- Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore.
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Nicholas Grigoropoulos
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Francesca Lim
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Michelle Limei Poon
- Department of Haematology, National University Cancer Institute, Singapore, Singapore
| | - Anand Jeyasekharan
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Kheng Wei Yeoh
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Division of Radiation Oncology, National University Cancer Institute, Singapore, Singapore
| | - Daryl Tan
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Georg Lenz
- Department of Medicine A, Department of Hematology, Oncology and Pneumology, University Hospital Münster, Münster, Germany
| | - Choon Kiat Ong
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
- Lymphoma Genomic Translational Research Laboratory, Cellular and Molecular Research, National Cancer Centre Singapore, Singapore, Singapore.
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore.
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
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13
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Khwaja J, Cwynarski K. Management of primary and secondary CNS lymphoma. Hematol Oncol 2023; 41 Suppl 1:25-35. [PMID: 37294958 DOI: 10.1002/hon.3148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Central nervous system (CNS) lymphoma has traditionally had very poor outcomes however advances in management have seen dramatic improvements and long-term survival of patients. In primary CNS lymphoma there are now randomised trial data to inform practice, however secondary CNS lymphoma has a lack of randomised trial data and CNS prophylaxis remains a contentious area. We describe treatment strategies in these aggressive disorders. Dynamic assessment of patient fitness and frailty is key throughout treatment alongside delivery of CNS-bioavailable therapy and enrolment in clinical trials. Intensive high-dose methotrexate-containing induction followed by autologous stem cell transplantation is preferred for patients who are fit. Less intensive chemoimmunotherapy, whole brain radiotherapy and novel therapies may be reserved for patients unfit or chemoresistant. It is essential to better define patients at increased risk of CNS relapse, as well as effective prophylactic strategies to prevent it. Future prospective studies incorporating novel agents are key.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, England
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, England
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14
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El-Sharkawi D, Sud A, Prodger C, Khwaja J, Shotton R, Hanley B, Peacock V, Peng YY, Arasaretnam A, Sharma S, Aldridge F, Sharma B, Wotherspoon A, Cheung B, De Lord C, Johnston R, Kassam S, Pettengel R, Linton K, Greaves P, Cook L, Naresh KN, Cwynarski K, Eyre TA, Chau I, Cunningham D, Iyengar S. A retrospective study of MYC rearranged diffuse large B-cell lymphoma in the context of the new WHO and ICC classifications. Blood Cancer J 2023; 13:54. [PMID: 37072385 PMCID: PMC10113386 DOI: 10.1038/s41408-023-00827-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023] Open
Affiliation(s)
- Dima El-Sharkawi
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Amit Sud
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Catherine Prodger
- Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Rohan Shotton
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Brian Hanley
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ying Ying Peng
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Sarkhara Sharma
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Frances Aldridge
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Bhupinder Sharma
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Andrew Wotherspoon
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | | | - Corinne De Lord
- Epsom and St Helier University Hospitals NHS Trust, London, UK
| | | | - Shireen Kassam
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ruth Pettengel
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Kim Linton
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Paul Greaves
- Barking, Havering and Redbridge University Hospitals NHS Trust, Essex, UK
| | - Lucy Cook
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Kate Cwynarski
- University College Hospitals NHS Foundation Trust, London, UK
| | - Toby A Eyre
- Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - David Cunningham
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Sunil Iyengar
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK.
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15
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Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica 2023; 108:673-689. [PMID: 36384246 PMCID: PMC9973486 DOI: 10.3324/haematol.2022.281457] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.
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Affiliation(s)
- Sabela Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milan
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London
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16
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Cwynarski K, Cummin T, Osborne W, Lewis J, Chaganti S, Smith J, Linton K, Greaves P, McKay P, Fox CP. Management of secondary central nervous system lymphoma. Br J Haematol 2023; 200:160-169. [PMID: 36408800 DOI: 10.1111/bjh.18539] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/07/2022] [Accepted: 10/17/2022] [Indexed: 11/22/2022]
Affiliation(s)
- Kate Cwynarski
- Department of Haematology, University College London Hospitals NHS Trust, London, UK
| | - Thomas Cummin
- Department of Haematology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Wendy Osborne
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Joanne Lewis
- Department of Haematology, Newcastle Upon Tyne Hospitals NHS Trust, Newcastle Upon Tyne, UK
| | - Sridhar Chaganti
- Department of Haematology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jeff Smith
- The Clatterbridge Cancer Centre NHS Foundation Trust, Liverpool University Hospitals NHS Trust, Liverpool, UK
| | - Kim Linton
- Haematology and Transplant Unit, The Christie NHS Foundation Trust, Manchester, UK
| | - Paul Greaves
- Department of Haematology, Barking Havering and Redbridge University Hospital NHS Trust, Romford, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Christopher P Fox
- Department of Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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17
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Alsuliman T, Stocker N, Corre E, Dulery R, Sestili S, Ricard L, Malard F, Mohty M, Coppo P, Marjanovic Z. Autologous hematopoietic cell transplantation as a part of a sequential multi-phase therapeutic approach (R-COPADM/CYVE/ASCT) as first-line treatment of high-grade B-cell lymphoma: results of a retrospective study with long-term follow-up. Bone Marrow Transplant 2022; 58:437-439. [PMID: 36550199 DOI: 10.1038/s41409-022-01902-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022]
Abstract
Patients with high-risk lymphoma have a poor prognosis when treated with standard chemoimmunotherapy. This retrospective study included 23 high-risk lymphoma patients with a median age at diagnosis of 59 (range, 35-68) years. They received 2 cycles of R-COPADM and 2 cycles of CYVE, completed by ASCT for fit patients. With a median follow-up of 46 (range, 3-78) months, three (13%) patients in the cohort died. Nearly half of the patients had an ECOG performance status of 2 or 3. Most patients in the cohort (91%, n = 21) had Ann Arbor stage III-IV disease, and 88% (n = 20) had an IPI of 3 to 5. LDH levels were elevated in 83% (n = 19) of patients. Overall, 30% of patients were identified as having double-expressor lymphoma and 22% as having DHL, while two patients (9%) had THL. The origin of the lymphoma was GC B-cell-like in 15 patients (65%) and ABC-like in 8 patients (35%). Cumulative incidence of relapse at 46 months was 14% (95% CI, 5-37), while overall survival was 87% (95% CI, 64-95) and progression-free survival was 83% (95% CI, 60-93). These results showed the efficacy and an acceptable safety profile of the R-COPADM/CYVE/ASCT regimen in high-risk lymphoma, including patients with DHL.
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Affiliation(s)
- Tamim Alsuliman
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Nicolas Stocker
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Elise Corre
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Rémy Dulery
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Simona Sestili
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Laure Ricard
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Florent Malard
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Mohamad Mohty
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France.,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France
| | - Paul Coppo
- Sorbonne University, Paris, France.,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France
| | - Zora Marjanovic
- Sorbonne University, Paris, France. .,Service d'Hématologie Clinique et Thérapie Cellulaire, Hôpital Saint-Antoine, AP-HP, Paris, France. .,INSERM, UMRs 938, Centre de Recherche Saint-Antoine, Paris, France.
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18
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Wilson MR, Bobillo S, Cwynarski K. CNS prophylaxis in aggressive B-cell lymphoma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:138-145. [PMID: 36485105 PMCID: PMC9820554 DOI: 10.1182/hematology.2022000331] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
The prevention of central nervous system (CNS) relapse in diffuse large B-cell lymphoma (DLBCL) continues to be one of the most contentious areas of lymphoma management. Outcomes for patients with secondary CNS lymphoma (SCNSL) have historically been very poor. However, in recent years improved responses have been reported with intensive immunochemotherapy approaches, and there is a growing interest in potential novel/cellular therapies. Traditional methods for selecting patients for CNS prophylaxis, including the CNS International Prognostic Index, are hampered by a lack of specificity, and there is accumulating evidence to question the efficacy of widely employed prophylactic interventions, including intrathecal and high-dose methotrexate (HD-MTX). Given the potential toxicity of HD-MTX in particular and the ongoing need to prioritize systemic disease control in high-risk patients, there is an urgent need to develop more robust methods for identifying patients at highest risk of CNS relapse, as well as investigating prophylactic interventions with greater efficacy. Here we review new evidence in this field from the last 5 years, focusing on the potential use of molecular diagnostics to improve the identification of high-risk patients, recent large data sets questioning the efficacy of HD-MTX, and the current approach to management of patients with SCNSL. We provide a suggested algorithm for approaching this very challenging clinical scenario.
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Affiliation(s)
- Matthew R. Wilson
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, United Kingdom
| | - Sabela Bobillo
- Department of Haematology, Vall d’Hebron Institute of Oncology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Kate Cwynarski
- Department of Haematology, University College London Hospital, London, United Kingdom
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19
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On S, Chang A. Treatment of lymphoma with rituximab and chemotherapy during pregnancy. Leuk Lymphoma 2022; 63:2897-2904. [PMID: 35856478 DOI: 10.1080/10428194.2022.2100368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Safety of chemoimmunotherapy during pregnancy for treatment of Non-Hodgkin's lymphoma (NHL) is controversial. We review 37 cases of mothers with high grade NHL treated with rituximab and concurrent chemotherapy during pregnancy. Majority (95%) of mothers were treated in their second and third trimester, and a median of 4 cycles of combination therapy was administered. Complete remission occurred in 14/17 (82%) mothers whose disease outcomes were reported. There were 2 spontaneous abortions and 1 trimester fetal death that occurred in 3 mothers who received treatment in their first and second trimesters. Among the 34 (92%) live births, there were 6 cases of respiratory/cardiac complications requiring intervention and 5 cases of hematologic abnormalities reported. This review highlights the efficacy and safety of chemoimmunotherapy for mothers treated in second and third trimester. Further data is needed to establish recommendations for management of mothers with aggressive NHL in their first trimester of pregnancy.
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Affiliation(s)
- Sandy On
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, USA
| | - Abraham Chang
- Department of Pharmacy, Stanford Health Care, Palo Alto, CA, USA
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20
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Eyre TA, Savage KJ, Cheah CY, El-Galaly TC, Lewis KL, McKay P, Wilson MR, Evens AM, Bobillo S, Villa D, Maurer MJ, Cwynarski K, Ferreri AJM. CNS prophylaxis for diffuse large B-cell lymphoma. Lancet Oncol 2022; 23:e416-e426. [DOI: 10.1016/s1470-2045(22)00371-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 05/30/2022] [Accepted: 06/01/2022] [Indexed: 11/25/2022]
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21
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Fleming M, Huang Y, Dotson E, Bond DA, Reneau J, Epperla N, Alinari L, Brammer J, Christian B, Baiocchi RA, Maddocks K, Sawalha Y. Outcomes of patients with diffuse large B-cell and high-grade B-cell lymphomas with synchronous CNS and systemic involvement at diagnosis treated with high-dose methotrexate and R-CHOP: a single-center retrospective study. Ther Adv Hematol 2022; 13:20406207221112900. [PMID: 35898434 PMCID: PMC9310204 DOI: 10.1177/20406207221112900] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/01/2022] [Indexed: 12/12/2022] Open
Abstract
Background: The optimal treatment of patients with systemic diffuse large B-cell (DLBCL) or high-grade B-cell (HGBL) lymphomas with synchronous central nervous system (CNS) involvement at diagnosis is not well defined. High-dose methotrexate administered concurrently with R-CHOP (RM-CHOP) is a commonly used regimen, but data on outcomes achieved with this regimen are limited. Objective: To report our experience with RM-CHOP in patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis. Design: A single-center retrospective analysis. Methods: We identified consecutive patients with systemic DLBCL or HGBL with synchronous CNS involvement at diagnosis who were treated with RM-CHOP from January 2012 to January 2021. Results: Fifty patients were included with a median age of 62 years; 82% had DLBCL (n = 41) and 18% had HGBL (n = 9). Treatment with RM-CHOP was followed by consolidative autologous hematopoietic cell transplantation in 14 patients (28%). The complete response (CR) rate following RM-CHOP was 62%. With a median follow-up of 40 months, the median progression-free (PFS) and overall (OS) survivals were 16 and 58 months, and the 2-year PFS and OS were 41% and 57%, respectively. The 2-year cumulative incidence of CNS progression/relapse was 29%. Outcomes were particularly poor in HGBL, with median PFS and OS of 6 and 7 months, compared with median PFS and OS of 22 months and not reached in DLBCL, respectively. The outcomes of patients with relapsed/progressive disease were poor, with only 63% of patients receiving subsequent treatments and only 21% achieving CR to next subsequent treatment. Most patients (58%) with disease relapse/progression had CNS involvement which was associated with very poor outcomes (median OS of 2 months). Conclusion: CNS involvement in aggressive B-cell non-Hodgkin lymphoma at diagnosis dictates clinical outcomes and requires more effective treatment options.
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Affiliation(s)
- Megan Fleming
- Department of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - Ying Huang
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Emily Dotson
- Department of Pharmacy, The Ohio State University, Columbus, OH, USA
| | - David A Bond
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - John Reneau
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | | | - Lapo Alinari
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Jonathan Brammer
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Beth Christian
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Robert A Baiocchi
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Kami Maddocks
- Division of Hematology, The Ohio State University, Columbus, OH, USA
| | - Yazeed Sawalha
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center, The Ohio State University, 1140B Lincoln Tower, 1800 Cannon Dr, Columbus, OH 43210, USA
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22
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Wight J, Ku M, Garwood M, Carradice D, Lasica M, Keamy L, Hawkes EA, Grigg A. Toxicity associated with high-dose intravenous methotrexate for hematological malignancies. Leuk Lymphoma 2022; 63:2375-2382. [DOI: 10.1080/10428194.2022.2074987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Joel Wight
- Austin Health, Heidelberg, Australia
- Olivia Newton John Cancer Research Institute, Victoria, Australia
- The University of Melbourne, Melbourne, Australia
- Townsville University Hospital, Townsville, Australia
| | - Matthew Ku
- The University of Melbourne, Melbourne, Australia
- St Vincent’s Hospital, Melbourne, Australia
| | | | | | | | - Louise Keamy
- The University of Melbourne, Melbourne, Australia
- Western Health, Melbourne, Australia
| | - Eliza A. Hawkes
- Austin Health, Heidelberg, Australia
- Olivia Newton John Cancer Research Institute, Victoria, Australia
- The University of Melbourne, Melbourne, Australia
- Monash University, Melbourne, Australia
| | - Andrew Grigg
- Austin Health, Heidelberg, Australia
- The University of Melbourne, Melbourne, Australia
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23
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Gordon MJ, Westin JR. Fitting double-hit lymphoma into the aggressive lymphoma spectrum: a square peg in a round hole? Leuk Lymphoma 2022; 63:1034-1044. [PMID: 34842019 DOI: 10.1080/10428194.2021.2008383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements or both, commonly called double-hit lymphoma (DHL), is an aggressive B-cell lymphoma that is molecularly distinct from diffuse large B-cell lymphoma (DLBCL) and is associated with poor outcomes. Recent advances in the molecular classification of DLBCL have identified distinct subsets, including genetic signatures which correlate with DHL and survival. DHL with concomitant TP53 mutation appears to be associated with a very poor prognosis. Standard chemo-immunotherapy is not an effective treatment for these patients and personalized, innovative strategies are needed. In this review, we summarize recent advances in the subclassification of DLBCL, with a focus on DHL. We also incorporate early, promising clinical trial data using CAR T and targeted therapies. Rationally designed clinical trials for DLBCL are needed to advance the care of patients with DHL and other adverse risk DLBCL subgroups.
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Affiliation(s)
- Max J Gordon
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jason R Westin
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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24
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Paszkiewicz-Kozik E, Michalski W, Taszner M, Mordak-Domagała M, Romejko-Jarosińska J, Knopińska-Posłuszny W, Najda J, Borawska A, Chełstowska M, Świerkowska M, Dąbrowska-Iwanicka A, Malenda A, Druzd-Sitek A, Konecki R, Kumiega B, Osowiecki M, Ostrowska B, Szpila T, Szymański M, Targoński Ł, Domańska-Czyż K, Popławska L, Giebel S, Lange A, Pluta A, Zaucha JM, Rymkiewicz G, Walewski J. Ofatumumab with iphosphamide, etoposide and cytarabine for patients with transplantation-ineligible relapsed and refractory diffuse large B-cell lymphoma. Br J Haematol 2022; 198:73-81. [PMID: 35362096 PMCID: PMC9322457 DOI: 10.1111/bjh.18166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
The efficacy of salvage treatment of diffuse large B-cell lymphoma (DLBCL) patients who relapse or progress (rrDLBCL) after initial therapy is limited. Efficacy and safety of ofatumumab with iphosphamide, etoposide and cytarabine (O-IVAC) was evaluated in a single-arm study. Dosing was modified for elderly patients. Patients received up to six cycles of treatment. The primary end-point was the overall response rate (ORR). Patients were evaluated every two cycles and then six and 12 months after treatment. Other end-points included progression-free survival (PFS), event-free survival (EFS), overall survival (OS) and safety. Seventy-seven patients received salvage treatment with O-IVAC. The average age was 56.8 years; 39% had an Eastern Cooperative Oncology Group (ECOG) performance status of at least 3; 78% had disease of Ann Arbor stage 3 or 4; 58% received one or more prior salvage therapies. The ORR for O-IVAC was 54.5%. The median duration of study follow-up was 70 months. The median PFS and EFS were 16.3 months each. The median OS was 22.7 months. Age, ECOG performance status and the number of prior therapy lines were independent predictors of survival. Treatment-related mortality was 15.5%. O-IVAC showed a high response rate in a difficult-to-treat population and is an attractive treatment to bridge to potentially curative therapies.
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Affiliation(s)
| | - Wojciech Michalski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Monika Mordak-Domagała
- Lower Silesian Center for Cellular Transplantation with National Bone Marrow Donor Registry, Wroclaw, Poland
| | | | - Wanda Knopińska-Posłuszny
- Maritime Hospital, Gdynia, Poland.,Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Jacek Najda
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Anna Borawska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Monika Świerkowska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Agata Malenda
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Robert Konecki
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Beata Kumiega
- Sniadecki Memorial Specialist Hospital, Nowy Sacz, Poland
| | - Michał Osowiecki
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Beata Ostrowska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Szpila
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Marcin Szymański
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Łukasz Targoński
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Lidia Popławska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Andrzej Lange
- Lower Silesian Center for Cellular Transplantation with National Bone Marrow Donor Registry, Wroclaw, Poland
| | - Andrzej Pluta
- Department of Hematology, Brzozow Oncology Center, Brzozow, Poland
| | - Jan Maciej Zaucha
- Medical University of Gdansk, Gdansk, Poland.,Maritime Hospital, Gdynia, Poland
| | - Grzegorz Rymkiewicz
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Walewski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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25
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Ma'koseh M, Amarin R, Tamimi F, Sharaf B, Abufara A, Shahin O, Manassra MKM, Halahleh K. Treatment of adult Burkitt lymphoma with the CALGB 1002 protocol: a single center experience in Jordan. Blood Res 2021; 56:279-284. [PMID: 34880141 PMCID: PMC8721458 DOI: 10.5045/br.2021.2021116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/28/2021] [Accepted: 10/13/2021] [Indexed: 12/24/2022] Open
Abstract
Background The treatment of adult Burkitt lymphoma with pediatric-based chemotherapy protocols usually results in high cure rates, although with significant toxicity. We report our experience with the Cancer and Leukemia Group B1002 (CALGB 1002) protocol. Methods The files of adult patients diagnosed with Burkitt lymphoma and treated with the CALGB 1002 protocol at King Hussein Cancer Center between 2008 and 2017 were reviewed. Baseline demographics, clinical laboratory features, treatment details, and responses were collected. The correlations between clinical and laboratory variables with event-free survival (EFS) and overall survival (OS) were determined by univariate and multivariate analyses using backward stepwise Cox regression models. EFS and OS were plotted using Kaplan‒Meier curves. Results This study included 19 patients with a median age of 33 years (range, 19‒65). Eleven (58%) and two (10.5%) patients had advanced-stage and central nervous system disease, respectively. Among 106 administered cycles, the median interval between cycles was 23 days (range, 19‒84 days). Sixteen patients (84%) achieved a complete response. After a median follow-up of 40.8 months, the 3-year EFS and OS rates were 78.95%. Patients with a low-risk International Prognostic Index (IPI) had better survival than those with intermediate-or high-risk IPI. Grade III‒IV hematological toxicities occurred in 88% of patients, while 73% had grade III‒IV mucositis. Conclusion In adult Burkitt lymphoma, the CALGB 1002 protocol provides high cure rates and can be administered promptly, but is associated with significant toxicity. Risk-adapted approaches and other, less toxic, chemotherapeutic regimens should be considered.
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Affiliation(s)
- Mohammad Ma'koseh
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Rula Amarin
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Faris Tamimi
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Baha' Sharaf
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Alaa Abufara
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | - Omar Shahin
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
| | | | - Khalid Halahleh
- Department of Medical Oncology, King Hussein Cancer Center, Amman, Jordan
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26
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Dunleavy K. Double-hit lymphoma: optimizing therapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:157-163. [PMID: 34889402 PMCID: PMC8791152 DOI: 10.1182/hematology.2021000247] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Aggressive B-cell lymphoma is a heterogeneous entity with disparate outcomes based on clinical and pathological characteristics. While most tumors in this category are diffuse large B-cell lymphoma (DLBCL), the recognition that some cases have high-grade morphology and frequently harbor MYC and BCL2 and/or BCL6 translocations has led to their separate categorization. These cases are now considered distinct from DLBCL and are named "high-grade B-cell lymphoma" (HGBL). Most are characterized by distinct rearrangements, but others have high-grade morphological features without these and are called HGBL-not otherwise specified. Studies have demonstrated that this group of diseases leads to poor outcomes following standard rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone therapy; retrospective and recent single-arm, multicenter studies suggest they should be approached with dose-intense treatment platforms. As yet, this has not been validated in randomized trial settings due to the rarity of these diseases. In the relapsed and refractory setting, novel approaches such as anti-CD19 chimeric antigen receptor T cells and antibodies against CD19 have demonstrated high efficacy in this subgroup. Recently, genomic studies have made much progress in investigating some of the molecular underpinnings that drive their lymphomagenesis and have paved the way for testing additional novel approaches.
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Affiliation(s)
- Kieron Dunleavy
- Correspondence Kieron Dunleavy, Division of Hematology and Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20057; e-mail:
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27
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Feasibility of High-dose Methotrexate Administered on Day 1 of (R)CHOP in aggressive non-Hodgkin Lymphomas. Blood Adv 2021; 6:460-472. [PMID: 34788387 PMCID: PMC8791577 DOI: 10.1182/bloodadvances.2021005999] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 10/27/2021] [Indexed: 11/20/2022] Open
Abstract
HDMTX administration on day 1 of (R)CHOP is feasible and compares favorably with reports of HDMTX administration midcycle. Delaying prophylactic HDMTX beyond cycle 1 of (R)CHOP might lower the risks of neutropenic fever and acute kidney injury.
The optimal timing for administering high-dose methotrexate (HDMTX) when combined with (R)CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone, with/without rituximab) is unclear. Recent data showed that the administration of prophylactic HDMTX before day 10 of R- CHOP may lead to fewer treatment delays. Herein, we report our experience with HDMTX administered on day 1 of (R)CHOP in patients with aggressive non-Hodgkin lymphoma (NHL). We identified 140 patients treated with ≥1 cycle of HDMTX combined with (R)CHOP for prophylaxis against (n = 84) or treatment of (n = 56) central nervous system (CNS) involvement. Overall, (R)CHOP treatment delays ≥7 days (4% of cycles, 13% of patients), doxorubicin, and/or cyclophosphamide dose reductions (1% of cycles, 6% of patients) or (R)CHOP discontinuations due to toxicity (4% of patients) were uncommon. Neutropenic fever (NF) occurred in 7% of cycles and 24% of patients and was more common during HDMTX-containing cycles. Acute kidney injury (AKI) occurred in 19% of cycles but was mostly grade ≤2. Grade ≥3 hepatotoxicity and mucositis were uncommon (each 2% of cycles). In the prophylaxis cohort, the rates of NF and grade ≥2 AKI were lower in patients who initiated HDMTX with cycle 2 or later (11% vs 30%, P = .03 and 16% vs 39%, P = .03, respectively). Our data show that HDMTX administration on day 1 of (R)CHOP may improve the deliverability of (R)CHOP and the overall safety of the regimen compared with historical data of HDMTX administration on day 10 or later of R-CHOP. Delaying prophylactic HDMTX beyond cycle 1 of (R)CHOP may reduce the risk of NF and AKI.
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28
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Sonnevi K, Ljungqvist M, Jóelsson JK, Harrysson S, Wästerlid T, Bernell P, Wahlin BE. Excellent survival after R‐Hyper‐CVAD in hospitalized patients with high‐risk large B‐cell lymphoma: The Karolinska experience. EJHAEM 2021; 2:774-784. [PMID: 35845206 PMCID: PMC9175941 DOI: 10.1002/jha2.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 11/06/2022]
Abstract
Patients with high‐risk aggressive B‐cell lymphoma exhibit poor survival after R‐CHOP. More intensive regimens yield higher rates of remission but also of complication. We investigated all 401 patients < 70 years with high‐risk (age‐adjusted [aa] international prognostic index [IPI] ≥2, extranodal, or bulky) aggressive B‐cell lymphoma hospitalized at Karolinska for urgent start of immunochemotherapy (129 R‐Hyper‐CVAD; 261 R‐CHOP/R‐CHOEP). Patients showed IPI 3–5 (70%), WHO PS ≥2 (49%), bulky disease (70%), extranodal (75%) and CNS (8%) involvement. Five‐year overall/progression‐free survival (OS/PFS) was better in patients who started R‐Hyper‐CVAD (84%/77%) compared with R‐CHOP/R‐CHOEP (66%/55%). Differences were independent in multivariable analysis, seen in all patient categories, and accentuated in extreme high‐risk disease: R‐Hyper‐CVAD vs. R‐CHOP/R‐CHOEP showed 5‐year PFS 69% vs.40% in aaIPI 3 and 88% vs. 38% in CNS involvement. For validation, survival was compared between the two Karolinska sites and calendar periods. Survival was superior 2006–2010 at the site that introduced R‐Hyper‐CVAD/R‐MA 2006, identical at both sites 2011–2017 after the other site adopted R‐Hyper‐CVAD/R‐MA 2011, and excellent 2018–2020 when R‐Hyper‐CVAD/R‐MA use increased to 75% of patients. Despite considerable toxicity, also patients aged 61–69 years showed better survival with R‐Hyper‐CVAD/R‐MA. This is the largest single‐centre series of patients treated with R‐Hyper‐CVAD/R‐MA, showing favourable outcome in high‐risk aggressive B‐cell lymphoma.
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Affiliation(s)
- Kristina Sonnevi
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
| | - Maria Ljungqvist
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Jóel Kristinn Jóelsson
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Sara Harrysson
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Tove Wästerlid
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Per Bernell
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine Karolinska Institutet Stockholm Sweden
| | - Björn Engelbrekt Wahlin
- Haematology Medical Unit Karolinska University Hospital Stockholm Sweden
- Division of Haematology, Department of Medicine, Huddinge Karolinska Institutet Stockholm Sweden
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29
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Wight J, Hamad N, Campbell BA, Ku M, Lee K, Rose H, Armytage T, Latimer M, Lee HP, Lee ST, Dickinson M, Khor R, Verner E. Diffuse large B-cell lymphoma: A consensus practice statement from the Australasian Lymphoma Alliance. Intern Med J 2021; 52:1609-1623. [PMID: 34532916 DOI: 10.1111/imj.15533] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 06/29/2021] [Accepted: 09/12/2021] [Indexed: 11/28/2022]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype, accounting for 30-40% of lymphoma diagnoses. Though aggressive, cure is achievable in approximately 60% of cases with primary chemo-immunotherapy, and in a further substantial minority by salvage therapy and autologous stem cell transplantation. Despite promising activity in early phase clinical trials, no intensified or novel treatment regimen has improved outcomes over R-CHOP21 in randomised studies. However, there remain several areas of controversy including the most appropriate prognostic markers, CNS prophylaxis and the optimal treatment for patients with high-risk disease. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- J Wight
- Townsville University Hospital, Townsville, Australia.,Austin Health, Heidelberg, Australia.,The University of Melbourne, Melbourne, Australia.,James Cook University, Townsville, Australia
| | - N Hamad
- Department of Haematology, St Vincent's Hospital Sydney, Australia.,School of Medicine, Sydney, University of Notre Dame Australia.,St Vincent's Clinical School, Sydney, University of New South UK
| | - B A Campbell
- Department of Radiation oncology, Peter MacCallum Cancer Centre, Parkville, Victoria.,Department of Clinical Pathology, University of Melbourne, Parkville, Victoria
| | - M Ku
- St Vincent's Hospital, Melbourne, Victoria
| | - K Lee
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Anatomical Pathology Department, NSW Health Pathology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - H Rose
- University Hospital Geelong, Victoria.,School of Medicine, Deakin University Geelong, Victoria
| | - T Armytage
- Department of haematology, Gosford Hospital, Gosford, New South, UK
| | - M Latimer
- Canberra Hospital, Canberra, Australia.,Australian National University, Canberra, Australia
| | - H P Lee
- Flinders Medical Centre, Adelaide, Australia
| | - S T Lee
- Austin Health, Heidelberg, Australia
| | - M Dickinson
- The University of Melbourne, Melbourne, Australia.,Department of Haematology, Peter MacCallum Cancer Centre, Parkville, Victoria
| | - R Khor
- Austin Health, Heidelberg, Australia
| | - E Verner
- School of Medicine, University of Sydney, Sydney, New South Wales, Australia.,Department of Haematology, Concord Repatriation General Hospital, Sydney, New South Wales, Australia
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30
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Defining and Treating High-grade B-cell lymphoma, NOS. Blood 2021; 140:943-954. [PMID: 34525177 DOI: 10.1182/blood.2020008374] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/10/2021] [Indexed: 11/20/2022] Open
Abstract
High-grade B-cell lymphoma, not otherwise specified (HGBL, NOS) is a recently introduced diagnostic category for aggressive B-cell lymphomas. It includes tumors with Burkitt-like or blastoid morphology that do not have double-hit cytogenetics and that cannot be classified as other well-defined lymphoma subtypes. HBCL, NOS are rare and heterogeneous; most have germinal center B-cell phenotype, and up to 45% carry a single-hit MYC rearrangement, but otherwise they have no unifying immunophenotypic or cytogenetic characteristics. Recent analyses utilizing gene expression profiling (GEP) revealed that up to 15% of tumors currently classified as diffuse large B-cell lymphoma display a HGBL-like GEP signature, indicating a potential to significantly expand the HGBL category using more objective molecular criteria. Optimal treatment of HGBL, NOS is poorly defined due to its rarity and inconsistent diagnostic patterns. A minority of patients have early-stage disease which can be managed with standard RCHOP-based approaches with or without radiation. For advanced-stage HGBL, NOS, which often presents with aggressive, disseminated disease, high lactate dehydrogenase, and involvement of extranodal organs (including the central nervous system [CNS]), intensified Burkitt lymphoma-like regimens with CNS prophylaxis may be appropriate. However, many patients diagnosed at age > 60 years are not eligible for intensive immunochemotherapy. An improved, GEP and/or genomic-based pathologic classification that could facilitate HGBL-specific trials is needed to improve outcomes for all patients. In this review, we discuss the current clinicopathologic concept of HGBL, NOS, existing data on its prognosis and treatment, and delineate potential future taxonomy enrichments based on emerging molecular diagnostics.
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31
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Oiwa K, Fujita K, Lee S, Morishita T, Tsukasaki H, Negoro E, Hara T, Tsurumi H, Ueda T, Yamauchi T. Prognostic impact of six versus eight cycles of standard regimen in patients with diffuse large B-cell lymphoma: propensity score-matching analysis. ESMO Open 2021; 6:100210. [PMID: 34271313 PMCID: PMC8287142 DOI: 10.1016/j.esmoop.2021.100210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 02/07/2023] Open
Abstract
Background R-CHOP-21 has been the standard treatment for diffuse large B-cell lymphoma (DLBCL), but there is a paucity of evidence focusing on the number of cycles of regimens. Patients and methods We conducted a retrospective study to compare the effectiveness of six cycles of standard regimens versus eight cycles for overall survival (OS) in DLBCL patients using propensity score matching, in consideration of relative dose intensity (RDI). Results A total of 685 patients with newly diagnosed DLBCL were identified in three institutions from 2007 to 2017. Patients treated using six cycles of standard regimens were matched by propensity scores with those treated using eight cycles. A 1 : 1 propensity score matching yielded 138 patient pairs. Eight cycles did not significantly improve OS in the conventional Cox proportional hazards model (hazard ratio 0.849, 95% confidence interval 0.453-1.588, P = 0.608). Restricted cubic spline Cox models for OS confirmed that the effect of the number of cycles was not modified by total average RDI, the International Prognostic Index, and age. Occurrence of adverse events did not differ between six and eight cycles. Conclusion Even considering the impact of RDI, six cycles of the initial standard regimen for DLBCL is not inferior to eight cycles. The optimal number of cycles of standard regimens including R-CHOP-21 for newly diagnosed DLBCL has not been determined. This study was conducted to verify whether six cycles or eight cycles of standard regimen improved the prognosis of DLBCL. Propensity score matching and a Cox hazards model with restricted cubic spline were used in this study. No survival benefit of eight cycles compared with six cycles was seen, even taking into account RDI. Prognosis was no better with eight cycles of (R-)CHOP-21 or THP-COP-21 than with six cycles, after age and IPI modifications.
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Affiliation(s)
- K Oiwa
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan; Department of Hematology and Oncology, Nagoya City University, Aichi, Japan
| | - K Fujita
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan; Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - S Lee
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan; Department of Hematology, Matsunami General Hospital, Gifu, Japan.
| | - T Morishita
- Department of Healthcare Economics and Quality Management, Graduate School of Medicine, Kyoto University, Yoshida Konoe-cho, Kyoto, Japan
| | - H Tsukasaki
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan; Department of Hematology, Fukui Red Cross Hospital, Fukui, Japan
| | - E Negoro
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan
| | - T Hara
- Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - H Tsurumi
- Department of Hematology, Matsunami General Hospital, Gifu, Japan
| | - T Ueda
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan
| | - T Yamauchi
- Department of Hematology and Oncology, University of Fukui, Fukui, Japan
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Lim CH, Hyun SH, Cho YS, Choi JY, Lee KH. Prognostic significance of bone marrow 2-[ 18F]-fluoro-2-deoxy-d-glucose uptake in diffuse large B-cell lymphoma: relation to iliac crest biopsy results. Clin Radiol 2021; 76:550.e19-550.e28. [PMID: 33762136 DOI: 10.1016/j.crad.2021.02.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 02/11/2021] [Indexed: 11/24/2022]
Abstract
AIM To investigate the prognostic significance of bone marrow (BM) 2-[18F]-fluoro-2-deoxy-d-glucose (FDG) uptake in relation to posterior iliac crest BM biopsy (BMB) results in diffuse large B-cell lymphoma (DLBCL). MATERIALS AND METHODS Pretreatment integrated positron-emission tomography(PET)/computed tomography (CT) images of 512 DLBCL patients who underwent BMB and received rituximab combined with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) chemotherapy were analysed retrospectively. BM uptake was assessed visually and by maximum standard uptake value (SUVmax). Associations with lymphoma-specific survival (LSS) were assessed using Kaplan-Meier and Cox regression analyses. RESULTS FDG(+) BM was observed in 64 cases (41 focal, 12 heterogeneous, 11 diffuse). This finding distinguished iliac crest involvement (positive in 59 and negative in 453) with 89.6% accuracy (459/512) and 93.6% specificity (424/453). In BMB(+) patients, BM-to-liver SUVmax ratio >1.8 concurred perfectly with FDG(+) BM. During 52 months of follow-up, there were 156 lymphoma-related deaths. In the entire population, multivariate analysis revealed high International Prognostic Index (IPI; p<0.001), old age (p=0.003), bulky disease (p=0.011), BMB(+) (p=0.028), and FDG(+) BM (p=0.019) as independent predictors of worse LSS. In the BMB(+) subgroup, high National Comprehensive Cancer Network-revised IPI (NCCN-IPI; p=0.029) and FDG(+) BM (p=0.008) were significant independent predictors. Among BMB(+) patients with low to low-intermediate NCCN-IPI, FDG(+) BM was associated with significantly worse 2-year LSS (33.3% versus 100%; p=0.017). The same was true among those with high-intermediate NCCN-IPI (34.7% versus 76.9%.; p=0.026). CONCLUSION Increased BM FDG in DLBCL is a predictor of worse LSS independent of BMB results and other prognostic variables including IPI/NCCN-IPI.
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Affiliation(s)
- C H Lim
- Department of Nuclear Medicine, Soonchunhyang University Hospital, Seoul, South Korea
| | - S H Hyun
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Y S Cho
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - J Y Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - K-H Lee
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea.
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Cordoba R, Luminari S, Eyre TA. The use of frailty assessments in treating older adults with aggressive lymphomas. Br J Haematol 2021; 194:677-685. [PMID: 33713435 DOI: 10.1111/bjh.17384] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/08/2021] [Indexed: 01/06/2023]
Abstract
Non-Hodgkin lymphomas (NHL) are most commonly diagnosed among people aged 65-74 years, with a median age at diagnosis of 67 years. The percentage of NHL-related deaths is highest among people aged 75-84 years, with a median age at death of 76 years from cases between 2014 and 2018. In light of these recent data, attending physicians of patients with NHL will recognize that the majority of their patients will be of advanced age, with many suffering from a spectrum of frailties. The excess rate of death among older adults with NHL may be related to a range of different factors such as more challenging biologic features, undertreatment received due to a patient's chronology and treatment-related toxicity. The aim of this review is to provide an updated overview of the knowledge generated over recent years regarding epidemiology, prognosis and treatment options in older adults with lymphoma, focusing on Diffuse Large B-cell Lymphoma (DLBCL) where the most robust evidence base is available.
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Affiliation(s)
- Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Stefano Luminari
- Programma di Ricerca ClinicaOncoematologica, S.C. Ematologia, AUSL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Modena, Italy
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford, UK
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Vincristine upregulates PD-L1 and increases the efficacy of PD-L1 blockade therapy in diffuse large B-cell lymphoma. J Cancer Res Clin Oncol 2021; 147:691-701. [PMID: 33389078 DOI: 10.1007/s00432-020-03446-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Accepted: 10/28/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Some chemotherapy drugs have immunomodulatory effects on specific tumors. The potential of vincristine (VCR) in the R-CHOP regimen to act as both a chemotherapeutic and an immunomodulatory agent via PD-L1 in tumor cells remains unclear. METHODS In vitro screening VCR showed that the IC50 value of VCR in the DLBCL cell lines was approximately 2 nM. Western blotting and q-PCR were used to detect the expression of PD-L1. The effect of VCR combined with PD-L1 mAb was tested in a co-culture system of LY-OCI-3 cells and peripheral blood mononuclear cells and in DLBCL xenograft mouse model. Flow cytometry was used to determine the proportion of T lymphocyte subsets. The effect of the STAT3 inhibitor nifuroxazide on VCR-induced PD-L1 expression was tested in LY-OCI-3 and SU-DHL-4 cells. RESULTS VCR upregulated PD-L1 protein and mRNA expression in various DLBCL cell lines. PD-L1 Ab combined with VCR significantly increased the proportion of CD8 + Granzyme B + , INF-γ + or TNF-α + CD3 + T cells. VCR + PD-L1 Ab inhibited tumor growth more effectively than VCR monotherapy, whereas PD-L1 Ab alone had no significant effect. Survival time did not differ significantly between the PD-L1 Ab group and the control group, whereas it was significantly longer in the VCR monotherapy and combination groups which showed more longer survival compared with the former. Nifuroxazide downregulated p-STAT3 and PD-L1 protein levels. CONCLUSIONS VCR upregulated PD-L1 expression in DLBCL cells partially by promoting the p-STAT3; VCR combined with PD-L1 Ab activated effector T cells and increased the antitumor immune response in vitro and in vivo.
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McMillan AK, Phillips EH, Kirkwood AA, Barrans S, Burton C, Rule S, Patmore R, Pettengell R, Ardeshna KM, Lawrie A, Montoto S, Paneesha S, Clifton-Hadley L, Linch DC. Favourable outcomes for high-risk diffuse large B-cell lymphoma (IPI 3-5) treated with front-line R-CODOX-M/R-IVAC chemotherapy: results of a phase 2 UK NCRI trial. Ann Oncol 2020; 31:1251-1259. [PMID: 32464282 PMCID: PMC7487775 DOI: 10.1016/j.annonc.2020.05.016] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Outcomes for patients with high-risk diffuse large B-cell lymphoma (DLBCL) treated with R-CHOP chemotherapy are suboptimal but, to date, no alternative regimen has been shown to improve survival rates. This phase 2 trial aimed to assess the efficacy of a Burkitt-like approach for high-risk DLBCL using the dose-intense R-CODOX-M/R-IVAC regimen. PATIENTS AND METHODS Eligible patients were aged 18-65 years with stage II-IV untreated DLBCL and an International Prognostic Index (IPI) score of 3-5. Patients received alternating cycles of CODOX-M (cyclophosphamide, vincristine, doxorubicin and high-dose methotrexate) alternating with IVAC chemotherapy (ifosfamide, etoposide and high-dose cytarabine) plus eight doses of rituximab. Response was assessed by computed tomography after completing all four cycles of chemotherapy. The primary end point was 2-year progression-free survival (PFS). RESULTS A total of 111 eligible patients were registered; median age was 50 years, IPI score was 3 (60.4%) or 4/5 (39.6%), 54% had a performance status ≥2 and 9% had central nervous system involvement. A total of 85 patients (76.6%) completed all four cycles of chemotherapy. There were five treatment-related deaths (4.3%), all in patients with performance status of 3 and aged >50 years. Two-year PFS for the whole cohort was 67.9% [90% confidence interval (CI) 59.9-74.6] and 2-year overall survival was 76.0% (90% CI 68.5-82.0). The ability to tolerate and complete treatment was lower in patients with performance status ≥2 who were aged >50 years, where 2-year PFS was 43.5% (90% CI 27.9-58.0). CONCLUSIONS This trial demonstrates that R-CODOX-M/R-IVAC is a feasible and effective regimen for the treatment of younger and/or fit patients with high-risk DLBCL. These encouraging survival rates demonstrate that this regimen warrants further investigation against standard of care. TRIAL REGISTRATION ClinicalTrials.gov (NCT00974792) and EudraCT (2005-003479-19).
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Affiliation(s)
- A K McMillan
- Haematology Department, Nottingham University Hospitals NHS Trust, Nottingham, UK.
| | - E H Phillips
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK; Division of Cancer Sciences, University of Manchester and The Christie Hospital NHS Trust, Manchester, UK
| | - A A Kirkwood
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK
| | - S Barrans
- HMDS, St James' University Hospital, Leeds, UK
| | - C Burton
- HMDS, St James' University Hospital, Leeds, UK
| | - S Rule
- Plymouth University Medical School, Plymouth, UK
| | - R Patmore
- Haematology Department, Castle Hill Hospital, Hull, UK
| | - R Pettengell
- Clinical Sciences, St George's University of London, London, UK
| | - K M Ardeshna
- Haematology Department, University College Hospital London, London, UK
| | - A Lawrie
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK
| | - S Montoto
- Centre for Haemato-oncology, Barts Health NHS Trust, London, UK
| | - S Paneesha
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - L Clifton-Hadley
- Cancer Research UK and UCL Cancer Trials Centre, UCL Cancer Institute, University College London, London, UK
| | - D C Linch
- Haematology Department, University College Hospital London, London, UK; UCL Cancer Institute, University College London, UK
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