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Tobin JWD, Hapgood G, Johnston A, Cheah CY, Lee ST, Trotman J, Inam S, Campbell BA, Norris D, MacManus M, Hertzberg M, Hawkes E. Diagnosis, management and follow-up of follicular lymphoma: a consensus practice statement from the Australasian Lymphoma Alliance. Intern Med J 2024; 54:1384-1395. [PMID: 39099075 DOI: 10.1111/imj.16454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 05/30/2024] [Indexed: 08/06/2024]
Abstract
Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma subtype, accounting for 15-20% of all lymphoma diagnoses. Although typically slow-growing and responsive to frontline therapies, advanced-stage FL remains incurable with current treatments and typically follows a chronic relapsing/remitting course with increasingly shorter responses to subsequent lines of therapy. Outcomes are highly variable; some patients experience prolonged first remissions that may approximate a 'functional cure'. By contrast, a significant minority of patients experience disease progression shortly after frontline treatment resulting in high rates of lymphoma-related mortality. Reflecting on the heterogeneous natural history of FL, clinical practice varies widely, particularly in controversial areas, including appropriate disease staging, selection of management strategies and duration of clinical follow-up. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice.
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Affiliation(s)
- Joshua W D Tobin
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Greg Hapgood
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- University of Queensland, Brisbane, Queensland, Australia
| | - Anna Johnston
- The Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Chan Y Cheah
- Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
- University of Western Australia, Perth, Western Australia, Australia
| | - Sze T Lee
- Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
| | - Judith Trotman
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
- University of Sydney, Sydney, New South Wales, Australia
| | | | - Belinda A Campbell
- University of Melbourne, Melbourne, Victoria, Australia
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | | | - Michael MacManus
- University of Melbourne, Melbourne, Victoria, Australia
- Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Mark Hertzberg
- University of Sydney, Sydney, New South Wales, Australia
- Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Eliza Hawkes
- Austin Health, Melbourne, Victoria, Australia
- University of Melbourne, Melbourne, Victoria, Australia
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2
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Zhong Q, Liu Y, Wu Y, Liu X, Chen S, Chen B, Su F, Li G, Xu Y, Liu L, Chen F, Qi S, Li Y. Impact of age on long-term relative survival benefit of radiotherapy for early-stage grade I-II follicular lymphoma from the SEER database (2000-2015). Leuk Lymphoma 2024; 65:312-322. [PMID: 37987687 DOI: 10.1080/10428194.2023.2283296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 09/07/2023] [Indexed: 11/22/2023]
Abstract
The aim of this study was to investigate the effect of age on long-term mortality and net survival benefit of radiotherapy (RT) for early-stage grade I-II FL. Five thousand three hundred and five patients with early-stage grade I-II FL in the SEER database (2000-2015) were identified. Primary therapy included RT alone (RT, 20.7%), chemotherapy alone (CT, 27.6%), combined modality therapy (CMT, 5.9%), and observation (45.8%). Inverse probability of treatment weighting (IPTW) was conducted to balance the treatment arms. Relative survival (RS), the standardized mortality ratio (SMR), and transformed Cox regression were used to compare survival differences between treatments. RT with or without CT had significantly higher 10-year OS (approximately 78%) and RS (>95%), but lower SMR (1.47-1.76), compared with CT (67.8%; 86.3%; 2.35; ps < .001), observation (70.2%; 91.2%; 1.82; ps < .05). RT was an independent predictor of better OS and RS in multivariate analyses (p < .001). No significant interaction between age and RT was identified for RS (Pinteraction = .509) or OS (Pinteraction = .769), indicating similar survival benefits across all-ages patients. RT was associated with long-term OS and net survival benefits in patients with early-stage grade I-II FL, irrespective of age.HighlightsThe pattern and incidence of mortality varied by age-group as elderly patients often die of other diseases other than FL beyond 5 years.Radiotherapy was associated with higher long-term OS/RS and better SMR compared with other approaches, regardless of age.
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Affiliation(s)
- Qiuzi Zhong
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Ye Liu
- Peking University Fifth School of Clinical Medicine, Beijing, PR China
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, PR China
| | - Yunpeng Wu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Xin Liu
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Siye Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Bo Chen
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Fei Su
- Institute of Geriatric Medicine, Clinical Biobank, Beijing Hospital, National Center of Gerontology, National Health Commission, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Gaofeng Li
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Yonggang Xu
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Lipin Liu
- Department of Radiation Oncology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, PR China
| | - Fan Chen
- Affiliated Hospital of Qinghai University, Qinghai, PR China
| | - Shunan Qi
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
| | - Yexiong Li
- Department of Radiation Oncology, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), Beijing, PR China
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3
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Peters A, Keating MM, Nikonova A, Doucette S, Prica A. Management of Marginal Zone Lymphoma: A Canadian Perspective. Curr Oncol 2023; 30:1745-1759. [PMID: 36826096 PMCID: PMC9955247 DOI: 10.3390/curroncol30020135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 01/25/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Marginal zone lymphomas (MZL) are a rare, heterogenous group of lymphomas, accounting for 5-17% of indolent non-Hodgkin lymphomas in the western world. They can be further divided into three subtypes: extranodal MZL, splenic MZL, and nodal MZL. These subtypes differ in clinical presentation and behavior, which influences how they are managed. There is currently no standard of care for the treatment of MZL, owing to the difficulty in conducting phase 3 randomized trials in MZL, and the fact that there are limited data on the efficacy of therapy in individual subtypes. Treatment practices are thus largely borrowed from other indolent lymphomas and are based on patient and disease characteristics, as well as access to therapy. This review summarizes the Canadian treatment landscape for MZL and how these therapies may be sequenced in practice.
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Affiliation(s)
- Anthea Peters
- Department of Oncology, Cross Cancer Institute, University of Alberta, Edmonton, AB T6G 1Z2, Canada
- Correspondence:
| | - Mary-Margaret Keating
- Division of Hematology, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, NS B3H 2Y9, Canada
| | - Anna Nikonova
- Division of Hematology, McGill University Health Centre, Montreal, QC H4A 3J1, Canada
| | | | - Anca Prica
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, ON M5G 2C1, Canada
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4
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Mustafa Ali MK, Samhouri Y, Law JY, Khan C, Wegner R, Lee ST, Lister J. Patterns of treatment and their outcomes in primary breast lymphoma; a comprehensive population-based analysis. Breast Cancer 2022; 29:1022-1031. [PMID: 35788963 DOI: 10.1007/s12282-022-01382-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary breast lymphoma (PBL) is managed differently among centers, using surgery, systemic therapy and/or radiation. With data derived from the National Cancer Database (NCDB), we aim to describe treatments utilized in the United States, estimate the overall survival (OS) of different therapeutic modalities and determine the role of systemic therapy in patients with PBL. METHODS We conducted a retrospective cohort study using de-identified data from the NCDB. The NCDB provided records of 4616 patients diagnosed with PBL between 2004 and 2015. We excluded patients diagnosed with HIV, with no survival data, not treated in the reporting facility, without histologic confirmation, with stage III/ IV disease and for whom surgery, radiation, or systemic therapy was contraindicated. Both propensity score weighting and Cox models were used to obtain adjusted estimates. Based on histopathology, PBL was classified into indolent (I-PBL) and aggressive (A-PBL). RESULTS In a sample size of 2063 PBL patients, the median age was 67 years (interquartile range (IQR): 57-78), and 97% were females. In 1027 patients with I-PBL, the median follow-up was 66 months (95% confidence interval (CI): 32.6-107.2) and 60% of patients had extranodal marginal zone subtype. Systemic therapy did not improve adjusted-OS (median: 154 vs. 143 months, P = 0.36) (Hazard ratio (HR): 0.86, 95% CI: 0.60-1.25, P = 0.42). The treatment arms associated with the highest adjusted 5-year OS were as follows: radiation (85%), surgery (79%), systemic & radiation (87%) and radiation & surgery (87%) (P = 0.9). In 1036 patients with A-PBL, the median follow-up was 67.4 months (95% CI: 35.9-105), and 87% of patients had diffuse large B-cell subtype. Patients with A-PBL who received systemic therapy had an improved adjusted-OS (median: 115 vs. 72 months, P < 0.01) (HR: 0.45, 95% CI: 0.38-0.53, P < 0.001). The treatment arms associated with the highest adjusted 5-year OS were: systemic (69%), systemic & radiation (77%), systemic & radiation & surgery (79%) and systemic & surgery (79%) (P = 0.4). CONCLUSIONS Systemic therapy used as first-line treatment is essential in A-PBL. Local therapy in the I-PBL using surgery and/or radiation is effective in long-term disease control. There is significant variation in front-line treatment modalities utilized in PBL across the US, many associated with similar outcomes.
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Affiliation(s)
- Moaath K Mustafa Ali
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, 21201, USA.
| | - Yazan Samhouri
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Jennie Y Law
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - Cyrus Khan
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Rodney Wegner
- Division of Radiation Oncology, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
| | - Seung Tae Lee
- Marlene and Stewart Greenebaum Comprehensive Cancer Center, University of Maryland Medical Center, 22 South Greene Street, Baltimore, MD, 21201, USA
| | - John Lister
- Division of Hematology and Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA, USA
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5
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Jeong SH. Treatment of indolent lymphoma. Blood Res 2022; 57:120-129. [PMID: 35483936 PMCID: PMC9057664 DOI: 10.5045/br.2022.2022054] [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: 03/01/2022] [Revised: 04/08/2022] [Accepted: 04/21/2022] [Indexed: 11/18/2022] Open
Abstract
Treatment of indolent lymphoma has improved significantly in recent decades since the advent of rituximab (anti-CD20 monoclonal antibody). Although, some patients with limited disease can be cured with radiation therapy alone, most patients experience disease progression and recurrence during follow-up despite early initiation of treatment. Thus, watch-and-wait is still regarded the standard for asymptomatic patients. Patients with indolent lymphoma have a significant heterogeneity in terms of tumor burden, symptoms (according to anatomical sites) and the need for instant therapy. Therefore, the initiation of treatment and treatment option should be decided with a clear goal in each patient according to the need for therapy and clinical benefits with the chosen treatment. In this review, we cover the current treatment of follicular lymphoma and marginal zone lymphoma.
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Affiliation(s)
- Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon, Korea
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6
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Hadi I, Schummer A, Dreyling M, Eze C, Bodensohn R, Roengvoraphoj O, Belka C, Li M. Effectiveness and tolerability of radiotherapy for patients with indolent non-Hodgkin's lymphoma: a monocenter analysis. Sci Rep 2021; 11:22586. [PMID: 34799601 PMCID: PMC8604980 DOI: 10.1038/s41598-021-01851-w] [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: 04/01/2021] [Accepted: 10/26/2021] [Indexed: 12/30/2022] Open
Abstract
To analyze the effectiveness and toxicities of radiotherapy in indolent non-Hodgkin's lymphoma (iNHL) patients treated in our institution. Patients with iNHL treated with radiotherapy between 1999 and 2016 were included. The primary endpoint was progression-free survival (PFS). Secondary endpoints were local control (LC), overall survival (OS) and toxicities. PFS, LC, and OS were analyzed using Kaplan-Meier method. Log-rank test was used to investigate the differences between subgroups. Cox proportional hazard model was used for univariate continuous analysis. Seventy-five patients were identified in our institutional database between 1999 and 2016. Fifty-eight (77.3%) had stage I after Ann-Arbor and 17 patients (22.7%) had stage II. The median follow-up was 87 months (95% CI 72-102 months). Median single dose per fraction was 2.0 Gy (range 1.5-2 Gy) and median total dose was 30.6 Gy (range 16-45 Gy). Radiotherapy was performed in 2D (n = 10; 13.3%), 3D (n = 63; 84.0%) and VMAT (n = 2; 2.7%) techniques, respectively. The median PFS was 14.0 years (95% CI 8.3-19.7 years). The estimated PFS after 5 and 10 years were 73.0% and 65.5% in Kaplan-Meier analysis, respectively. The 5- and 10-year LC were 94.9% and 92.3%, respectively. The 5- and 10-year OS were 88.6% and 73.9%. In univariate analyses of PFS, younger patients (≤ 60 years old) had significantly superior PFS to those older than 60 years old (5-year PFS 81.9% vs. 65.1%, p = 0.021). Dose escalation > 36.0 Gy had no prognostic influence in term of PFS (p = 0.425). Extranodal involvement, stage and histology had no prognostic impact on PFS. Depending on the site of lymphomas, the most common acute side effects were: dermatitis CTCAE° I-II (8.0%), xerostomia CTC° I (8.0%), cataract CTC° I (12.0%) and dry eyes CTC° I-II (14.6%). No adverse event CTC° III was reported. Most acute side effects recovered at 3 to 6 months after radiotherapy except for CTC° I cataract and xerostomia. Local Radiotherapy was highly effective for treatment of early stage iNHL with no serious side effects in our cohort. The most acute CTCAE° I-II side effects recovered 3 to 6 months later. Technique advances seem to have further improved effectiveness and tolerability of radiotherapy.Trial registration: Local ethics committee of Ludwig-Maximilian-University (LMU) Munich approved this retrospective analysis on the May 7th, 2019 (Nr. 19-137).
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Affiliation(s)
- I Hadi
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - A Schummer
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - M Dreyling
- Department of Internal Medicine III - Oncology, University Hospital, LMU Munich, Munich, Germany
| | - C Eze
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | - R Bodensohn
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany
| | | | - C Belka
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany.,German Cancer Consortium DKTK, Munich, Germany
| | - M Li
- Department of Radiation Oncology, University Hospital, LMU Munich, 81377, Munich, Germany.
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7
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Lo AC, James LP, Prica A, Raymakers A, Peacock S, Qu M, Louie AV, Savage KJ, Sehn L, Hodgson D, Yang JC, Eich HTT, Wirth A, Hunink MGM. Positron-emission tomography-based staging is cost-effective in early-stage follicular lymphoma. J Nucl Med 2021; 63:543-548. [PMID: 34413148 PMCID: PMC8973292 DOI: 10.2967/jnumed.121.262324] [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: 03/25/2021] [Revised: 07/15/2021] [Indexed: 11/17/2022] Open
Abstract
The objective was to assess the cost-effectiveness of staging PET/CT in early-stage follicular lymphoma (FL) from the Canadian health-care system perspective. Methods: The study population was FL patients staged as early-stage using conventional CT imaging and planned for curative-intent radiation therapy (RT). A decision analytic model simulated the management after adding staging PET/CT versus using staging CT alone. In the no-PET/CT strategy, all patients proceeded to curative-intent RT as planned. In the PET/CT strategy, PET/CT information could result in an increased RT volume, switching to a noncurative approach, or no change in RT treatment as planned. The subsequent disease course was described using a state-transition cohort model over a 30-y time horizon. Diagnostic characteristics, probabilities, utilities, and costs were derived from the literature. Baseline analysis was performed using quality-adjusted life years (QALYs), costs (2019 Canadian dollars), and the incremental cost-effectiveness ratio. Deterministic sensitivity analyses were conducted, evaluating net monetary benefit at a willingness-to-pay threshold of $100,000/QALY. Probabilistic sensitivity analysis using 10,000 simulations was performed. Costs and QALYs were discounted at a rate of 1.5%. Results: In the reference case scenario, staging PET/CT was the dominant strategy, resulting in an average lifetime cost saving of $3,165 and a gain of 0.32 QALYs. In deterministic sensitivity analyses, the PET/CT strategy remained the preferred strategy for all scenarios supported by available data. In probabilistic sensitivity analysis, the PET/CT strategy was strongly dominant in 77% of simulations (i.e., reduced cost and increased QALYs) and was cost-effective in 89% of simulations (i.e., either saved costs or had an incremental cost-effectiveness ratio below $100,000/QALY). Conclusion: Our analysis showed that the use of PET/CT to stage early-stage FL patients reduces cost and improves QALYs. Patients with early-stage FL should undergo PET/CT before curative-intent RT.
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Affiliation(s)
| | | | | | | | | | - Melody Qu
- London Health Sciences Centre, Canada
| | | | | | | | | | - Joanna C Yang
- University of California, San Francisco, United States
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8
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Tobin JWD, Crothers A, Ma TE, Mollee P, Gandhi MK, Scuffham P, Hapgood G. A cost-effectiveness analysis of front-line treatment strategies in early-stage follicular lymphoma. Leuk Lymphoma 2021; 62:3484-3492. [PMID: 34323129 DOI: 10.1080/10428194.2021.1957866] [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: 10/20/2022]
Abstract
Recent data suggest the use of radiotherapy alone (RT) in Early-Stage Follicular Lymphoma is declining. Cost-effectiveness analysis of treatments has not been performed. We constructed a partitioning model (15-year horizon) to compare RT, combined-modality therapy (CMT) and immunochemotherapy with rituximab maintenance (ICT + RM) from a PET-staged cohort from the Australian Lymphoma Alliance. Lifetime direct health care costs, quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) were calculated. AUD $75,000 was defined as the willingness-to-pay threshold (WTP). The direct healthcare costs were: RT $12,791, CMT $29,391 and ICT + RM $42,644. Compared with RT, CMT demonstrated minimal improvement in QALYs (+0.01) and an ICER well above the WTP threshold ($1,535,488). Compared with RT, ICT + RM demonstrated an improvement in QALYs (+0.41) with an ICER of $73,319. Modeling a 25% cost reduction with a rituximab biosimilar led to further ICER reductions with ICT + RM ($52,476). ICT + RM is cost-effective in early-stage FL from the Australian taxpayer perspective.
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Affiliation(s)
- Joshua W D Tobin
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Anna Crothers
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Ti Eric Ma
- Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Peter Mollee
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Maher K Gandhi
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Paul Scuffham
- Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia
| | - Greg Hapgood
- Department of Haematology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Department of Medicine, University of Queensland, Brisbane, Queensland, Australia
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9
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Abstract
Radiotherapy (RT) plays a diverse and essential role in the contemporary management of non-Hodgkin lymphoma (NHL) and remains the single most powerful monotherapeutic intervention for both aggressive and indolent subtypes. Over the past decade, there have been significant advancements in radiation oncology practice, which have made modern treatments safer and more conformal. Despite this sophistication and evidence supporting a continued role for RT, numerous data suggest that utilization is on the decline. In this review, we discuss the rationale for RT in 4 commonly encountered scenarios: combined modality therapy for limited-stage aggressive NHL, consolidation therapy for advanced-stage aggressive NHL, and the changing roles of salvage RT for relapsed/refractory NHL in an era of new frontiers such as cellular therapies. We also evaluate current strategies to treat indolent histologies. We conclude with perspectives on how RT for the hematological malignancies may continue to evolve.
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10
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Girard J, Karimi Y, Carty S, Wilcox R, Kaminiski M, Malek S, Phillips T. Targeted Therapies for Follicular Lymphoma. Curr Hematol Malig Rep 2021; 16:25-31. [PMID: 33754292 DOI: 10.1007/s11899-021-00614-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2021] [Indexed: 11/28/2022]
Abstract
Follicular lymphoma (FL) is the 2nd most common lymphoma in the USA/Western Europe. While incurable, the majority of patients are able to survive at least a decade with this disease. Response duration though varies, and subset of patients will relapse within 24 months of initial therapy (POD24). These patients have shortened survival compared to those who achieve more durable responses. Treatment interventions for patients are varied and include observation, radiation, or systemic therapies. Treatment outcomes have improved considerably over the last several decades with the introduction of new agents such as the CD 20 antibody rituximab and more recently with the advent of more targeted therapy. Most of the newer agents work differently from cytotoxic chemotherapy and either inhibit tumor-specific mutations, survival pathways, or harness the immune systems. While outcomes with traditional cytotoxic agents have been historically poor in certain subtypes such as POD24 and rituximab refractory disease, the reported outcomes with the newer agents have been encouraging as evident by several new drug approvals in FL. The biggest impact has been in the relapsed/refractory setting where we have approval of the immunomodulatory agent lenalidomide given in combination with rituximab. Based on the AUGMENT study, this agent has been approved for patients with R/R FL after one previous line of therapy. The EZH2 inhibitor, tazemetostat, was approved recently for patients with a known EZH2 mutation after one prior line of therapy or for FL patients who are deemed intolerant to other agents given the impressive safety profile in all patients. Finally, there is a plethora of agents that are designed to harness the immune system to combat this lymphoma. The data for these agents is still very early but nonetheless very impressive. In summary, FL is an incurable lymphoma without any standard of care options but has numerous treatments that have demonstrated some degree of efficacy. Recently we have made enormous strides in the understanding of some of the biological drivers of this disease which has allowed for refinement of treatment options. Moving forward, I would anticipate that we will continue to explore the use of agents that target specific mutations or utilize the immune system to hopefully one day achieve a cure.
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Affiliation(s)
- Jennifer Girard
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Yasmin Karimi
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Shannon Carty
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Ryan Wilcox
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Mark Kaminiski
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Sami Malek
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA
| | - Tycel Phillips
- Rogel Cancer Center, University of Michigan, Ann Arbor, MI, 48130, USA.
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11
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Lumish M, Falchi L, Imber BS, Scordo M, von Keudell G, Joffe E. How we treat mature B-cell neoplasms (indolent B-cell lymphomas). J Hematol Oncol 2021; 14:5. [PMID: 33407745 PMCID: PMC7789477 DOI: 10.1186/s13045-020-01018-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 12/02/2020] [Indexed: 12/30/2022] Open
Abstract
Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.
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Affiliation(s)
- Melissa Lumish
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Lorenzo Falchi
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Brandon S Imber
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Michael Scordo
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Gottfried von Keudell
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA
| | - Erel Joffe
- Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, SR-441B, New York, NY, 10065, USA.
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Cencini E, Fabbri A, Mecacci B, Bocchia M. How to manage early-stage follicular lymphoma. Expert Rev Hematol 2020; 13:1093-1105. [PMID: 32869685 DOI: 10.1080/17474086.2020.1818226] [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: 10/23/2022]
Abstract
INTRODUCTION Early-stage follicular lymphoma (FL) is characterized by good prognosis and can be cured with involved-field radiotherapy (IF-RT) in most cases. PET scan is a milestone of diagnostic work-up, with the aim of identifying a truly localized disease; however, staging in most of the studies was without PET. AREAS COVERED We have searched in MEDLINE (inclusive dates 1994-2020) data about localized FL management. While high-quality evidence is lacking, current guidelines recommend IFRT or involved-site RT as first-line treatment in limited stages FL. Since a significant proportion of disease relapse occurred in non-irradiated areas, it has been hypothesized that occult disease could be present at diagnosis and could persist after RT, contributing to relapse. Available treatment options include watch-and-wait, chemotherapy, RT plus chemo- or chemo-immunotherapy, and RT combined with rituximab (R). EXPERT OPINION RT combined with chemotherapy could increase PFS, but a clear OS benefit is lacking and toxic effects could be unacceptable. A promising strategy is represented by R combined with IF-RT, with low relapse rate outside the radiation fields and without the toxicity reported with chemotherapy. The study of prognostic factors in PET-staged patients, the reduction of RT fields and doses, and a response-adapted strategy represent new perspectives to investigate.
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Affiliation(s)
- Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena, Italy
| | - Alberto Fabbri
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena, Italy
| | - Bianca Mecacci
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena, Italy
| | - Monica Bocchia
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena, Italy
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Wirth A, Mikhaeel NG, Aleman BM, Pinnix CC, Constine LS, Ricardi U, Illidge TM, Eich HT, Hoppe BS, Dabaja B, Ng AK, Kirova Y, Berthelsen AK, Dieckmann K, Yahalom J, Specht L. Involved Site Radiation Therapy in Adult Lymphomas: An Overview of International Lymphoma Radiation Oncology Group Guidelines. Int J Radiat Oncol Biol Phys 2020; 107:909-933. [DOI: 10.1016/j.ijrobp.2020.03.019] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/11/2020] [Indexed: 12/15/2022]
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Romancik JT, Cohen JB. Is Limited-Stage Mantle Cell Lymphoma Curable and How Is It Best Managed? Hematol Oncol Clin North Am 2020; 34:849-859. [PMID: 32861282 DOI: 10.1016/j.hoc.2020.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Limited-stage (stage I-II) mantle cell lymphoma (MCL) is rarely encountered. There is no standard approach to treatment and available data to guide management decisions mainly are retrospective studies. A thorough staging evaluation, including positron emission tomography/computed tomography, bone marrow biopsy, and gastrointestinal evaluation, should be completed because disseminated disease is common. Radiation therapy is effective for local control, and, although prolonged remission can be achieved, distant relapses are common and there are insufficient data to say that patients can be cured using this treatment. This article reviews literature pertaining to management of patients with limited-stage MCL and discusses approach to treatment.
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Affiliation(s)
- Jason T Romancik
- Department of Hematology and Medical Oncology, Emory University - Winship Cancer Institute, 1365C Clifton Road, Northeast, Suite B4000D, Atlanta, GA 30322, USA
| | - Jonathon B Cohen
- Department of Hematology and Medical Oncology, Emory University - Winship Cancer Institute, 1365C Clifton Road, Northeast, Suite B4000D, Atlanta, GA 30322, USA.
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15
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Bordes J, Incerti S, Mora-Ramirez E, Tranel J, Rossi C, Bezombes C, Bordenave J, Bardiès M, Brown R, Bordage MC. Monte Carlo dosimetry of a realistic multicellular model of follicular lymphoma in a context of radioimmunotherapy. Med Phys 2020; 47:5222-5234. [PMID: 32623743 DOI: 10.1002/mp.14370] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 04/20/2020] [Accepted: 06/15/2020] [Indexed: 12/31/2022] Open
Abstract
PURPOSE Small-scale dosimetry studies generally consider an artificial environment where the tumors are spherical and the radionuclides are homogeneously biodistributed. However, tumor shapes are irregular and radiopharmaceutical biodistributions are heterogeneous, impacting the energy deposition in targeted radionuclide therapy. To bring realism, we developed a dosimetric methodology based on a three-dimensional in vitro model of follicular lymphoma incubated with rituximab, an anti-CD20 monoclonal antibody used in the treatment of non-Hodgkin lymphomas, which might be combined with a radionuclide. The effects of the realistic geometry and biodistribution on the absorbed dose were highlighted by comparison with literature data. Additionally, to illustrate the possibilities of this methodology, the effect of different radionuclides on the absorbed dose distribution delivered to the in vitro tumor were compared. METHODS The starting point was a model named multicellular aggregates of lymphoma cells (MALC). Three MALCs of different dimensions and their rituximab biodistribution were considered. Geometry, antibody location and concentration were extracted from selective plane illumination microscopy. Assuming antibody radiolabeling with Auger electron (125 I and 111 In) and β- particle emitters (177 Lu, 131 I and 90 Y), we simulated energy deposition in MALCs using two Monte Carlo codes: Geant4-DNA with "CPA100" physics models for Auger electron emitters and Geant4 with "Livermore" physics models for β- particle emitters. RESULTS MALCs had ellipsoid-like shapes with major radii, r, of ~0.25, ~0.5 and ~1.3 mm. Rituximab was concentrated in the periphery of the MALCs. The absorbed doses delivered by 177 Lu, 131 I and 90 Y in MALCs were compared with literature data for spheres with two types of homogeneous biodistributions (on the surface or throughout the volume). Compared to the MALCs, the mean absorbed doses delivered in spheres with surface biodistributions were between 18% and 38% lower, while with volume biodistribution they were between 15% and 29% higher. Regarding the radionuclides comparison, the relationship between MALC dimensions, rituximab biodistribution and energy released per decay impacted the absorbed doses. Despite releasing less energy, 125 I delivered a greater absorbed dose per decay than 111 In in the r ~ 0.25 mm MALC (6.78·10-2 vs 6.26·10-2 µGy·Bq-1 ·s-1 ). Similarly, the absorbed doses per decay in the r ~ 0.5 mm MALC for 177 Lu (2.41·10-2 µGy·Bq-1 ·s-1 ) and 131 I (2.46·10-2 µGy·Bq-1 ·s-1 ) are higher than for 90 Y (1.98·10-2 µGy·Bq-1 ·s-1 ). Furthermore, radionuclides releasing more energy per decay delivered absorbed dose more uniformly through the MALCs. Finally, when considering the radiopharmaceutical effective half-life, due to the biological half-life of rituximab being best matched by the physical half-life of 177 Lu and 131 I compared to 90 Y, the first two radionuclides delivered higher absorbed doses. CONCLUSION In the simulated configurations, β- emitters delivered higher and more uniform absorbed dose than Auger electron emitters. When considering radiopharmaceutical half-lives, 177 Lu and 131 I delivered absorbed doses higher than 90 Y. In view of real irradiation of MALCs, such a work may be useful to select suited radionuclides and to help explain the biological effects.
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Affiliation(s)
- Julien Bordes
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France
| | - Sébastien Incerti
- Université de Bordeaux, CENBG, UMR 5797, Gradignan, F-33170, France.,CNRS, IN2P3, CENBG, UMR 5797, Gradignan, F-33170, France
| | - Erick Mora-Ramirez
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France.,Escuela de Física, CICANUM, Universidad de Costa Rica, San José, 11501-2060, Costa Rica
| | - Jonathan Tranel
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France.,Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, 94143, USA
| | - Cédric Rossi
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France.,CHU Dijon, Hématologie Clinique, Hôpital François Mitterand, Dijon, 21000, France
| | - Christine Bezombes
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France
| | - Julie Bordenave
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France
| | - Manuel Bardiès
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France
| | - Richard Brown
- Institute of Nuclear Medicine, University College London, 235 Euston Road, London, NW1 2BU, UK
| | - Marie-Claude Bordage
- CRCT, UMR 1037 INSERM, Université Paul Sabatier, Toulouse, F-31037, France.,UMR 1037, CRCT, Université Toulouse III-Paul Sabatier, Toulouse, F-31037, France
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McNamara C, Montoto S, Eyre TA, Ardeshna K, Burton C, Illidge T, Linton K, Rule S, Townsend W, Wong WL, McKay P. The investigation and management of follicular lymphoma. Br J Haematol 2020; 191:363-381. [PMID: 32579717 DOI: 10.1111/bjh.16872] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
| | - Silvia Montoto
- St Bartholomew’s and The Royal London NHS Trust London UK
| | - Toby A. Eyre
- Department of Clinical Haematology Oxford University Hospitals NHS Foundation Trust Oxford UK
| | - Kirit Ardeshna
- Department of Haematology University College London Hospital LondonUK
| | - Cathy Burton
- Department of Haematology Leeds Cancer Centre Leeds UK
| | - Tim Illidge
- Institute of Cancer Sciences the Christie NHS Foundation Trust University of Manchester Manchester UK
| | - Kim Linton
- Department of Medical Oncology The Christie Hospital NHS Trust Manchester UK
| | - Simon Rule
- Department of Haematology University of Plymouth Medical School Plymouth UK
| | - William Townsend
- Department of Haematology University College London Hospital LondonUK
| | - Wai L. Wong
- Paul Strickland Scanner Centre Mount Vernon Hospital Northwood UK
| | - Pam McKay
- Department of Haematology Beatson West of Scotland Cancer Centre Glasgow Scotland UK
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17
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König L, Herfarth K, Hörner-Rieber J, Dietrich S, Wiegel T, Debus J, Viardot A. Oncological outcome and recurrence pattern analysis after involved-field irradiation in combination with rituximab for early-stage nodal and extranodal follicular lymphoma. Strahlenther Onkol 2020; 196:705-714. [PMID: 32377821 PMCID: PMC7385027 DOI: 10.1007/s00066-020-01624-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
Purpose Combined radioimmunotherapy (RIT) in follicular lymphomas (FL) has shown promising treatment efficacy in the Mabthera® and Involved field Radiation (MIR) study. Aim of this study was to analyze treatment efficacy and recurrence patterns after RIT in early-stage nodal and extranodal FL. Methods We reviewed 107 patients who were treated with combined RIT in two centers. Treatment consisted of 4 × rituximab followed by RIT with 4 × rituximab and involved field (IF) radiotherapy with 30/40 Gy. Median follow-up period was 71 months. In contrast to the MIR study, extranodal involvement and grade 3A histology were included in the analysis. Results Extranodal involvement and grade 3A histology were present in 21.8% and 13.1%, respectively. Overall response rate (ORR) after 4 × rituximab, after completion of RIT, and after 6 months was 78.1%, 98.8%, and 98.8%, respectively, with increasing rates of complete remissions (CR). Predictive factors associated with superior PFS were tumor size, completely excised lymphomas, and response to first 4 × rituximab. 5‑year PFS rate was 87.3%, with mostly outfield recurrences (94.1%). Second-line treatment was effective, with 53.3% CR and 46.7% partial remissions (PR). 5‑year OS was 98.1%. RIT was tolerated well, with mainly grade 1–2 acute side effects. Conclusion The real-world efficacy of RIT is comparable with the results of the MIR study. Additionally, this analysis shows that extranodal involvement and grade 3A histology are not associated with inferior PFS.
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Affiliation(s)
- Laila König
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany.
- National Center for Tumor diseases (NCT), Heidelberg, Germany.
| | - Klaus Herfarth
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
| | - Juliane Hörner-Rieber
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
| | - Sascha Dietrich
- Department of Internal Medicine V, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Wiegel
- Department of Radiation Oncology, University Hospital Ulm, Ulm, Germany
| | - Jürgen Debus
- Department of Radiation Oncology, University Hospital Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Heidelberg Institute of Radiation Oncology (HIRO), Heidelberg, Germany
- National Center for Tumor diseases (NCT), Heidelberg, Germany
| | - Andreas Viardot
- Department of Internal Medicine III, University Hospital Ulm, Ulm, Germany
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18
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Carbone A, Roulland S, Gloghini A, Younes A, von Keudell G, López-Guillermo A, Fitzgibbon J. Follicular lymphoma. Nat Rev Dis Primers 2019; 5:83. [PMID: 31831752 DOI: 10.1038/s41572-019-0132-x] [Citation(s) in RCA: 134] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/29/2019] [Indexed: 12/12/2022]
Abstract
Follicular lymphoma (FL) is a systemic neoplasm of the lymphoid tissue displaying germinal centre (GC) B cell differentiation. FL represents ~5% of all haematological neoplasms and ~20-25% of all new non-Hodgkin lymphoma diagnoses in western countries. Tumorigenesis starts in precursor B cells and becomes full-blown tumour when the cells reach the GC maturation step. FL is preceded by an asymptomatic preclinical phase in which premalignant B cells carrying a t(14;18) chromosomal translocation accumulate additional genetic alterations, although not all of these cells progress to the tumour phase. FL is an indolent lymphoma with largely favourable outcomes, although a fraction of patients is at risk of disease progression and adverse outcomes. Outcomes for FL in the rituximab era are encouraging, with ~80% of patients having an overall survival of >10 years. Patients with relapsed FL have a wide range of treatment options, including several chemoimmunotherapy regimens, phosphoinositide 3-kinase inhibitors, and lenalidomide plus rituximab. Promising new treatment approaches include epigenetic therapeutics and immune approaches such as chimeric antigen receptor T cell therapy. The identification of patients at high risk who require alternative therapies to the current standard of care is a growing need that will help direct clinical trial research. This Primer discusses the epidemiology of FL, its molecular and cellular pathogenesis and its diagnosis, classification and treatment.
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Affiliation(s)
- Antonino Carbone
- Centro di Riferimento Oncologico di Aviano IRCCS, Aviano, Italy.
| | - Sandrine Roulland
- Aix Marseille University, CNRS, INSERM, Centre d'Immunologie de Marseille-Luminy, Marseille, France
| | - Annunziata Gloghini
- Department of Diagnostic Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale Tumori, Milan, Italy
| | - Anas Younes
- Lymphoma Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | | | - Jude Fitzgibbon
- Barts Cancer Institute, Queen Mary University of London, London, UK
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19
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Campbell BA, Plastaras JP, Savage KJ. Keeping Our Finger on the Pulse: Reaffirming the Role of Radiation Therapy in the Curative Management of Early Stage Follicular Lymphoma. Int J Radiat Oncol Biol Phys 2019; 105:459-465. [DOI: 10.1016/j.ijrobp.2019.06.2505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 06/04/2019] [Accepted: 06/08/2019] [Indexed: 11/25/2022]
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20
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Andraos TY, Ayoub Z, Nastoupil LJ, Milgrom SA, Pinnix CC, Ng SP, Gunther JR, Fowler NH, Neelapu SS, Samaniego F, Fayad LE, Dabaja BS. Additional therapy improves outcomes in completely resected, limited-stage follicular lymphoma. Leuk Lymphoma 2019; 60:3258-3265. [PMID: 31234671 DOI: 10.1080/10428194.2019.1627535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Patients with early-stage nodal follicular lymphoma (FL) may be rendered free of detectable disease by a diagnostic excisional biopsy. We reviewed the management and outcomes of 48 patients with FL, diagnosed from 2003-2013, treated at a single institution. The primary endpoints were local control (LC) and progression-free survival (PFS).Median age at diagnosis was 54.5 years (range 15-74 years). Forty-seven patients were stage I (97.9%); 15 patients (31.3%) had grade 3 disease. Initial management consisted of observation (12 patients; 25.0%), radiation therapy (RT) alone (12 patients; 25.0%), systemic therapy alone (9 cases; 18.8%), or both (15 patients; 31.3%). Median follow-up was 4.92 years (range 0.5-13.83 years). 4-year PFS and OS were 80.9% and 97.1%, respectively. Patients treated with additional therapy experienced significantly better 4-year LC (100% vs. 81.8%; p = .012) and 4-year PFS (86.7% vs. 63.6%; p = .006).Patients with completely resected limited-stage FL would benefit from therapy beyond excisional biopsy alone.
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Affiliation(s)
- Therese Y Andraos
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zeina Ayoub
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Loretta J Nastoupil
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sarah A Milgrom
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chelsea C Pinnix
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sweet Ping Ng
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jillian R Gunther
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Nathan H Fowler
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sattva S Neelapu
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Felipe Samaniego
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis E Fayad
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.,Department of Lymphoma, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bouthaina S Dabaja
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Abstract
Duodenal-type follicular lymphoma (D-FL) is a newly recognized entity in the 2016 World Health Organization classification update. It has an immunophenotype similar to that of other FLs and usually carries the typical t(14;18)(q32;q21) translocation. However, unlike other FLs, D-FL is almost always diagnosed at a low stage and stays localized to the small intestine, most commonly the second portion of the duodenum, whereas the vast majority of other FLs are diagnosed at an advanced stage. Additionally, D-FL gene expression and pathogenesis appear to be more closely related to extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue than to other types of FL. Therefore, many oncologists have opted to treat this variant of FL in a "watch and wait" manner because of its excellent prognosis and the rarity of D-FL to progress even when no treatments are attempted.
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Affiliation(s)
| | - Yang Shi
- From the Department of Pathology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, New York
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22
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Definitive radiotherapy for localized follicular lymphoma staged by 18F-FDG PET-CT: a collaborative study by ILROG. Blood 2018; 133:237-245. [PMID: 30446493 DOI: 10.1182/blood-2018-04-843540] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 10/31/2018] [Indexed: 12/12/2022] Open
Abstract
Radiotherapy (RT) can be curative in patients with localized follicular lymphoma (FL), with historical series showing a 10-year disease-free survival of 40 to 50%. As 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography with computerized tomography (PET-CT) upstages 10 to 60% of patients compared to CT, we sought to evaluate outcomes in patients staged by PET-CT, to determine if more accurate staging leads to better patient selection and results. We conducted a multicenter retrospective study under the direction of the International Lymphoma Radiation Oncology Group (ILROG). Inclusion criteria were: RT alone for untreated stage I to II FL (grade 1-3A) with dose equivalent ≥24 Gy, staged by PET-CT, age ≥18 years, and follow-up ≥3 months. End points were freedom from progression (FFP), local control, and overall survival (OS). A total of 512 patients treated between 2000 and 2017 at 16 centers were eligible for analysis; median age was 58 years (range, 20-90); 410 patients (80.1%) had stage I disease; median RT dose was 30 Gy (24-52); and median follow-up was 52 months (3.2-174.6). Five-year FFP and OS were 68.9% and 95.7%. For stage I, FFP was 74.1% vs 49.1% for stage II (P < .0001). Eight patients relapsed in-field (1.6%). Four had marginal recurrences (0.8%) resulting in local control rate of 97.6%. On multivariable analysis, stage II (hazard ratio [HR], 2.11; 95% confidence interval [CI], 1.44-3.10) and BCL2 expression (HR, 1.62; 95% CI, 1.07-2.47) were significantly associated with less favorable FFP. Outcome after RT in PET-CT staged patients appears to be better than in earlier series, particularly in stage I disease, suggesting that the curative potential of RT for truly localized FL has been underestimated.
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Gonzalez-Lugo JD, Kabarriti R, Mantzaris I. Osteoradionecrosis of the jaw in a patient with lymphoma treated with rituximab and concomitant involved field radiation therapy. Adv Radiat Oncol 2018; 3:701-704. [PMID: 30370372 PMCID: PMC6200873 DOI: 10.1016/j.adro.2018.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/12/2018] [Accepted: 05/31/2018] [Indexed: 11/12/2022] Open
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Outcome of patients with early-stage follicular lymphoma staged with 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) and treated with radiotherapy alone. Eur J Nucl Med Mol Imaging 2018; 46:80-86. [PMID: 30083824 DOI: 10.1007/s00259-018-4112-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/26/2018] [Indexed: 01/02/2023]
Abstract
PURPOSE/OBJECTIVE(S) To evaluate the impact of positron emission tomography (PET) staging on overall survival (OS) and progression-free survival (PFS) in patients with early-stage (stages I and II) follicular lymphoma (ESFL) treated with radiation therapy alone. MATERIALS/METHODS Eighty-five patients with ESFL treated with curative-intent radiation therapy (RT) between December 2000 and May 2011 were identified. Of those, 13 who had no PET staging and 25 who received additional systemic therapy were excluded from the analysis. Thus, we analyzed 47 patients with PET-staged ESFL treated with definitive radiation therapy alone (dose > 23Gy). Tumour features, pre-treatment computed tomography (CT) and PET stage, dose fractionation, and radiation therapy field extent were recorded. The Kaplan-Meier method was used to estimate the OS and PFS. Patterns of failure were assessed as cumulative incidences assuming competing risks. RESULTS Median age was 57 years (range 24-83); 43% were females. Most were PET stage 1 (76.6%). Median maximum nodal diameter was 3 cm. Median pre-treatment lactate dehydrogenase (LDH) was 327.5 (range 123-607, upper normal limit = 220). Twenty-six patients (55.3%) had infra-diaphragmatic disease. All received 30-36Gy in 15-24 fractions, with 59.6% treated with involved-field radiation therapy (IFRT) techniques. There was no significant difference in PFS between CT stage I and stage II (HR 1.30 95% CI [0.25-6.72], p = 0.75) with a 5-year PFS of 77% and 78% respectively. However, stage I on PET staging had a significantly better PFS than stage II (HR 4.66 95% CI [1.15-18.8], p = 0.038), with 5-year PFS of 84% and 60% respectively. Ten patients had recurrent disease, with distant disease being the first site of failure in seven patients. Seven-year OS was 91% (95% CI 79-100) for the whole cohort. CONCLUSION FDG-PET should be considered an essential element in the evaluation of patients with ESFL being considered for RT.
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Spukti EU, Schmidt LH, Schulze A, Schliemann C, Görlich D, Wardelmann E, Hartmann W, Lenz G, Berdel WE, Kerkhoff A. 90 Y-ibritumomab-tiuxetan as a therapeutic alternative for follicular lymphoma (FL): A single-center experience. Eur J Haematol 2018; 101:514-521. [PMID: 29993147 DOI: 10.1111/ejh.13138] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/30/2018] [Accepted: 07/02/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Follicular lymphoma (FL) is the most frequent indolent lymphoma subtype in adults. Maintenance therapy with rituximab is frequently applied to FL patients with complete or partial response following initial chemoimmunotherapy. However, radioimmunotherapy with 90 Y-ibritumomab-tiuxetan represents a therapeutic alternative. METHODS To compare the clinical and the prognostic impact of both therapies, a study collective of n = 56 patients diagnosed with indolent B-cell lymphoma was retrospectively investigated. The study collective was subdivided into two groups: n = 36 patients treated with rituximab maintenance therapy vs n = 20 patients treated with 90 Y-ibritumomab-tiuxetan. RESULTS No prognostic differences for performance status, FLIPI score, gender, or B-symptoms were found for 90 Y-ibritumomab-tiuxetan or rituximab maintenance therapy. Overall survival rates and progression-free survival did not differ between both maintenance therapies. CONCLUSION Our retrospective single-center analysis of two patient groups without major differences in prognostic parameters revealed similar outcome with two different maintenance therapies. Hence, 90 Y-ibritumomab-tiuxetan therapy might offer a valuable alternative treatment option for FL patients with partial response. However, large prospective trials are needed to confirm the reported findings.
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Affiliation(s)
- Eva U Spukti
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Lars Henning Schmidt
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Arik Schulze
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Christoph Schliemann
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Dennis Görlich
- Institute of Biostatistics and Clinical Research, Westfaelische Wilhelms-Universitaet Muenster, Muenster, Germany
| | - Eva Wardelmann
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | - Wolfgang Hartmann
- Gerhard-Domagk-Institute of Pathology, University Hospital Muenster, Muenster, Germany
| | - Georg Lenz
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Wolfgang E Berdel
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
| | - Andrea Kerkhoff
- Department of Medicine A, Hematology, Oncology and Pulmonary Medicine, University Hospital Muenster, Muenster, Germany
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Pulsoni A, Cappelli LV, Ballotta L, Canichella M, Serrao A, Annechini G, D'Elia GM, Foà R. Current and future therapeutic approaches for the treatment of follicular lymphoma. Expert Rev Anticancer Ther 2018; 18:931-941. [PMID: 29972084 DOI: 10.1080/14737140.2018.1493926] [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: 10/28/2022]
Abstract
INTRODUCTION Recent advances in prognostication as well as management of Follicular Lymphoma (FL) are moving to personalized approach. Areas covered: Prognostic scores as well as consolidated and innovative therapeutic approaches are evaluated according to the various presentation modalities. For asymptomatic, low-tumor burden FL, a 'watch and wait' policy is currently the first-choice approach, although possible alternatives are discussed. Early stage FL may be treated with local radiotherapy although the role of minimal residual disease in possible additional agents should be determined. The first line treatment for symptomatic FL is chemo-immunotherapy followed by two years maintenance therapy with anti-CD20 monoclonal antibodies. A deeper knowledge of FL biology has opened new perspectives regarding the timing of therapy and has offered new targets for the development of novel agents that aim to change the therapeutic scenario of FL management. Expert commentary: The introduction of novel agents could question the incurability of FL and change the therapeutic goal from prolonging the complete remission state to eradicating the disease in young/fit patients, as well as improving quality of life in elderly/unfit patients. In the near future, combining new biologic agents and adoptive cell therapies could help in achieving these aims.
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Affiliation(s)
- Alessandro Pulsoni
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Luca Vincenzo Cappelli
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Laura Ballotta
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Martina Canichella
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Alessandra Serrao
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Giorgia Annechini
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Gianna Maria D'Elia
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
| | - Robin Foà
- a Hematology, Department of Cellular Biotechnologies and Hematology , Sapienza University , Rome , Italy
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Sorigue M, Tuset V, Sancho JM. Treatment of localized-stage follicular lymphoma. Eur J Haematol 2018; 101:245-256. [PMID: 29754401 DOI: 10.1111/ejh.13093] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2018] [Indexed: 12/15/2022]
Abstract
Follicular lymphoma (FL) is the most common indolent lymphoma, and it most frequently presents in an advanced stage. Therapeutic considerations for advanced stage are different from those of localized-stage FL, in which radiotherapy (RT) is generally recommended. However, the available evidence suffers from shortcomings that are relatively specific to this clinical entity due to its rarity and long survival with all available treatment modalities, including that most of the existing evidence originated at a time when diagnostic classifications, staging procedures and radiotherapeutic standards were different from those available today and when anti-CD20 monoclonal antibodies were not available. Available treatment modalities include observation, systemic therapy only, RT only and RT in combination with systemic therapy. We review the evidence available with each of them and the data from present-day clinical practice studies as well as briefly discuss what diagnostic and therapeutic developments may take place in the next few years.
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Affiliation(s)
- Marc Sorigue
- Department of Hematology, ICO-Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Victòria Tuset
- Department of Radiation Oncology, ICO Badalona, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Juan-Manuel Sancho
- Department of Hematology, ICO-Hospital Germans Trias i Pujol, Institut de Recerca Josep Carreras, Universitat Autònoma de Barcelona, Badalona, Spain
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28
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Yokohama A, Hashimoto Y, Takizawa M, Shimizu H, Miyazawa Y, Saitoh A, Toyama K, Ishizaki T, Mitsui T, Saitoh T, Murayama K, Matsumoto M, Sawamura M, Murakami H, Hirato J, Kojima M, Nojima Y, Handa H, Tsukamoto N. Clinical management and outcomes of completely resected stage I follicular lymphoma. J Clin Exp Hematop 2018; 58:10-16. [PMID: 29415976 DOI: 10.3960/jslrt.17031] [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: 11/01/2022] Open
Abstract
Recent studies have revealed the clinical and biological features of stage I follicular lymphoma (FL), but information about patients with stage I FL who underwent total resection after tissue biopsy is limited. Among 305 FL patients diagnosed between 2001 and 2013, clinical stage I disease was observed in 36 patients. Of these, 18 patients underwent total resection after diagnostic tissue biopsy. We used 18F-fluorodeoxyglucose positron emission CT for staging assessment in 13 of 18 patients (72.2%). The median age was 56.5 years. Six patients (33.3%) were male. The soluble interleukin-2 receptor alpha concentration was significantly lower than in patients with residual disease. Among these 18 patients, 7 patients (38.9%) were treated with a "watch-and-wait" (WW) policy, 7 (38.9%) were treated with involved-field irradiation, and 4 (22.2%) received systemic chemotherapy. Patients with resected disease were treated with significantly different strategies from those with residual disease (p = 0.0026). Five patients experienced relapse during follow-up (median follow-up: 48.2 months). All relapses were distant from the primary site, irrespective of treatment strategy. Among all stage I patients, disease resection was not a significant factor for survival (p = 0.9294). Collectively, the choice of treatment strategy was significantly influenced by patient status. Resection status was not significantly associated with survival after several treatment strategies.
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Affiliation(s)
- Akihiko Yokohama
- Blood Transfusion Service, Gunma University Hospital, Faculty of Medicine, Gunma University, Maebashi, Gunma, Japan
| | - Yoko Hashimoto
- Department of Hematology, Gunma University Graduate School of Medicine
| | - Makiko Takizawa
- Department of Hematology, Gunma University Graduate School of Medicine
| | - Hiroaki Shimizu
- Department of Hematology, Gunma University Graduate School of Medicine
| | - Yuri Miyazawa
- Division of Hematology, National Hospital Organization Shibukawa Medical Center, Shibukawa, Gunma, Japan
| | - Akio Saitoh
- Department of Hematology, Fujioka General Hospital, Fujioka, Gunma, Japan
| | - Kohtaro Toyama
- Department of Hematology, Fujioka General Hospital, Fujioka, Gunma, Japan
| | - Takuma Ishizaki
- Department of Hematology, Gunma University Graduate School of Medicine
| | - Takeki Mitsui
- Department of Hematology, Gunma University Graduate School of Medicine
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- Department of Hematology, Gunma University Graduate School of Medicine
| | - Takayuki Saitoh
- Gunma University Graduate School of Health Sciences, Maebashi, Gunma, Japan
| | - Kayoko Murayama
- Division of Hematology and Oncology, Gunma Cancer Center, Ohta, Gunma, Japan
| | - Morio Matsumoto
- Division of Hematology, National Hospital Organization Shibukawa Medical Center, Shibukawa, Gunma, Japan
| | - Morio Sawamura
- Division of Hematology, National Hospital Organization Shibukawa Medical Center, Shibukawa, Gunma, Japan
| | - Hirokazu Murakami
- Gunma University Graduate School of Health Sciences, Maebashi, Gunma, Japan
| | - Junko Hirato
- Clinical Department of Pathology, Gunma University Hospital, Maebashi, Gunma, Japan
| | - Masaru Kojima
- Anatomic and Diagnostic Pathology, Dokkyo University School of Medicine, Mibu, Tochigi, Japan
| | - Yoshihisa Nojima
- Department of Hematology, Gunma University Graduate School of Medicine
| | - Hiroshi Handa
- Department of Hematology, Gunma University Graduate School of Medicine
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29
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König L, Herfarth K. Radiation Therapy in Follicular Lymphoma. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_21-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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30
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Cencini E, Puccini B, Rigacci L, Fabbri A, Kovalchuk S, Mannelli L, Benelli G, Carfagno T, Simontacchi G, Bocchia M, Bosi A. Radiotherapy plus rituximab as first-line regimen for localized follicular lymphoma. Leuk Lymphoma 2017; 59:1420-1426. [PMID: 28994343 DOI: 10.1080/10428194.2017.1387909] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Early-stage follicular lymphoma (FL) can be cured with involved-field radiotherapy (IF-RT); however, many patients relapse in non-irradiated areas. A combined association with chemotherapy could increase treatment efficacy, but toxic effects could be unacceptable. In vitro synergistic effect between rituximab (R) and RT has been observed, but clinical data are limited. We retrospectively analyzed 41 early-stage FL patients receiving R and IF-RT as first-line treatment. We administered R 375mg/m2 weekly for four courses, before or after IF-RT (median dose 24 Gy). Primary outcome was PFS, secondary endpoints were CR rate, OS and safety. All patients achieved CR, after a median follow-up of 46 months only three patients relapsed after 18, 26 and 42 months; estimated 5-year PFS was 90%. We suggest R in association with IF-RT could represent a feasible first-line treatment option for early-stage FL and could increase efficacy without additional toxicity compared to available data about RT alone.
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Affiliation(s)
- Emanuele Cencini
- a Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena , Italy
| | - Benedetta Puccini
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Luigi Rigacci
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Alberto Fabbri
- a Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena , Italy
| | - Sofia Kovalchuk
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Lara Mannelli
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Gemma Benelli
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Tommaso Carfagno
- c Radiotherapy Department , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Gabriele Simontacchi
- d Radiotherapy Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
| | - Monica Bocchia
- a Unit of Hematology, Azienda Ospedaliera Universitaria Senese & University of Siena , Siena , Italy
| | - Alberto Bosi
- b Hematology Department , Azienda Ospedaliera Universitaria Careggi , Firenze , Italy
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31
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Bentur OS, Gurion R, Gafter-Gvili A, Gatt M, Shvidel L, Horowitz NA, Ram R, Herishanu Y, Sarid N, Paltiel O, Ganzel C, Kreiniz N, Dally N, Gutwein O, Raanani P, Avivi I, Perry C. Treatment and prognosis of stage I follicular lymphoma in the modern era - does PET matter? Leuk Lymphoma 2017; 59:1163-1171. [PMID: 28901817 DOI: 10.1080/10428194.2017.1375102] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Follicular lymphoma (FL) is the most common subtype of indolent non-Hodgkin lymphoma. Patients with stage I disease are usually treated with radiotherapy (RT). In previous studies, mostly from the pre positron emission tomography-computed tomography (PET-CT) era, the 5 year progression-free survival (PFS) and overall survival (OS) rates of stage I disease were 60-80% and 80-93%, respectively. This study retrospectively evaluated the outcome of stage I FL which was treated with involved field RT in the PET-CT era between 2002 and 2015. Ninety-one patients were enrolled. Five year PFS and OS rates were 73% and 97%, respectively. Relapse occurred in 19 (21%) patients, 74% occurring outside the radiation field. In conclusion, PET-CT staging of clinical stage I FL may contribute to the improved prognosis in patients treated with RT compared to historical cohorts, possibly due to better identification of "genuine" stage I disease.
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Affiliation(s)
- Ohad S Bentur
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Ronit Gurion
- b Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center , Petah-Tikva , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Anat Gafter-Gvili
- b Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center , Petah-Tikva , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel.,d Department of Medicine A , Rabin Medical Center , Petah-Tikva , Israel
| | - Moshe Gatt
- e Hadassah Medical Center , Jerusalem , Israel.,f Faculty of Medicine , Hebrew University of Jerusalem , Jerusalem , Israel
| | - Lev Shvidel
- f Faculty of Medicine , Hebrew University of Jerusalem , Jerusalem , Israel.,g Kaplan Medical Center , Rehovot , Israel
| | - Netanel A Horowitz
- h Rambam Medical Center and Rappaport Faculty of Medicine - Technion , Israel
| | - Ron Ram
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Yair Herishanu
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Nadav Sarid
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel
| | - Ora Paltiel
- e Hadassah Medical Center , Jerusalem , Israel.,f Faculty of Medicine , Hebrew University of Jerusalem , Jerusalem , Israel
| | - Chezi Ganzel
- f Faculty of Medicine , Hebrew University of Jerusalem , Jerusalem , Israel.,i Shaare Zedek Medical Center , Jerusalem , Israel
| | | | - Najib Dally
- k Faculty of Medicine, Ziv Medical Center and Bar Ilan University , Safed , Israel
| | - Odit Gutwein
- c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel.,l Assaf Harofe Medical Center , Tel Aviv , Israel
| | - Pia Raanani
- b Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center , Petah-Tikva , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Irit Avivi
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
| | - Chava Perry
- a Department of Hematology , Tel Aviv Sourasky Medical Center , Tel Aviv , Israel.,c Sackler Faculty of Medicine , Tel Aviv University , Tel Aviv , Israel
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Subramanian J, Cavenagh J, Desai B, Jacobs I. Rituximab in the treatment of follicular lymphoma: the future of biosimilars in the evolving therapeutic landscape. Cancer Manag Res 2017; 9:131-140. [PMID: 28479860 PMCID: PMC5411111 DOI: 10.2147/cmar.s120589] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Follicular lymphoma (FL) is the second most common type of non-Hodgkin's lymphoma. FL is an incurable disease with treatment options ranging from a "watch-and-wait" approach to localized therapy with radiation or systemic therapy with rituximab in combination with chemotherapy regimens. This review summarizes the role of rituximab across the spectrum of FL treatment and the evolving therapeutic landscape with the emergence of novel agents currently in clinical development. Despite the prospect of new agents on the horizon, it is widely accepted that rituximab will remain as the cornerstone of therapy because of its established long-term efficacy. Many biologics, including rituximab, have lost exclusivity of composition-of-matter patent or will do so in the next few years, which is a concern for patients and physicians alike. Moreover, access to rituximab is challenging, particularly in countries with restricted resources. Together, these concerns have fueled the development of safe and effective biosimilars. The term "biosimilar" refers to a biologic product that is highly similar to an approved reference (or originator) product, notwithstanding minor differences in clinically inactive components, and for which there are no clinically meaningful differences in purity, potency, or safety. Biosimilars are developed to treat the same condition(s) using the same treatment regimens as an approved reference biologic, and have the potential to increase access to more affordable treatment of FL. Herein, we also discuss the potential benefits of eagerly awaited rituximab biosimilars, which may mitigate the impact of the lack of access to rituximab.
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Affiliation(s)
| | - Jamie Cavenagh
- Department of Haematology, St. Bartholomew’s Hospital, London, UK
| | | | - Ira Jacobs
- Global Established Pharma, Pfizer Inc., New York, NY, USA
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Radioimmunotherapy for non-Hodgkin's lymphoma: positioning, safety, and efficacy of 90Y-ibritumomab. 10 years of experience and follow-up. Rev Esp Med Nucl Imagen Mol 2017. [DOI: 10.1016/j.remnie.2016.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Demoor-Goldschmidt C, Agape P, Barillot I, Mahé MA. [Radiotherapy in localized stages of follicular and diffuse non-Hodgkin's lymphomas]. Cancer Radiother 2016; 20:530-4. [PMID: 27614527 DOI: 10.1016/j.canrad.2016.07.090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 07/22/2016] [Indexed: 11/25/2022]
Abstract
Treatment with monoclonal antibodies, especially rituximab, is more and more frequent and questions the interest of radiotherapy in limited stages of diffuse B-cell large cell and follicular non-Hodgkin's lymphomas. From a review of literature, it appears that radiotherapy is of interest in bulky disease, patients with incomplete metabolic response, elderly patients receiving short chemotherapy and those with recurrence after exclusive chemotherapy. Finally, this article gives recommendations on available techniques of radiotherapy and doses to be delivered.
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Affiliation(s)
- C Demoor-Goldschmidt
- Inserm, UMRS 1018, institut Gustave-Roussy, 114, rue Edouard-Vaillant, 94805 Villejuif, France
| | - P Agape
- Département d'oncologie médicale, institut de cancérologie de l'Ouest-René-Gauducheau, boulevard Jacques-Monod, 44800 Saint-Herblain, France
| | - I Barillot
- Centre universitaire de cancérologie Henry-s-Kaplan, CHU, 37000 Tours, France
| | - M A Mahé
- Département de radiothérapie, institut de cancérologie de l'Ouest-René-Gauducheau, boulevard Jacques-Monod, 44800 Saint-Herblain, France.
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35
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Limited Stage Follicular Lymphoma: Current Role of Radiation Therapy. Mediterr J Hematol Infect Dis 2016; 8:e2016041. [PMID: 27648204 PMCID: PMC5016012 DOI: 10.4084/mjhid.2016.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 07/18/2016] [Indexed: 12/04/2022] Open
Abstract
Radiation therapy (RT) alone has been considered for a long time as the standard therapeutic option for limited stage FL, due to its high efficacy in terms of local disease control with a quite significant proportion of “cured” patients (without further relapses at 10–15 years). Multiple therapeutic choices are currently accepted for the management of early stage FL at diagnosis, and better staging procedures as well as better systemic therapy partially modified the role of RT in this setting. RT has also changed in terms of prescribed dose as well as treatment volumes. In this review, we present and discuss the current role of RT for limited stage FL in light of the historical data and the modern RT concepts along with the possible combination with systemic therapy.
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36
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Martínez A, Martínez-Ramirez M, Martínez-Caballero D, Beneit P, Clavel J, Figueroa G, Verdú J. Radioimmunotherapy for non-Hodgkin's lymphoma; positioning, safety, and efficacy of 90Y-Ibritumomab. 10 years of experience and follow-up. Rev Esp Med Nucl Imagen Mol 2016; 36:13-19. [PMID: 27422155 DOI: 10.1016/j.remn.2016.05.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Radioimmunotherapy (RIT) is one of the therapies directed against molecular targets in non-Hodgkin's lymphoma (NHL). OBJECTIVE To evaluate the positioning, safety, and effectiveness of RIT with 90Y-Ibritumomab in NHL patients. METHOD A retrospective study was conducted on patients with NHL who received RIT with 90Y-Ibritumomab. An evaluation was made of the concordance with clinical guidelines, toxicity as rated by the Common Terminology Criteria for Adverse Events (CTCAE), and effectiveness was assessed based on response to treatment, overall survival (OS), and progression-free survival (PFS). RESULTS RIT was requested in 26 patients, of whom 21 (11 women, mean age 56±10 years) were included in the study, with the following distribution: Follicular NHL, 67%, Mantle NHL, 14%, Diffuse large B-cell NHL, 9.5%, and Transformed NHL 9.5%. Twelve patients with refractory NHL, 7 for consolidation response, and 2 transplant conditioning, were treated. Adverse effects were observed in 71% of patients, which were usually manageable and transient, and with the most common being thrombocytopenia. At 3-4 months, overall response rate was 76.2% (71.4% complete and 4.8% partial response), and 19% had progression of disease. With a median follow up of 70 months, the OS was 96±8 months, and the PFS was 54±11 months. CONCLUSION RIT showed a moderate correlation with clinical guidelines, and is probably underused. Adverse effects were common, mild, and manageable. The data show a high complete response rate and an increase in the OS and PFS.
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Affiliation(s)
- A Martínez
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España.
| | - M Martínez-Ramirez
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España
| | - D Martínez-Caballero
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España
| | - P Beneit
- Servicio de Hematología, Hospital Universitario San Juan de Alicante, Alicante, España
| | - J Clavel
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España
| | - G Figueroa
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España
| | - J Verdú
- Servicio de Medicina Nuclear, Hospital Universitario San Juan de Alicante, Alicante, España
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37
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Reagan PM, Friedberg JW. Follicular lymphoma: first-line treatment without chemotherapy for follicular lymphoma. Curr Treat Options Oncol 2016; 16:32. [PMID: 26031546 DOI: 10.1007/s11864-015-0351-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Opinion statement: The optimal initial treatment of follicular lymphoma (FL) is not known, and initial management of patients varies considerably between providers and institutions. The assertion that patients with low tumor burden can be observed for a period of time is being challenged owing to the safety and tolerability of novel therapeutics and the movement of the field away from traditional chemotherapy agents. Single agent rituximab has become increasingly popular as initial management of patients with low tumor burden disease, and there is evidence that prolonged treatment with rituximab can improve progression-free survival (PFS) when compared to induction with rituximab or observation. Radioimmunotherapy (RIT) has similarly shown efficacy in low tumor burden disease. Novel agents such as lenalidomide, idelalisib, and ibrutinib are being studied in the first-line setting. Importantly, none of these strategies have demonstrated an improved overall survival in a randomized study versus observation. It is the opinion of the authors that endpoints such as PFS alone, while important, should not drive changes in management with limited resources. Composite endpoints including quality of life are more informative on the true impact of treatments on patients with follicular lymphoma. Providers should encourage all patients to be treated in the context of an appropriate clinical trial when possible. If a patient is not a clinical trial candidate, we typically treat patients with advanced stage and high tumor burden with chemoimmunotherapy. The decision to give maintenance rituximab is individualized to the patient, as there is no overall survival benefit. In patients with early stage disease, we favor consideration of radiation therapy if the patient is a candidate. Our initial recommendation to patients with advanced stage, low tumor burden disease, is close observation or "watch and wait." We have observed that most patients become comfortable over time with an observation approach. If a patient is not comfortable with this recommendation, we will use single agent rituximab. If the patient responds to therapy, we do not recommend maintenance rituximab in low tumor burden disease but rather prefer a retreatment strategy or an extended schedule of four additional doses of rituximab.
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Affiliation(s)
- Patrick M Reagan
- University of Rochester Medical Center, 601 Elmwood Ave, Box 704, Rochester, NY, 14642, USA,
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Gastaud L, Rossignol B, Peyrade F, Ré D, Thariat J, Thyss A, Doyen J. Place de la radiothérapie dans la prise en charge des lymphomes malins non hodgkiniens. Cancer Radiother 2016; 20:236-47. [DOI: 10.1016/j.canrad.2016.01.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 12/27/2015] [Accepted: 01/29/2016] [Indexed: 12/11/2022]
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Bista A, Sharma S, Shah BK. Disparities in Receipt of Radiotherapy and Survival by Age, Sex, and Ethnicity among Patient with Stage I Follicular Lymphoma. Front Oncol 2016; 6:101. [PMID: 27200290 PMCID: PMC4848288 DOI: 10.3389/fonc.2016.00101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 04/11/2016] [Indexed: 11/13/2022] Open
Abstract
Background Radiotherapy (RT) is a first-line treatment option for stage I follicular lymphoma (FL). We studied disparities in receipt of RT and survival among patients with stage I FL. Methods Adult patients (age ≥18 years) with stage I FL, as the first primary cancer, diagnosed between 1992 and 2007 were identified using Surveillance, Epidemiology, and End Results (SEER) 18 database. Study population was divided into various subgroups based on age, sex, race, and marital status. Factors associated with receipt of RT and survival, among patients receiving RT, was evaluated using regression analysis and Cox PH modeling, respectively. SEER*Stat was used to compute 1- and 5-year RS for various subgroups and compared using Z score. Results Of the total 7315 patients (median age: 64 years), 2671 (36.5%) received RT. African-Americans, older age group, and single and separated/divorced/widow marital status predicted omission of RT. The 1- and 5-year RS were significantly better in patients receiving RT. In multivariate analysis, male sex, age <60 years, Caucasian race, and married marital status were found to be independent predictor of better RS among patients receiving RT (P < 0.0001). Conclusion This study showed that 36.5% patients with stage I FL received RT. Survival rates were significantly better for patients who received RT.
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Affiliation(s)
- Amir Bista
- Guthrie Robert Packer Hospital , Sayre, PA , USA
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Follicular lymphoma: evolving therapeutic strategies. Blood 2016; 127:2055-63. [DOI: 10.1182/blood-2015-11-624288] [Citation(s) in RCA: 123] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/26/2015] [Indexed: 12/28/2022] Open
Abstract
Abstract
Follicular lymphoma (FL) is the most common indolent non-Hodgkin lymphoma in the Western hemisphere. After decades of stagnation, the natural history of FL appears to have been favorably impacted by the introduction of rituximab. Randomized clinical trials have demonstrated that the addition of rituximab to standard chemotherapy induction has improved the overall survival. Maintenance rituximab strategies can improve progression-free survival. Even chemotherapy platforms have changed in the past 5 years, as bendamustine combined with rituximab has rapidly become a standard frontline strategy in North America and parts of Europe. Recent discoveries have identified patients at high risk for poor outcomes to first-line therapy (m7–Follicular Lymphoma International Prognostic Index [m7-FLIPI]) and for poor outcomes after frontline therapy (National LymphoCare Study). However, several unmet needs remain, including a better ability to identify high-risk patients at diagnosis, the development of predictive biomarkers for targeted agents, and strategies to reduce the risk of transformation. The development of targeted agents, exploiting our current understanding of FL biology, is a high research priority. A multitude of novel therapies are under investigation in both the frontline and relapsed/refractory settings. It will be critical to identify the most appropriate populations for new agents and to develop validated surrogate end points, so that novel agents can be tested (and adopted, if appropriate) efficiently.
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Ruella M, Filippi AR, Bruna R, Di Russo A, Magni M, Caracciolo D, Passera R, Matteucci P, Di Nicola M, Corradini P, Parvis G, Gini G, Olivieri A, Ladetto M, Ricardi U, Tarella C, Devizzi L. Addition of Rituximab to Involved-Field Radiation Therapy Prolongs Progression-free Survival in Stage I-II Follicular Lymphoma: Results of a Multicenter Study. Int J Radiat Oncol Biol Phys 2015; 94:783-91. [PMID: 26972651 DOI: 10.1016/j.ijrobp.2015.12.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Revised: 11/28/2015] [Accepted: 12/02/2015] [Indexed: 12/30/2022]
Abstract
PURPOSE Rituximab (Rit) therapy added to involved-field radiation therapy (RT) has been proposed as an effective treatment for stage I-II follicular lymphoma (FL). The results of an observational multicenter study on the Rit-RT combination in limited-stage FL are here reported. METHODS AND MATERIALS Data have been collected from 2 consecutive cohorts of 94 patients with stage I-II FL treated between 1985 and 2011 at 5 Italian institutions. All patients had grade 1-3a FL, a median age of 54 years (range: 25-82). The first 51 patients received RT alone (control group), while the subsequent series of 43 patients received 4 rituximab courses (375 mg/m(2), days 1, 8, 15, 22) before RT (Rit-RT). Molecular disease was evaluated by nested bcl-2/IgH PCR or clonal IgH rearrangement was available in 33 Rit-RT patients. RESULTS At a median follow-up of 10.9 years (range: 1.8-22.9), the 10-year progression-free survival (PFS) and overall survival (OS) projections for the whole cohort were 57% and 87.5%, respectively. The 10-year PFS was significantly longer (P<.05) in the Rit-RT group (64.6%) compared to RT alone (50.7%), whereas the 10-year OS projections were not significantly different. On bivariate analysis controlling for stage, there was only a trend toward improved PFS for Rit-RT (HR, 0.55; P=.081). Follicular lymphoma international prognostic index and age were associated with OS but not with PFS on Cox regression analysis. Bone marrow molecular analysis showing PCR positivity at diagnosis was strongly associated with relapse risk upon univariate and multivariate analysis. CONCLUSIONS This multicenter observational study suggests a potential benefit of adding rituximab to radiation therapy for stage I-II FL. The results of the currently ongoing randomized studies are required to confirm these results. The study underlines the importance of molecular disease monitoring also for patient with limited-stage disease.
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Affiliation(s)
- Marco Ruella
- Division of Haematology and Cell Therapy, Mauriziano Hospital and University of Torino, Torino, Italy; Center for Cellular Immunotherapies, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - Riccardo Bruna
- Division of Haematology and Cell Therapy, Mauriziano Hospital and University of Torino, Torino, Italy
| | - Anna Di Russo
- Radiation Oncology, Istituto Nazionale Tumori, Milano, Italy
| | - Michele Magni
- Division of Medical Oncology, Istituto Nazionale Tumori, and University of Milano, Milano, Italy
| | - Daniele Caracciolo
- Division of Haematology, San Giovanni Battista Hospital and University of Torino, Torino, Italy
| | - Roberto Passera
- Division of Nuclear Medicine, San Giovanni Battista Hospital and University of Torino, Torino, Italy
| | - Paola Matteucci
- Division of Medical Oncology, Istituto Nazionale Tumori, and University of Milano, Milano, Italy
| | - Massimo Di Nicola
- Division of Medical Oncology, Istituto Nazionale Tumori, and University of Milano, Milano, Italy
| | - Paolo Corradini
- Division of Haematology, Istituto Nazionale Tumori, and University of Milano, Milano, Italy
| | - Guido Parvis
- Division of Haematology, San Luigi Gonzaga Hospital, Orbassano, Torino, Italy
| | - Guido Gini
- Division of Haematology, Ospedali Riuniti, Ancona, Italy
| | | | - Marco Ladetto
- Division of Haematology, San Giovanni Battista Hospital and University of Torino, Torino, Italy
| | - Umberto Ricardi
- Department of Oncology, Radiation Oncology, University of Torino, Torino, Italy
| | - Corrado Tarella
- Division of Haematology and Cell Therapy, Mauriziano Hospital and University of Torino, Torino, Italy; Hemato-Oncology Division, European Institute of Oncology, Milano, Italy.
| | - Liliana Devizzi
- Division of Medical Oncology, Istituto Nazionale Tumori, and University of Milano, Milano, Italy
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Barzenje DA, Cvancarova Småstuen M, Liestøl K, Fosså A, Delabie J, Kolstad A, Holte H. Radiotherapy Compared to Other Strategies in the Treatment of Stage I/II Follicular Lymphoma: A Study of 404 Patients with a Median Follow-Up of 15 Years. PLoS One 2015; 10:e0131158. [PMID: 26147646 PMCID: PMC4492987 DOI: 10.1371/journal.pone.0131158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 05/31/2015] [Indexed: 01/04/2023] Open
Abstract
Purpose To investigate outcome for patients with follicular lymphoma (FL) stage I-II treated at a population-based referral institution with a median follow-up of 15 years. Overall and cause-specific survival was compared to that of a sex, age and residency matched individuals from normal population. Material and Methods 404 patients with early stage FL treated between 1980 and 2005 were retrospectively analyzed. Two of three patients had stage I disease. Based on clinical characteristics, first line treatments were radiotherapy (RT) (48% of patients), chemotherapy (CT) (16%), combined chemo-and radiotherapy (CRT) (16%) or observation (OBS) (15%). Survival was modeled with Kaplan-Meier methodology. Multivariate analyses were performed with the Cox model. Results Fifteen years overall survival (OS), progression free survival (PFS) and time to next treatment (TNT) were 50% (95% confidence interval [CI]: 45–55), 42% (95% CI: 36–47) and 48% (95% CI, 42–54), respectively. For patients treated with RT 97% achieved a complete remission, and 15 year OS, PFS and TNT were 57% (95% CI, 50–64), 46% (95% CI, 39–54) and 49% (95% CI, 42–57), respectively. Relapse rate after RT and CRT was 49% and 36%, respectively. Only 2% of patients who received RT or CRT relapsed inside the radiation field and 5% had isolated near-field relapse. No statistical differences were found between treatment groups regarding death from cardiovascular disease or incidence of second cancer. Compared to a matched normal population, non-lymphoma cancer mortality was higher among patients given RT, hazard ratio 1.66 (95% CI: 1.14–2.42; P<0.01). Compared to other treatment modalities, patients selected for observation without treatment did not have inferior outcome. Conclusions A differentiated treatment strategy in early stage FL results in long term survival for the majority of patients. OBS is a valid initial choice for selected patients without lymphoma-related symptoms.
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Affiliation(s)
| | | | - Knut Liestøl
- Center for Cancer Biomedicine, University of Oslo, Oslo, Norway
- Department of informatics, University of Oslo, Oslo, Norway
| | - Alexander Fosså
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Jan Delabie
- Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Arne Kolstad
- Department of Oncology, Oslo University Hospital, Oslo, Norway
| | - Harald Holte
- Department of Oncology, Oslo University Hospital, Oslo, Norway
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Shah BK, Ghimire KB. Survival in adult stage I follicular lymphoma treated with and without radiotherapy - a population-based study. Acta Oncol 2015; 54:951-3. [PMID: 25417735 DOI: 10.3109/0284186x.2014.974829] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Binay Kumar Shah
- Cancer Center and Blood Institute, St Joseph Regional Medical Center , Lewiston, ID , USA
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R-CHOP therapy alone for limited-stage follicular lymphoma. Leuk Res 2015; 39:582-5. [DOI: 10.1016/j.leukres.2015.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2014] [Revised: 02/16/2015] [Accepted: 03/05/2015] [Indexed: 11/18/2022]
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Kuruvilla J, Assouline S, Hodgson D, MacDonald D, Stewart D, Christofides A, Komolova M, Connors J. A Canadian Evidence-Based Guideline for the First-Line Treatment of Follicular Lymphoma: Joint Consensus of the Lymphoma Canada Scientific Advisory Board. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:59-74. [DOI: 10.1016/j.clml.2014.07.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Revised: 07/18/2014] [Accepted: 07/29/2014] [Indexed: 11/30/2022]
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Abstract
The standard frontline therapy for diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), and mantle cell lymphoma (MCL) includes the use of chemoimmunotherapy and/or radiation therapy. When patients with these diseases relapse or are refractory to therapy, their diseases are considered incurable outside of the setting of an autologous or allogeneic stem cell transplant, which many patients are not candidates for due to age or comorbidities. The oral Bruton's tyrosine kinase (BTK) inhibitor, ibrutinib, targets the B-cell receptor (BCR) signaling pathway that is critical in the survival of these malignancies. It has shown promising activity in certain subtypes of DLBCL, in relapsed or refractory FL, and in relapsed or refractory MCL for which it has recently received FDA approval and should be considered for use in patients in first relapse. Ibrutinib is an oral therapy taken daily that has been well tolerated by patients. Given the high response rates, tolerability, and acceptable toxicities of ibrutinib therapy, it is now being evaluated in combination therapy both in relapsed B-cell malignancies and frontline studies in DLBCL and MCL. Several other promising agents targeting different kinases in the BCR signaling pathway also are currently under investigation.
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Affiliation(s)
- Kami Maddocks
- Department of Hematology, Arthur G James Comprehensive Cancer Center, The Ohio State University, 320 W 10th Avenue, A350C Starling Loving Hall, Columbus, OH, 43210, USA,
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Janikova A, Bortlicek Z, Campr V, Kopalova N, Benesova K, Belada D, Prochazka V, Pytlik R, Vokurka S, Pirnos J, Duras J, Mocikova H, Mayer J, Trneny M. Radiotherapy with rituximab may be better than radiotherapy alone in first-line treatment of early-stage follicular lymphoma: is it time to change the standard strategy? Leuk Lymphoma 2015; 56:2350-6. [PMID: 25426666 DOI: 10.3109/10428194.2014.990010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Early-stage follicular lymphoma (FL) has traditionally been treated with involved-field radiotherapy (RT). Rituximab (R) is a low-toxic, efficient systemic therapy for FL, but there are no data about its clinical impact in early FL. We retrospectively analyzed 93 patients with stage I-II indolent FL treated with RT (n=65) or RT+R (n=14) or R alone (n=14). Median follow-up was 5.0 years for patients with RT, 2.8 years for the RT+R subgroup and 2.5 years for patients treated with R. The complete response rate was 92%, 100% and 86% (not significant) and the median PFS was 3.3 years, not reached and 4.9 years (p=0.035) for the RT, RT+R and R arms, with no impact on overall survival. R combined with RT seems to give better results in terms of global FL control, but longer follow-up and prospective comparison are needed to verify these results.
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Affiliation(s)
- Andrea Janikova
- a Department of Internal Medicine - Hematology and Oncology , Masaryk University and University Hospital Brno , Brno , Czech Republic
| | - Zbynek Bortlicek
- b Institute of Biostatistics and Analyses, Faculty of Medicine and Faculty of Science, Masaryk University , Brno , Czech Republic
| | - Vit Campr
- c Department of Pathology and Molecular Medicine , 2nd Faculty of Medicine, Charles University and Faculty Hospital in Motol , Prague , Czech Republic
| | - Natasa Kopalova
- a Department of Internal Medicine - Hematology and Oncology , Masaryk University and University Hospital Brno , Brno , Czech Republic
| | - Katerina Benesova
- d 1st Department of Medicine , Charles University General Hospital , Prague , Czech Republic
| | - David Belada
- e Department of Clinical Hematology , University Hospital Hradec Kralove , Hradec Kralove , Czech Republic
| | - Vit Prochazka
- f Department of Hematology , University Hospital Olomouc , Olomouc , Czech Republic
| | - Robert Pytlik
- d 1st Department of Medicine , Charles University General Hospital , Prague , Czech Republic
| | - Samuel Vokurka
- g Department of Hematooncology , Charles University and University Hospital Pilsen , Pilsen , Czech Republic
| | - Jan Pirnos
- h Department of Oncology , Hospital Ceske Budejovice , Ceske Budejovice , Czech Republic
| | - Juraj Duras
- i Department of Clinical Hematology , Teaching Hospital Ostrava , Ostrava , Czech Republic
| | - Heidi Mocikova
- j Department of Hematology , University Hospital Kralovske Vinohrady , Prague , Czech Republic
| | - Jiri Mayer
- a Department of Internal Medicine - Hematology and Oncology , Masaryk University and University Hospital Brno , Brno , Czech Republic
| | - Marek Trneny
- d 1st Department of Medicine , Charles University General Hospital , Prague , Czech Republic
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Aguiar-Bujanda D, Blanco-Sánchez MJ, Jiménez-Gallego P, Mori-De Santiago M, Hernández-Sosa M, Galván-Ruíz S, Hernández-Sarmiento S, Saura-Grau S, Bohn-Sarmiento U. Therapeutic approaches in patients with newly diagnosed follicular lymphoma. Future Oncol 2014; 10:1967-80. [DOI: 10.2217/fon.14.104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
ABSTRACT The prognosis of follicular lymphoma (FL) has significantly improved over the last decade, particularly following the introduction of the anti-CD20 monoclonal antibody rituximab, which has challenged the old concept of FL as an incurable disease. However, the decision whether to start treatment in a patient with advanced FL or adopt a watch-and-wait policy remains a subject of controversy. Furthermore, the optimal first-line treatment for FL remains a clinical challenge owing to the numerous different therapeutic options available. In this review, the authors focus on the initial management of patients with newly diagnosed FL, consider the different treatment options for every stage, paying special consideration to the therapeutic approaches for each clinical scenario, and discuss future directions.
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Affiliation(s)
- David Aguiar-Bujanda
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - María Jesús Blanco-Sánchez
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Pedro Jiménez-Gallego
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Marta Mori-De Santiago
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - María Hernández-Sosa
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Saray Galván-Ruíz
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Samuel Hernández-Sarmiento
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Salvador Saura-Grau
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
| | - Uriel Bohn-Sarmiento
- Department of Medical Oncology, Hospital Universitario de Gran Canaria Dr Negrin, C/Barranco de la Ballena s/n, 35010, Las Palmas de Gran Canaria, Spain
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Rapid decline of follicular lymphoma-associated chylothorax after low dose radiotherapy to retroperitoneal lymphoma localization. Case Rep Hematol 2014; 2014:684689. [PMID: 24891961 PMCID: PMC4033525 DOI: 10.1155/2014/684689] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2014] [Accepted: 04/27/2014] [Indexed: 01/30/2023] Open
Abstract
Chylothorax is caused by disruption or obstruction of the thoracic duct or its tributaries that results in the leakage of chyle into the pleural space. A number of interventions have been used to treat chylothorax including the treatment of the underlying disease. Lymphoma is found in 70% of cases with nontraumatic malignant aetiology. Although patients usually have advanced lymphoma, supradiaphragmatic disease is not always present. We discuss the case of a 63-year-old woman presenting with progressive respiratory symptoms due to chylothorax. She was diagnosed with a stage IIE retroperitoneal grade 1 follicular lymphoma extending from the coeliac trunk towards the pelvic inlet. Despite thoracocentesis and medium-chain triglycerides (MCT), diet chylothorax reoccurred. After low dose radiotherapy (2 × 2 Gy) to the abdominal lymphoma there was a marked decrease in lymphadenopathy at the coeliac trunk and a complete regression of the pleural fluid. In this case, radiotherapy was shown to be an effective nontoxic treatment option for lymphoma-associated chylothorax with long-term remission of pleural effusion.
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Hiddemann W, Cheson BD. How we manage follicular lymphoma. Leukemia 2014; 28:1388-95. [PMID: 24577532 DOI: 10.1038/leu.2014.91] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Accepted: 02/12/2014] [Indexed: 01/08/2023]
Abstract
Major changes have taken place within the last few years in the management of follicular lymphoma (FL) leading to substantial improvement in prognosis and overall survival. For some patients with limited disease stages I and II, radiotherapy may be associated with durable responses; however, it is unclear whether patients are cured and new approaches such as the combination of irradiation with rituximab or even single-agent rituximab need to be explored. Whereas watch and wait is the current standard for stage III and IV disease with low tumour burden, better indices are warranted to potentially select patients for whom early intervention is preferred. For advanced stages with a high tumour burden, immunochemotherapy followed by 2 years of rituximab maintenance is widely accepted as standard therapy, although re-treatment at recurrence may be an alternative option. Highly attractive new therapeutic options have recently arisen from new antibodies, and from new agents targeting oncogenic pathways such as B-cell receptor signalling pathways or inhibition of bcl 2. Furthermore, immunomodulatory drugs may add to the therapeutic armamentarium and may lead to 'chemotherapy-free' therapies in the near future. Hence, the management of FLs has become a moving target and the hope is justified that the long-term perspectives of patients suffering from the disease will be further improved in the near future.
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Affiliation(s)
- W Hiddemann
- Department of Internal Medicine III, University of Munich, Campus Großhadern, Munich, Germany
| | - B D Cheson
- Georgetown University Hospital, Lombardi Comprehensive Cancer Center, Washington, DC, USA
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