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Yamasaki S. Appropriate Treatment Intensity for Diffuse Large B-Cell Lymphoma in the Older Population: A Review of the Literature. Hematol Rep 2024; 16:317-330. [PMID: 38921180 PMCID: PMC11204029 DOI: 10.3390/hematolrep16020032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/13/2024] [Accepted: 05/22/2024] [Indexed: 06/27/2024] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) are >65 years of age, with the number of patients expected to increase in the coming years. A comprehensive geriatric assessment that carefully evaluates fitness status and comorbidities is essential for selecting the appropriate treatment intensity. Although generally healthy patients or those <80 years of age may benefit from standard immunochemotherapy, unfit/frail patients or patients >80 years old may require reduced-intensity chemotherapy or less-toxic drugs. Some new drugs are currently being tested as single or combined agents for first-line treatment, aiming to improve the outcomes of conventional chemotherapy. This review systematically collates and discusses the outcomes associated with the use of immunochemotherapy in older patients with DLBCL, as well as considering the impact of full-dose immunochemotherapy on quality of life in older and frail patients, summarizing the rationale for reduced dosing in the older population, and presenting recommendations for selecting patients likely to benefit from reduced dosing. If preliminary efficacy and safety data are confirmed in future clinical trials, non-chemotherapy-based immunotherapy approaches could become an alternative potentially curative option in frail patients and those >80 years of age with DLBCL.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Hematology, St. Mary’s Hospital, 422 Tsubukuhonmachi, Kurume 830-8543, Japan; ; Tel.: +81-942-35-3322; Fax: +81-9442-34-3115
- Department of Internal Medicine, Kyushu University Beppu Hospital, Beppu 874-0838, Japan
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-0065, Japan
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2
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Yhim HY, Park Y, Kim JA, Shin HJ, Do YR, Moon JH, Kim MK, Lee WS, Kim DS, Lee MW, Choi YS, Jeong SH, Kim KH, Kim J, Lee CH, Song GY, Yang DH, Kwak JY. Geriatric risk model for older patients with diffuse large B-cell lymphoma (GERIAD): a prospective multicenter cohort study. Korean J Intern Med 2024; 39:501-512. [PMID: 38287501 PMCID: PMC11076889 DOI: 10.3904/kjim.2023.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 11/27/2023] [Indexed: 01/31/2024] Open
Abstract
BACKGROUND/AIMS Optimal risk stratification based on simplified geriatric assessment to predict treatment-related toxicity and survival needs to be clarified in older patients with diffuse large B-cell lymphoma (DLBCL). METHODS This multicenter prospective cohort study enrolled newly diagnosed patients with DLBCL (≥ 65 yr) between September 2015 and April 2018. A simplified geriatric assessment was performed at baseline using Activities of Daily Living (ADL), Instrumental ADL (IADL), and Charlson's Comorbidity Index (CCI). The primary endpoint was event-free survival (EFS). RESULTS The study included 249 patients, the median age was 74 years (range, 65-88), and 125 (50.2%) were female. In multivariable Cox analysis, ADL, IADL, CCI, and age were independent factors for EFS; an integrated geriatric score was derived and the patients stratified into three geriatric categories: fit (n = 162, 65.1%), intermediate-fit (n = 25, 10.0%), and frail (n = 62, 24.9%). The established geriatric model was significantly associated with EFS (fit vs. intermediate-fit, HR 2.61, p < 0.001; fit vs. frail, HR 4.61, p < 0.001) and outperformed each covariate alone or in combination. In 87 intermediate-fit or frail patients, the relative doxorubicin dose intensity (RDDI) ≥ 62.4% was significantly associated with worse EFS (HR, 2.15, 95% CI 1.30-3.53, p = 0.002). It was related with a higher incidence of grade ≥ 3 symptomatic non-hematologic toxicities (63.2% vs. 27.8%, p < 0.001) and earlier treatment discontinuation (34.5% vs. 8.0%, p < 0.001) in patients with RDDI ≥ 62.4% than in those with RDDI < 62.4%. CONCLUSION This model integrating simplified geriatric assessment can risk-stratify older patients with DLBCL and identify those who are highly vulnerable to standard dose-intensity chemoimmunotherapy.
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Affiliation(s)
- Ho-Young Yhim
- Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju,
Korea
| | - Yong Park
- Department of Internal Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Jeong-A Kim
- Department of Internal Medicine, The Catholic University of Korea, St. Vincent Hospital, Suwon,
Korea
| | - Ho-Jin Shin
- Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | - Young Rok Do
- Department of Internal Medicine, Keimyung University Dongsan Medical Center, Daegu,
Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu,
Korea
| | - Min Kyoung Kim
- Department of Internal Medicine, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu,
Korea
| | - Won Sik Lee
- Department of Internal Medicine, Inje University Busan Paik Hospital, Busan,
Korea
| | - Dae Sik Kim
- Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul,
Korea
| | - Myung-Won Lee
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon,
Korea
| | - Yoon Seok Choi
- Department of Internal Medicine, Chungnam National University College of Medicine, Daejeon,
Korea
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Seong Hyun Jeong
- Department of Hematology-Oncology, Ajou University School of Medicine, Suwon,
Korea
| | - Kyoung Ha Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul,
Korea
| | - Jinhang Kim
- Department of Internal Medicine, The Catholic University of Korea, St. Vincent Hospital, Suwon,
Korea
| | - Chang-Hoon Lee
- Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju,
Korea
| | - Ga-Young Song
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun,
Korea
| | - Deok-Hwan Yang
- Department of Internal Medicine, Chonnam National University Hwasun Hospital, Chonnam National University Medical School, Hwasun,
Korea
| | - Jae-Yong Kwak
- Department of Internal Medicine, Jeonbuk National University Medical School, Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju,
Korea
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3
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Tucci A, Masina L, Luminari S. Curative intent therapy for DLBCL in the elderly. Leuk Lymphoma 2024; 65:560-569. [PMID: 38206922 DOI: 10.1080/10428194.2024.2302323] [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: 09/14/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024]
Abstract
Older patients with aggressive lymphoma are extremely heterogeneous due to the high frequency of functional limitations and comorbidities and to the different biological profiles and clinical behavior of the disease. The stratification in three geriatric categories (fit-unfit-frail) based on multidimensional geriatric assessment (GA) helps physicians tailor a potentially curative treatment.While an intensive approach with the standard R-CHOP regimen is feasible in fit patients, leading to similar long-term response and survival rates compared to younger ones, in unfit patients a balance between treatment toxicity and curative intent can be obtained through the reduction of dose intensity. Frail patients, treated with best supportive care so far, could benefit from a chemo-free approach with new target drugs. These novel agents, either alone or in combination with chemo-immunotherapy, are changing the therapeutic landscape of older patients with aggressive lymphoma, both in first-line therapy and in the setting of the relapsed/refractory disease.
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Affiliation(s)
| | | | - Stefano Luminari
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
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4
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Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol 2024; 204:1178-1192. [PMID: 38247115 DOI: 10.1111/bjh.19273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Graham McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sally F Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Cathy Burton
- Department of Haematology, The Leeds Teaching Hospitals, Leeds, UK
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, UK
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, UK
| | - Timothy Illidge
- Division of Cancer Sciences, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Nagesh Kalakonda
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Andrea Kuhnl
- Department of Haematology, King's College Hospital, London, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Andrew J Davies
- Cancer Sciences Division, Centre for Cancer Immunology, University of Southampton, Southampton, UK
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5
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Zhang KD, Jost E, Panse J, Herwartz R, Lindemann-Docter K, Jonigk D, Kricheldorf K, Köchel A, Sauerbrunn N, Brümmendorf TH, Koschmieder S, Isfort S. Bone marrow biopsy in geriatric patients above the age of 85 years: invaluable or unnecessary? A retrospective analysis. Ann Hematol 2024; 103:1149-1158. [PMID: 38336973 PMCID: PMC10940467 DOI: 10.1007/s00277-024-05650-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/31/2024] [Indexed: 02/12/2024]
Abstract
Bone marrow biopsy (BMB) is a well-established diagnostic tool for various hematological, oncological, and other medical conditions. However, treatment options for geriatric patients (pts) facing these diseases are often constrained. In this single-center, retrospective analysis we assessed the diagnostic value of BMB in geriatric pts aged ≥ 85 years and examined its impact on therapeutic decisions. We examined 156 BMB procedures in 129 pts, extracting data from the electronic patient records and applying descriptive statistical methods. Nearly half of the primary diagnostic procedures (26; 44.1%) resulted in a modification of the initially suspected diagnosis. Notably, 15 (25.4%) of these procedures, led to changes in both the diagnosis and planned interventional treatment. Among the 15 follow-up procedures (36.6%), disease progression was initially suspected based on symptoms, but BMB results excluded such progression. In lymphoma staging biopsies, only 2 (3.6%) prompted a change in therapeutic intervention. Importantly, no BMB-related complications, such as bleeding, infection or nerve damage, were reported. Median survival after BMB was 16.1 months across all pts, yet it varied based on the diagnosis and comorbidity score. The survival of pts with a change in therapy based on BMB results did not significantly differ from those who did not undergo a therapy change. In conclusion, BMB proved to be generally safe and beneficial in this geriatric cancer patient cohort beyond the age of 85 years. However, the advantages of lymphoma staging in this patient population warrant further consideration.
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Affiliation(s)
- Kailun David Zhang
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
- Department of Neurology, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Germany
| | - Edgar Jost
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Reinhild Herwartz
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Katharina Lindemann-Docter
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
- German Center for Lung Research (DZL), BREATH, Hannover, Germany
| | - Danny Jonigk
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
- German Center for Lung Research (DZL), BREATH, Hannover, Germany
| | - Kim Kricheldorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Anja Köchel
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Nicolas Sauerbrunn
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Susanne Isfort
- Department of Hematology, Oncology, Hemostaseology and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany.
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Medical School Hannover, Hannover, Germany.
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6
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Bandini A, Calabrò PF, Banchi M, Orlandi P, Bocci G. Metronomic Chemotherapy in Elderly Patients. Curr Oncol Rep 2024; 26:359-376. [PMID: 38448722 PMCID: PMC11021319 DOI: 10.1007/s11912-024-01505-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2024] [Indexed: 03/08/2024]
Abstract
PURPOSE OF REVIEW This review describes the most relevant studies found in the scientific literature regarding metronomic chemotherapy (MCT) in the geriatric oncology population to support its use as a feasible treatment of care in the frail elderly patients. RECENT FINDINGS Recent years have seen a reevaluation of cancer chemotherapeutic drugs and MCT is an emerging schedule in phase II and III clinical trials. Ageing is one of the risk factors for the development of cancer, the incidence of whom increases dramatically in people who live longer. To date, standard oncological protocols involve chemotherapeutic drugs in short cycles of therapy at the maximum tolerated dose (MTD). Although these therapeutic regimens may be successful, they can cause important adverse drug reactions, especially in elderly or frail patients. MCT is a different modality of delivery of chemotherapeutic drugs (frequent low dose for prolonged time) and it looks at the overcoming of the limitations and disadvantages of MTD, in particular the toxicity aspect. We reviewed the experience of clinicians who have used MCT in clinical trials enrolling elderly patients with different cancer types.
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Affiliation(s)
- Arianna Bandini
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy
| | - Pasquale Fabio Calabrò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy
| | - Marta Banchi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy
| | - Paola Orlandi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy
| | - Guido Bocci
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 55, 56126, Pisa, Italy.
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7
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Al-Sarayfi D, Brink M, Chamuleau MED, Brouwer R, van Rijn RS, Issa D, Deenik W, Huls G, Mous R, Vermaat JSP, Diepstra A, Zijlstra JM, van Meerten T, Nijland M. R-miniCHOP versus R-CHOP in elderly patients with diffuse large B-cell lymphoma: A propensity matched population-based study. Am J Hematol 2024; 99:216-222. [PMID: 38014799 DOI: 10.1002/ajh.27151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/19/2023] [Accepted: 10/25/2023] [Indexed: 11/29/2023]
Abstract
For elderly frail patients with diffuse large B-cell lymphoma (DLBCL), an attenuated chemo-immunotherapy strategy of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone (R-miniCHOP) was introduced as a treatment option as from 2014 onward in the Netherlands. Although R-miniCHOP is more tolerable, reduction of chemotherapy could negatively affect survival compared to R-CHOP. The aim of this analysis was to assess survival of patients treated with R-miniCHOP compared to R-CHOP. DLBCL patients ≥65 years, newly diagnosed in 2014-2020, who received ≥1 cycle of R-miniCHOP or R-CHOP were identified in the Netherlands Cancer Registry, with survival follow-up through 2022. Patients were propensity-score-matched for baseline characteristics. Main endpoints were progression-free survival (PFS), overall survival (OS), and relative survival (RS). The use of R-miniCHOP in DLBCL increased from 2% in 2014 to 15% in 2020. In total, 384 patients treated with R-miniCHOP and 384 patients treated with R-CHOP were included for comparison (median age; 81 years, stage 3-4; 68%). The median number of R-(mini)CHOP cycles was 6 (range, 1-8). The 2-year PFS, OS and RS were inferior for patients treated with R-miniCHOP compared to R-CHOP (PFS 51% vs. 68%, p < .01; OS 60% vs. 75%, p < .01; RS 69% vs. 86%, p < .01). In multivariable analysis, patients treated with R-miniCHOP had higher risk of all-cause mortality compared to patients treated with R-CHOP (HR 1.73; 95%CI, 1.39-2.17). R-miniCHOP is effective for most elderly patients. Although survival is inferior compared to R-CHOP, the use of R-miniCHOP as initial treatment is increasing. Therefore, fitness needs to be carefully weighed in treatment selection.
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Affiliation(s)
- D Al-Sarayfi
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - M Brink
- Department of Research and Development, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands
| | - M E D Chamuleau
- Department of Hematology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - R Brouwer
- Department of Hematology, Reinier de Graaf Gasthuis, Delft, The Netherlands
| | - R S van Rijn
- Department of Hematology, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - D Issa
- Department of Hematology, Jeroen Bosch Hospital, Hertogenbosch, The Netherlands
| | - W Deenik
- Department of Hematology, Rijnstate Hospital, Arnhem, The Netherlands
| | - G Huls
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - R Mous
- Department of Hematology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J S P Vermaat
- Department of Hematology, Leiden University Medical Center, Leiden, The Netherlands
| | - A Diepstra
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, The Netherlands
| | - J M Zijlstra
- Department of Hematology, Amsterdam UMC Locatie VUmc, Amsterdam, The Netherlands
| | - T van Meerten
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - M Nijland
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
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8
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Yamasaki S. Feasibility of Quality of Life Assessment in Patients with Lymphoma Aged ≥80 Years Receiving Reduced-Intensity Chemotherapy: A Single-Institute Study. Hematol Rep 2023; 16:1-10. [PMID: 38247991 PMCID: PMC10801517 DOI: 10.3390/hematolrep16010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 10/19/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Quality of life (QOL) must be carefully monitored in older patients with lymphoma who are suitable for chemotherapy, but few reports have assessed QOL in older patients who received reduced-intensity chemotherapy. This study investigated QOL in patients with lymphoma aged ≥80 years to clarify the feasibility of such assessments following reduced-intensity chemotherapy. QOL was prospectively analyzed (using the QOL Questionnaire for Cancer Patients Treated with Anticancer Drugs (QOL-ACD)] and the SF-36®, a comprehensive survey of patient health) among 13 patients (seven women) aged ≥80 years with lymphoma who received reduced-intensity chemotherapy at 4-week intervals at Kyushu University Beppu Hospital between June 2022 and August 2023. Patients were assessed at baseline, in the middle of the protocol, at the end of the protocol, and 6 months after the end of the protocol. The overall response rate was 69%. Almost all severe adverse events (10 patients) occurred during early cycles (cycles 1-2). Common adverse events included hematological toxicities such as neutropenia (10 patients). The daily activity (p = 0.048) and social attitude (p = 0.027) scores of the QOL-ACD and the general health perception (p = 0.044) and social functioning (p = 0.030) scores of the SF-36® were significantly improved during and after chemotherapy. Reduced-dose chemotherapy, if implemented before treatment selection, might permit evaluations of QOL in older patients aged ≥80 years; further investigation is warranted.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka 810-0065, Japan; or ; Tel.: +81-977-27-1600; Fax: +81-977-27-1641
- Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumihara, Tsurumi, Beppu 874-0838, Japan
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9
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Gini G, Tani M, Tucci A, Marcheselli L, Cesaretti M, Bellei M, Pascarella A, Ballerini F, Petrini M, Merli F, Olivieri A, Lanza F, Annibali O, Zilioli VR, Liberati AM, Tisi MC, Arcari A, Marino D, Musuraca G, Pavone V, Fabbri A, Pozzi S, Mannina D, Plenteda C, Celli M, Luminari S. Lenalidomide plus rituximab for the initial treatment of frail older patients with DLBCL: the FIL_ReRi phase 2 study. Blood 2023; 142:1438-1447. [PMID: 37418685 DOI: 10.1182/blood.2022019173] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 06/09/2023] [Accepted: 06/09/2023] [Indexed: 07/09/2023] Open
Abstract
Treatment of diffuse large B-cell lymphoma (DLBCL) in older patients is challenging, especially for those who are not eligible for anthracycline-containing regimens. Fondazione Italiana Linfomi (FIL) started the FIL_ReRi study, a 2-stage single-arm trial to investigate the activity and safety of the chemo-free combination of rituximab and lenalidomide (R2) in ≥70-year-old untreated frail patients with DLBCL. Frailty was prospectively defined using a simplified geriatric assessment tool. Patients were administered a maximum of 6 28-day cycles of 20 mg oral lenalidomide from days 2 to 22 and IV rituximab 375 mg/m2 on day 1, with response assessment after cycles 4 and 6. Patients with partial response or complete response (CR) at cycle 6 were administered lenalidomide 10 mg/d from days 1 to 21 for every 28 cycles for a total of 12 cycles or until progression or unacceptable toxicity. The primary end point was the overall response rate (ORR) after cycle 6; the coprimary end point was the rate of grade 3 or 4 extrahematological toxicity. The ORR was 50.8%, with 27.7% CR. After a median follow-up of 24 months, the median progression-free survival was 14 months, and the 2-year duration of response was 64%. Thirty-four patients experienced extrahematological toxicity according to the National Cancer Institute Common Terminology Criteria for Adverse Events grade ≥3. The activity of the R2 combination was observed in a significant proportion of subjects, warranting further exploration of a chemo-free approach in frail older patients with DLBCL. This trial was registered at EudraCT as #2015-003371-29 and clinicaltrials.gov as #NCT02955823.
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Affiliation(s)
- Guido Gini
- Struttura Organizzativa Dipartimentale di Clinica Ematologica, Azienda Ospedaliero Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Monica Tani
- Unità di Ematologia, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Alessandra Tucci
- Unità di Ematologia, Azienda Socio Sanitaria Territoriale Spedali Civili di Brescia, Brescia, Italy
| | - Luigi Marcheselli
- Uffici Studi Fondazione Italiana Linfomi, sede di Modena, Modena, Italy
| | - Marina Cesaretti
- Uffici Studi Fondazione Italiana Linfomi, sede di Modena, Modena, Italy
| | - Monica Bellei
- Uffici Studi Fondazione Italiana Linfomi, sede di Modena, Modena, Italy
| | - Anna Pascarella
- Unità Operativa Complessa di Ematologia, Ospedale dell'Angelo, Venice-Mestre, Italy
| | - Filippo Ballerini
- Clinica Ematologica, IRCCS Ospedale Policlinico San Martino, Università di Genova, Genoa, Italy
| | - Mauro Petrini
- Struttura Organizzativa Dipartimentale di Clinica Ematologica, Azienda Ospedaliero Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Francesco Merli
- Ematologia, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy
| | - Attilio Olivieri
- Struttura Organizzativa Dipartimentale di Clinica Ematologica, Azienda Ospedaliero Universitaria delle Marche, Università Politecnica delle Marche, Ancona, Italy
| | - Francesco Lanza
- Unità di Ematologia, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Ombretta Annibali
- Unità di Ematologia e Trapianto di Cellule Staminali, Università Campus Bio-Medico, Rome, Italy
| | - Vittorio Ruggero Zilioli
- Divisione di Ematologia, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Anna Marina Liberati
- Struttura Complessa di Oncoematologia e Autotrapianto, Azienda Ospedaliera Santa Maria, Università degli Studi di Perugia, Terni, Italy
| | - Maria Chiara Tisi
- Ematologia, Ospedale San Bortolo, Azienda Unità Sanitaria Locale Socio Sanitaria 8 "Berica," Vicenza, Italy
| | - Annalisa Arcari
- Unità di Ematologia, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Dario Marino
- Oncologia 1, Istituto Oncologico Veneto IRCCS, Padua, Italy
| | - Gerardo Musuraca
- Ematologia, IRCCS Istituto Romagnolo per lo Studio dei Tumori, Meldola, Italy
| | - Vincenzo Pavone
- Unità Operativa Complessa di Ematologia e Trapianto, Ospedale Pia Fondazione Cardinale Panico, Tricase, Italy
| | - Alberto Fabbri
- Unità di Ematologia, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Samantha Pozzi
- Dipartimento di Scienze Mediche e Chirurgiche Materno-Infantili e dell'Adulto, Università di Modena e Reggio Emilia, Centro Oncologico, Modena, Italy
| | - Donato Mannina
- Dipartimento di Oncoematologia, Ospedale Papardo, Messina, Italy
| | - Caterina Plenteda
- Unità Operativa di Ematologia e Centro Trapianti di Midollo Osseo, Azienda Ospedaliero Universitaria di Parma, Parma, Italy
| | - Melania Celli
- Unità Operativa di Ematologia, Ospedale degli Infermi, Rimini, Italy
| | - Stefano Luminari
- Ematologia, Azienda Unità Sanitaria Locale - IRCCS, Reggio Emilia, Italy
- Dipartimento Chirurgico, Medico, Odontoiatrico e di Scienze Morfologiche con interesse Trapiantologico, Oncologico e di Medicina Rigenerativa, Università di Modena e Reggio Emilia, Reggio Emilia, Italy
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10
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Isbell LK, Uibeleisen R, Friedl A, Burger E, Dopatka T, Scherer F, Orban A, Lauer E, Malenica N, Semenova I, Vreden A, Valk E, Wendler J, Neumaier S, Fricker H, El Rabih AAH, Gloggengießer C, Hilbig D, Bleul S, Weis J, Gmehlin D, Backenstrass M, Wirtz S, Ihorst G, Finke J, Illerhaus G, Schorb E. Age-adjusted high-dose chemotherapy followed by autologous stem cell transplantation or conventional chemotherapy with R-MP as first-line treatment in elderly primary CNS lymphoma patients - the randomized phase III PRIMA-CNS trial. BMC Cancer 2023; 23:767. [PMID: 37596517 PMCID: PMC10436648 DOI: 10.1186/s12885-023-11193-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 07/19/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Older primary central nervous system lymphoma (PCNSL) patients have an inferior prognosis compared to younger patients because available evidence on best treatment is scarce and treatment delivery is challenging due to comorbidities and reduced performance status. High-dose chemotherapy and autologous stem cell transplantation (HCT-ASCT) after high-dose methotrexate (MTX)-based immuno-chemotherapy has become an increasingly used treatment approach in eligible elderly PCNSL patients with promising feasibility and efficacy, but has not been compared with conventional chemotherapy approaches. In addition, eligibility for HCT-ASCT in elderly PCNSL is not well defined. Geriatric assessment (GA) may be helpful in selecting patients for the best individual treatment choice, but no standardized GA exists to date. A randomized controlled trial, incorporating a GA and comparing age-adapted HCT-ASCT treatment with conventional chemotherapy is needed. METHODS This open-label, multicenter, randomized phase III trial with two parallel arms will recruit 310 patients with newly diagnosed PCNSL > 65 years of age in 40 centers in Germany and Austria. The primary objective is to demonstrate that intensified chemotherapy followed by consolidating HCT-ASCT is superior to conventional chemotherapy with rituximab, MTX, procarbazine (R-MP) followed by maintenance with procarbazine in terms of progression free survival (PFS). Secondary endpoints include overall survival (OS), event free survival (EFS), (neuro-)toxicity and quality of life (QoL). GA will be conducted at specific time points during the course of the study. All patients will be treated with a pre-phase rituximab-MTX (R-MTX) cycle followed by re-assessment of transplant eligibility. Patients judged transplant eligible will be randomized (1:1). Patients in arm A will be treated with 3 cycles of R-MP followed by maintenance therapy with procarbazine for 6 months. Patients in arm B will be treated with 2 cycles of MARTA (R-MTX/AraC) followed by busulfan- and thiotepa-based HCT-ASCT. DISCUSSION The best treatment strategy for elderly PCNSL patients remains unknown. Treatments range from palliative to curative but more toxic therapies, and there is no standardized measure to select patients for the right treatment. This randomized controlled trial will create evidence for the best treatment strategy with the focus on developing a standardized GA to help define eligibility for an intensive treatment approach. TRIAL REGISTRATION German clinical trials registry DRKS00024085 registered March 29, 2023.
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Affiliation(s)
- Lisa K Isbell
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Roswitha Uibeleisen
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Alexander Friedl
- Department of Endocrinology, Diabetology and Geriatrics, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Elvira Burger
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Tatja Dopatka
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Florian Scherer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Andras Orban
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Eliza Lauer
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Natalie Malenica
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Inna Semenova
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Annika Vreden
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Elke Valk
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Julia Wendler
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Simone Neumaier
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Heidi Fricker
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Abed Al Hadi El Rabih
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Cora Gloggengießer
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Daniela Hilbig
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Sabine Bleul
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Joachim Weis
- Endowed Professorship Self-Help Research, Comprehensive Cancer Center, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Dennis Gmehlin
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Matthias Backenstrass
- Institute for Clinical Psychology, Klinikum Stuttgart, Prießnitzweg 24, 70374, Bad Cannstatt, Germany
| | - Sebastian Wirtz
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Jürgen Finke
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Elisabeth Schorb
- Department Medicine I, Faculty of Medicine, Medical Center-University of Freiburg, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany.
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11
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Lee B, Pierpont T, August A, Richards K. Monoclonal antibodies binding to different epitopes of CD20 differentially sensitize DLBCL to different classes of chemotherapy. Front Oncol 2023; 13:1159484. [PMID: 37601699 PMCID: PMC10436104 DOI: 10.3389/fonc.2023.1159484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 07/04/2023] [Indexed: 08/22/2023] Open
Abstract
Introduction Rituximab (R), an anti-CD20 monoclonal antibody (mAb) and the world's first approved antibody for oncology patients, was combined with the CHOP chemotherapy regimen and markedly improved the prognosis of all B- cell-derived lymphomas, the most common hematological malignancy worldwide. However, there is a 35% disease recurrence with no advancement in the first-line treatment since R was combined with the archetypal CHOP chemotherapy regimen nearly 30 years ago. There is evidence that R synergizes with chemotherapy, but the pharmacological interactions between R and CHOP or between newer anti-CD20 mAbs and CHOP remain largely unexplored. Methods We used in vitro models to score pharmacological interactions between R and CHOP across various lymphoma cell lines. We compared these pharmacological interactions to ofatumumab, a second-generation anti-CD20 mAb, and CHOP. Lastly, we used RNA-sequencing to characterize the transcriptional profiles induced by these two antibodies and potential molecular pathways that mediate their different effects. Results We discovered vast heterogeneity in the pharmacological interactions between R and CHOP in a way not predicted by the current clinical classification. We then discovered that R and ofatumumab differentially synergize with the cytotoxic and cytostatic capabilities of CHOP in separate distinct subsets of B-cell lymphoma cell lines, thereby expanding favorable immunochemotherapy interactions across a greater range of cell lines beyond those induced by R-CHOP. Lastly, we discovered these two mAbs differentially modulate genes enriched in the JNK and p38 MAPK family, which regulates apoptosis and proliferation. Discussion Our findings were completely unexpected because these mAbs were long considered to be biological and clinical equivalents but, in practice, may perform better than the other in a patient-specific manner. This finding may have immediate clinical significance because both immunochemotherapy combinations are already FDA-approved with no difference in toxicity across phase I, II, and III clinical trials. Therefore, this finding could inform a new precision medicine strategy to provide additional therapeutic benefit to patients with B-cell lymphoma using immunochemotherapy combinations that already meet the clinical standard of care.
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Affiliation(s)
- Brian Lee
- Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, IL, United States
| | - Tim Pierpont
- Department of Microbiology and Immunology, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Avery August
- Department of Microbiology and Immunology, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Kristy Richards
- Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
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12
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Chan JY, Somasundaram N, Grigoropoulos N, Lim F, Poon ML, Jeyasekharan A, Yeoh KW, Tan D, Lenz G, Ong CK, Lim ST. Evolving therapeutic landscape of diffuse large B-cell lymphoma: challenges and aspirations. Discov Oncol 2023; 14:132. [PMID: 37466782 PMCID: PMC10361453 DOI: 10.1007/s12672-023-00754-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 07/13/2023] [Indexed: 07/20/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) represents the commonest subtype of non-Hodgkin lymphoma and encompasses a group of diverse disease entities, each harboring unique molecular and clinico-pathological features. The understanding of the molecular landscape of DLBCL has improved significantly over the past decade, highlighting unique genomic subtypes with implications on targeted therapy. At the same time, several new treatment modalities have been recently approved both in the frontline and relapsed settings, ending a dearth of negative clinical trials that plagued the past decade. Despite that, in the real-world setting, issues like drug accessibility, reimbursement policies, physician and patient preference, as well as questions regarding optimal sequencing of treatment options present difficulties and challenges in day-to-day oncology practice. Here, we review the recent advances in the therapeutic armamentarium of DLBCL and discuss implications on the practice landscape, with a particular emphasis on the context of the healthcare system in Singapore.
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Affiliation(s)
- Jason Yongsheng Chan
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore.
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
| | - Nagavalli Somasundaram
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
| | - Nicholas Grigoropoulos
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Francesca Lim
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Department of Haematology, Singapore General Hospital, Singapore, Singapore
| | - Michelle Limei Poon
- Department of Haematology, National University Cancer Institute, Singapore, Singapore
| | - Anand Jeyasekharan
- Cancer Science Institute of Singapore, National University of Singapore, Singapore, Singapore
- Department of Haematology-Oncology, National University Cancer Institute, Singapore, Singapore
| | - Kheng Wei Yeoh
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore
- Division of Radiation Oncology, National University Cancer Institute, Singapore, Singapore
| | - Daryl Tan
- Mount Elizabeth Novena Hospital, Singapore, Singapore
| | - Georg Lenz
- Department of Medicine A, Department of Hematology, Oncology and Pneumology, University Hospital Münster, Münster, Germany
| | - Choon Kiat Ong
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
- Lymphoma Genomic Translational Research Laboratory, Cellular and Molecular Research, National Cancer Centre Singapore, Singapore, Singapore.
| | - Soon Thye Lim
- Division of Medical Oncology, National Cancer Centre Singapore, 30 Hospital Blvd, Singapore, 168583, Singapore.
- Cancer and Stem Cell Biology, Duke-NUS Medical School, National Cancer Centre Singapore, 8 College Road, Singapore, 169857, Singapore.
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13
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Arcari A, Cavallo F, Puccini B, Vallisa D. New treatment options in elderly patients with Diffuse Large B-cell Lymphoma. Front Oncol 2023; 13:1214026. [PMID: 37465115 PMCID: PMC10351275 DOI: 10.3389/fonc.2023.1214026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 05/18/2023] [Indexed: 07/20/2023] Open
Abstract
Most patients with Diffuse Large B-cell Lymphoma (DLBCL) are old (>65 years of age) and this population is expected to increase in the following years. A simplified geriatric assessment based on a careful evaluation of the fitness status and comorbidities is essential to choose the correct intensity of treatment. Fit older patients can benefit from a standard immunochemotherapy, while unfit/frail patients frequently need reduced doses or substitution of particular agents with less toxic ones. This review focuses on new therapies (e.g., polatuzumab vedotin, tafasitamab, bispecific antibodies) that have indicated promising results in relapsed/refractory patients, particularly in cases not eligible to transplant. Some of these new drugs have been tested as single agents or in combinations as first-line treatment, aiming to improve the outcome of the traditional chemotherapy. If preliminary efficacy and safety data are confirmed in future clinical trials, a chemo-free immunotherapic approach could become an alternative option to offer a curative treatment even in frail patients.
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Affiliation(s)
- Annalisa Arcari
- Hematology and Bone Marrow Transplant Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/Azienda Ospedaliera Universitaria (AOU) Città della Salute e della Scienza di Torino, Torino, Italy
| | - Benedetta Puccini
- Hematology Department, University of Florence and Azienda Ospedaliera Universitaria (AOU) Careggi, Firenze, Italy
| | - Daniele Vallisa
- Hematology and Bone Marrow Transplant Unit, Guglielmo da Saliceto Hospital, Piacenza, Italy
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Di M, Keeney T, Belanger E, Huntington SF, Olszewski AJ, Panagiotou OA. Functional status and therapy for older adults with diffuse large B-cell lymphoma in nursing homes: A population-based study. J Am Geriatr Soc 2023; 71:2239-2249. [PMID: 36882865 PMCID: PMC10483014 DOI: 10.1111/jgs.18302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 01/20/2023] [Accepted: 01/28/2023] [Indexed: 03/09/2023]
Abstract
OBJECTIVES To characterize the prevalence of functional and cognitive impairments, and associations between impairments and treatment among older patients with diffuse large B cell lymphoma (DLBCL) receiving nursing home (NH) care. METHODS We used the Surveillance, Epidemiology, and End Results-Medicare database to identify beneficiaries diagnosed with DLBCL 2011-2015 who received care in a NH within -120 ~ +30 days of diagnosis. Multivariable logistic regression was used to compare receipt of chemoimmunotherapy (including multi-agent, anthracycline-containing regimens), 30-day mortality, and hospitalization between NH and community-dwelling patients, estimating odds ratios (OR) and 95% confidence interval (CI). We also examined overall survival (OS). Among NH patients, we examined receipt of chemoimmunotherapy based on functional and cognitive impairment. RESULTS Of the eligible 649 NH patients (median age: 82 years), 45% received chemoimmunotherapy; among the recipients, 47% received multi-agent, anthracycline-containing regimens. Compared with community-dwelling patients, those in a NH were less likely to receive chemoimmunotherapy (OR: 0.34, 95%CI: 0.29-0.41), had higher 30-day mortality (OR: 2.00, 95%CI: 1.43-2.78) and hospitalization (OR: 1.51, 95%CI: 1.18-1.93), and poorer OS (hazard ratio: 1.36, 95%CI: 1.11-1.65). NH patients with severe functional (61%) or any cognitive impairment (48%) were less likely to receive chemoimmunotherapy. CONCLUSIONS High rates of functional and cognitive impairment and low rates of chemoimmunotherapy were observed among NH residents diagnosed with DLBCL. Further research is needed to better understand the potential role of novel and alternative treatment strategies and patient preferences for treatment to optimize clinical care and outcomes in this high-risk population.
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Affiliation(s)
- Mengyang Di
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Tamra Keeney
- Center for Aging and Serious Illness, Massachusetts General Hospital, Mongan Institute, Boston, Massachusetts, USA
- Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Services, Policy and Practice, Brown University Health School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Emmanuelle Belanger
- Department of Services, Policy and Practice, Brown University Health School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Scott F. Huntington
- Department of Hematology/Oncology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J. Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Orestis A. Panagiotou
- Department of Services, Policy and Practice, Brown University Health School of Public Health, Providence, Rhode Island, USA
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA
- Department of Epidemiology, Brown University School of Public Health, Providence, Rhode Island, USA
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15
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Amanda M, Daniela C, Fernando G, Silvia M, Sofia L, Márcia D, Francisco A, Jeane V, Cármino DS. Association of KIR genes polymorphism and its HLA ligands in Diffuse Large B-cell Lymphoma. CLINICAL LYMPHOMA MYELOMA AND LEUKEMIA 2023; 23:438-445. [PMID: 37105848 DOI: 10.1016/j.clml.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 02/18/2023] [Accepted: 03/02/2023] [Indexed: 03/11/2023]
Abstract
INTRODUCTION Non-Hodgkin lymphoma (NHL) is a heterogeneous disease, with each subtype associated with different risk factors. Within this group, diffuse large B-cell lymphoma (DLBCL) can be highlighted, the most common type of NHL.NK cells are key components of the innate immune response and may play an important antitumor role. OBJECTIVE The objective of the present work was to determine the polymorphism of KIR genes in Brazilian patients with DLBCL. MATERIALS AND METHODS Furthermore, we evaluated the association between the polymorphism of these genes and their ligands with the clinical course of the disease. For the study, 112 patients with DLBCL and 222 voluntary blood and bone marrow donors. The genetic material of these samples were extracted for KIR and HLA typing, determination of HLA ligands, determination of the KIR haplotype and search for the deletion of 22 bp in the KIR2DS4 gene. KIR genotype distributions were made by direct counting using 2 × 2 contingency tables using Fisher's exact test. The magnitude of the association was measured by odds ratio (OR) and 95% confidence interval. P values <.05 were considered significant. Overall survival and progression-free survival were assessed with a Kaplan-Meier estimator. RESULTS In the present study, an association of HLA-Bw4 and HLA-Bw480I ligand was found with more advanced stages of the disease. Also, an association of the KIR2DL3 gene with a better response to treatment was found. CONCLUSION With this, we can conclude that the polymorphism of KIR genes and the association with HLA ligands can influence the prognosis of DLBCL, as well as the response to treatment was found. With this, we can conclude that the polymorphism of KIR genes and the association with HLA ligands can influence the prognosis of DLBCL, as well as the response to treatment.Non-Hodgkin lymphoma (NHL) is a heterogeneous disease, with each subtype associated with different risk factors. Within this group, diffuse large B-cell lymphoma (DLBCL) can be highlighted, the most common type of NHL.NK cells are key components of the innate immune response and may play an important antitumor role. The objective of the present work was to determine the polymorphism of KIR genes in Brazilian patients with DLBCL. Furthermore, we evaluated the association between the polymorphism of these genes and their ligands with the clinical course of the disease. For the study, 112 patients with DLBCL and 222 voluntary blood and bone marrow donors. The genetic material of these samples were extracted for KIR and HLA typing, determination of HLA ligands, determination of the KIR haplotype and search for the deletion of 22 bp in the KIR2DS4 gene. KIR genotype distributions were made by direct counting using 2 × 2 contingency tables using Fisher's exact test. The magnitude of the association was measured by odds ratio (OR) and 95% confidence interval. P values <.05 were considered significant. Overall survival and progression-free survival were assessed with a Kaplan-Meier estimator. In the present study, an association of HLA-Bw4 and HLA-Bw480I ligand was found with more advanced stages of the disease. Also, an association of the KIR2DL3 gene with a better response to treatment was found. With this, we can conclude that the polymorphism of KIR genes and the association with HLA ligands can influence the prognosis of DLBCL, as well as the response to treatment was found. With this, we can conclude that the polymorphism of KIR genes and the association with HLA ligands can influence the prognosis of DLBCL, as well as the response to treatment.
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16
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Wang Y, Ren X, Huang K, Liang X, Pu L, Hu L, Zhai Z. Comparison of first-line treatments for elderly patients with diffuse large B-cell lymphoma: A systematic review and network meta-analysis. Front Immunol 2023; 13:1082293. [PMID: 36685597 PMCID: PMC9845876 DOI: 10.3389/fimmu.2022.1082293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 12/12/2022] [Indexed: 01/05/2023] Open
Abstract
Background The incidence of DLBCL in elderly patients has been gradually increased. Considering their comorbidities and performance status, the first-line standard treatment hasn't been determined for the elderly. Methods We performed a systemic review and network meta-analysis to compare the efficacy and safety of all eligible regimens as first line treatment for elderly patients with DLBCL. We searched PubMed, Cochrane Library, and Embase Library proceedings up to March 2022. Results Our search yielded thirteen trials including 1839 patients. R2CHOP21 showed the best PFS with a statistical difference and the most favorable OS without a statistical difference. RCOMP showed the most clinical benefits in EFS, CR and OR with no significant difference. The point estimate was in favored improved DFS with RCHOP14 than RCHOP21, although this was not statistically significant. In a subgroup analysis concerning 3-4 grade AEs revealed R-COMP was associated with a decrease in grade III/IV neutropenia and cardiac toxic events; RminiCEOP was associated with the lower rates of 3-4 grade anemia, thrombocytopenia and infection; RCHOP21 had the lowest rate of 3-4 grade AE of neurotoxicity. Conclusion The findings of our meta-analysis indicated that R2CHOP21 provided the best disease control in PFS and represented an optimal first-line treatment option in the elderly with DLBCL. Furthermore, RCOMP, RminiCEOP and RCHOP21 exhibited lower rates in different 3-4 grade AEs and might be reasonable treatment options in the elderly with poor general conditions.
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Affiliation(s)
| | | | | | | | | | - Linhui Hu
- *Correspondence: Zhimin Zhai, ; Linhui Hu,
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McCurry D, Flowers CR, Bermack C. Immune-based therapies in diffuse large B-cell lymphoma. Expert Opin Investig Drugs 2023; 32:479-493. [PMID: 37394970 DOI: 10.1080/13543784.2023.2230137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/23/2023] [Indexed: 07/04/2023]
Abstract
INTRODUCTION Diffuse large B-cell lymphoma (DLBCL) is an aggressive and clinically heterogeneous malignancy originating from B-cells with up to 40% of patients experiencing primary refractory disease or relapse after first-line treatment. However, the past 5 years have seen a flurry of new drug approvals for DLBCL anchored upon new immune therapies, including chimeric antigen receptor (CAR) T-cells and antibody-based therapies. AREAS COVERED This article summarizes recent advances in the treatment of DLBCL, including in the first line and relapsed and refractory setting (second-line and beyond). A literature search was conducted for publications relevant to the immunotherapeutic approach to DLBCL from 2000 through March 2023 within PubMed and articles were reviewed. The search terms were immunotherapy, monoclonal antibodies, chimeric antigen receptor modified T-cell (CAR-T), and classification of DLBCL. Relevant clinical trials and pre-clinical studies exploring the strengths and weaknesses of current immune therapies against DLBCL were chosen. We additionally explored how intrinsic differences amongst DLBCL subtype biology and endogenous host immune recruitment contribute to variable therapeutic efficacy. EXPERT OPINION Future treatments will minimize chemotherapy exposure and be chosen by underlying tumor biology, paving the way for the promise of chemotherapeutic free regimens and improved outcomes for poor-risk subgroups.
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Affiliation(s)
- Dustin McCurry
- Oncology Fellow, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Christopher R Flowers
- Division Head Ad Interim of Cancer Medicine, Chair and Professor of the Department of Lymphoma-Myeloma, The University of Texas MD Anderson Cancer Center, Houston, USA
| | - Casey Bermack
- Oncology Fellow, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA
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Hiroi T, Hosoi H, Kuriyama K, Murata S, Morimoto M, Mushino T, Nishikawa A, Tamura S, Sonoki T. An evaluation based on relative treatment intensity in older patients treated with reduced-dose R-THP-COP therapy for diffuse large B-cell lymphoma: A multicenter retrospective cohort study. J Geriatr Oncol 2023; 14:101396. [PMID: 36328877 DOI: 10.1016/j.jgo.2022.10.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 09/14/2022] [Accepted: 10/18/2022] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The number of older patients with diffuse large B-cell lymphoma (DLBCL) is increasing. Although the standard treatment for newly diagnosed younger patients with DLBCL has been established, no consensus has been reached regarding the optimal chemotherapy intensity and regimen for older patients with DLBCL. In addition, no method for evaluating treatment intensity in retrospective studies when different numbers of chemotherapy courses are administered has been elucidated. MATERIALS AND METHODS A multicenter retrospective analysis was conducted to evaluate the outcomes of a reduced-dose R-THP-COP regimen, which included 30 mg/m2 of pirarubicin, in 54 patients with DLBCL who were aged ≥75. To assess treatment intensity, we defined the relative treatment intensity (RTI) as the number of courses administered multiplied by the relative dose intensity (RDI). RESULTS The estimated four-year overall survival rates (OS) of the patients aged 75-80 and ≥ 80 were 55.1% and 60.6%, respectively. There was no significant difference in four-year OS between these age groups. In our cohort, there was no significant difference in the estimated four-year OS between the patients who received reduced-dose R-THP-COP at an RDI of ≥61% and those that received it at an RDI of <61% (P = 0.35). On the other hand, the patients who received reduced-dose R-THP-COP at an RTI of ≥2.7 exhibited a significantly higher estimated four-year OS than those treated at an RTI of <2.7 (68.5% vs. 28.7%; P < 0.001). Multivariate analysis revealed that the RTI was a significant independent predictor of OS. The cumulative incidence of treatment-related mortality (TRM) at one year was 4.2% and 3.4% in the 75-80 and ≥ 80 age groups, respectively. The cumulative incidence of TRM was significantly worse among the patients with Charlson Comorbidity Index (CCI) scores of ≥2 than among those with CCI scores of 0 or 1. DISCUSSION Our study suggests that the reduced-dose R-THP-COP regimen is a suitable treatment option for older patients with DLBCL, especially those with CCI scores of <2. Our study also showed that the RTI may be a valuable tool for assessing treatment intensity in retrospective studies involving older patients.
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Affiliation(s)
- Takayuki Hiroi
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Internal Medicine, Kainan Municipal Medical Center, Wakayama, Japan
| | - Hiroki Hosoi
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Internal Medicine, Kainan Municipal Medical Center, Wakayama, Japan.
| | - Kodai Kuriyama
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Internal Medicine, Kainan Municipal Medical Center, Wakayama, Japan; Department of Hematology, Japanese Red Cross Kyoto Daiichi Hospital, Kyoto, Japan
| | - Shogo Murata
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Masaya Morimoto
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Hematology, Kinan Hospital, Wakayama, Japan
| | - Toshiki Mushino
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Hematology, Kinan Hospital, Wakayama, Japan
| | - Akinori Nishikawa
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
| | - Shinobu Tamura
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan; Department of Hematology, Kinan Hospital, Wakayama, Japan
| | - Takashi Sonoki
- Department of Hematology/Oncology, Wakayama Medical University, Wakayama, Japan
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19
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Sekiguchi Y, Tsutsumi H, Gomyo A, Kudo M, Iizaki Y, Maseki N, Kawamura M, Kobayashi K, Nishimura Y, Kanda H, Nitta H, Noguchi M, Kobayashi H. Use of R-mini-CHP in combination with polatuzumab vedotin (pola-R-mini-CHP) as the primary treatment in ≥80-year-old cases with diffuse large B-cell lymphoma. J Clin Exp Hematop 2023; 63:262-265. [PMID: 38148017 PMCID: PMC10861370 DOI: 10.3960/jslrt.23043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Affiliation(s)
| | - Hiroki Tsutsumi
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Ayumi Gomyo
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Masahisa Kudo
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Yoshie Iizaki
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Nobuo Maseki
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
| | - Machiko Kawamura
- Department of Hematology, Saitama Cancer Center, Saitama, Japan
- Department of Clinical Laboratory Medicine, Saitama Cancer Center, Saitama, Japan
| | - Kazuhiko Kobayashi
- Department of Inspection Engineering, Saitama Cancer Center, Saitama, Japan
| | - Yu Nishimura
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
| | - Hiroaki Kanda
- Department of Pathology, Saitama Cancer Center, Saitama, Japan
| | - Hideaki Nitta
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
| | - Masaaki Noguchi
- Department of Hematology, Juntendo University Urayasu Hospital, Chiba, Japan
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20
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Vodicka P, Klener P, Trneny M. Diffuse Large B-Cell Lymphoma (DLBCL): Early Patient Management and Emerging Treatment Options. Onco Targets Ther 2022; 15:1481-1501. [PMID: 36510607 PMCID: PMC9739046 DOI: 10.2147/ott.s326632] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/29/2022] [Indexed: 12/07/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) represents a curable disease with a 60-70% chance of cure with current R-CHOP chemoimmunotherapy. However, 30-40% of patients are refractory or relapsing. Many attempts failed to improve the outcome of DLBCL patients, including the intensification of R-CHOP regimen, consolidation, or maintenance therapy since the introduction of R-CHOP in 2000. Better understanding of both molecular biology of lymphoma cells and the tumor microenvironment raised the hope for future improvement of DLBCL patients' survival. Novel molecular findings have initiated clinical trials exploring targeted therapy based on driver genetic alterations with an intent to improve survival of high-risk subsets of patients. But the preliminary results remain ambiguous. The approach "agnostic" to specific molecular alterations of lymphoma cell includes antibody-drug conjugates (especially polatuzumab vedotin), immunotherapy comprising different antibodies with immunomodulatory effect (tafasitamab, lenalidomide), and T-cell engaging therapy (bispecific antibodies, early use of CAR T-cell). This approach could increase the cure rates and change the current therapeutic paradigm. However, better prognostic stratification, smarter designs of clinical trials, modification of endpoints including the use of ctDNA are needed. This review covers the complexity of DLBCL management.
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Affiliation(s)
- Prokop Vodicka
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Pavel Klener
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Marek Trneny
- First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic,Correspondence: Marek Trneny, First Department of Medicine, First Faculty of Medicine, Charles University and General University Hospital, U Nemocnice 499/2, Prague, 128 08, Czech Republic, Tel +420 224 96 25 27, Fax +420 224 96 35 56, Email
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21
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First-line Treatment With Bendamustine and Rituximab for Old and Frail Patients With Aggressive Lymphoma: Results of the B-R-ENDA Trial. Hemasphere 2022; 6:e808. [PMID: 36479544 PMCID: PMC9722574 DOI: 10.1097/hs9.0000000000000808] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 10/31/2022] [Indexed: 01/24/2023] Open
Abstract
The incidence of aggressive B-cell lymphomas increases with age, but for elderly or frail patients not eligible for doxorubicin-containing treatment standard therapy remains to be defined. In this prospective, multicenter, phase-2 B-R-ENDA trial, we investigated the feasibility, toxicity, and efficacy of 8 cycles rituximab combined with 6 cycles bendamustine (BR) in elderly or frail aggressive B-cell lymphoma patients: 39 patients aged >80 years and 29 patients aged 61-80 years with elevated Cumulative Illness Rating Scalescore >6 were included. Progression-free survival (PFS) and overall survival (OS) at 2 years were 45% (95% confidence interval [CI], 28%-61%) and 46% (28%-63%) for the patients age >80, as well 32% (13%-51%) and 37% (17%-57%) for frail patients age 64-80, respectively. In a preplanned retrospective analysis, we found no significant differences in PFS and OS comparing the outcome of the 39 patients age >80 years with 40 patients aged 76-80 years treated with 6xR-CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone) and 2 x rituximab in the RICOVER-60 trial (DSHNHL 1999-1, NCT00052936, EU-20243), yet we detected lower rates of infections and treatment-related deaths in the BR-treated patients. We demonstrate that older and frail patients with aggressive B-cell lymphoma who are not able to receive standard CHOP-based therapy can benefit from anthracycline-free therapy as a feasible and effective therapeutic option.
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22
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Destroying the Shield of Cancer Stem Cells: Natural Compounds as Promising Players in Cancer Therapy. J Clin Med 2022; 11:jcm11236996. [PMID: 36498571 PMCID: PMC9737492 DOI: 10.3390/jcm11236996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/21/2022] [Accepted: 11/24/2022] [Indexed: 11/29/2022] Open
Abstract
In a scenario where eco-sustainability and a reduction in chemotherapeutic drug waste are certainly a prerogative to safeguard the biosphere, the use of natural products (NPs) represents an alternative therapeutic approach to counteract cancer diseases. The presence of a heterogeneous cancer stem cell (CSC) population within a tumor bulk is related to disease recurrence and therapy resistance. For this reason, CSC targeting presents a promising strategy for hampering cancer recurrence. Increasing evidence shows that NPs can inhibit crucial signaling pathways involved in the maintenance of CSC stemness and sensitize CSCs to standard chemotherapeutic treatments. Moreover, their limited toxicity and low costs for large-scale production could accelerate the use of NPs in clinical settings. In this review, we will summarize the most relevant studies regarding the effects of NPs derived from major natural sources, e.g., food, botanical, and marine species, on CSCs, elucidating their use in pre-clinical and clinical studies.
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23
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Wendler J, Fox CP, Valk E, Steinheber C, Fricker H, Isbell LK, Neumaier S, Okosun J, Scherer F, Ihorst G, Cwynarski K, Schorb E, Illerhaus G. Optimizing MATRix as remission induction in PCNSL: de-escalated induction treatment in newly diagnosed primary CNS lymphoma. BMC Cancer 2022; 22:971. [PMID: 36088292 PMCID: PMC9464101 DOI: 10.1186/s12885-022-09723-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Primary diffuse large B-cell lymphoma (DLBCL) of the central nervous system (PCNSL) is a rare disorder with an increasing incidence over the past decades. High-level evidence has been reported for the MATRix regimen (high-dose methotrexate (HD-MTX), high-dose AraC (HD-AraC), thiotepa and rituximab) followed by high-dose chemotherapy and autologous stem cell transplantation (HCT-ASCT) supporting this approach to be considered a standard therapy in newly diagnosed PCNSL patients ≤ 70 years. However, early treatment-related toxicities (predominantly infectious complications), occurring in up to 28% per MATRix cycle, diminish its therapeutic success. Furthermore, sensitivity to first-line treatment is an independent prognostic factor for improved overall survival (OS) in PCNSL. Thus, patients achieving early partial remission (PR) after 2 cycles of MATRix might be over-treated with 4 cycles, in the context of consolidation HCT-ASCT. METHODS This is an open-label, multicentre, randomized phase III trial with two parallel arms. 326 immunocompetent patients with newly diagnosed PCNSL will be recruited from 37 German, 1 Austrian and 12 UK sites. Additional IELSG (International Extranodal Lymphoma Study Group) sites are planned. The objective is to demonstrate superiority of a de-escalated and optimised remission induction treatment strategy, followed by HCT-ASCT. Randomization (1:1) will be performed after completion of all screening procedures. Patients in Arm A (control treatment) will receive 4 cycles of MATRix. Patients in Arm B (experimental treatment) will receive a pre-phase (R/HD-MTX), followed by 2 cycles of MATRix. Patients in both arms achieving PR or better will proceed to HCT-ASCT (BCNU, thiotepa). The primary endpoint of the study is event-free-survival (EFS), defined as time from randomization to premature end of treatment due to any reason, lymphoma progression or death whichever occurs first. Secondary endpoints include OS, progression free survival (PFS), toxicity, neurocognitive impairment and quality of life. Minimal follow-up is 24 months. DISCUSSION Current treatment options for PCNSL in patients ≤ 70 years have improved remarkably over recent years. However, the potential efficacy benefits are offset by an increased incidence of short-term toxicities which can impact on treatment delivery and hence on survival outcomes. In patients ≤ 70 years with newly diagnosed PCNSL addressing the need to reduce treatment-related toxicity by de-escalating and optimising the induction phase of treatment, is a potentially attractive treatment strategy. TRIAL REGISTRATION German clinical trials registry DRKS00022768 registered June 10th, 2021.
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Affiliation(s)
- Julia Wendler
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Christopher P Fox
- Russell Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, City Campus, Hucknall Road, Nottingham, NG5 1PB, UK
| | - Elke Valk
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Cora Steinheber
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Heidi Fricker
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Lisa K Isbell
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Simone Neumaier
- Stuttgart Cancer Center - Tumorzentrum Eva Mayer-Stihl, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany
| | - Jessica Okosun
- Centre for Haemato-Oncology, Barts Cancer Institute, Queen Mary University of London, London, UK
| | - Florian Scherer
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Elsässer Straße 2, 79110, Freiburg, Germany
| | - Kate Cwynarski
- Department of Haematology, University College of London Hospitals, NHS Foundation Trust, London, UK
| | - Elisabeth Schorb
- Department Medicine I, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Straße 55, 79106, Freiburg, Germany
| | - Gerald Illerhaus
- Clinic of Hematology, Oncology and Palliative Care, Klinikum Stuttgart, Kriegsbergstraße 60, 70174, Stuttgart, Germany.
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24
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Chemotherapy-free treatment in unfit patients aged 75 years and older with DLBCL: toward a new paradigm? THE LANCET. HEALTHY LONGEVITY 2022; 3:e453-e454. [PMID: 36102755 DOI: 10.1016/s2666-7568(22)00150-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/13/2022] [Indexed: 01/15/2023] Open
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25
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Papageorgiou SG, Thomopoulos TP, Liaskas A, Vassilakopoulos TP. Monoclonal Antibodies in the Treatment of Diffuse Large B-Cell Lymphoma: Moving beyond Rituximab. Cancers (Basel) 2022; 14:1917. [PMID: 35454825 PMCID: PMC9026383 DOI: 10.3390/cancers14081917] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/23/2022] Open
Abstract
Although rituximab has revolutionized the treatment of diffuse large B-cell lymphoma (DLBCL), a significant proportion of patients experience refractory disease or relapse early after the end of treatment. The lack of effective treatment options in the relapsed/refractory (R/R) setting had made the prognosis of these patients dismal. The initial enthusiasm for novel anti-CD20 antibodies had been short-lived as they failed to prove their superiority to rituximab. Therefore, research has focused on developing novel agents with a unique mechanism of action. Among them, two antibody-drug conjugates, namely polatuzumab vedotin (PolaV) and loncastuximab tesirine, along with tafasitamab, an anti-CD19 bioengineered antibody, have been approved for the treatment of R/R DLBCL. Whereas PolaV has been FDA and EMA approved, EMA has not approved loncastuximab tesirine and tafasitamab yet. Results from randomized trials, as well as real-life data for PolaV have been promising. Novel agents as bispecific antibodies bridging CD3 on T-cells to CD20 have shown very promising results in clinical trials and are expected to gain approval for treatment of R/R DLBCL soon. As the therapeutic armamentarium against DLBCL is expanding, an improvement in survival of patients with R/R and higher cure rates might soon become evident.
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Affiliation(s)
- Sotirios G. Papageorgiou
- Hematology Unit, Second Propaedeutic Department of Internal Medicine and Research Institute, School of Medicine, National and Kapodistrian University of Athens, University General Hospital “Attikon”, 18120 Athens, Greece; (S.G.P.); (T.P.T.)
| | - Thomas P. Thomopoulos
- Hematology Unit, Second Propaedeutic Department of Internal Medicine and Research Institute, School of Medicine, National and Kapodistrian University of Athens, University General Hospital “Attikon”, 18120 Athens, Greece; (S.G.P.); (T.P.T.)
| | - Athanasios Liaskas
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece;
| | - Theodoros P. Vassilakopoulos
- Department of Haematology and Bone Marrow Transplantation, National and Kapodistrian University of Athens, Laikon General Hospital, 11527 Athens, Greece;
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Paszkiewicz-Kozik E, Michalski W, Taszner M, Mordak-Domagała M, Romejko-Jarosińska J, Knopińska-Posłuszny W, Najda J, Borawska A, Chełstowska M, Świerkowska M, Dąbrowska-Iwanicka A, Malenda A, Druzd-Sitek A, Konecki R, Kumiega B, Osowiecki M, Ostrowska B, Szpila T, Szymański M, Targoński Ł, Domańska-Czyż K, Popławska L, Giebel S, Lange A, Pluta A, Zaucha JM, Rymkiewicz G, Walewski J. Ofatumumab with iphosphamide, etoposide and cytarabine for patients with transplantation-ineligible relapsed and refractory diffuse large B-cell lymphoma. Br J Haematol 2022; 198:73-81. [PMID: 35362096 PMCID: PMC9322457 DOI: 10.1111/bjh.18166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 03/14/2022] [Accepted: 03/15/2022] [Indexed: 11/29/2022]
Abstract
The efficacy of salvage treatment of diffuse large B-cell lymphoma (DLBCL) patients who relapse or progress (rrDLBCL) after initial therapy is limited. Efficacy and safety of ofatumumab with iphosphamide, etoposide and cytarabine (O-IVAC) was evaluated in a single-arm study. Dosing was modified for elderly patients. Patients received up to six cycles of treatment. The primary end-point was the overall response rate (ORR). Patients were evaluated every two cycles and then six and 12 months after treatment. Other end-points included progression-free survival (PFS), event-free survival (EFS), overall survival (OS) and safety. Seventy-seven patients received salvage treatment with O-IVAC. The average age was 56.8 years; 39% had an Eastern Cooperative Oncology Group (ECOG) performance status of at least 3; 78% had disease of Ann Arbor stage 3 or 4; 58% received one or more prior salvage therapies. The ORR for O-IVAC was 54.5%. The median duration of study follow-up was 70 months. The median PFS and EFS were 16.3 months each. The median OS was 22.7 months. Age, ECOG performance status and the number of prior therapy lines were independent predictors of survival. Treatment-related mortality was 15.5%. O-IVAC showed a high response rate in a difficult-to-treat population and is an attractive treatment to bridge to potentially curative therapies.
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Affiliation(s)
| | - Wojciech Michalski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Monika Mordak-Domagała
- Lower Silesian Center for Cellular Transplantation with National Bone Marrow Donor Registry, Wroclaw, Poland
| | | | - Wanda Knopińska-Posłuszny
- Maritime Hospital, Gdynia, Poland.,Warmian-Masurian Cancer Center of the Ministry of the Interior and Administration's Hospital, Olsztyn, Poland
| | - Jacek Najda
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Anna Borawska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Monika Świerkowska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Agata Malenda
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Robert Konecki
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Beata Kumiega
- Sniadecki Memorial Specialist Hospital, Nowy Sacz, Poland
| | - Michał Osowiecki
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Beata Ostrowska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Tomasz Szpila
- Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Marcin Szymański
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Łukasz Targoński
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | | | - Lidia Popławska
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Sebastian Giebel
- Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice, Poland
| | - Andrzej Lange
- Lower Silesian Center for Cellular Transplantation with National Bone Marrow Donor Registry, Wroclaw, Poland
| | - Andrzej Pluta
- Department of Hematology, Brzozow Oncology Center, Brzozow, Poland
| | - Jan Maciej Zaucha
- Medical University of Gdansk, Gdansk, Poland.,Maritime Hospital, Gdynia, Poland
| | - Grzegorz Rymkiewicz
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
| | - Jan Walewski
- Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw, Poland
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Di M, Keeney T, Belanger E, Panagiotou OA, Olszewski AJ. Global Risk Indicator and Therapy for Older Patients With Diffuse Large B-Cell Lymphoma: A Population-Based Study. JCO Oncol Pract 2022; 18:e383-e402. [PMID: 34846916 PMCID: PMC8932488 DOI: 10.1200/op.21.00513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 09/04/2021] [Accepted: 10/27/2021] [Indexed: 12/17/2022] Open
Abstract
PURPOSE To examine the impact of global risk, a measure comprising age, comorbidities, function, and cognitive statuses, on treatment selection and outcomes among older home care recipients with diffuse large B-cell lymphoma. METHODS From SEER-Medicare, we selected home care recipients diagnosed with diffuse large B-cell lymphoma in 2011-2015, who had pretreatment Outcome and Assessment Information Set (OASIS) evaluations. We created a global risk indicator categorizing patients as low-, moderate-, or high-risk on the basis of OASIS assessments. We examined the association of global risk with receipt of therapy and among chemotherapy recipients, with mortality, emergency department visits, hospitalization, and intensive care unit admission within 30 days from first treatment in logistic models, reporting adjusted odds ratios (OR) with 95% CI. We compared overall survival across risk groups estimating adjusted hazard ratios. RESULTS Of the 1,232 patients (median age, 80 years), 65% received chemotherapy. High-risk patients (v moderate-risk) were less likely to receive any chemotherapy (OR, 0.50; 95% CI, 0.39 to 0.64) and curative regimens (OR, 0.59; 95% CI, 0.40 to 0.86) if treated, although even in the moderate-risk group, only 61% received curative regimens. High-risk patients were more likely to experience acute mortality (OR, 2.24; 95% CI, 1.43 to 3.52), emergency department visits (OR, 1.35; 95% CI, 1.00 to 1.83), hospitalization (OR, 1.60; 95% CI, 1.19 to 2.17), or intensive care unit admission (OR, 1.52; 95% CI, 1.04 to 2.22) and had inferior overall survival (hazard ratio, 1.41; 95% CI, 1.11 to 1.78). CONCLUSION Global risk on the basis of OASIS is easily available, suggesting a potential way to improve patient selection for curative treatment and institution of preventive measures.
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Affiliation(s)
- Mengyang Di
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
- Division of Hematology/Oncology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, CT
| | - Tamra Keeney
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, RI
| | - Emmanuelle Belanger
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Orestis A. Panagiotou
- Mongan Institute, Center for Aging and Serious Illness, Massachusetts General Hospital, Boston, MA
- Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, RI
| | - Adam J. Olszewski
- Department of Medicine, Alpert Medical School of Brown University, Providence, RI
- Division of Hematology-Oncology, Rhode Island Hospital, Providence, RI
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Brem EA, Li H, Beaven AW, Caimi PF, Cerchietti L, Alizadeh A, Olin R, Henry NL, Dillon H, Little RF, Laubach C, LeBlanc M, Friedberg JW, Smith SM. SWOG 1918: A phase II/III randomized study of R-miniCHOP with or without oral azacitidine (CC-486) in participants age 75 years or older with newly diagnosed aggressive non-Hodgkin lymphomas - Aiming to improve therapy, outcomes, and validate a prospective frailty tool. J Geriatr Oncol 2022; 13:258-264. [PMID: 34686472 PMCID: PMC9879719 DOI: 10.1016/j.jgo.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 01/28/2023]
Abstract
Diffuse large B cell lymphoma (DLBCL) is an aggressive but potentially curable malignancy; however, cure is highly dependent on the ability to deliver intensive, anthracycline-based chemoimmunotherapy. Nearly one third of cases of DLBCL occur in patients over age 75 years, and advanced age is an important adverse feature in prognostic models. Despite this incidence in older patients, there is no clear accepted standard of care due to under-representation of this group in large randomized clinical trials. Furthermore, insufficient assessments of baseline frailty and prediction of toxicity hamper clinical decision-making. Here, we present an ongoing randomized study of R-miniCHOP chemoimmunotherapy with or without oral azacitidine (CC-486, Onureg) for patients age 75 and older with newly diagnosed DLBCL and associated aggressive lymphomas. The incorporation of an oral hypomethylating agent is based on increased tumor methylation as a biologic feature of older patients with DLBCL and a desire to minimize the injection burden for this population. This is the first randomized study in this population conducted in North America by the National Clinical Trials Network (NCTN) and will enroll up to 422 patients including 40 patients in a safety run-in phase. This study incorporates an objective assessment of baseline frailty (the FIL Tool) and a serial comprehensive geriatric assessment (CGA). Key correlative tests will include circulating tumor DNA (ctDNA) assays at pre-specified timepoints to explore if ctDNA quantity and methylation patterns correlate with response. S1918 has the potential to impact future trial design and to change the standard of care for patients 75 years and older with aggressive lymphoma given its randomized design, prospective incorporation of geriatric assessments, and exploration of ctDNA correlatives. Trial registration: The trial is registered with ClinicalTrial.gov Identifier NCT04799275.
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Affiliation(s)
| | - Hongli Li
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center University of North Carolina, Chapel Hill, NC
| | - Paolo F. Caimi
- Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, Cleveland, OH
| | | | - Ash Alizadeh
- Stanford University Medical Center, Stanford, CA
| | - Rebecca Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | | | - Richard F. Little
- National Cancer Institute, Cancer Therapy Evaluation Program (CTEP), Bethesda, MD
| | | | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
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Hounsome L, Eyre TA, Ireland R, Hodson A, Walewska R, Ardeshna K, Chaganti S, McKay P, Davies A, Fox CP, Kalakonda N, Fields PA. Diffuse large B cell lymphoma (DLBCL) in patients older than 65 years: analysis of 3 year Real World data of practice patterns and outcomes in England. Br J Cancer 2022; 126:134-143. [PMID: 34611308 PMCID: PMC8727618 DOI: 10.1038/s41416-021-01525-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Revised: 07/10/2021] [Accepted: 08/11/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND We wished to examine treatment and outcome patterns in older diffuse large B-cell lymphoma (DLBCL) patients, with a focus on the effect of route-to-diagnosis to outcome. METHODS Data were extracted from Public Health England's National Cancer Registration and Analysis Service between 2013 and 2015 included route-to-diagnosis, disease characteristics and survival for 9186 patients ≥65 years. Systemic Anti-Cancer Therapy data identified front-line regimens, cycles and doses. RESULTS Route-to-diagnosis were emergency (34%), NHS urgent cancer pathway (rapid haemato-oncologist review <2 weeks), (29%) and standard GP referral (25%). The most common regimen was R-CHOP (n = 4392). 313 patients received R-miniCHOP (7% of R-CHOP). For all patients, 3-year overall survival (OS) for 65-79 years was 57% and for ≥80 years was 32%. Three-year OS for R-CHOP-treated patients diagnosed via emergency presentation was 54% (adjusted hazard ratio (HR) 1.63, p < 0.01) and 75% (adjusted HR 0.81, p < 0.01) on the NHS urgent cancer pathway (reference HR:1.00: GP referrals). 3-year OS was 54% for both R-miniCHOP and R-CHOP in ≥80 years. CONCLUSIONS Our comprehensive population analysis is the first to show that the NHS urgent cancer pathway is associated with a superior survival after adjusting for multiple confounders. Equivalent survival for R-CHOP and R-mini-CHOP was demonstrated in those ≥80 years.
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Affiliation(s)
- L. Hounsome
- grid.271308.f0000 0004 5909 016XPublic Health England, London, UK
| | - T. A. Eyre
- grid.410556.30000 0001 0440 1440Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R. Ireland
- grid.13097.3c0000 0001 2322 6764Department of Haematology, Kings College London Hospitals, London, UK
| | - A. Hodson
- grid.414810.80000 0004 0399 2412Department of Haematology, Ipswich Hospital, Ipswich, UK
| | - R. Walewska
- Department of Haematology, University Hospitals Dorset, Bournemouth, UK
| | - K. Ardeshna
- grid.52996.310000 0000 8937 2257Department of Haematology, UCLH, London, UK
| | - S. Chaganti
- grid.412563.70000 0004 0376 6589Department of Haematology, University Hospitals Birmingham, Birmingham, UK
| | - P. McKay
- Department of Haematology, Beatson Cancer Centre, Glasgow, UK
| | - A. Davies
- grid.123047.30000000103590315Department of Medical Oncology, Southampton General Hospital, Southampton, UK
| | - C. P. Fox
- grid.240404.60000 0001 0440 1889Department of Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - N. Kalakonda
- grid.10025.360000 0004 1936 8470Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - P. A. Fields
- grid.425213.3Department of Haematology, Guys and St Thomas’ Hospital, London, UK
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A simplified frailty score predicts survival and can aid treatment-intensity decisions in older patients with DLBCL. Blood Adv 2021; 5:4771-4782. [PMID: 34543384 PMCID: PMC8759139 DOI: 10.1182/bloodadvances.2021004777] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 07/04/2021] [Indexed: 11/22/2022] Open
Abstract
A simplified frailty score predicts survival and toxicity in older patients with DLBCL and can inform treatment-intensity decisions. Full-dose R-CHOP is not superior to R-miniCHOP in older unfit DLBCL patients, whereas older fit patients likely benefit from full-dose R-CHOP.
Patients with diffuse large B-cell lymphoma (DLBCL) have a median age of 70 years. Yet, empirical knowledge about the treatment of older patients is limited because they are frequently excluded from clinical trials. We aimed to construct a simplified frailty score and examine survival and treatment-related mortality (TRM) according to frailty status and treatment intensity in an older real-world population with DLBCL. All patients aged ≥70 years diagnosed with DLBCL between 2006 and 2016 in southeastern Norway (N = 784) were included retrospectively and divided into training (n = 522) and validation (n = 262) cohorts. We constructed and validated a frailty score based on geriatric assessment variables and examined survival and TRM according to frailty status and treatment. The frailty score identified 3 frailty groups with distinct survival and TRM, independent of established prognostic factors (2-year overall survival [OS]: fit, 82%; unfit, 47%; frail, 14%; P < .001). For fit patients, full-dose R-CHOP (initial dosage >80%) was associated with better survival than attenuated R-CHOP ([R-miniCHOP]; 2-year OS: 86% vs 70%; P = .012), also in adjusted analyses. For unfit and frail patients, full-dose R-CHOP was not superior to R-miniCHOP, whereas an anthracycline-free regimen was associated with poorer survival in adjusted analyses. A simplified frailty score identified unfit and frail patients with a higher risk for death and TRM, which can aid treatment-intensity decisions in older patients with DLBCL. In this study, fit patients benefited from full-dose R-CHOP, whereas unfit and frail patients had no benefit from full-dose R-CHOP over R-miniCHOP. An online calculator for assessment of the frailty score is available at https://wide.shinyapps.io/app-frailty/.
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A comprehensive approach to therapy of haematological malignancies in older patients. LANCET HAEMATOLOGY 2021; 8:e840-e852. [PMID: 34624238 DOI: 10.1016/s2352-3026(21)00241-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Revised: 07/29/2021] [Accepted: 08/02/2021] [Indexed: 12/11/2022]
Abstract
Haematological malignancies are a heterogeneous group of diseases with diverse incidence. In Europe, the median age at diagnosis across all disease entities is 69 years. Incidence generally increases with age, reaching a maximum at 75-99 years, with the notable exceptions of Hodgkin lymphoma and acute lymphocytic leukaemia. Overall survival for patients aged 75 years and older with haematological malignancies is generally poor, particularly for acute leukaemias. Understanding the heterogeneity in outcomes for haematological malignancies, treatment challenges, and management of frailty and comorbidities among older patients could help physicians to better address the haematological cancer burden and mortality in ageing populations. The aim of this Series paper is to provide an updated overview of the knowledge accumulated over the past decade regarding treatment options and broader management considerations in older adults with haematological malignancies, focusing on the most common entities encountered across lymphoma, acute leukaemia, chronic leukaemia, and multiple myeloma disease categories. Future strategies, such as increasing enrolment rates of older adults in clinical trials and incorporating patient-reported outcome measurements in daily clinical practice, will assist in providing more individualised health care.
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Briand M, Gerard S, Gauthier M, Garric M, Steinmeyer Z, Balardy L. Impact of therapeutic management and geriatric evaluation on patient of eighty years and older with diffuse large B-cell lymphoma on survival: A systematic review. Eur J Haematol 2021; 108:3-17. [PMID: 34496073 DOI: 10.1111/ejh.13704] [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] [Received: 03/13/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Diffuse large B cell lymphoma (DLBCL) is an aggressive disease. The first-line treatment is well defined in young patients; however, in oldest old patients treatment remains unclear. OBJECTIVES To investigate the impact of therapeutics management and geriatric evaluation on survival in aged patients with DLBCL. METHODS We performed a systematic review of PubMed and COCHRANE databases of published report on elderly patients (median age 80 and above) with DLBCL, from January 2002 to January 2020. RESULTS We included 32 studies (6 prospective and 26 retrospective). Patients treated with anthracyclines-containing chemoimmunotherapy had a 2-year overall survival (OS) of 59%-74.3% in prospective studies and 48.1-64.6% in retrospective studies. With less intensive treatment without anthracyclines, 2-year OS was 28%-53%. Without specific treatment, median OS was 2 months. History of falls and severe comorbidities were associated with a decreased survival. CONCLUSIONS Chemoimmunotherapy with anthracyclines increases survival in selected very elderly patients in comparison with less intensive regimen. Geriatric assessment, in particular altered mobility disorders and severe comorbidities, is predictive of survival and should be associated with the therapeutic decision. More comparative studies are needed to guide the management of frailer patients.
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Affiliation(s)
- Marguerite Briand
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Stephane Gerard
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Martin Gauthier
- Department of Hematology, Institut Universitaire du Cancer de Toulouse-Oncopole, Toulouse, France.,Department of Internal Medicine, Centre Hospitalier de Cahors, Cahors, France
| | - Marie Garric
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Zara Steinmeyer
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Laurent Balardy
- Geriatric Department, Internal Medicine and Oncogeriatry Unit, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
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Škubník J, Pavlíčková VS, Ruml T, Rimpelová S. Vincristine in Combination Therapy of Cancer: Emerging Trends in Clinics. BIOLOGY 2021; 10:849. [PMID: 34571726 PMCID: PMC8468923 DOI: 10.3390/biology10090849] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 02/07/2023]
Abstract
Treatment of blood malignancies and other cancer diseases has been mostly unfeasible, so far. Therefore, novel treatment regimens should be developed and the currently used ones should be further elaborated. A stable component in various cancer treatment regimens consists of vincristine, an antimitotic compound of natural origin. Despite its strong anticancer activity, mostly, it cannot be administered as monotherapy due to its unspecific action and severe side effects. However, vincristine is suitable for combination therapy. Multidrug treatment regimens including vincristine are standardly applied in the therapy of non-Hodgkin lymphoma and other malignancies, in which it is combined with drugs of different mechanisms of action, mainly with DNA-interacting compounds (for example cyclophosphamide), or drugs interfering with DNA synthesis (for example methotrexate). Besides, co-administration of vincristine with monoclonal antibodies has also emerged, the typical example of which is the anti-CD20 antibody rituximab. Although in some combination anticancer therapies, vincristine has been replaced with other drugs exhibiting lesser side effects, though, in most cases, it is still irreplaceable. This is strongly evidenced by the number of active clinical trials evaluating vincristine in combination cancer therapy. Therefore, in this article, we have reviewed the most common cancer treatment regimens employing vincristine and bring an overview of current trends in the clinical development of this compound.
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Affiliation(s)
| | | | | | - Silvie Rimpelová
- Department of Biochemistry and Microbiology, University of Chemistry and Technology Prague, Technická 3, 166 28 Prague, Czech Republic; (J.Š.); (V.S.P.); (T.R.)
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Zhang XY, Collins GP, Cutter DJ, Eyre TA. Limited-stage diffuse large B-cell lymphoma: current management and challenges. Br J Haematol 2021; 194:508-517. [PMID: 33618434 DOI: 10.1111/bjh.17359] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Accepted: 01/17/2021] [Indexed: 11/29/2022]
Abstract
Twenty-five to thirty per cent of diffuse large B-cell lymphoma (DLBCL) presents as limited stage (I-II). Prognosis is generally excellent with four to six cycles of R-CHOP alone (rituximab, cyclophosphamide, vincristine, doxorubicin, prednisolone) or combined-modality therapy with three or four cycles and involved-site radiotherapy (RT). There is growing interest in optimising algorithms to retain disease control whilst minimising long-term toxicity, with several recent studies focusing on the safety of abbreviating chemotherapy and omitting RT in low-risk patients and the utility of PET-based response-adapted approaches. As these studies are limited to younger patients without risk factors, application of similar approaches in elderly or higher-risk patients is hampered by a lack of evidence. Whilst there has been a move away from using RT in low-risk patients, it remains a useful adjunct in specific situations. Current evidence cannot exclude a clinically meaningful benefit from RT even in low-risk patients and, given the low expected toxicity from modern RT techniques, a risk-benefit assessment should be individualised and considered in a multidisciplinary fashion. The optimal approach for extranodal limited-stage DLBCL (~40% of cases) varies according to site of origin. Herein we discuss the latest clinical trial evidence and how this can be applied in routine practice.
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Affiliation(s)
- Xiao-Yin Zhang
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Graham P Collins
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - David J Cutter
- Department of Oncology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Clinical Trial Service Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Toby A Eyre
- Department of Clinical Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Yamasaki S, Matsushima T, Minami M, Kadowaki M, Takase K, Iwasaki H. Clinical impact of comprehensive geriatric assessment in patients aged 80 years and older with diffuse large B-cell lymphoma receiving rituximab-mini-CHOP: a single-institute retrospective study. Eur Geriatr Med 2021; 13:195-201. [PMID: 34254266 DOI: 10.1007/s41999-021-00539-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 07/05/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Comprehensive geriatric assessment (CGA) has been used to help identify elderly patients with diffuse large B-cell lymphoma (DLBCL) who were suitable for rituximab combined with CHOP therapy (cyclophosphamide, Adriamycin, vincristine, and prednisolone), but there are few reports of CGA for elderly patients with DLBCL who received R-mini-CHOP. METHODS We retrospectively analyzed the risk factors for outcomes among 142 patients aged 80 years and older (≤ 85 years, n = 102; > 85 years, n = 40) with DLBCL who received R-mini-CHOP at 4-week intervals at our institute between 2008 and 2019. We performed a comparison between CGA and treatment outcomes. RESULTS There were significant differences in progression-free survival between patients with international prognostic index (IPI) scores of > 3 and ≤ 3 at diagnosis and in overall survival between patients with instrumental activities of daily living (IADL) scores of ≥ 5 and IADL < 5 before the initial treatment and patients aged ≤ 85 years and > 85 years. CONCLUSION Strategies that carefully select elderly patients aged 80 years and older with DLBCL using CGA may help to identify individuals suitable for novel therapies.
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Affiliation(s)
- Satoshi Yamasaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan. .,Department of Internal Medicine, Kyushu University Beppu Hospital, 4546 Tsurumihara, Tsurumi, Beppu, Oita, 874-0838, Japan.
| | - Takumi Matsushima
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Mariko Minami
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Masanori Kadowaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Ken Takase
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Hiromi Iwasaki
- Department of Hematology and Clinical Research Institute, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
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Cheng L, Song Q, Liu M, Wang Y, Yi H, Qian Y, Xu P, Cheng S, Wang C, Wang L, Zhao W. Case Report: Successful Management of a Refractory Plasmablastic Lymphoma Patient With Tislelizumab and Lenalidomide. Front Immunol 2021; 12:702593. [PMID: 34322131 PMCID: PMC8312258 DOI: 10.3389/fimmu.2021.702593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 06/25/2021] [Indexed: 01/15/2023] Open
Abstract
Plasmablastic lymphoma (PBL) is a rare and aggressive hematological malignancy. PBL commonly occurs in immune incompetent patients, such as those with human immunodeficiency virus (HIV), post-transplant status, or immunosenescence. Given its rarity, there is no specific standard treatment for PBL. However, small case series have shown that intensive chemotherapies combined with anti-myeloma agents such as bortezomib and lenalidomide were effective in treating PBL. Unfortunately, some fragile patients could not tolerate intensive chemotherapeutic regimens, especially the elderly patients. Here we presented a 76-year-old female PBL patient refractory to miniCHOP regimen combined with bortezomib but achieved complete remission when treated with tislelizumab combined with lenalidomide, indicating that immune therapy may be a potential treatment for PBL. To our knowledge, this is the first chemoresistant PBL patient that has been successfully treated with checkpoint inhibitor plus lenalidomide, thus providing new insight towards PBL management.
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Affiliation(s)
- Lili Cheng
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Song
- Department of Radiology, Shanghai Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Mengke Liu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongmei Yi
- Department of Pathology, Shanghai Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ying Qian
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Pengpeng Xu
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shu Cheng
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Chaofu Wang
- Department of Pathology, Shanghai Rui Jin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Li Wang
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Weili Zhao
- Shanghai Institute of Hematology, State Key Laboratory of Medical Genomics, National Research Center for Translational Medicine at Shanghai, Ruijin Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Rosko AE, Cordoba R, Abel G, Artz A, Loh KP, Klepin HD. Advances in Management for Older Adults With Hematologic Malignancies. J Clin Oncol 2021; 39:2102-2114. [PMID: 34043442 PMCID: PMC8260925 DOI: 10.1200/jco.21.00242] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/23/2021] [Accepted: 03/10/2021] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ashley E. Rosko
- Division of Hematology, The Ohio State University, Columbus, OH
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Gregory Abel
- Leukemia Program, Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, MA
| | - Andrew Artz
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope, Duarte, CA
| | - Kah Poh Loh
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, Department of Medicine, University of Rochester Medical Center, Rochester, NY
| | - Heidi D. Klepin
- Section on Hematology and Oncology, Wake Forest Baptist Health, Winston-Salem, NC
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Infection-related morbidity and mortality among older patients with DLBCL treated with full- or attenuated-dose R-CHOP. Blood Adv 2021; 5:2229-2236. [PMID: 33890978 DOI: 10.1182/bloodadvances.2021004286] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/20/2021] [Indexed: 11/20/2022] Open
Abstract
Infection-related morbidity and mortality are increased in older patients with diffuse large B-cell lymphoma (DLBCL) compared with population-matched controls. Key predictive factors for infection-related hospitalization during treatment with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and deaths as a result of infection in older patients during and after treatment with R-CHOP remain incompletely understood. For this study, 690 consecutively treated patients age 70 years or older who received full-dose or attenuated-dose R-CHOP treatment were analyzed for risk of infection-related hospitalization and infection-related death. Median age was 77 years, and 34.4% were 80 years old or older. Median follow-up was 2.8 years (range, 0.4-8.9 years). Patient and baseline disease characteristics were assessed in addition to intended dose intensity (IDI). Of all patients, 72% were not hospitalized with infection. In 331 patients receiving an IDI ≥80%, 33% were hospitalized with ≥1 infections compared with 23.3% of 355 patients receiving an IDI of <80% (odds ratio, 1.61; 95% confidence interval, 1.15-2.25; P = .006). An increased risk of infection-related admission was independently associated with IDI >80% across the whole cohort. Primary quinolone prophylaxis independently reduced infection-related admission. A total of 51 patients died as a result of infection. The 6-month, 12-month, 2-year, and 5-year cumulative incidences of infection-related death were 3.3%, 5.0%, 7.2%, and 11.1%, respectively. Key independent factors associated with infection-related death were an International Prognostic Index (IPI) score of 3 to 5, Cumulative Illness Rating Scale for Geriatrics (CIRS-G) score ≥6, and low albumin, which enabled us to generate a predictive risk score. We defined a smaller group (15%) of patients (IPI score of 0-2, albumin >36 g/L, CIRS-G score <6) in which no cases of infection-related deaths occurred at 5 years of follow-up. Whether patients at higher risk of infection-related death could be targeted with enhanced antimicrobial prophylaxis remains unknown and will require a randomized trial.
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Cordoba R, Luminari S, Eyre TA. The use of frailty assessments in treating older adults with aggressive lymphomas. Br J Haematol 2021; 194:677-685. [PMID: 33713435 DOI: 10.1111/bjh.17384] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 02/08/2021] [Indexed: 01/06/2023]
Abstract
Non-Hodgkin lymphomas (NHL) are most commonly diagnosed among people aged 65-74 years, with a median age at diagnosis of 67 years. The percentage of NHL-related deaths is highest among people aged 75-84 years, with a median age at death of 76 years from cases between 2014 and 2018. In light of these recent data, attending physicians of patients with NHL will recognize that the majority of their patients will be of advanced age, with many suffering from a spectrum of frailties. The excess rate of death among older adults with NHL may be related to a range of different factors such as more challenging biologic features, undertreatment received due to a patient's chronology and treatment-related toxicity. The aim of this review is to provide an updated overview of the knowledge generated over recent years regarding epidemiology, prognosis and treatment options in older adults with lymphoma, focusing on Diffuse Large B-cell Lymphoma (DLBCL) where the most robust evidence base is available.
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Affiliation(s)
- Raul Cordoba
- Lymphoma Unit, Department of Hematology, Fundacion Jimenez Diaz University Hospital, Health Research Institute IIS-FJD, Madrid, Spain
| | - Stefano Luminari
- Programma di Ricerca ClinicaOncoematologica, S.C. Ematologia, AUSL-IRCCS di Reggio Emilia, Università di Modena e Reggio Emilia, Modena, Italy
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Churchill Hospital, Oxford, UK
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Tavares A, Moreira I. Diffuse large B-cell lymphoma in very elderly patients: Towards best tailored treatment - A systematic review. Crit Rev Oncol Hematol 2021; 160:103294. [PMID: 33675907 DOI: 10.1016/j.critrevonc.2021.103294] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Revised: 02/02/2021] [Accepted: 02/27/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Diffuse large B cell Lymphoma (DLBCL) is a potentially curative lymphoma with increasing incidence with ageing. Treatment of elderly DLBCL patients represents a particular challenge due to their comorbidities and performance status. METHODS A search for original articles focused on the treatment of elderly DLBCL patients was performed in PubMed database and 633 were found and reviewed. Thirty-eight studies meeting our inclusion criteria were published since 2007. RESULTS Thirteen studies were retrospective and 25 phase II/III clinical trials. Most of them investigated the efficacy of dose-adjusted R-CHOP regimen. Alternative therapeutic drugs together with geriatric assessment were also evaluated. For fit patients aged 80 and over, the strongest evidence favours R-miniCHOP regimen. CONCLUSION A dose-adjusted R-CHOP may be the recommended treatment in elderly DLBCL patients. New tools such as the Comprehensive Geriatric Assessment provide useful guidance for treatment choice, based on comorbidities and frailty index of this group.
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Affiliation(s)
- Alda Tavares
- Department of Medical Oncology, Hospital Pedro Hispano, Matosinhos Local Health Unit, Matosinhos, Portugal.
| | - Ilídia Moreira
- Department of Onco-Hematology, Portuguese Institute of Oncology of Porto, Porto, Portugal
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Abstract
Large B-cell lymphomas, with an estimated 150,000 new cases annually worldwide, represent almost 30% of all cases of non-Hodgkin’s lymphoma. Patients typically present with progressive lymphadenopathy, extranodal disease, or both and require therapy. Despite the advanced stage at presentation in the majority of patients, more than 60% can be cured with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) immunochemotherapy (Fig. 1A). Patients with treatment failure after R-CHOP often have a poor outcome — in particular, those with disease that is refractory to frontline or subsequent therapies — although some patients can have a durable remission and be cured after secondary therapies. Over the past two decades, improved insights into large B-cell lymphomas, in terms of epidemiology, prognostic factors, and biologic heterogeneity, have led to a refinement of disease classification and the development of new therapeutic approaches.
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Affiliation(s)
- Laurie H Sehn
- From the BC Cancer Centre for Lymphoid Cancer and the University of British Columbia, Vancouver, Canada (L.H.S.); and the Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York (G.S.)
| | - Gilles Salles
- From the BC Cancer Centre for Lymphoid Cancer and the University of British Columbia, Vancouver, Canada (L.H.S.); and the Lymphoma Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York (G.S.)
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Merli F, Luminari S, Tucci A, Arcari A, Rigacci L, Hawkes E, Chiattone CS, Cavallo F, Cabras G, Alvarez I, Fabbri A, Re A, Puccini B, Barraclough A, Delamain MT, Ferrero S, Usai SV, Ferrari A, Cencini E, Pennese E, Zilioli VR, Marino D, Balzarotti M, Cox MC, Zanni M, Di Rocco A, Lleshi A, Botto B, Hohaus S, Merli M, Sartori R, Gini G, Nassi L, Musuraca G, Tani M, Bottelli C, Kovalchuk S, Re F, Flenghi L, Molinari A, Tarantini G, Chimienti E, Marcheselli L, Mammi C, Spina M. Simplified Geriatric Assessment in Older Patients With Diffuse Large B-Cell Lymphoma: The Prospective Elderly Project of the Fondazione Italiana Linfomi. J Clin Oncol 2021; 39:1214-1222. [PMID: 33577377 DOI: 10.1200/jco.20.02465] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To prospectively validate the use of a simplified geriatric assessment (sGA) at diagnosis and to integrate it into a prognostic score for older patients with diffuse large B-cell lymphoma (DLBCL). METHODS We conducted the prospective Elderly Project study on patients with DLBCL older than 64 years who underwent our Fondazione Italiana Linfomi original geriatric assessment (oGA) (age, Cumulative Illness Rating Scale for Geriatrics, activities of daily living, and instrumental activities of daily living) before treatment. Treatment choice was left to the physician's discretion. The primary end point was overall survival (OS) (ClinicalTrials.gov identifier: NCT02364050). RESULTS We analyzed 1,163 patients (median age 76 years), with a 3-year OS of 65% (95% CI, 62 to 68). Because at multivariate analysis on oGA, age > 80 years retained an independent correlation with OS, we also developed a new, simplified version of the GA (sGA) that classifies patients as fit (55%), unfit (28%), and frail (18%) with significantly different 3-year OS of 75%, 58%, and 43%, respectively. The sGA groups, International Prognostic Index, and hemoglobin levels were independent predictors of OS and were used to build the Elderly Prognostic Index (EPI). Three risk groups were identified: low (23%), intermediate (48%), and high (29%), with an estimated 3-year OS of 87% (95% CI, 81 to 91), 69% (95% CI, 63 to 73), and 42% (95% CI, 36 to 49), respectively. The EPI was validated using an independent external series of 328 cases. CONCLUSION The Elderly Project validates sGA as an objective tool to assess fitness status and defines the new EPI to predict OS of older patients with DLBCL.
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Affiliation(s)
- Francesco Merli
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Stefano Luminari
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy.,Department CHIMOMO, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Alessandra Tucci
- Hematology Division, ASST Spedali Civili Brescia, Brescia, Italy
| | - Annalisa Arcari
- Hematology Unit, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Luigi Rigacci
- Haematology Unit, Careggi University Hospital, Firenze, Italy
| | - Eliza Hawkes
- Department of Oncology and Clinical Haematology, Olivia Newton-John Cancer Research Institute at Austin Health, Heidelberg, Melbourne, Australia
| | - Carlos S Chiattone
- Santa Casa Medical School, Sao Paulo, Brazil.,Samaritano Hospital, Sao Paulo, Brazil
| | - Federica Cavallo
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/AOU "Città della Salute e della Scienza di Torino," Torino, Italy
| | - Giuseppina Cabras
- Division of Hematology, Ospedale Oncologico Armando Businco, Cagliari, Italy
| | - Isabel Alvarez
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Alberto Fabbri
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Alessandro Re
- Hematology Division, ASST Spedali Civili Brescia, Brescia, Italy
| | | | | | | | - Simone Ferrero
- Division of Hematology, Department of Molecular Biotechnologies and Health Sciences, University of Torino/AOU "Città della Salute e della Scienza di Torino," Torino, Italy
| | - Sara Veronica Usai
- Division of Hematology, Ospedale Oncologico Armando Businco, Cagliari, Italy
| | - Angela Ferrari
- Hematology Unit, Azienda Unità Sanitaria Locale-IRCCS, Reggio Emilia, Italy
| | - Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena, Italy
| | - Elsa Pennese
- Lymphoma Unit, Department of Hematology, Ospedale Spirito Santo, Pescara, Italy
| | | | - Dario Marino
- Department of Clinical and Experimental Oncology, Medical Oncology 1, Veneto Institute of Oncology IOV-IRCCS, Padova, Italy
| | - Monica Balzarotti
- Department of Medical Oncology and Hematology, Humanitas Clinical Research Hospital-IRCCS, Rozzano (MI), Italy
| | | | - Manuela Zanni
- Hematology Unit, Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Alice Di Rocco
- Institute of Hematology, Department of Translational and Precision Medicine "Sapienza," University of Roma, Roma, Italy
| | - Arben Lleshi
- Division of Medical Oncology and Immune-related Tumors, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano (PN), Italy
| | - Barbara Botto
- Division of Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Stefan Hohaus
- University Policlinico Gemelli Foundation-IRCCS, Catholic University of the Sacred Heart, Roma, Italy
| | - Michele Merli
- Division of Hematology, Ospedale di Circolo e Fondazione Macchi-ASST Sette Laghi, University of Insubria, Varese, Italy
| | - Roberto Sartori
- Department of Clinical and Experimental Oncology, Oncohematology Unit, Veneto Institute of Oncology, IOV-IRCCS, Castelfranco Veneto (TV), Italy
| | - Guido Gini
- Division of Hematology, Azienda Ospedaliera Universitaria Ospedali Riuniti, Ancona, Italy
| | - Luca Nassi
- Hematology, AOU Maggiore della Carità and University of Eastern Piedmont, Novara, Italy
| | - Gerardo Musuraca
- Hematology Unit, IRCCS-Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) SRL, Meldola (FC), Italy
| | - Monica Tani
- Hematology Unit, Santa Maria delle Croci Hospital, Ravenna, Italy
| | - Chiara Bottelli
- Hematology Division, ASST Spedali Civili Brescia, Brescia, Italy
| | - Sofia Kovalchuk
- Haematology Unit, Careggi University Hospital, Firenze, Italy
| | - Francesca Re
- Hematology and BMT Center, Azienda Ospedaliera Universitaria, Parma, Italy
| | - Leonardo Flenghi
- Hematology, Santa Maria della Misericordia Hospital, Perugia, Italy
| | | | - Giuseppe Tarantini
- Haematology and BMT Unit, Ospedale Monsignor R. Dimiccoli, Barletta, Italy
| | - Emanuela Chimienti
- Division of Medical Oncology and Immune-related Tumors, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano (PN), Italy
| | | | - Caterina Mammi
- Gruppo Amici dell'Ematologia GRADE-Onlus Foundation, Reggio Emilia, Italy
| | - Michele Spina
- Division of Medical Oncology and Immune-related Tumors, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano (PN), Italy
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Oberic L, Peyrade F, Puyade M, Bonnet C, Dartigues-Cuillères P, Fabiani B, Ruminy P, Maisonneuve H, Abraham J, Thieblemont C, Feugier P, Salles G, Bijou F, Pica GM, Damaj G, Haioun C, Casasnovas RO, Farhat H, Le Calloch R, Waultier-Rascalou A, Malak S, Paget J, Gat E, Tilly H, Jardin F. Subcutaneous Rituximab-MiniCHOP Compared With Subcutaneous Rituximab-MiniCHOP Plus Lenalidomide in Diffuse Large B-Cell Lymphoma for Patients Age 80 Years or Older. J Clin Oncol 2021; 39:1203-1213. [PMID: 33444079 DOI: 10.1200/jco.20.02666] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The prognosis of elderly patients with diffuse large B-cell lymphoma (DLBCL) is worse than that of young patients. An attenuated dose of chemotherapy-cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab (R-miniCHOP)-is a good compromise between efficacy and safety in very elderly patients. In combination with R-CHOP (R2-CHOP), lenalidomide has an acceptable level of toxicity and may mitigate the negative prognosis of the non-germinal center B-cell-like phenotype. The Lymphoma Study association conducted a multicentric, phase III, open-label, randomized trial to compare R-miniCHOP and R2-miniCHOP. PATIENTS AND METHODS Patients of age 80 years or older with untreated DLBCL were randomly assigned into the R-miniCHOP21 group or the R2-miniCHOP21 group for six cycles and stratified according to CD10 expression and age. The first cycle of rituximab was delivered by IV on D1 after a prephase and then delivered subcutaneously on D1 of cycles 2-6. Lenalidomide was delivered at a dose of 10 mg once daily on D1-D14 of each cycle. The primary end point was overall survival (OS). RESULTS A total of 249 patients with new DLBCL were randomly assigned (127 R-miniCHOP and 122 R2-miniCHOP). The median age was 83 years (range, 80-96), and 55% of the patients were classified as non-GCB. The delivered dose for each R-miniCHOP compound was similar in both arms. Over a median follow-up of 25.1 months, the intention-to-treat analysis revealed that R2-miniCHOP did not improve OS (2-year OS 66% in R-miniCHOP and 65.7% in R2-miniCHOP arm, P = .98) in the overall population or in the non-GCB population. Grade 3-4 adverse events occurred in 53% of patients with R-miniCHOP and in 81% of patients with R2-miniCHOP. CONCLUSION The addition of lenalidomide to R-miniCHOP does not improve OS. Rituximab delivered subcutaneously was safe in this population.
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Affiliation(s)
- Lucie Oberic
- Department of Hematology, Institut Universitaire du Cancer, Toulouse-Oncopole, Toulouse, France
| | - Frederic Peyrade
- Department of Medical Oncology, Centre Antoine Lacassagne, Nice, France
| | - Mathieu Puyade
- Department of Oncology-Haematology and Cell Therapy, CHU, Poitiers, INSERM, Inserm CIC 1402, Poitiers, France
| | - Christophe Bonnet
- Clinical Hematology Unit, CHU Liège, Liège Université, Campus Universitaire de Sart Tilman, Liège, Belgique
| | - Peggy Dartigues-Cuillères
- Anapath Research Unit (EA) EA4340 and Pathology Laboratory, Versailles University and APHP, Ambroise Paré Hospital, Boulogne, France
| | - Bettina Fabiani
- Department of Pathology, Hopital Saint-Antoine, APHP, Paris, France
| | | | - Hervé Maisonneuve
- Department of Clinical Hematology, Centre Hospitalier Départemental Vendée, La Roche-sur-Yon, France
| | - Julie Abraham
- Department of Hematology, CHU Dupuytren, Limoges, France
| | - Catherine Thieblemont
- APHP, Hopital Saint-Louis, Hemato-oncologie; Université de Paris, Paris Diderot, Paris, France
| | - Pierre Feugier
- Department of Haematology, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre Les Nancy, France
| | - Gilles Salles
- Department of Hematology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Pierre Benite, France
| | - Fontanet Bijou
- Department of Hematology, Hospital Bergonié, Bordeaux, France
| | - Gian-Matteo Pica
- Department of Hematology, Centre Hospitalier Métropole Savoie, Chambery, France
| | - Gandhi Damaj
- Department of Hematology, CHU Caen, Caen, France
| | - Corinne Haioun
- Department of Hematology, Henri Mondor University Hospital, UPEC, Creteil, France
| | | | - Hassan Farhat
- Department of Hematology, Centre Hospitalier de Versailles André Mignot, Versailles, France
| | - Ronan Le Calloch
- Centre hospitalier de Quimper Cornouaille/Université de Bretagne Occidentale, France
| | | | - Sandra Malak
- Department of Hematology, CLCC Rene Huguenin Institut Curie, Saint-Cloud, France
| | - Jerome Paget
- LYSARC, The Lymphoma Academic Research Organisation, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Elodie Gat
- LYSARC, The Lymphoma Academic Research Organisation, Centre Hospitalier Lyon-Sud, Pierre-Bénite, France
| | - Hervé Tilly
- Department of Hematology, Centre Henri Becquerel, UNIROUEN, University of Normandy, INSERM U1245, Rouen, France
| | - Fabrice Jardin
- Department of Hematology, Centre Henri Becquerel, UNIROUEN, University of Normandy, INSERM U1245, Rouen, France
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Wang L, Li LR, Young KH. New agents and regimens for diffuse large B cell lymphoma. J Hematol Oncol 2020; 13:175. [PMID: 33317571 PMCID: PMC7734862 DOI: 10.1186/s13045-020-01011-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
As a widely recognized standard regimen, R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) is able to cure two-thirds patients with diffuse large B cell lymphoma (DLBCL), and the remaining patients suffer from refractory or relapsed disease due to resistance to R-CHOP and fare poorly. Unsatisfied outcomes for those relapsed/refractory patients prompted efforts to discover new treatment approaches for DLBCL, including chimeric antigen receptor T cells, bispecific T cell engagers, immunomodulatory drugs, immune checkpoint inhibitors, monoclonal antibodies, antibody-drug conjugates, molecular pathway inhibitors, and epigenetic-modifying drugs. Herein, up-to-date data about the most promising treatment approaches for DLBCL are recapitulated, and novel genetic classification systems are introduced to guide individualized treatment for DLBCL.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/pharmacology
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Drug Development
- Epigenesis, Genetic/drug effects
- Humans
- Immune Checkpoint Inhibitors/pharmacology
- Immune Checkpoint Inhibitors/therapeutic use
- Immunoconjugates/pharmacology
- Immunoconjugates/therapeutic use
- Immunologic Factors/pharmacology
- Immunologic Factors/therapeutic use
- Immunotherapy/methods
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/immunology
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/therapy
- Signal Transduction
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Affiliation(s)
- Liang Wang
- Department of Hematology, Beijing TongRen Hospital, Capital Medical University, Beijing, 100730, China.
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University & Capital Medical University, Beijing TongRen Hospital, Beijing, 100730, China.
| | - Lin-Rong Li
- Peking Union Medical College Hospital, Beijing, 100560, China
| | - Ken H Young
- Division of Hematopathology, Department of Pathology, Duke University Medical Center and Cancer Institute, Durham, NC, 27710, USA.
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Di M, Huntington SF, Olszewski AJ. Challenges and Opportunities in the Management of Diffuse Large B-Cell Lymphoma in Older Patients. Oncologist 2020; 26:120-132. [PMID: 33230948 DOI: 10.1002/onco.13610] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/10/2020] [Indexed: 12/12/2022] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) are diagnosed at age 60 years or older. Challenges to effective therapy among older individuals include unfavorable biologic features of DLBCL, geriatric vulnerabilities, suboptimal treatment selection, and toxicities of cytotoxic chemotherapy. Wider application of geriatric assessments may help identify fit older patients who benefit from standard immunochemotherapy without unnecessary dose reductions. Conversely, attenuated regimens may provide a better balance of risk and benefit for selected unfit or frail patients. Supportive care with the use of corticosteroid-based prephase, prophylactic growth factors, and early institution of supportive and palliative care can help maximize treatment tolerance. Several novel or emerging therapies have demonstrated favorable toxicity profiles, thus facilitating effective treatment for elderly patients. In the relapsed or refractory setting, patients who are not candidates for stem cell transplantation can benefit from newly approved options including polatuzumab vedotin-based combinations or tafasitamab plus lenalidomide, which may have higher efficacy and/or lower toxicity than historical chemotherapy regimens. Chimeric antigen receptor T-cell therapy has been successfully applied to older patients outside of clinical trials. In the first-line setting, emerging immunotherapy options (bispecific antibodies) and targeted therapies (anti-CD20 antibodies combined with lenalidomide and/or B-cell receptor inhibitors) may provide chemotherapy-free approaches for DLBCL. Enrolling older patients in clinical trials will be paramount to fully examine potential efficacy and toxicity of these strategies. In this review, we discuss recent advances in fitness stratification and therapy that have expanded curative options for older patients, as well as future opportunities to improve outcomes in this population. IMPLICATIONS FOR PRACTICE: Management of diffuse large B-cell lymphoma in older patients poses challenges due to aggressive disease biology and geriatric vulnerability. Although R-CHOP remains standard first-line treatment, geriatric assessment may help evaluate patients' fitness for immunochemotherapy. Corticosteroid prephase, prophylactic growth factors, and early palliative care can improve tolerance of treatment. Novel salvage options (polatuzumab vedotin-based combinations, tafasitamab plus lenalidomide) or chimeric antigen receptor T-cell therapy should be considered in the relapsed or refractory setting for patients ineligible for stem cell transplantation. Emerging immunotherapies (bispecific antibodies) and targeted therapies provide potential first-line chemotherapy-free approaches, which need to be rigorously assessed in clinical trials that involve geriatric patients.
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Affiliation(s)
- Mengyang Di
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Scott F Huntington
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Adam J Olszewski
- Department of Medicine, The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Bartlett NL. Approaches to aggressive B-cell lymphomas in less fit patients. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2020; 2020:140-147. [PMID: 33275710 PMCID: PMC7727524 DOI: 10.1182/hematology.2020000099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Treating unfit patients with aggressive B-cell lymphoma poses the dilemma of balancing potential cure while minimizing toxicity because of frailty and comorbidities. Age greater than 80 years and common comorbidities such as cardiovascular disease and poorly controlled diabetes mellitus often preclude the use of full-dose anthracyclines and steroids, the backbones of standard regimens for aggressive B-cell lymphomas. Assessing patient fitness remains subjective, with no consensus on best practice or how to integrate assessment tools into decision making. Incorporation of prephase steroids for all unfit patients may markedly improve performance status with consideration of standard dose therapy, especially in patients less than age 80. Although randomized studies are lacking, current data suggest patients age ≥ 80 years are considered unfit a priori and should receive dose-reduced anthracycline regimens or anthracycline-free regimens. Severe toxicity is highest after the first cycle of chemotherapy. Dose reductions for cycle 1 in unfit patients with plans to escalate as tolerated is often an effective strategy. Unfit patients often benefit from comanagement with gerontologists, cardio-oncologists, and endocrinologists depending on age and the nature of comorbidities. Palliative therapy for patients with newly diagnosed aggressive B-cell lymphoma results in median survivals of less than 3 months, and in general, should only be considered in patients with untreatable comorbidities such as advanced dementia or refractory metastatic solid tumors. Incorporating new, potentially less toxic agents such as novel antibodies, antibody-drug conjugates, and bispecific antibodies into first-line therapy is an exciting future direction with potential for substantial benefit in less fit patients.
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Affiliation(s)
- Nancy L Bartlett
- Washington University School of Medicine, Siteman Cancer Center, St. Louis, MO
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Zettl F, Ziepert M, Altmann B, Zeynalova S, Held G, Pöschel V, Hohloch K, Wulf GG, Glass B, Schmitz N, Loeffler M, Trümper L. Age-dependent increase of treatment-related mortality in older patients with aggressive B cell lymphoma: analysis of outcome, treatment feasibility, and toxicity in 1171 elderly patients with aggressive B cell lymphoma-data from phase II and III trials of the DSHNHL (German High-Grade Non-Hodgkin's Lymphoma Study Group). Ann Hematol 2020; 100:1031-1038. [PMID: 33242101 PMCID: PMC7960591 DOI: 10.1007/s00277-020-04345-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 11/11/2020] [Indexed: 01/21/2023]
Abstract
In elderly patients (pts) with aggressive B cell lymphoma (aNHL), curative treatment often cannot be administered because of comorbidities and tolerability. We analyzed the influence of age in pts > 60 years receiving the R-CHOP-14 regimen within different prospective DSHNHL trials. Of the RICOVER-60 trial and CHOP-R-ESC trials, 1171 aNHL pts were included in this retrospective analysis of age-dependent event-free survival (EFS), progression-free survival (PFS), and overall survival (OS). All patients received prophylactic G-CSF, and anti-infective prophylaxis with amphotericin B mouth wash and oral fluorchinolone was optional. In the CHOP-R-ESC trials, prophylaxis was augmented to include mandatory continuous orally administered aciclovir and a pneumocystis prophylaxis with cotrimoxazole as well as oral fluorchinolones during neutropenia. The patient population was separated into 4 age groups (61-65 years, 66-70 years, 71-75 years, and 76-80 years). The results from the RICOVER-60 trial were subsequently confirmed in the following CHOP-R-ESC trials by a multivariate analysis adjusted for IPI factors and gender. Significant differences (p < 0.001) in EFS, PFS, and OS were seen between age groups (RICOVER-60). Hematotoxicity, infections, and TRM increased with age. TRM was significantly elevated in the age group 76-80 years. Therefore, this analysis shows that an age above 75 years defines an especially vulnerable patient population when being treated with chemoimmunotherapy for aNHL. Prophylactic anti-infective drugs are essential and clinically effective in reducing morbidity when treating elderly aNHL pts.
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Affiliation(s)
- Florian Zettl
- Department of Hematology, Oncology and Palliative Care, Klinikum Traunstein, Traunstein, Germany.
| | - Marita Ziepert
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Bettina Altmann
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Samira Zeynalova
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Gerhard Held
- Department of Internal Medicine, University Hospital Saarland, Homburg, Germany
| | - Viola Pöschel
- Department of Internal Medicine, University Hospital Saarland, Homburg, Germany
| | - Karin Hohloch
- Department of Hematology and Medical Oncology, Georg August University Göttingen, Göttingen, Germany.,Hematology and Oncology, Kantonsspital Graubünden, Chur, Switzerland
| | - Gerald G Wulf
- Department of Hematology and Medical Oncology, Georg August University Göttingen, Göttingen, Germany
| | - Bertram Glass
- Department of Hematology, Oncology, and Tumor Immunology, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Norbert Schmitz
- Department of Internal Medicine A, University of Münster, Münster, Germany
| | - Markus Loeffler
- Institute for Medical Informatics, Statistics and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Lorenz Trümper
- Department of Hematology and Medical Oncology, Georg August University Göttingen, Göttingen, Germany
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Fractures are common within 18 months following first-line R-CHOP in older patients with diffuse large B-cell lymphoma. Blood Adv 2020; 4:4337-4346. [PMID: 32915975 DOI: 10.1182/bloodadvances.2020002553] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 07/15/2020] [Indexed: 12/21/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) and osteoporotic fracture are both more common in older patients. Exposure to R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) is likely to increase the risk of fracture, but evidence is lacking to define fracture incidence in this group. Data on consecutive patients with DLBCL aged ≥70 years treated with 1 to 8 cycles of full or attenuated R-CHOP were retrospectively collected across 10 UK centers (2009-2019). Patients were followed up from starting R-CHOP for a minimum of 6 months and censored at 18 months; at last follow-up if <18 months; or at progression or death. Of 877 patients identified, 148 were excluded: 121 had progression or died before 6 months; 23 had follow-up <6 months. Across 729 remaining patients, the median age was 77 years, and 68% had an Eastern Cooperative Oncology Group performance status of 0 to 1. Eighty-one fractures occurred within 18 months of follow-up; 42 were symptomatic, including 30 requiring hospital attendance or admission. The cumulative fracture incidence was 6.2% (95% confidence interval [CI], 4.7-8.2) at 6 months; 9.7% (95% CI, 7.8-12.1) at 12 months; and 11.4% (95% CI, 9.3-14.0) at 18 months. Multivariate analysis identified a predisposing history (osteoporosis, osteopenia, prior fracture, and rheumatoid arthritis [RhA]), DLBCL bone involvement at baseline, and receipt of prephase steroids as independent risk factors for fracture. There is a clinically relevant fracture risk and significant associated morbidity in older patients receiving R-CHOP. Careful attention to bone health is warranted in older patients receiving R-CHOP. Randomized studies are required to better define the most effective strategies to reduce fracture risk.
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Frontline therapy with R-CHOP for diffuse large B-cell lymphoma: Where have we come (or not come)? A Perspective. J Geriatr Oncol 2020; 12:320-325. [PMID: 32972884 DOI: 10.1016/j.jgo.2020.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/10/2020] [Accepted: 09/16/2020] [Indexed: 11/24/2022]
Abstract
A major evolution in the treatment of patients with diffuse large B-cell lymphoma (DLBCL) occurred almost two decades ago, with clinical trials demonstrating that the addition of rituximab (R) to cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP), which had been the "gold standard" of therapy since 1976, significantly improved outcome, including response rate and disease-free survival, of these patients. Since the adoption of R-CHOP, subsequent clinical trials have attempted to improve upon outcomes achieved with R-CHOP, with a variety of approaches examined. These have included dose intensification, which may be applicable in younger patients, but not in the many older or frailer patients with a disease with median age at diagnosis in the 60's. Newer anti-CD20 monoclonal antibodies have been substituted for rituximab in frontline regimens. A series of new agents, with unique mechanisms of action, have been added to the R-CHOP backbone. Rituximab-based, non-anthracycline regimens have been studied for older, more frail patients. The utility of maintenance therapy in responding patients has been re-examined, despite the lack of benefit found in the US Intergroup trial. Advances in molecular and genetic aspects of DLBCL have emerged since the seminal R-CHOP trials, demonstrating the DLBCL is not a single entity, but instead a spectrum of multiple disease subtypes. Attempts have been made to identify those patients at baseline who have poorer outcomes with standard approaches, utilizing laboratory and imaging findings. Moving forward, different risk-adapted treatment approaches will be studied to in an effort to improve overall outcome beyond R-CHOP.
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Abstract
PURPOSE OF REVIEW Older patients with diffuse large B-cell lymphoma (DLBCL) may face challenges in treatment due to comorbidities and tolerance of chemotherapy. RECENT FINDINGS Older patients are at increased risk for treatment-related toxicity if they are unfit or frail by comprehensive geriatric assessment (CGA); however, treatment with non-anthracycline chemotherapy is associated with inferior outcomes in fit and unfit patients. Many older patients remain curable with standard R-CHOP chemotherapy. Careful assessment of frailty, function, and comorbidities using CGA may aid clinicians in initial therapy choices.
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