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Williams MJ, Atienza SD, Aranda RH, Flint KB, Sana S, Medlin SC, Gul Z, Sanchez FA, Thompson MA. Central Nervous System Prophylaxis Utilization in Patients With Newly Diagnosed Diffuse Large B-Cell Lymphoma Within a Large Community Health System. J Patient Cent Res Rev 2024; 11:81-87. [PMID: 39044850 PMCID: PMC11262842 DOI: 10.17294/2330-0698.2060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
Purpose The impact of central nervous system (CNS) prophylaxis in diffuse large B-cell lymphoma (DLBCL) is contentious. The CNS International Prognostic Index (IPI) calculator offers prognostic guidance in identifying those patients who may be at highest risk of disease progression or relapse to the CNS. However, it is unclear whether this tool has guided clinician decision-making in a real-world setting. Studies have suggested that CNS prophylaxis may not offer clinically significant benefit in terms of preventing CNS disease progression. Given this, we investigated the utilization of CNS prophylaxis within our own population and documentation of the CNS-IPI score. Methods We retrospectively evaluated patients with newly diagnosed DLBCL between January 1, 2014, and December 31, 2017. Patients were assessed for receipt of CNS prophylaxis in the form of intrathecal (IT) chemotherapy and/or high-dose intravenous (IV) methotrexate. CNS-IPI scores were calculated for all patients who received CNS prophylaxis or those who experienced CNS disease. Long-term outcomes at five years from diagnosis included CNS progression/relapse and survival. Results Of 234 patients who met criteria, 20 (8.6%) received either IV methotrexate or IT chemotherapy; most received IT methotrexate. No patients in the IT prophylaxis group developed CNS disease, while two of eight IV methotrexate patients experienced CNS disease involvement. The incidence of CNS progression was 3.7% in the no prophylaxis group and 10% in those who received prophylaxis. Conclusions This study revealed low utilization of CNS prophylaxis and CNS-IPI documentation in a community hospital system. Given large differences between groups, claims of CNS prophylaxis efficacy are unable to be made. CNS relapse rates were consistent with existing literature and promote continued evaluation of the utility of current CNS prophylaxis approaches in DLBCL. New unambiguously effective therapeutic approaches are needed and may encourage a higher rate of standardized use.
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Affiliation(s)
- Michael J. Williams
- Department of Pharmacy Services, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Sol D. Atienza
- Department of Pharmacy Services, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Renee H. Aranda
- Department of Pharmacy Services, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Kayleigh B. Flint
- Department of Pharmacy Services, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
- Providence Cancer Institute, Portland, OR
| | - Sherjeel Sana
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Stephen C. Medlin
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Zartash Gul
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Federico A. Sanchez
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
| | - Michael A. Thompson
- Aurora Cancer Care, Aurora St. Luke’s Medical Center, Advocate Health, Milwaukee, WI
- Tempus AI, Chicago, IL
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Thieblemont C, Altmann B, Frontzek F, Renaud L, Chartier L, Ketterer N, Récher C, Poeschel V, Fitoussi O, Held G, Casasnovas O, Haioun C, Morschhauser F, Glass B, Mounier N, Tilly H, Rosenwald A, Ott G, Lenz G, Molina T, Ziepert M, Schmitz N. Central nervous system relapse in younger patients with diffuse large B-cell lymphoma: a LYSA and GLA/DSHNHL analysis. Blood Adv 2023; 7:3968-3977. [PMID: 36716220 PMCID: PMC10410133 DOI: 10.1182/bloodadvances.2022008888] [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: 09/07/2022] [Revised: 01/17/2023] [Accepted: 01/18/2023] [Indexed: 01/31/2023] Open
Abstract
Most patients with diffuse large B-cell lymphoma (DLBCL) can be cured with immunochemotherapy such as R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone). Patients with progression or relapse in the central nervous system (CNS) face dismal outcomes. The impact of more aggressive regimens used in frontline therapy has not been systematically investigated in this context. To this end, we analyzed a large cohort of 2203 younger patients with DLBCL treated on 10 German (German Lymphoma Alliance [GLA]/The German High Grade Non-Hodgkin's Lymphoma Study Group [DSHNHL]) and French (The Lymphoma Study Association [LYSA]) prospective phase 2 and 3 trials after first-line therapy with R-CHOP, R-CHOEP (R-CHOP + etoposide), dose-escalated R-CHOEP followed by repetitive stem cell transplantation (R-MegaCHOEP), or R-ACVBP (rituximab, doxorubicin, cyclophosphamide, vindesine, bleomycine, and prednisone) followed by consolidation including multiple drugs crossing the blood-brain barrier (BBB). Patients with DLBCL with an age-adjusted International Prognostic Index (aaIPI) of 0 to 1 showed very low cumulative incidence rates of CNS relapse regardless of first-line therapy and CNS prophylaxis (3-year cumulative incidences 0%-1%). Younger high-risk patients with aaIPI of 2 to 3 had 3-year cumulative incidence rates of 1.6% and 4% after R-ACVBP plus consolidation or R-(Mega)CHO(E)P, respectively (hazard ratio 2.4; 95% confidence interval: 0.8-7.4; P = .118). Thus, for younger high-risk patients, frontline regimens incorporating agents crossing the BBB may reduce often fatal CNS relapse.
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Affiliation(s)
- Catherine Thieblemont
- Université de Paris, Assistance Publique-Hôpitaux de Paris (APHP), Hemato-oncologie, Saint-Louis Hôpital, Paris, France
| | - Bettina Altmann
- Institute for Medical Informatics, Statistics, and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Fabian Frontzek
- Department of Medicine A, Hematology, Oncology, and Pneumonology, Münster University Hospital, Münster, Germany
| | - Loïc Renaud
- Université de Paris, Assistance Publique-Hôpitaux de Paris (APHP), Hemato-oncologie, Saint-Louis Hôpital, Paris, France
| | - Loic Chartier
- Statistique, Lymphoma Academic Research Organisation, Pierre-Benite, France
| | - Nicolas Ketterer
- Centre d’Oncologie-Hématologie, Bois-Cerf Clinique, Lausanne, Switzerland
| | - Christian Récher
- Centre Hospitalier Universitaire de Toulouse, Institut Universitaire du Cancer de Toulouse Oncopole, Université Toulouse III Paul Sabatier, Toulouse, France
| | - Viola Poeschel
- Department of Internal Medicine I, Medical School, Saarland University, Homburg/Saar, Germany
| | - Olivier Fitoussi
- Oncologie-Hematologie, Polyclinique Bordeaux Nord Aquitaine, Bordeaux, France
| | - Gerhard Held
- Department for Hematology and Oncology, Westpfalz-Klnikum Kaiserslautern, Kaiserslautern, Germany
| | - Olivier Casasnovas
- Service d'Hématologie Clinique, Centre Hospitalier Universitaire Dijon, INSERM UMR1231, Dijon, France
| | - Corinne Haioun
- APHP, Hematologie, Hôpital Henri Mondor, Creteil, France
| | | | - Bertram Glass
- Department for Hematology, Oncology, Tumor Immunology, and Palliative Care, Helios Klinikum Berlin-Buch, Berlin, Germany
| | - Nicolas Mounier
- Hematologie, Centre Hospitalier Universitaire L’Archet, Nice, France
| | - Herve Tilly
- INSERM U1245, Centre Henri Becquerel, Rouen, France
| | | | - German Ott
- Department of Clinical Pathology, Dr. Margarete Fischer-Bosch Institute for Clinical Pharmacology, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Georg Lenz
- Department of Medicine A, Hematology, Oncology, and Pneumonology, Münster University Hospital, Münster, Germany
| | - Thierry Molina
- Université de Paris, APHP, Anatomo-pathologie, Necker Hôpital, Paris, France
| | - Marita Ziepert
- Institute for Medical Informatics, Statistics, and Epidemiology, University of Leipzig, Leipzig, Germany
| | - Norbert Schmitz
- Department of Medicine A, Hematology, Oncology, and Pneumonology, Münster University Hospital, Münster, Germany
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Khwaja J, Cwynarski K. Management of primary and secondary CNS lymphoma. Hematol Oncol 2023; 41 Suppl 1:25-35. [PMID: 37294958 DOI: 10.1002/hon.3148] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 03/28/2023] [Indexed: 06/11/2023]
Abstract
Central nervous system (CNS) lymphoma has traditionally had very poor outcomes however advances in management have seen dramatic improvements and long-term survival of patients. In primary CNS lymphoma there are now randomised trial data to inform practice, however secondary CNS lymphoma has a lack of randomised trial data and CNS prophylaxis remains a contentious area. We describe treatment strategies in these aggressive disorders. Dynamic assessment of patient fitness and frailty is key throughout treatment alongside delivery of CNS-bioavailable therapy and enrolment in clinical trials. Intensive high-dose methotrexate-containing induction followed by autologous stem cell transplantation is preferred for patients who are fit. Less intensive chemoimmunotherapy, whole brain radiotherapy and novel therapies may be reserved for patients unfit or chemoresistant. It is essential to better define patients at increased risk of CNS relapse, as well as effective prophylactic strategies to prevent it. Future prospective studies incorporating novel agents are key.
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Affiliation(s)
- Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London, England
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, England
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Wang X, Yu L, Jiang X, Ding K. Real-world data for lenalidomide maintenance in responding patients of diffuse large B-cell lymphoma. Cancer Med 2023; 12:10553-10562. [PMID: 36912128 DOI: 10.1002/cam4.5790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/04/2022] [Accepted: 02/27/2023] [Indexed: 03/14/2023] Open
Abstract
BACKGROUND Approximately 40% patients of diffuse large B-cell lymphoma (DLBCL) would develop disease recurrence/progression after first-line R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) induction therapy, with highly poor prognosis. An effective strategy to prolong the survival of this patient population is the additional single-drug maintenance therapy. lenalidomide, an immunomodulatory drug with oral activity, has direct anti-tumor activity and indirect effects mediated by multiple immune cells in the tumor microenvironment, such as B, T, natural killer (NK), and dendritic cells. Combining its controllable toxicity, it is promising in long-term maintenance therapy. This study aims at evaluating the clinical effect of lenalidomide maintenance therapy in responding DLBCL patients with R-CHOP treatment. METHODS This retrospective study was devised in DLBCL cases who obtained complete response (CR) or partial response (PR) following 6-8 cycles of R-CHOP treatment between January 1, 2015 and July 31, 2019. Patients (n = 141) included were respectively assigned to receive lenalidomide maintenance treatment (lenalidomide, n = 50) and drug-free maintenance treatment (control, n = 91) after CR/PR. lenalidomide was provided orally at 25 mg/day for 10 days, with a cycle of 21 days and a treatment course of 2 years. Progression-free survival (PFS) was taken as the primary outcome. RESULTS Of the total 141 subjects, the median follow-up time was 30.9 months (range, 5.7-68.9 months). The 2-year PFS was 84% (95% CI: 74%-94%) in the lenalidomide group and 53% (95% CI: 43%-63%) in the control group. The median PFS of the lenalidomide group was not reached, and that of the control group was 42.9 months (HR = 0.32; 95% CI: 0.16-0.63; p = 0.001). No remarkable difference in overall survival (OS) between the two groups was indicated (HR = 0.42; 95% CI: 0.16-1.12; p = 0.08). Central nervous system (CNS) recurrence happened in 5 patients (5.5%) of the control group, while none of the patients with lenalidomide had CNS recurrence. Additionally, neutropenia and cutaneous reactions were the most common Grade 1-2 adverse reactions after lenalidomide treatment, and neutropenia was the most frequent Grade 3-4 adverse reaction. CONCLUSION Two-year lenalidomide maintenance treatment can significantly prolong the PFS of DLBCL patients who obtained CR/PR to first-line R-CHOP treatment.
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Affiliation(s)
- Xiaoyan Wang
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Lu Yu
- Department of Hematology, Anqing Municipal Hospital, Anhui Medical University, Anqing, China
| | - Xinlu Jiang
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China
| | - Kaiyang Ding
- Department of Hematology, Anhui Provincial Hospital, Anhui Medical University, Hefei, China.,Department of Hematology, the First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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5
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Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica 2023; 108:673-689. [PMID: 36384246 PMCID: PMC9973486 DOI: 10.3324/haematol.2022.281457] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.
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Affiliation(s)
- Sabela Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milan
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London
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Zhang W, Huang C, Liu R, Zhang H, Li W, Yin S, Wang L, Liu W, Liu L. Case report: CD19-directed CAR-T cell therapy combined with BTK inhibitor and PD-1 antibody against secondary central nervous system lymphoma. Front Immunol 2022; 13:983934. [PMID: 36275715 PMCID: PMC9581047 DOI: 10.3389/fimmu.2022.983934] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 09/14/2022] [Indexed: 12/08/2022] Open
Abstract
Current therapeutic strategies for central nervous system (CNS) relapse of diffuse large B-cell lymphoma (DLBCL) are extremely limited. Secondary central nervous system lymphoma (SCNSL) also shows a grave prognosis and high mortality. This report describes a young female patient with DLBCL and CNS relapse who received low-dose CD19-directed chimeric antigen receptor T (CAR-T) cell therapy followed with Bruton’s tyrosine kinase inhibitor and programmed cell death protein 1 antibody after several lines of chemotherapy. However, limited reports on CAR-T cell therapy are applied for SCNSL, particularly those in combination with targeted agents. The current treatment combination for this case provides a new regimen for CNS relapse from DLBCL.
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Affiliation(s)
- Wenqi Zhang
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Chen Huang
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Tumor Microenvironment and Drug Resistance, Shijiazhuang, China
| | - Ruixia Liu
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Huichao Zhang
- Clinical Laboratory, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Weijing Li
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Shaoning Yin
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lianjing Wang
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Wei Liu
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lihong Liu
- Department of Hematology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
- Hebei Provincial Key Laboratory of Tumor Microenvironment and Drug Resistance, Shijiazhuang, China
- *Correspondence: Lihong Liu,
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7
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Simard J, Roschewski M. SOHO State of the Art Updates and Next Questions: Prophylaxis and Management of Secondary CNS Lymphoma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:709-717. [PMID: 35787364 PMCID: PMC9529879 DOI: 10.1016/j.clml.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/01/2022] [Accepted: 06/04/2022] [Indexed: 06/15/2023]
Abstract
Secondary CNS lymphoma (SCNSL) is a rare but frequently fatal complication of systemic lymphoma. There is no standard treatment for SCNSL, and patients who develop SCNSL at diagnosis or after frontline therapy often receive highly intensive chemotherapy regimens that are inactive against primary chemorefractory disease and too toxic for older, frail patients to tolerate. Because the prognosis of SCNSL is so poor, management has historically emphasized prevention, but the current methods of CNS prophylaxis are not universally effective. To improve both the prevention and management of SCNSL, better characterization of the molecular determinants of CNS invasion is needed. Novel treatments that are currently being studied in SCNSL include targeted pathway inhibitors and cellular therapy, but SCNSL patients are often excluded from clinical trials of promising new therapies.
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Affiliation(s)
- Jillian Simard
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD
| | - Mark Roschewski
- Lymphoid Malignancies Branch, Center for Cancer Research, National Cancer Institute, Bethesda, MD.
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8
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Lin Z, Chen X, Liu L, Zeng H, Li Z, Xu B. The role of central nervous system (CNS) prophylaxis in preventing DLBCL patients from CNS relapse: A network meta-analysis. Crit Rev Oncol Hematol 2022; 176:103756. [PMID: 35809794 DOI: 10.1016/j.critrevonc.2022.103756] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 06/25/2022] [Accepted: 07/02/2022] [Indexed: 10/17/2022] Open
Abstract
BACKGROUND Secondary central nervous system (CNS) relapses are an uncommon yet devastating complication in diffuse large B cell lymphoma (DLBCL). Although several prophylaxis attempts were employed clinically in order to reduce the CNS relapse rate, the optimal management remained uncertain. METHODS We employed conventional meta-analysis along with Network meta-analysis to investigate an optimal prophylactic strategy. The primary outcome was CNS relapse rate. RESULTS A total of thirty-six studies comprising 5 RCTs, one clinical trial and 30 observational studies were included. Rituximab overall was superior in reducing CNS relapse rate, and the statistical significance exists (RR 0.79(0.68-0.93), p = 0.004). In rituximab era, none of intravenous, intrathecal administration or novel target agents could significantly decrease CNS relapse rate in high CNS risk patients. Intensive chemotherapy regimen containing HD-MTX with HD-Ara-C (SUCRA 93.4 %) was ranked as the first in reducing CNS relapse rate followed by no prophylaxis (SUCRA 57.5 %), HD-MTX (SUCRA 53.1 %), IT (SUCRA 34.5 %) and lenalidomide maintenance (SUCRA 11.5 %). In addition, intercalated HD-MTX had a trend of reducing CNS relapse but without statistical significance (RR 0.86(0.44-1.68), p = 0.67). However, i-HD-MTX was associated with increased grade 3-4 toxicities and prolonged inpatient stay. Early HD-MTX exposure also increased the treatment related death. CONCLUSION Our network meta-analysis provides an overview of the relative efficacy of all available CNS prophylaxis strategies in DLBCL. In rituximab era, none of intravenous, intrathecal administration or novel target agents could significantly decrease CNS relapse rate in high CNS risk patients. Further studies with prospective, randomized clinical trials as well as with more focus on novel target agents that could spread blood-brain barriers are suggested.
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Affiliation(s)
- Zhijuan Lin
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Xing Chen
- Department of Nephrology, the First Affiliated Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
| | - Long Liu
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Hanyan Zeng
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China
| | - Zhifeng Li
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China.
| | - Bing Xu
- Department of Hematology, the First Affiliated Hospital of Xiamen University and Institute of Hematology, School of Medicine, Xiamen University, Xiamen, China; Key Laboratory of Xiamen for Diagnosis and Treatment of Hematological Malignancy, Xiamen, China.
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CNS prophylaxis in DLBCL: first do no harm. Blood 2022; 139:2420-2421. [PMID: 35446381 DOI: 10.1182/blood.2022015432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 01/31/2022] [Indexed: 11/20/2022] Open
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10
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Gogia A, Sasi A. Preventing central nervous system relapses of diffuse large B-cell lymphoma: A brief summary of current evidence. CANCER RESEARCH, STATISTICS, AND TREATMENT 2022. [DOI: 10.4103/crst.crst_151_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Puckrin R, El Darsa H, Ghosh S, Peters A, Owen C, Stewart D. Ineffectiveness of high-dose methotrexate for prevention of CNS relapse in diffuse large B-cell lymphoma. Am J Hematol 2021; 96:764-771. [PMID: 33811794 DOI: 10.1002/ajh.26181] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 12/12/2022]
Abstract
Central nervous system (CNS) relapse affects 5% of diffuse large B-cell lymphoma (DLBCL) patients and portends a poor prognosis. Prophylactic intravenous high-dose methotrexate (HD-MTX) is frequently employed to reduce this risk, but there is limited evidence supporting this practice. We conducted a multicenter retrospective study to determine the CNS relapse risk with HD-MTX in DLBCL patients aged 18-70 years treated in Alberta, Canada between 2012 and 2019. Provincial guidelines recommended HD-MTX for patients at high-risk of CNS relapse based upon CNS-IPI score, double-hit lymphoma, or testicular involvement. Among 906 patients with median follow-up 35.3 months (range 0.29-105.7), CNS relapse occurred in 1.9% with CNS-IPI 0-1, 4.9% with CNS-IPI 2-3, and 12.2% with CNS-IPI 4-6 (p < .001). HD-MTX was administered to 115/326 (35.3%) high-risk patients, of whom 96 (83.5%) had CNS-IPI score 4-6, 45 (39.1%) had double-hit lymphoma, and four (3.5%) had testicular lymphoma. The median number of HD-MTX doses was two (range 1-3). Central nervous system relapse risk was similar with versus without HD-MTX (11.2% vs. 12.2%, p = .82) and comparable to previous reports of high-risk patients who did not receive CNS prophylaxis (10-12%). In multivariate and propensity score analyses, HD-MTX demonstrated no association with CNS relapse, progression-free survival, or overall survival. This study did not demonstrate a benefit of prophylactic HD-MTX in this high-risk patient population. Further study is required to determine the optimal strategy to prevent CNS relapse in DLBCL.
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Affiliation(s)
- Robert Puckrin
- Postgraduate Medical Education, University of Calgary, Calgary, Alberta, Canada
| | - Haidar El Darsa
- Postgraduate Medical Education, University of Alberta, Edmonton, Alberta, Canada
| | - Sunita Ghosh
- Alberta Health Services Cancer Control Alberta, Edmonton, Alberta, Canada
| | - Anthea Peters
- University of Alberta and Cancer Cross Institute, Edmonton, Alberta, Canada
| | - Carolyn Owen
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Douglas Stewart
- University of Calgary and Tom Baker Cancer Centre, Calgary, Alberta, Canada
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12
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Greve P, Meyer-Wentrup FAG, Peperzak V, Boes M. Upcoming immunotherapeutic combinations for B-cell lymphoma. IMMUNOTHERAPY ADVANCES 2021; 1:ltab001. [PMID: 35919738 PMCID: PMC9326875 DOI: 10.1093/immadv/ltab001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/11/2020] [Accepted: 01/09/2021] [Indexed: 11/13/2022] Open
Abstract
After initial introduction for B-cell lymphomas as adjuvant therapies to established cancer treatments, immune checkpoint inhibitors and other immunotherapies are now integrated in mainstream regimens, both in adult and pediatric patients. We here provide an overview of the current status of combination therapies for B-cell lymphoma, by in-depth analysis of combination therapy trials registered between 2015–2020. Our analysis provides new insight into the rapid evolution in lymphoma treatment, as propelled by new additions to the treatment arsenal. We conclude with prospects on upcoming clinical trials which will likely use systematic testing approaches of more combinations of established chemotherapy regimens with new agents, as well as new combinations of immunotherapy and targeted therapy. Future trials will be set up as basket or umbrella-type trials to facilitate the evaluation of new drugs targeting specific genetic changes in the tumor or associated immune microenvironment. As such, lymphoma patients will benefit by receiving more tailored treatment that is based on synergistic effects of chemotherapy combined with new agents targeting specific aspects of tumor biology and the immune system.
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Affiliation(s)
- Patrick Greve
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Hematology-Oncology, Princess Máxima Center for Pediatric Oncology, Utrecht, The Netherlands
| | | | - Victor Peperzak
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Marianne Boes
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Pediatrics, University Medical Center Utrecht, Utrecht, The Netherlands
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13
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Chamuleau ME, Burggraaff CN, Nijland M, Bakunina K, Mous R, Lugtenburg PJ, Dierickx D, van Imhoff GW, Vermaat JS, A.F.Marijt E, Visser O, Mandigers C, Bilgin YM, Beeker A, Durian MF, van Rees BP, Bohmer LH, Tick LW, Boersma RS, Snijders TJ, Schouten HC, Koene HR, de Jongh E, Hijmering N, Diepstra A, van de Berg A, Arens AI, Huijbregts J, Hoekstra O, Zijlstra JM, de Jong D, Kersten MJ. Treatment of patients with MYC rearrangement positive large B-cell lymphoma with R-CHOP plus lenalidomide: results of a multicenter HOVON phase II trial. Haematologica 2020; 105:2805-2812. [PMID: 33256379 PMCID: PMC7716355 DOI: 10.3324/haematol.2019.238162] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 12/06/2019] [Indexed: 11/09/2022] Open
Abstract
Patients with MYC-rearrangement positive large B-cell lymphoma (MYC+ LBCL) have an inferior prognosis following standard first-line therapy with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP) as compared to patients without MYC rearrangement. Although intensive chemotherapy regimens yield higher remission rates, toxicity remains a concern. Lenalidomide is an oral immunomodulatory drug which downregulates MYC and its target genes thereby providing support using lenalidomide as additional therapeutic option for MYC+ LBCL. A phase II trial was conducted evaluating the efficacy of lenalidomide (15 mg day 1-14) in combination with R-CHOP (R2CHOP) in newly diagnosed MYC+ LBCL patients identified through a nationwide MYC-FISH screening program. The primary endpoint was complete metabolic response (CMR) on centrally reviewed 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)-computer tomography (CT)-scan at end-of-treatment. Secondary endpoints were overall survival (OS), disease-free survival (DFS) and event-free survival (EFS). Eighty-two patients with stage II-IV MYC+ LBCL were treated with 6 cycles of R2CHOP. At EOT, 67% (confidence interval (CI) 58-75%) of the patients reached CMR. With a median follow-up of 25.4 months, 2-year estimates (95% CI) for OS, DFS, EFS were 73% (62-82%), 75% (63-84%) and 63% (52-73%) respectively. In this prospective trial for newly diagnosed MYC+ LBCL patients, we found that administering R2CHOP was safe, and yields comparable CMR and survival rates as in studies applying more intensive chemotherapy regimens. Hence, these findings offer new prospects for MYC+ LBCL patients and warrant comparison in prospective randomized clinical trials. This trial was registered at www.clinicaltrialsregister.eu (#2014-002654-39).
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Affiliation(s)
- Martine E.D. Chamuleau
- Department of Hematology, Amsterdam UMC, VU University Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Coreline N. Burggraaff
- Department of Hematology, Amsterdam UMC, VU University Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Marcel Nijland
- Department of Hematology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Katerina Bakunina
- Department of Hematology, HOVON Data Centre, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
| | - Rogier Mous
- Department of Hematology, UMC Utrecht Cancer Centre, University Medical Centre Utrecht, Utrecht, the Netherlands
| | | | - Daan Dierickx
- Department of Hematology, University Hospitals Leuven, Leuven, Belgium
| | - Gustaaf W. van Imhoff
- Department of Hematology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Joost S.P. Vermaat
- Department of Hematology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Eric A.F.Marijt
- Department of Hematology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Otto Visser
- Department of Hematology, Oncology Centre Isala, Zwolle, the Netherlands
| | - Caroline Mandigers
- Department of Hematology, Canisius-Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Yavuz M. Bilgin
- Department of Internal Medicine, Admiraal de Ruijter Hospital Goes, the Netherlands
| | - Aart Beeker
- Department of Internal Medicine, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Mark F. Durian
- Department of Internal Medicine, Tweesteden Hospital, Tilburg, the Netherlands
| | - Bas P. van Rees
- Department of Internal Medicine, Tjongerschans Hospital, Heerenveen, the Netherlands
| | - Lara H. Bohmer
- Department of Internal Medicine, Haga Hospital, Den Haag, the Netherlands
| | - Lidwine W. Tick
- Department of Internal Medicine, Maxima Medisch Centrum, Veldhoven, the Netherlands
| | - Rinske S. Boersma
- Department of Internal Medicine, Amphia Hospital, Breda, the Netherlands
| | | | - Harry C. Schouten
- Department of Hematology, Maastricht UMC, Maastricht, the Netherlands
| | - Harry R. Koene
- Department of Internal Medicine, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Eva de Jongh
- Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, the Netherlands
| | - Nathalie Hijmering
- Department of Pathology, Amsterdam UMC, location VU University Amsterdam, Amsterdam, the Netherlands
| | - Arjan Diepstra
- Department of Pathology and Medical Biology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Anke van de Berg
- Department of Pathology and Medical Biology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Anne I.J. Arens
- Department of Radiology and Nuclear Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Julia Huijbregts
- Department of Radiology and Nuclear Medicine, Gelre Hospital, Apeldoorn, the Netherlands
| | - Otto Hoekstra
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, VU University Amsterdam, Amsterdam, the Netherlands
| | - Josee M. Zijlstra
- Department of Hematology, Amsterdam UMC, VU University Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
| | - Daphne de Jong
- Department of Pathology, Amsterdam UMC, location VU University Amsterdam, Amsterdam, the Netherlands
| | - Marie José Kersten
- Department of Hematology, Amsterdam UMC, University of Amsterdam, Cancer Center Amsterdam, Amsterdam, the Netherlands
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14
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First-Line Treatment for Primary Breast Diffuse Large B-Cell Lymphoma Using Immunochemotherapy and Central Nervous System Prophylaxis: A Multicenter Phase 2 Trial. Cancers (Basel) 2020; 12:cancers12082192. [PMID: 32781541 PMCID: PMC7463683 DOI: 10.3390/cancers12082192] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 07/31/2020] [Accepted: 08/03/2020] [Indexed: 11/17/2022] Open
Abstract
There are limited data from prospective controlled trials regarding optimal treatment strategies in patients with primary breast diffuse large B-cell lymphoma (DLBCL). In this phase 2 study (NCT01448096), we examined the efficacy and safety of standard immunochemotherapy and central nervous system (CNS) prophylaxis using intrathecal methotrexate (IT-MTX). Thirty-three patients with newly diagnosed primary breast DLBCL received six cycles of rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and four fixed doses of IT-MTX (12 mg). The median age was 50 years (range, 29-75), and all patients were females. According to the CNS-International Prognostic Index, most patients (n = 28) were categorized as the low-risk group. Among the 33 patients, 32 completed R-CHOP, and 31 completed IT-MTX as planned. With a median follow-up of 46.1 months (interquartile range (IQR), 31.1-66.8), the 2-year progression-free and overall survival rates were 81.3% and 93.5%, respectively. Six patients experienced treatment failures, which included the CNS in four patients (two parenchyma and two leptomeninges) and breast in two patients (one ipsilateral and one contralateral). The 2-year cumulative incidence of CNS relapse was 12.5%. Although standard R-CHOP and IT-MTX without routine radiotherapy show clinically meaningful survival outcomes, this strategy may not be optimal for reducing CNS relapse and warrants further investigation.
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15
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Wang W, Zhang Y, Zhang L, Yang C, Feng J, Cai H, Chen M, Cao X, Zhuang J, Zhu T, Duan M, Zhang W, Li J, Zhou D. Intravenous methotrexate at a dose of 1 g/m 2 incorporated into RCHOP prevented CNS relapse in high-risk DLBCL patients: A prospective, historic controlled study. Am J Hematol 2020; 95:E80-E83. [PMID: 31925808 DOI: 10.1002/ajh.25723] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 12/09/2019] [Accepted: 01/03/2020] [Indexed: 11/06/2022]
Affiliation(s)
- Wei Wang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Yan Zhang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Lu Zhang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Chen Yang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Jun Feng
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Huacong Cai
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Miao Chen
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Xinxin Cao
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Junling Zhuang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Tienan Zhu
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Minghui Duan
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Wei Zhang
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Jian Li
- Department of Hematology Peking Union Medical College Hospital Beijing China
| | - Daobin Zhou
- Department of Hematology Peking Union Medical College Hospital Beijing China
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16
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Chiappella A, Crombie J, Guidetti A, Vitolo U, Armand P, Corradini P. Are We Ready to Treat Diffuse Large B-cell and High-Grade Lymphoma According to Major Genetic Subtypes? Hemasphere 2019; 3:e284. [PMID: 31942539 PMCID: PMC6919463 DOI: 10.1097/hs9.0000000000000284] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/17/2019] [Accepted: 07/01/2019] [Indexed: 02/06/2023] Open
Abstract
Diffuse Large B-Cell Lymphoma (DLBCL) is a clinically and biologically heterogeneous disease. The revised Classification of Lymphoproliferative diseases published in 2016 (WHO, 2016) refined the previous DLBLC subtypes and identified four categories: DLBCL not otherwise specified (NOS), other lymphomas of large B cells, high grade B-cell lymphoma, and B-cell lymphoma unclassifiable. High grade B-cell lymphomas include the entities carrying MYC, BCL2 and/or BCL6 translocations or cases with blastoid morphology without DH translocations. This classification also acknowledges the cell of origin (COO) classification, that has only a limited impact on the choice of frontline treatment for DLBCL, as most patients still receive R-CHOP chemoimmunotherapy. Attempts to improve the outcomes of specific subgroups, especially COO groups, have so far had limited success. Newer analyses have further subdivided DLBCL into genomically distinct subsets, not yet incorporated in the WHO classification, which may facilitate targeted approaches to therapy. In this review, we discuss the subgroups that are recognized by the WHO 2016 classification, review the newer genomic data, and speculate on how this could alter the treatment landscape of DLBCL in the future. We also discuss novel approaches to salvage therapy in the broad context of the heterogeneity of DLBCL.
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Affiliation(s)
- Annalisa Chiappella
- Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Jennifer Crombie
- Department of Medical Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Anna Guidetti
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- University of Milan, Italy
| | - Umberto Vitolo
- Hematology, Azienda Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Philippe Armand
- Dana-Farber Cancer Institute, 450 Brookline Avenue, Boston, MA, USA
| | - Paolo Corradini
- Division of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- University of Milan, Italy
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Santambrogio E, Nicolosi M, Vassallo F, Castellino A, Novo M, Chiappella A, Vitolo U. Aggressive Non-Hodgkin lymphomas: risk factors and treatment of central nervous system recurrence. Expert Rev Hematol 2019; 12:787-796. [DOI: 10.1080/17474086.2019.1643232] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Elisa Santambrogio
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Maura Nicolosi
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Francesco Vassallo
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Alessia Castellino
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Mattia Novo
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Annalisa Chiappella
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
| | - Umberto Vitolo
- Hematology, Città della Salute e della Scienza Hospital and University, Torino, Italy
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18
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Qualls D, Abramson JS. Advances in risk assessment and prophylaxis for central nervous system relapse in diffuse large B-cell lymphoma. Haematologica 2018; 104:25-34. [PMID: 30573511 PMCID: PMC6312016 DOI: 10.3324/haematol.2018.195834] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Accepted: 11/15/2018] [Indexed: 12/13/2022] Open
Abstract
Central nervous sytem recurrence of diffuse large B-cell lymphoma is an uncommon but devastating event, making identification of patients at high risk for relapse within the central nervous system essential for clinicians. Modern risk stratification includes both clinical and biological features. A validated clinical risk model employing the five traditional International Prognostic Index risk factors plus renal or adrenal involvement can identify a high-risk patient population with a central nervous system recurrence risk of greater than 10%. Lymphoma involvement of certain discrete extranodal sites such as the testis also confers increased risk, even in stage I disease. Adverse biological risk factors for central nervous system relapse include presence of translocations of MYC, BCL2 and/or BCL6, in so-called double- or triple-hit lymphoma. Immunohistochemically detectable co-expression of MYC and BCL2 in the absence of translocations also portends an increased risk of relapse within the central nervous system, particularly in the setting of the activated B-cell-like subtype of diffuse large B-cell lymphoma. The role, method, and timing of prophylactic therapy remain controversial based on the available data. We review both intrathecal and systemic strategies for prophylaxis in high-risk patients. Our preference is for systemic methotrexate in concert with standard chemoimmunotherapy in the majority of cases. Several novel agents have also demonstrated clinical activity in primary and secondary central nervous system lymphoma and warrant future investigation in the prophylactic setting.
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Affiliation(s)
- David Qualls
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
| | - Jeremy S Abramson
- Center for Lymphoma, Massachusetts General Hospital Cancer Center, Boston, MA, USA
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Lenalidomide plus R-CHOP21 in newly diagnosed diffuse large B-cell lymphoma (DLBCL): long-term follow-up results from a combined analysis from two phase 2 trials. Blood Cancer J 2018; 8:108. [PMID: 30410035 PMCID: PMC6224549 DOI: 10.1038/s41408-018-0145-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 09/12/2018] [Accepted: 09/25/2018] [Indexed: 12/20/2022] Open
Abstract
Lenalidomide-RCHOP (R2-CHOP21) has been shown to be safe and effective in patients with untreated diffuse large B-cell lymphoma (DLBCL). The aim of this analysis is to report long-term outcome and toxicities in newly diagnosed DLBCL patients who received R2-CHOP21 in two independent phase 2 trials, conducted by Mayo Clinic (MC) and Fondazione Italiana Linfomi (FIL). All patients received R-CHOP21 plus lenalidomide. Long-term progression-free survival (PFS), time to progression (TTP), overall survival (OS) and late toxicities and second tumors were analyzed. Hundred and twelve patients (63 MC, 49 FIL) were included. Median age was 69 years, 88% were stage III–IV. At a median follow-up of 5.1 years, 5y-PFS was 63.5%, 5y-TTP 70.1% and 5y-OS 75.4%; according to cell of origin (COO): 5y-PFS 52.8% vs 64.5%, 5y-TTP 61.6% vs 69.6% and 5y-OS 68.6% vs 74.1% in germinal center (GCB) vs non-GCB respectively. Four patients experienced grade 4–5 late toxicities. Grade ≤ 3 toxicities were infections (N = 4), thrombosis (N = 1) and neuropathy (N = 3). Seven seconds tumors were observed. Long-term follow-up demonstrates that R2-CHOP21 efficacy was maintained with high rates of PFS, TTP, and OS. Lenalidomide appears to mitigate the negative prognosis of non-GCB phenotype. Incidence of therapy-related secondary malignancies and late toxicities were low.
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Optimizing initial therapy in DLBCL. Best Pract Res Clin Haematol 2018; 31:199-208. [PMID: 30213389 DOI: 10.1016/j.beha.2018.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 08/06/2018] [Indexed: 01/02/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a group of lymphomas comprising heterogeneous molecular and biological subtypes, reflected in a broad range of clinical outcomes. With the standard R-CHOP regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone plus rituximab administered every 21 days, the treatment failure rate remains unacceptably high in certain DLBCL subsets. Here we review possible avenues for optimizing initial therapy. The role of functional imaging and biological features, such as double-hit lymphomas, defined by the dual translocation of MYC and BCL2, and dual protein-expresser lymphomas, defined by the overexpression of MYC and BCL2, activated B-cell (ABC)-like DLBCL, to better define these high-risk patient subsets, and their use to guide and personalize treatment decisions are discussed. Secondly, the implications of varying dose-intensification of the various agents administered, and the link to imaging are reviewed. Thirdly, the results of the addition of novel drugs to standard R-CHOP will be analyzed, when added at induction or in maintenance. Finally, with CNS relapse in DLBCL representing a major and devastating unmet medical need, an overview and future directions for CNS prophylaxis is presented.
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