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Cook MR, Williams LS, Dorris CS, Luo Y, Makambi K, Dunleavy K. Improved survival for dose-intensive chemotherapy in primary mediastinal B-cell lymphoma: a systematic review and meta-analysis of 4,068 patients. Haematologica 2024; 109:846-856. [PMID: 37646662 PMCID: PMC10905081 DOI: 10.3324/haematol.2023.283446] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 08/23/2023] [Indexed: 09/01/2023] Open
Abstract
Primary mediastinal B-cell lymphoma (PMBCL) is a distinct clinicopathologic entity. Currently, there is a paucity of randomized prospective data to inform on optimal front-line chemoimmunotherapy (CIT) and use of consolidative mediastinal radiation (RT). To assess if distinct CIT approaches are associated with disparate survival outcomes, we performed a systematic review and meta-analysis comparing dose-intensive (DI-CIT) versus standard CIT for the front-line treatment of PMBCL. Standard approach (S-CIT) was defined as R-CHOP-21/CHOP-21, with or without RT. DI-CIT were defined as regimens with increased frequency, dose, and/or number of systemic agents. We reviewed data on 4,068 patients (2,517 DI-CIT; 1,551 S-CIT) with a new diagnosis of PMBCL. Overall survival for DI-CIT patients was 88% (95% CI: 85-90) compared to 80% for the S-CIT cohort (95% CI: 74-85). Meta-regression revealed an 8% overall survival (OS) benefit for the DI-CIT group (P<0.01). Survival benefit was maintained when analyzing rituximab only regimens; OS was 91% (95% CI: 89-93) for the rituximab-DI-CIT arm compared to 86% (95% CI: 82-89) for the R-CHOP-21 arm (P=0.03). Importantly, 55% (95% CI: 43-65) of the S-CIT group received RT compared to 22% (95% CI: 15-31) of DI-CIT patients (meta-regression P<0.01). To our knowledge, this is the largest meta-analysis reporting efficacy outcomes for the front-line treatment of PMBCL. DI-CIT demonstrates a survival benefit, with significantly less radiation exposure, curtailing long-term toxicities associated with radiotherapy. As we await results of randomized prospective trials, our study supports the use of dose-intensive chemoimmunotherapy for the treatment of PMBCL.
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Affiliation(s)
- Michael R Cook
- Perelman School of Medicine, University of Pennsylvania, Abramson Cancer Center, Philadelphia, PA.
| | - Lacey S Williams
- Lombardi Comprehensive Cancer Center and Georgetown University Hospital, Washington, DC
| | | | - Yutong Luo
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University
| | - Kepher Makambi
- Department of Biostatistics, Bioinformatics and Biomathematics, Georgetown University
| | - Kieron Dunleavy
- Lombardi Comprehensive Cancer Center and Georgetown University Hospital, Washington, DC.
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2
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Donzel M, Pesce F, Trecourt A, Groussel R, Bachy E, Ghesquières H, Fontaine J, Benzerdjeb N, Mauduit C, Traverse-Glehen A. Molecular Characterization of Primary Mediastinal Large B-Cell Lymphomas. Cancers (Basel) 2023; 15:4866. [PMID: 37835560 PMCID: PMC10571533 DOI: 10.3390/cancers15194866] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 10/03/2023] [Indexed: 10/15/2023] Open
Abstract
Since the description of primary mediastinal large B-cell lymphoma (PMBL) as a distinct entity from diffuse large B-cell lymphomas (DLBCL), numerous studies have made it possible to improve their definition. Despite this, this differential diagnosis can be challenging in daily practice. However, in some centers, PMBL may be treated according to a particular regimen, distinct from those used in DLBCL, emphasizing the importance of accurate identification at diagnosis. This study aimed to describe the histological and molecular characteristics of PMBL to improve the accuracy of their diagnosis. Forty-nine cases of PMBL were retrospectively retrieved. The mean age at diagnosis was 39 years (21-83), with a sex ratio of 0.88. All cases presented a fibrous background with diffuse growth of intermediate to large cells with an eosinophil (26/49, 53%) or retracted cytoplasm (23/49, 47%). "Hodgkin-like" cells were observed in 65% of cases (32/49, 65%). The phenotype was: BCL6+ (47/49, 96%), MUM1+ (40/49, 82%), CD30+ (43/49, 88%), and CD23+ (37/49, 75%). Genomic DNAs were tested by next generation sequencing of 33 cases using a custom design panel. Pathogenic variants were found in all cases. The most frequent mutations were: SOCS1 (30/33, 91%), TNFAIP3 (18/33, 54.5%), ITPKB (17/33, 51.5%), GNA13 (16/33, 48.5%), CD58 (12/33, 36.4%), B2M (12/33; 36.4%), STAT6 (11/33, 33.3%) as well as ARID1A (10/33, 30.3%), XPO1 (9/33, 27.3%), CIITA (8/33, 24%), and NFKBIE (8/33, 24%). The present study describes a PMBL cohort on morphological, immunohistochemical, and molecular levels to provide pathologists with daily routine tools. These data also reinforce interest in an integrated histomolecular diagnosis to allow a precision diagnosis as early as possible.
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Affiliation(s)
- Marie Donzel
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
- Centre International de Recherche en Infectiologie (CIRI), UFR Lyon-1, Institut National de la Santé et de la Recherche Médicale (INSERM) U1111, Centre National de la Recherche Scientifique (CNRS), UMR5308, Ecole Normale Supérieure de Lyon, 69342 Lyon, France
| | | | - Alexis Trecourt
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
| | | | - Emmanuel Bachy
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
- Centre International de Recherche en Infectiologie (CIRI), UFR Lyon-1, Institut National de la Santé et de la Recherche Médicale (INSERM) U1111, Centre National de la Recherche Scientifique (CNRS), UMR5308, Ecole Normale Supérieure de Lyon, 69342 Lyon, France
- Hospices Civils de Lyon, Service d’Hématologie, Hôpital Lyon Sud, 69310 Lyon, France
| | - Hervé Ghesquières
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
- Centre International de Recherche en Infectiologie (CIRI), UFR Lyon-1, Institut National de la Santé et de la Recherche Médicale (INSERM) U1111, Centre National de la Recherche Scientifique (CNRS), UMR5308, Ecole Normale Supérieure de Lyon, 69342 Lyon, France
- Hospices Civils de Lyon, Service d’Hématologie, Hôpital Lyon Sud, 69310 Lyon, France
| | - Juliette Fontaine
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
| | - Nazim Benzerdjeb
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
| | - Claire Mauduit
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
- Centre International de Recherche en Infectiologie (CIRI), UFR Lyon-1, Institut National de la Santé et de la Recherche Médicale (INSERM) U1111, Centre National de la Recherche Scientifique (CNRS), UMR5308, Ecole Normale Supérieure de Lyon, 69342 Lyon, France
- Institut National de la Santé et de la Recherche Médicale, Centre Méditerranéen de Médecine Moléculaire (C3M), Unité 1065, Equipe 10, 06000 Nice, France
| | - Alexandra Traverse-Glehen
- Hospices Civils de Lyon, Institut de Pathologie Multisite, Hôpital Lyon Sud, 69310 Lyon, France (N.B.)
- UFR Claude Bernard Lyon 1, 69100 Villeurbanne, France
- Centre International de Recherche en Infectiologie (CIRI), UFR Lyon-1, Institut National de la Santé et de la Recherche Médicale (INSERM) U1111, Centre National de la Recherche Scientifique (CNRS), UMR5308, Ecole Normale Supérieure de Lyon, 69342 Lyon, France
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3
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Nabiałek-Trojanowska I, Jankowska H, Sławiński G, Dąbrowska-Kugacka A, Lewicka E. Echocardiographic Findings in Asymptomatic Mediastinal Lymphoma Survivors Years after Treatment Termination. J Clin Med 2023; 12:jcm12103427. [PMID: 37240533 DOI: 10.3390/jcm12103427] [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: 03/23/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 05/28/2023] Open
Abstract
Patients treated due to mediastinal lymphomas are at risk of cardiovascular complications, as they receive chemotherapy, usually containing anthracyclines, often combined with thoracic radiotherapy. The aim of this prospective study was to assess early asymptomatic cardiac dysfunction using resting and dobutamine stress echocardiography (DSE) at least 3 years after the end of mediastinal lymphoma treatment. Two groups of patients were compared: those treated with chemoradiotherapy and those exclusively treated with chemotherapy. Left ventricular contractile reserve (LVCR) during DSE was assessed using changes in LV ejection fraction (LVEF), LV global longitudinal strain (LV GLS), and a novel parameter-Force, which is the ratio of the systolic blood pressure to the LV end-systolic volume. The study included 60 patients examined at a median of 89 months after the end of treatment. Resting echocardiography showed normal LVEF of 58.9 ± 9.6%, borderline LV GLS of -17.7 ± 3%, decreased mean stroke volume (SV) of 51.4 ± 17 mL, and indexed SV of 27.3 ± 8 mL/m2, and the right ventricular free wall longitudinal strain (LS) was impaired in some patients but not in all. There were no significant differences between the groups, with the exception of arterial hypertension, which was more common in the chemotherapy group (32% vs. 62.5%, p = 0.04). In resting echocardiography, only LV posterior wall LS differed significantly and was impaired in patients treated with chemotherapy (-19.1 ± 3.1% vs. -16.5 ± 5.1%, p = 0.04). DSE, performed in 21 patients after a median of 166 months from the end of cancer treatment, detected new contractility disorders in 1 patient (4.8%) and decreased LVCR in the majority of patients when determined using changes in LVEF or LV GLS, and in all patients when assessed with changes in Force. Conclusions: Most asymptomatic mediastinal lymphoma survivors showed preserved ventricular function on resting echocardiography. However, all of them showed impaired LV contractile reserve on DSE, as assessed with a simple parameter-Force. This may indicate subtle LV dysfunction and confirms the need for long-term monitoring of patients with potentially cardiotoxic cancer treatment.
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Affiliation(s)
- Izabela Nabiałek-Trojanowska
- First Department of Cardiology, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Hanna Jankowska
- Division of Cardiac Diagnostics, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Grzegorz Sławiński
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Alicja Dąbrowska-Kugacka
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Faculty of Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
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4
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Zhou H, Liu Q, Lu S, Zou L. Primary mediastinal/thymic diffuse large B-cell lymphoma: a population-based study on incidence and survival. Ann Hematol 2023:10.1007/s00277-023-05225-2. [PMID: 37074378 DOI: 10.1007/s00277-023-05225-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 04/10/2023] [Indexed: 04/20/2023]
Abstract
Primary mediastinal large B-cell lymphoma is a rare subtype of lymphoma. The contemporary incidence of primary mediastinal large B-cell lymphoma remains unknown, and a large population-based study has not been reported. It is essential to provide guidance for further strategies in reducing the disease burden via population-based preventive initiatives. This study aims to explore the epidemiology and effect of therapeutic advances on the survival of patients with primary mediastinal large B-cell lymphoma. This population-based study was conducted using the Surveillance, Epidemiology, and End Results Program (SEER), covering the period from 1975 to 2018. A total of 774 patients in the SEER 9 and 1654 patients in the SEER 18 were analyzed. The age-adjusted incidence rate of primary mediastinal large B-cell lymphoma increased from 0.05/1,000,000 in 1975 to 2.38/1,000,000 in 2018. A significant positive linear increase in the incidence trend was found in primary mediastinal large B-cell lymphoma, with an annual percent change of 8.47% (95% confidence interval 7.7-9.2%, P < 0.001, z test). The survival in primary mediastinal large B-cell lymphoma was significantly superior to nodal diffuse large B-cell lymphoma. The incidence of PMBCL increases over the year. The survival of patients with primary mediastinal large B-cell lymphoma has improved over time.
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Affiliation(s)
- Huijie Zhou
- Division of Medical Oncology, Cancer Center and State Key Laboratory of Biotherapy, Sichuan University West China Hospital, Chengdu, China
| | - Qiuluo Liu
- Colorectal Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Siyan Lu
- Department of Radiology, Sichuan Provincial Maternity and Child Health Care Hospital, Chengdu, Sichuan, China
| | - Liqun Zou
- Division of Medical Oncology, Cancer Center and State Key Laboratory of Biotherapy, Sichuan University West China Hospital, Chengdu, China.
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5
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Radkiewicz C, Bruchfeld JB, Weibull CE, Jeppesen ML, Frederiksen H, Lambe M, Jakobsen L, El-Galaly TC, Smedby KE, Wästerlid T. Sex differences in lymphoma incidence and mortality by subtype: A population-based study. Am J Hematol 2023; 98:23-30. [PMID: 36178436 PMCID: PMC10092431 DOI: 10.1002/ajh.26744] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 09/06/2022] [Accepted: 09/21/2022] [Indexed: 02/04/2023]
Abstract
It is well established that the male sex is associated with increased risk for, as well as poorer survival of, most cancers. A similar pattern has been described in lymphomas but has not yet been comprehensively assessed. In this nationwide population-based cohort study, we used the Swedish Lymphoma Register to investigate sex differences in lymphoma subtype incidence and excess mortality in adults (age 18-99) diagnosed in 2000-2019. Male-to-female incidence rate ratios (IRRs) and excess mortality ratios (EMRs) adjusted for age and calendar year were predicted using Poisson regression. We identified 36 795 lymphoma cases, 20 738 (56.4%) in men and 16 057 (43.6%) in women. Men were at significantly higher risk of 14 out of 16 lymphoma subtypes with IRRs ranging from 1.15 (95% confidence interval [CI] 1.09-1.22) in follicular lymphoma to 5.95 (95% CI 4.89-7.24) in hairy cell leukemia. EMRs >1 were seen in 13 out of 16 lymphoma subtypes indicating higher mortality in men, although only statistically significant for classical Hodgkin lymphoma 1.26 (95% CI 1.04-1.54), aggressive lymphoma not otherwise specified 1.29 (95% CI 1.08-1.55), and small lymphocytic lymphoma 1.52 (95% CI 1.11-2.07). A corresponding analysis using data from the Danish Lymphoma Register was performed with comparable results. In conclusion, we demonstrate a significantly higher incidence and trend toward higher mortality in men for most lymphoma subtypes. Future studies with large patient material that include detailed clinicopathological prognostic factors are warranted to further delineate and explain sex differences in lymphoma survival to enable optimal management of lymphoma patients regardless of sex.
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Affiliation(s)
- Cecilia Radkiewicz
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Johanna B Bruchfeld
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Caroline E Weibull
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
| | - Mathias L Jeppesen
- Department of Hematology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Frederiksen
- Department of Hematology, Odense University Hospital (OUH), Denmark.,Academy of Geriatric Cancer Research, Odense University Hospital, Denmark
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institute, Stockholm, Sweden
| | - Lasse Jakobsen
- Department of Hematology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.,Department of Mathematical Sciences, Aalborg University, Aalborg, Denmark
| | - Tarec C El-Galaly
- Department of Hematology and Clinical Cancer Research Center, Aalborg University Hospital, Aalborg, Denmark.,Department of Hematology, Odense University Hospital (OUH), Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Karin E Smedby
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Tove Wästerlid
- Department of Medicine Solna, Clinical Epidemiology Division, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden.,Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
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Le Calvez B, Tessoullin B, Renaud L, Botella-Garcia C, Srour M, Le Gouill S, Guillerm G, Gressin R, Nguyen Quoc S, Furst S, Chauchet A, Sibon D, Lewalle P, Poiré X, Maillard N, Villate A, Loschi M, Paillassa J, Beguin Y, Dulery R, Tudesq JJ, Fayard A, Béné MC, Camus V, Chevallier P, Le Bourgeois A. Outcomes after allogeneic hematopoietic stem cell transplantation for adults with primary mediastinal B cell lymphoma: a SFGM-TC and LYSA study. Acta Oncol 2022; 61:1332-1338. [PMID: 36214787 DOI: 10.1080/0284186x.2022.2130709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Background: Despite therapeutic progress, 10 to 30% of adult patients with primary mediastinal B cell lymphoma (PMBCL) are primary refractory or experience early relapse (R/R). Allogeneic stem cell transplantation (allo-HSCT) thus remains a potentially curative option in this setting.Material and Methods: In this multicenter retrospective study, the outcomes of 33 French and Belgian adult patients allo-transplanted for R/R PMBCL between January 1999 and December 2018, were examined.Results: At allo-HSCT time, patients had received a median of 3 treatment lines, 50% of them were in complete response, 40% in partial response and 10% had a progressive disease. Forty-two percent of the donors were siblings and 39% matched related. The median follow-up for alive patients was 78 months (3.5-157). Considering the whole cohort, 2-year overall survival (OS), progression free survival (PFS) and graft-versus-host disease-free/relapse-free survival (GRFS) were 48% (95%CI: 33-70), 47% (95%CI: 33-68) and 38.5% (95%CI: 25-60) respectively. Cumulative incidence of relapse and non-relapse mortality rates were respectively 34% (95%CI: 18-50) and 18% (95%CI: 7-34). Disease status at transplant was the only factor predicting survivals, patients with progressive disease showing significant lower 2-year PFS (HR: 6.12, 95%CI: 1.32-28.31, p = 0.02) and OS (HR: 7.04, 95%CI: 1.52-32.75, p = 0.013). A plateau was observed for OS and PFS after 4 years with 10 patients alive after this date, suggesting that almost one third of the patients effectively salvaged and undergoing allo-SCT could be cured.Conclusion: This study indicates that allo-HSCT is a valid therapeutic option for R/R PMBCL, providing durable remissions.
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Affiliation(s)
| | | | - Loïc Renaud
- AP-HP, Hôpital Saint-Louis, Hemato-oncologie, DMU DHI, Université de Paris, Paris, France
| | | | - Micha Srour
- Maladie du sang, CHU de Lille, Lille, France
| | | | | | - Rémy Gressin
- Hématologie Clinique, CHU de Grenoble, Grenoble, France
| | | | - Sabine Furst
- Hématologie Clinique, Centre de Recherche en Cancérologie de Marseille, Institut Paoli Calmettes, Marseille, France
| | | | - David Sibon
- Hématologie Clinique, Hôpital Necker-Enfants Malades, Paris, France
| | | | - Xavier Poiré
- Hématologie Clinique, Hôpital Saint-Luc, Bruxelles, Belgium
| | | | | | | | | | - Yves Beguin
- Hématologie Clinique, University of Liège and CHU of Liège, Liège, Belgium
| | - Rémy Dulery
- Hématologie Clinique, Hôpital Saint Antoine, Paris, France
| | | | - Amandine Fayard
- Hématologie Clinique, CHU de Clermont Ferrand, Clermont Ferrand, France
| | - Marie C Béné
- Hématologie Biologie, CHU de Nantes, Nantes, France
| | - Vincent Camus
- Département d'Hématologie, Centre Henri Becquerel, Rouen, France
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Primary mediastinal Large B-cell Lymphoma. Blood 2021; 140:955-970. [PMID: 34496020 DOI: 10.1182/blood.2020008376] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/23/2021] [Indexed: 11/20/2022] Open
Abstract
Primary mediastinal large B-cell lymphoma (PMBCL) is a separate entity in the WHO classification based on clinico-pathologic features and a distinct molecular signature which overlaps with nodular sclerosis classical Hodgkin lymphoma (NScHL). Molecular classifiers can distinguish PMBCL from diffuse large B-cell lymphoma (DLBCL) using RNA derived from paraffin-embedded tissue and are integral to future studies. However, given that ~5% of DLBCL can have a 'molecular' PMBCL phenotype in the absence of mediastinal involvement, clinical information will remain critical for diagnosis. Studies over the last 10-20 years have elucidated the biologic hallmarks of PMBCL which are reminiscent of cHL, including the importance of JAK-STAT and NFKB signaling pathways as well as an immune evasion phenotype through multiple converging genetic aberrations. The outcome of PMBCL has improved in the modern rituximab era, however controversies remain whether there is a single standard treatment for all patients and when to integrate radiotherapy. Regardless of the frontline therapy, refractory disease can occur in up to 10% of patients and correlates with poor outcome. With emerging data supporting high efficacy of PD1 inhibitors in PMBCL, studies are underway integrating them into the up-front setting.
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