Dual institution experience of extranodal marginal zone lymphoma reveals excellent long-term outcomes

Clinical diagnostic model for predicting indolent or aggressive lymphoma based on clinical information and ultrasound features of superficial lymph nodes

PURPOSE

The aim of this study was to develop a diagnostic model for predicting indolent lymphoma or aggressive lymphoma using clinical information and ultrasound characteristics of superficial lymph nodes.

METHOD

Patients with confirmed pathological lymphoma subtypes who had undergone ultrasound and contrast-enhanced ultrasound examinations were enrolled. Clinical and ultrasound imaging features were retrospectively analysed and compared to the pathological results, which were considered the gold standard for diagnosis. Two diagnostic models were developed: a clinical model (Model-C) using clinical data only, and a combined model (Model-US) integrating ultrasound features into the clinical model. The efficacy of these models in differentiating between indolent and aggressive lymphoma was compared.

RESULTS

In total, 236 consecutive patients were enrolled, including 78 patients with indolent lymphomas and 158 patients with aggressive lymphomas. Receiver operating characteristic (ROC) curve analysis revealed that the areas under the curves of Model-C and Model-US were 0.78 (95 % confidence interval: 0.72-0.84) and 0.87 (95 % confidence interval: 0.82-0.92), respectively (p < 0.001). Model-US was further evaluated for calibration and is presented as a nomogram.

CONCLUSIONS

The diagnostic model incorporated clinical and ultrasound characteristics and offered a noninvasive method for assessing lymphoma with good discrimination and calibration.

Lymphoma as an Exclusion Criteria for CVID Diagnosis Revisited

PURPOSE

Hypogammaglobulinemia in a context of lymphoma is usually considered as secondary and prior lymphoma remains an exclusion criterion for a common variable immunodeficiency (CVID) diagnosis. We hypothesized that lymphoma could be the revealing symptom of an underlying primary immunodeficiency (PID), challenging the distinction between primary and secondary hypogammaglobulinemia.

METHODS

Within a French cohort of adult patients with hypogammaglobulinemia, patients who developed a lymphoma either during follow-up or before the diagnosis of hypogammaglobulinemia were identified. These two chronology groups were then compared. For patients without previous genetic diagnosis, a targeted next-generation sequencing of 300 PID-associated genes was performed.

RESULTS

A total of forty-seven patients had developed 54 distinct lymphomas: non-Hodgkin B cell lymphoma (67%), Hodgkin lymphoma (26%), and T cell lymphoma (7%). In 25 patients, lymphoma developed prior to the diagnosis of hypogammaglobulinemia. In this group of patients, Hodgkin lymphoma was overrepresented compared to the group of patients in whom lymphoma occurred during follow-up (48% versus 9%), whereas MALT lymphoma was absent (0 versus 32%). Despite the histopathological differences, both groups presented with similar characteristics in terms of age at hypogammaglobulinemia diagnosis, consanguinity rate, or severe T cell defect. Overall, genetic analyses identified a molecular diagnosis in 10/47 patients (21%), distributed in both groups and without peculiar gene recurrence. Most of these patients presented with a late onset combined immunodeficiency (LOCID) phenotype.

CONCLUSION

Prior or concomitant lymphoma should not be used as an exclusion criteria for CVID diagnosis, and these patients should be investigated accordingly.

An international analysis evaluating frontline bendamustine with rituximab in extranodal marginal zone lymphoma

Extranodal marginal zone lymphoma (EMZL) is a heterogeneous non-Hodgkin lymphoma. No consensus exists regarding the standard-of-care in patients with advanced-stage disease. Current recommendations are largely adapted from follicular lymphoma, for which bendamustine with rituximab (BR) is an established approach. We analyzed the safety and efficacy of frontline BR in EMZL using a large international consortium. We included 237 patients with a median age of 63 years (range, 21-85). Most patients presented with Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1 (n = 228; 96.2%), stage III/IV (n = 179; 75.5%), and intermediate (49.8%) or high (33.3%) Mucosa Associated Lymphoid Tissue International Prognosis Index (MALT-IPI). Patients received a median of 6 (range, 1-8) cycles of BR, and 20.3% (n = 48) received rituximab maintenance. Thirteen percent experienced infectious complications during BR therapy; herpes zoster (4%) was the most common. Overall response rate was 93.2% with 81% complete responses. Estimated 5-year progression-free survival (PFS) and overall survival (OS) were 80.5% (95% CI, 73.1% to 86%) and 89.6% (95% CI, 83.1% to 93.6%), respectively. MALT-IPI failed to predict outcomes. In the multivariable model, the presence of B symptoms was associated with shorter PFS. Rituximab maintenance was associated with longer PFS (hazard ratio = 0.16; 95% CI, 0.04-0.71; P = .016) but did not impact OS. BR is a highly effective upfront regimen in EMZL, providing durable remissions and overcoming known adverse prognosis factors. This regimen is associated with occurrence of herpes zoster; thus, prophylactic treatment may be considered.

Conventional Treatments Cannot Improve Outcomes of Early-Stage Primary Breast Marginal Zone Lymphoma

Introduction

Primary breast marginal zone lymphoma (PBMZL) is a rare occurrence and less is known about its characteristics, treatments, and outcomes.

Methods

We retrospectively reviewed 370 cases of early-stage PBMZL from the Surveillance, Epidemiology, and End Results database. Statistical analyses were performed to describe clinical features, determine prognostic factors, and compare different therapeutic strategies.

Results

At a median follow-up of 68.5 months, the 5-year overall survival (OS) and disease-specific survival (DSS) rate were 81.2 and 95.4%, respectively. We divided the cohort into four treatment groups and compared their characteristics and survival: radiotherapy (RT) ± surgery (Sx) (n = 142, 38.4%), Sx alone (n = 71, 19.2%), any chemotherapy (CT) (n = 63, 17.0%), and none of the above (n = 94, 25.4%). Age of onset and laterality of lesions tended to relate to the choice of different treatments. Multivariate Cox analysis showed that advanced age (>60 years), concomitant tumor, and any CT (vs RT ± Sx) predicted poorer OS, while for DSS, there was no meaningful indicator (P > 0.05). Patients aged >60 years or treated with any CT seemed to have shorter DSS, but the difference only approached statistical significance. Then we applied a propensity score-matched analysis to demonstrate that neither RT- nor Sx-containing therapy could bring a better OS or DSS. The competing risk model suggested that CT was the only contributor to higher PBMZL-specific mortality.

Conclusion

Our results show an indolent behavior of early-stage PBMZL with long-term survival. Conventional oncological treatments fail to bring survival benefits; especially CT is detrimental to survival, suggesting that observation may be advisable in the management of early-stage PBMZL, and further research on novel targeted agents is warranted for patients in need.

Treatments and Outcomes in Stage I Extranodal Marginal Zone Lymphoma in the United States

Simple Summary

Extranodal marginal zone lymphoma (EMZL) is a rare disease commonly diagnosed at an early stage and remains localized for prolonged periods of time. This unique characteristic makes the use of local therapies, such as radiation therapy (RT), the preferred approach. Excellent results were previously reported implementing RT; however, majority of these studies included a small number of patients, and treatment patterns in the United States are presently unknown. Furthermore, EMZL may arise in various organs, and whether the survival is similar at different locations is unclear. In the present study, we assessed the Surveillance, Epidemiology, and End Results (SEER) database aiming to examine management and survival of localized EMZL. While differences in survival were observed by primary disease location, similar survival was observed in RT-treated stage I EMZL patients and general U.S. population matched by sex, age, and calendar year.

Abstract

A considerable number of patients with extranodal marginal zone lymphoma (EMZL) are diagnosed with stage I disease. Information on treatments and survival by primary location remains limited. We extracted data from the Surveillance, Epidemiology, and End Results (SEER) database to assess treatment, primary location, and survival of patients with stage I EMZL. Results show that 7961 patients met inclusion criteria. Observation (no treatment) was the most common approach (31%) followed by radiation therapy (RT, 23%). The median overall survival (OS) was 17.3 years (95%CI 16.3 to 18.3). Shorter survival was observed in patients with stage I EMZL compared to expected survival in a cohort derived from the general U.S. population matched by sex, age, and calendar year at diagnosis. However, similar survival was observed in RT-treated patients. We identified age ≥ 60 years (SHR = 4.00, 95%CI 3.10–5.15; p < 0.001), higher grade transformation (SHR = 4.63, 95%CI 3.29–6.52; p < 0.001), and primary lung EMZL (SHR = 1.44, 95%CI 1.05–1.96; p = 0.022) as factors associated with shorter lymphoma-specific survival (LSS). Conversely, primary skin location (SHR = 0.50, 95%CI 0.33–0.77; p = 0.002) was associated with longer LSS. Our results support the use of RT as the preferred approach in localized EMZL.

How can we assess and measure prognosis for MALT lymphoma? A review of current findings and strategies

INTRODUCTION

: MALT (mucosa associated lymphoid tissue) lymphoma is a distinct type of B-cell lymphoma characterized by extranodal manifestation and an indolent clinical course with 10-year survival rates up to 90%. However, transformation to aggressive lymphoma may occur and treatment is indicated in case of symptomatic or progressive disease.

AREAS COVERED

: This review covers clinical and biological features potentially related to prognosis and outcome of MALT lymphoma patients, as well as available prognostic tools and risk stratification systems with a focus on the MALT-IPI (international prognostic index) and the POD24 (progression of disease at 24 months) cohort. In addition, we address the role of watch-and-wait, the importance of defining the optimal time point for treatment initiation and the relevance of depth of remission, which appear to be some of the central questions for physicians involved in the care of MALT lymphoma patients. A computerized database search using PubMed® was performed to identify available publications on prognostic factors and risk stratification tools in MALT lymphoma.

EXPERT OPINION

: Despite the development of disease-specific risk stratification systems, there is no clear concept how to measure prognosis and tailor treatment. Careful observation of the individual clinical course is essential to assess the optimal time point of treatment initiation and avoid overtreatment, particularly in patients with disseminated disease. In addition, early detection of patients with histological transformation is necessary, as these patients face a poor prognosis.

Flow cytometry detection of CD138 expression continuum between monotypic B and plasma cells is associated with both high IgM peak levels and MYD88 mutation and contributes to diagnosis of Waldenström macroglobulinemia

BACKGROUND

Differential diagnosis of Waldenström macroglobulinemia (WM) with other indolent B-cell malignancies is still a challenge. Here, we propose an original and simple analysis of routine flow cytometry (FCM) unraveling the characteristic ongoing plasma cell (PC) differentiation of WM tumor B-cells.

METHODS

FCM analysis of both B-cells and PC was performed on a series of 77 patients with IgM peak. MYD88 and CXCR4 mutations were studied using an allele-specific PCR and by high throughput sequencing.

RESULTS

Twenty seven (35%), 46 (58%) and 4 (5%) patients were classified as WM, IgM monoclonal gammopathy of undetermined significance (MGUS) or other B-NHL respectively. MYD88 mutation was found in 25/27 WM (93%) and in 29/46 MGUS (63%). Using FCM, monotypic B-cells were found in 27/27 WM (100%) and 34/46 MGUS (74%). Monotypic CD138pos/CD38pos PCs were detected in 23/27 WM (85%) and 25/46 MGUS (54%). Highlighting the ongoing PC differentiation of WM tumor B-cells by FCM, we evidenced a CD138 expression continuum between monotypic B-cells and PCs. This pattern remained absent in control samples and was significantly associated with higher IgM peaks (p = 6.10^-5 ) and MYD88 mutations (p = 10^-3 ) in both WM and MGUS cases.

CONCLUSIONS

FCM exploration of both B-cells and PC led to identify a CD138 expression continuum as an objective marker of ongoing PC differentiation of WM tumor cells and was strongly associated with increased IgM peak levels and MYD88 mutations. This approach could contribute to place FCM at the forefront of WM diagnosis.

Demographical and Clinical Features of Marginal Zone Lymphomas: A Retrospective Study of Turkish Oncology Group (TOG)

Marginal zone lymphomas (MZLs) are rare and indolent subtypes of non-Hodgkin lymphomas, and their clinical behaviours are heterogeneous. The aim of this study was to evaluate the clinical and prognostic characteristics of MZL. In this multicentre retrospective study, we analyzed demographical, clinical and prognostic features of 64 MZL patients. The median age was 54.0 and 78.1% of the patients had extra-nodal disease at presentation. Most of the patients were treated with chemotherapy. The 5 years and 10 years overall survival (OS) rates were 74.5% and 62.1%, respectively. The analysis of factors associated with OS showed that ECOG performance score was an important prognostic factor, with 133.0 months (95% CI 49.3-216.5) versus 18.0 months (95% CI 12.1-23.7) for ECOG 0-1 and 2-3, respectively (p = 0.011). Prognosis of MZL is favorable and ECOG performance score was found associated with OS. Further detailed studies with large patient numbers are needed to clarify the clinical features and treatment management of MZLs.

Management of relapsed/refractory marginal zone lymphoma: focus on ibrutinib

Marginal zone lymphomas (MZLs) consist of a diverse family of malignancies, which are derived from B-cells. The disease subtypes are recognized extranodal, nodal, and splenic MZLs. The disease characteristics, clinical course, and treatment vary considerably based on the site of involvement. In 2017, the US Food and Drug Administration approved ibrutinib, a first in class Bruton’s tyrosine kinase inhibitor that revolutionized the care of chronic lymphocytic leukemia patients; for, the treatment of relapsed/refractory MZL based on pivotal open-label Phase II trial demonstrated an overall response rate of 48%, with a complete response rate of 3%, median progression-free survival of 14.2 months, and median overall survival not yet reached at a median follow-up of 19.4 months. In this review, we aim to summarize the current conundrums in the management of MZL and the evolving role of ibrutinib in the treatment of MZL.

Marginal Zone Lymphoma: Clinicopathologic Variations and Approaches to Therapy

PURPOSE OF REVIEW

The purpose of the study is to summarize the current conundrums in the management of marginal zone lymphomas (MZL).

RECENT FINDINGS

In 2017, the US Food and Drug Administration (FDA) approved ibrutinib, a first in class Bruton Tyrosine Kinase inhibitor, for the treatment of relapsed/refractory MZL based on pivotal open-label phase II trial demonstrating an overall response rates of 48%. Clinical trials design utilizing chemotherapy-free regimens for relapsed/refractory disease are gaining popularity. Recent studies have identified multiple genetic biomarkers that helped characterize and prognosticate different subtypes of MZL. MZLs are heterogeneous, mostly indolent, malignancies derived from B lymphocytes. Three disease subtypes are recognized, extranodal, nodal, and splenic. The disease characteristics, clinical picture, and treatment algorithms vary considerably based on subtype and site of involvement. Recent discoveries have enhanced our knowledge of the pathogenesis of MZLs leading to development of more accurate prognostic models as well as novel targeted systemic therapies.