Anemia as a useful biomarker in patients with diffuse large B-cell lymphoma treated with R-CHOP immunochemotherapy

Hemoglobin-platelet index as a prognostic factor in patients with peripheral T-cell lymphoma

Peripheral T-cell lymphoma (PTCL) is a heterogeneous group of aggressive lymphomas with a poor prognosis. The International Prognostic Index (IPI) and the Prognostic Index for PTCL-unspecified (PIT) is used to predict the prognosis of PTCL. The hemoglobin-platelet index (HPI), based on anemia and thrombocytopenia status, is associated with the prognosis of diffuse large B-cell lymphoma. However, its significance in terms of predicting the prognosis of PTCL has not been fully investigated. We herein retrospectively analyzed 100 patients with newly diagnosed PTCL in our department. At a median follow-up of 3.2 years, the median progression-free survival (PFS) and overall survival (OS) was 0.72 (95% confidence interval [CI]: 0.56-1.2) years and 2.0 (95% CI: 1.5-4.7) years, respectively. Multivariate analysis revealed that elevated lactic dehydrogenase (LDH) and hypoalbuminemia were independent adverse variables for PFS. The HPI showed significant predictive value for both PFS and OS. As a new prognostic model comprising the HPI, LDH, and albumin, the LA-HPI allowed the stratification of patients into four distinct risk subgroups: low risk (zero risk factors), low-intermediate risk (one risk factors), high-intermediate risk (two or three risk factors), or high risk (four risk factors). The PFS and OS differed significantly among the patients by the LA-HPI score. The LA-HPI demonstrated better predictive performance compared to the IPI, PIT, and HPI. Our data demonstrated the prognostic utility of the HPI in patients with PTCL. The LA-HPI, incorporating four readily obtainable parameters, exhibited superior performance compared to traditional indices.

Clinicopathological Characteristics and Prognosis of Diffuse Large B-Cell Lymphoma in Relation to CA-125 and CA 19-9 Expression

Background: Some epithelial tumors express the carbohydrate antigen 125 (Cancer antigen-125, CA-125) and CA 19-9, especially ovarian and pancreatic tumors. Patients with non-Hodgkin lymphoma (NHL) were reported to have a close association between serum CA-125 levels and adverse prognostic factors with worse survival. We aimed to investigate CA-125 and 19-9 expression in nodal diffuse large B-cell lymphoma, not otherwise specified (DLBCL NOS) tissues using immunohistochemistry (IHC) and their relations to clinicopathological manifestations and patients' survival. Methods: 65 cases of DLBCL NOS were examined. A modified mechanical pencil tip was used to construct Manual Tissue Micro-array (TMA) blocks. Immunohistochemical staining for CA-125 and CA 19-9 was performed and scored semi-quantitatively. All relations were analyzed using established statistical methodologies. Results: Aberrant expression of CA 19-9 was detected in 12% of cases without any expression of CA-125. Moreover, 75% of the CA 19-9 positive cases were statistically significantly associated with anemia and performance status 1. Also, 75% of the CA 19-9 positive cases were females. Conclusions: CA 19-9 was aberrantly expressed in 12% of nodal DLBCL NOS cases and significantly related to anaemia and performance status but not to survival. In cases of DLBCL NOS, CA 19-9 expression cannot be considered an independent prognostic factor. CA-125 was not expressed in nodal DLBCL NOS tissues, necessitating re-evaluation studies. Therefore, it is advised to conduct more research to clarify the potential correlation between serum and tissue CA 19-9 levels and other clinic-pathological characteristics of nodal and extranodal DLBCL NOS patients.

Novel prognostic predictor of haemoglobin-platelet index in diffuse large B-cell lymphoma, not otherwise specified: Anaemia and thrombocytopenia are associated with IL-6 production in lymphoma cells

We previously reported that a novel haemoglobin-platelet index (HPI) based on anaemia and thrombocytopenia was useful to predict the prognosis of patients with diffuse large B-cell lymphoma not otherwise specified (DLBCL NOS). Here, we analyse the utility of HPI in a new validation cohort with DLBCL NOS (n  = 94). As a result, we confirm that HPI was effective for differentiating progression-free survival (PFS) and overall survival in this validation cohort. So, we further compare the utility of HPI with previously reported prognostic markers such as the National Comprehensive Center Network-International Prognostic Index (NCCN-IPI), Glasgow prognostic score (GPS), and platelet-albumin (PA) score, using a larger number of 160 patients consisting of the derivation cohort (n  = 66) and a validation cohort (n  = 94). As a result, the patients with a higher HPI score had significantly worse outcomes, and HPI predicted the prognosis of DLBCL NOS independently of NCCN-IPI. HPI was more sensitive than GPS and almost the same as PA score in predicting PFS. Moreover, the patients whose lymphoma cells were positive for interleukin-6 (IL-6) (75/111 cases) judged by immunohistochemical staining had significantly lower haemoglobin levels and platelet counts than IL-6-negative cases (36/111 cases), suggesting the involvement of IL-6 produced by lymphoma cells in anaemia and thrombocytopenia in DLBCL NOS patients.

Impact of serum soluble CD155 level at diagnosis on interim response to CHOP with or without rituximab in diffuse large B cell lymphoma

CD155 is frequently overexpressed in human malignant tumors, and it is associated with poor prognosis. The expression of its soluble form (sCD155) as well as its prognostic value were not studied previously in diffuse large B cell lymphoma (DLBCL). Serum sCD155 level was measured in DLBCL patients at diagnosis using enzyme-linked immunosorbent assay. Its impact on response following three cycles of CHOP with or without rituximab (CHOP ± R) was analyzed. Serum sCD155 level was significantly elevated in DLBCL patients at diagnosis than in controls (P < 0.001). Serum sCD155 level at diagnosis correlated significantly with International Prognostic Index risk score (P = 0.005). Elevated serum sCD155 was associated with lack of response following three cycles of CHOP ± R in univariate analysis (P = 0.003). On multivariate analysis, there was a 1.601 probability of lack of response in patients with increased sCD155 level (95% confidence interval = 0.774-3.309, P = 0.204). Serum sCD155 is overexpressed in DLBCL, and it is associated with lack of interim response to CHOP ± R.

Cancer-Related Fatigue, Laboratory Markers as Indicators for Nutritional Status among Patients with Colorectal Cancer

Our objective was to determine the relationship between cancer-related fatigue (CRF), laboratory markers, and nutritional status among patients with colorectal cancer (CRC). A cross-sectional design was used. A sample of 80 participants diagnosed with CRC participated and completed the study's surveys including the patient-generated subjective global assessment (PG-SGA), cancer fatigue scale (CFS), laboratory markers sheet, and patient-related factors sheet. Positive relationships were identified between PG-SGA and CRF, physical fatigue, cognitive fatigue, WBC, and calcium level (r = 0.781, 0.820, 0.751, 0.680, and 0.710; P = 0.001 respectively). Negative relationships were found between PG-SGA and sodium, potassium, and hemoglobin levels (r = -0.801, -0.761, and -0.810; P = 0.001 respectively). The regression analysis revealed an R₂ = 0.610 (adjusted R₂ = 0.590), F (4.58, P < 0.001). Finally, the above-mentioned independent variables accounted for 61.0% of the variance in PG-SGA. Patients with CRC are experiencing nutritional problems during their treatment. Cancer-related fatigue and other laboratory markers are considered indicators for nutritional status. Clinical dietitians and oncology nurses can work together to monitor these parameters and provide clinical treatment when needed.

Useful prognostic tools based on complete blood cell counts in diffuse large B-cell lymphoma

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) is the most frequent lymphoma. Three prognostic factors are widely used in DLBCL: International Prognostic Index (IPI), Revised-IPI (R-IPI), and National Comprehensive Cancer Network-IPI (NCCN-IPI).

METHOD

We established a prognostic model using peripheral blood absolute lymphocyte/absolute monocyte counts ratio (LMR), hemoglobin, and platelet counts obtained from complete blood cell counts (CBC) data at diagnosis based on 214 cases of DLBCL who received more than one course of R-CHOP therapy at a single institution.

RESULTS

The cutoff values for using the receiver operating characteristics (ROC) curve for LMR, hemoglobin, and platelet counts were 1.6, 100 g/L, and 150 × 10⁹ /L, respectively. Stratification was performed using the three factors (LMR < 1.6, hemoglobin < 100 g/L, and platelet counts < 150 × 10⁹ /L). CBC Group 1 (none of the 3 factors) included 92 cases, CBC Group 2 (1 or 2 of these factors) included 108 cases, and CBC Group 3 (all 3 factors) included 11 cases. The 5-year OS rates were 78.2%, 60.9%, and 10.1%, respectively. In multivariate analysis, CBC Group 3 (hazard ratio, 2.9760; 95% confidence interval, 1.2670-6.991; P = .01) were prognostic factors for OS. CBC Group 3 had factors based on which the further stratification of the poor prognosis group into IPI high-risk and R-IPI poor-risk groups (P = .01, <.0001, respectively) was possible.

CONCLUSIONS

In DLBCL, combination of three CBC parameters has the potential to be a useful prognostic tool.

Epidemiology of Chemotherapy-Induced Anemia in Patients with Non-Hodgkin Lymphoma

INTRODUCTION

Anemia is a common adverse effect of myelosuppressive chemotherapy, and the development of chemotherapy-induced anemia (CIA) is more common in patients with hematologic malignant tumors.

OBJECTIVE

To assess the incidence and treatment pattern of CIA in patients diagnosed with non-Hodgkin lymphoma (NHL) from a large managed care organization in California.

METHODS

Patients diagnosed with NHL between 2010 and 2012 were studied to provide an updated picture of CIA in current hematology-oncology practice. Trends in anemia treatment patterns were examined from 2000 to 2013. All data were collected from Kaiser Permanente Southern California electronic health records.

RESULTS

Of 699 chemotherapy-treated patients with NHL diagnosed between 2010 and 2012, 36.9% and 11.6% developed moderate (hemoglobin < 10 g/dL) and severe (hemoglobin < 8 g/dL) CIA during chemotherapy, respectively. Proportions of moderate CIA events treated with erythropoiesis-stimulating agents (ESAs) decreased from 2000 to 2013: 34% in phase 1 (January 1, 2000, to December 31, 2006), 22% in phase 2 (January 1, 2007, to March 24, 2010), and 6% in phase 3 (March 25, 2010, to June 30, 2013). An increasing trend of red blood cell transfusion was observed: 12% in phase 1, 22% in phase 2, and 27% in phase 3. Similar calendar trends were observed for management of severe CIA events.

DISCUSSION

In contrast to previous European reports, we note a higher incidence of CIA in patients with NHL in this US community practice setting.

CONCLUSION

Moderate to severe CIA is common in patients with NHL receiving chemotherapy. Multiple ESA-related policy changes occurred from 2000 to 2013. A large proportion of CIA episodes were currently not treated with ESA, and transfusions have become more common. Further studies are needed to determine associations between CIA symptom burden and CIA treatment as they relate to patient outcomes and quality of life.

Prognostic Value of D-Dimer in Patients with Diffuse Large B-cell Lymphoma: A Retrospective Study

This study evaluated the significance of serum D-Dimer for predicting survival of patients with diffuse large B-cell lymphoma (DLBCL). We analyzed the clinical data from 113 patients who were newly diagnosed with DLBCL at Tongji Hospital from January 2012 to January 2016. The results indicated that there were higher levels of D-Dimer in DLBCL patients with the following characteristics: stage III/IV, lymphocyte monocyte ratio (LMR) <2.27, lactate dehydrogenase (LDH) > upper limit of normal (ULN), albumin (ALB) < 35 g/L, and anemia. After the first chemotherapeutic regimen, D-Dimer was significantly decreased concomitantly with LDH. Cox univariate regression analysis showed that the overall survival (OS) was negatively affected by the following factors: age > 60 years, stage III/W, LDH > ULN, LMR < 2.27, anemia and D-Dimer > 0.92. Multivariate analysis showed that only LDH > ULN (P=0.038) and age > 60 years (P=0.047) were independent adverse prognostic factors. However, it was suggested that D-Dimer could be regarded as a marker of high tumor burden and a potential prognostic screening tool for patients with DLBCL, not otherwise specified (NOS).

Frequency and causes of anemia in Lymphoma patients

Objective:

Purpose of this study was to find out frequency of anemia and its causes in newly diagnosed treatment naive lymphoma patients.

Methods:

We retrospectively studied all lymphoma patients (> 18 years age) diagnosed and treated at Shaukat Khanum Memorial Cancer Hospital and Research Centre, from January 2016 till January 2017. The data was collected from electronic Hospital Information System. Descriptive statistics were done by using summary measures for categorical variables as well as continuous variables.

Results:

Out of a total 408 patients, 272 were males and 136 females. Median age of patients was 33 years (18-76). Hodgkin lymphoma (HL) and diffuse large B cell lymphoma (DLBCL) were the diagnosis in 201 and 134 patients respectively; rest of the patients had low grade lymphomas. Anemia was present in 184 (45%) patients. Anemia of chronic disease was the commonest cause of anemia and was present in 61 (33.1%) patients. Remaining patients had anemia secondary to marrow involvement 50(27.17%); iron deficiency anemia, Vitamin B-12 deficiency anemia and hemolytic anemia were the causes in 7.6, 1.6%, % and 0.54% respectively.

Conclusion:

Anemia is a common feature in newly diagnosed lymphoma patients with anemia of chronic disease as the commonest cause. It is more frequent in patients with higher stages of lymphoma especially when bone marrow is involved by lymphoma. Since anemia is an important adverse prognostic factor for the outcome of lymphoma patients, work up for anemia prior to initiation of chemotherapy should be done in every lymphoma patient in order to help improve the management of these patients.

Long-term outcome of diffuse large B-cell lymphoma: Impact of biosimilar rituximab and radiation

INTRODUCTION

Rituximab (R)-CHOP improves survival over CHOP in diffuse large B-cell lymphoma (DLBCL). The availability of biosimilar rituximab in India has increased access of this drug. We report on the impact of treatment on outcomes with special emphasis on the impact of biosimilar rituximab and radiation.

METHODS

Outcomes of adults (age 15-60 years) treated with CHOP+/- Rituximab radiation were analyzed retrospectively to look at baseline features, treatment, and event-free and overall survival (EFS and OS).

RESULTS

In the period 2000-2013, 444 patients (median age 47 years: 15-60; males: 288 [65%]; Stage III/IV: 224 [50%]; age-adjusted international prognostic index [aaIPI] Score 2 or 3 in 50%) received either CHOP (n = 325 [73%]) or RCHOP (n = 119 [27%]) therapy. Biosimilar rituximab and the original were used in 95 (80%) and 24 (20%) patients, respectively. Radiation was given in 134 (30%) patients (Stages I and II, 100/220 [45%] and Stages III and IV, 34/224 [15%]). After a median follow-up of 46 (0.2-126) months, the 5-year EFS and OS were 59% and 68%, respectively. The factors predicting inferior EFS and OS were age> 40 years, performance status 2-4, Stage III/IV, hemoglobin <12 g/dL, the aaIPI Score 2 or 3, and nonuse of rituximab and radiation. Radiation used in early stage disease benefitted all subgroups regardless of bulky disease, use of rituximab, or the number of cycles of chemotherapy. Addition of rituximab improved survival across all categories of aaIPI.

CONCLUSION

Availability of biosimilar rituximab has increased access and survival of patients with DLBCL in India. Radiotherapy improved outcomes in early stages.

Anemia Associated with Worse Outcome in Diffuse Large B-Cell Lymphoma Patients: A Single-Center Retrospective Study

Objective

Useful prognostic biomarkers for diffuse large B-cell lymphoma (DLBCL) patients have been reported. To determine the prognostic value of hemoglobin (Hb) level in DLBCL patients, we performed a retrospective study.

Materials and Methods

We evaluated disease outcome, progression-free survival (PFS), overall survival as the endpoint, and clinical and laboratory factors affecting the outcome of 185 DLBCL patients who had received rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone therapy during 2004-2014.

Results

The study group included 121 men and 64 women with a median age of 66 years minimum-maximum: 21-83 years. In univariate analysis, factors independently associated with worse PFS were Eastern Cooperative Oncology Group performance status ≥2, Ann Arbor stage III or IV, anemia with Hb levels of <10 g/dL, and serum albumin of <3.5 g/dL. In multivariate analysis, anemia with Hb levels of <10 g/dL and Ann Arbor stage III or IV were found to be international index-independent prognostic factors (hazard ratio: 2.4; p=0.04).

Conclusion

Anemia is an independent prognostic marker of poor outcome in DLBCL patients. Hb can be an easily available prognostic marker for risk stratification in these patients.

Baseline renal function as a prognostic indicator in patients with newly diagnosed diffuse large B-cell lymphoma

Background

The association between baseline renal impairment (RI) and the prognosis of diffuse large B-cell lymphoma (DLBCL) was previously not defined. The aim of this study was to evaluate the prognostic value of RI in patients with DLBCL treated with three-weekly rituximab plus cyclophosphamide, Adriamycin, vincristine, and prednisolone immunochemotherapy (R-CHOP21).

Methods

Patients with newly diagnosed de novo DLBCLs treated with ≥1 cycle of R-CHOP21 were analyzed retrospectively. Pretreatment blood samples were collected and the glomerular filtration rate (GFR) was calculated. RI was defined by a GFR of <60 mL/min/1.73 m² according to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) formula.

Results

Of the 185 patients enrolled in the present study, 19 patients (10.3%) had RI. The reasons for baseline RI were pre-existing CKD (N=5), acute kidney injury due to either obstruction (N=2) or electrolyte imbalance (N=2) related to DLBCL, and undefined causes (N=10). Patients with baseline RI showed inferior overall survival (OS) compared to those without RI (P<0.001). In multivariate analysis, RI was identified as an International Prognostic Index (IPI)-independent prognostic indicator. A baseline hemoglobin level of <10 g/dL and the presence of RI effectively discriminated a portion of the patients with far inferior event-free survival and OS among the patients having high or high-intermediate risk cancers according to either the standard- or the National Comprehensive Cancer Network-IPI.

Conclusion

Pretreatment RI was an independent prognostic marker for inferior OS in patients with DLBCL treated with R-CHOP21 immunochemotherapy.

Prognostic Value of Anemia and C-Reactive Protein Levels in Diffuse Large B-Cell Lymphoma

PURPOSE

To determine the prognostic value of pretreatment anemia, pretreatment elevated C-reactive protein (CRP) levels, and 6-month posttreatment anemia in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL) treated with rituximab, cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisolone (R-CHOP).

PATIENTS AND METHODS

A total of 104 patients with newly diagnosed DLBCL were retrospectively included. Pretreatment hemoglobin and CRP levels and 6-month posttreatment hemoglobin levels were measured. Cox regression analyses were used to determine the associations of laboratory assessments and National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI) risk groups with progression-free survival (PFS) and overall survival (OS).

RESULTS

Pretreatment anemia, elevated pretreatment CRP levels, and higher risk NCCN-IPI groups were significantly associated with reduced PFS and OS (P = .001 and P = .003 for pretreatment anemia, P = .035 and P = .029 for elevated CRP, and P < .001 and P < .001 for higher risk NCCN-IPI groups). On multivariate Cox regression analysis, only the NCCN-IPI risk group remained as an independent significant predictor for PFS (P < .001) and OS (P < .001). In the subgroup of patients in complete remission 6 months after chemotherapy (n = 80), 6-month posttreatment anemia was significantly associated with reduced PFS (P = .046) but not OS (P = .062), and higher risk NCCN-IPI groups were significantly associated with both reduced PFS (P = .008) and OS (P = .017). On multivariate Cox regression analysis, only the NCCN-IPI group remained an independent significant predictor for PFS (P = .008) and OS (P = .017).

CONCLUSION

Pretreatment anemia, pretreatment CRP levels, and 6-month posttreatment anemia are significantly associated with poor outcome, but were not proven to be of additional prognostic value to the current risk stratification index for DLBCL.

Prognostic impact of hepatitis C virus infection in patients with diffuse large B-cell lymphoma treated with immunochemotherapy in the context of a novel prognostic index

OBJECTIVE

Patients with hepatitis C virus (HCV) infection have been associated with development of diffuse large B-cell lymphoma (DLBCL), yet its impact on several clinical aspects, including phenotypic characteristics and treatment-related toxicities as well as survival outcome after rituximab-based immunochemotherapy, remains controversial.

METHODS

To elucidate the characteristics of HCV-positive DLBCL in the context of a new prognostic model, the National Comprehensive Cancer Network International Prognostic Index (NCCN-IPI), we retrospectively analyzed DLBCL patients diagnosed and treated with immunochemotherapy at our institute during the last decade.

RESULTS

In all, HCV infection was identified in 22 (17.7%) of 124 DLBCL patients. Except for being more likely to present with an advanced stage of disease, patients with HCV infection were phenotypically indistinguishable from HCV-negative cases. Multivariate analysis showed 3 factors independently predicted a dismal overall survival (OS) outcome: lower albumin level (<3 g/dL vs. ≥3 g/dL, p<0.001; HR=13.21, 95% CI=2.69-64.98, p=0.001), presence of HCV infection (vs. HCV-negative; HR=9.75, 95% CI=1.97-48.34, p=0.005), and poor NCCN-IPI risk (high-intermediate or high vs. low-intermediate or low; HR=5.56, 95% CI=1.17-26.55, p=0.031).

CONCLUSIONS

Our study has demonstrated that HCV infection status and low serum albumin level add important prognostic values to the newly proposed NCCN-IPI model for patients with DLBCL.

Positive effects on hematological and biochemical imbalances in patients with metastatic breast cancer stage IV, of BP-C1, a new anticancer substance

A benzene-poly-carboxylic acid complex with cis-diammineplatinum(II) dihydrocholride, BP-C1 is currently used in clinical trials in treating metastatic breast cancer. BP-C1 controls tumor growth with a few mild side-effects, improving quality of life.

METHODS

The data consisted of prospectively collected laboratory results from 47 patients in two controlled clinical trials of daily intramuscular injections of BP-C1 for 32 days. Study I was performed as an open, nonrandomized, Phase I dose-response, multicenter study with a three-level, between-patient, response surface pathway design. The second study was a randomized, double-blind, and placebo-controlled, multicenter study with a stratified semi-crossover design.

RESULTS

Hemoglobin (Hb) and hematocrit (Hct) increased significantly (P<0.01) during BP-C1 treatment, while red blood cell (RBC) count increased but not significantly. The most pronounced increase in Hb, RBC, Hct, and white blood cell (WBC) was in anemic patients (P≤0.01). WBC count and neutrophils increased significantly (P=0.01) in the overall data. WBCs and neutrophils (P<0.01), eosinophils (P=0.05) and monocytes (P<0.01) increased significantly and markedly in patients with lowest baseline levels. Additionally, low levels of thrombocytes significantly increased. No changes in liver parameters, amylase, glucose, creatinine, or albumin, were detected except for albumin in the subgroup with low baseline levels, where levels increased significantly (P=0.04). An increase in K(+), Ca(2+), and PO4 (3-) was most pronounced in patients with low baseline levels (P≤0.02). A similar pattern detected for Mg(2+), prothrombin time (PT), coagulation factors II, VII, X (KFNT), and C-reactive protein (CRP), which increased significantly (P≤0.05) in the groups with the lowest values.

CONCLUSION

Our findings support the safety profile of BP-C1 use in cancer patients. BP-C1 did not induce anemia, infection, bleeding, hepatic insufficiency or electrolyte imbalances. In contrast, BP-C1 corrected abnormalities. No hematological and biochemical toxicity was observed.