The significance of pretreatment anemia in the era of R-IPI and NCCN-IPI prognostic risk assessment tools: a dual-center study in diffuse large B-cell lymphoma patients

The Impact of Anemia on the Survival of Patients Diagnosed With Low-Grade Malignant B-cell Lymphomas

INTRODUCTION

B-cell lymphomas with a low degree of malignancy represent a heterogeneous group of diseases, that evolve slowly, but present particularities in terms of long-term survival.

METHODS

We investigated the impact of anemia from the time of diagnosis in 249 patients with malignant B-cell lymphomas, diagnosed between January 2011 and December 2015, in the Hematology Department of the Sibiu County Emergency Hospital, Romania.

RESULTS

We included 126 (50.6%) male and 123 (49.4%) female patients with the average age being 68.2 years. Among all patients, 106 (42.6%) were diagnosed with chronic lymphocytic leukemia (CLL), 61 (24.5%) with marginal zone lymphoma (MZL), 53 (21.3%) with multiple myeloma (MM), 16 (6.4%) with follicular lymphoma (FL), nine (3.6%) with plasmacytoma, and four cases with hairy cell leukemia (HCL). The serum Hb value in the subject group varied between 2.6 g/dL and 17 g/dL. At diagnosis, 18 (7.2%) patients had severe anemia, 32 (12.9%) had moderate anemia, 58 (23.3%) had mild anemia, and 141 (56.6%) had no anemia at all at the time of diagnosis. In our group, the higher degree of anemia was correlated with a more advanced stage of the disease but not with the older age of the patients. Our study's highest median value of LDH corresponded to moderate anemia and the lowest value to patients who did not have anemia. Patients who did not have anemia at diagnosis had the best survival at five years, followed by those with mild anemia, then those with moderate anemia.

CONCLUSION

In our cohort, subjects with the lowest Hb value at diagnosis had the worst survival. The results of our study conclude that anemia represents a negative impact factor not only on the patient's quality of life but also on their survival.

The prognostic value of IPI in patients with primary breast lymphoma, a multicenter retrospective study

Background

Due to the rarity of PBL and the lack of large-scale studies, the prognostic value of IPI in PBL was controversial. Especially in the rituximab era, the ability of IPI to stratify prognosis in patients receiving immunochemotherapy was severely reduced. Then revised IPI (R-IPI) and National Comprehensive Cancer Network IPI (NCCN-IPI) were introduced. The present study aimed to evaluate the prognostic value of IPI and the other IPIs in patients with PBL in a Chinese population.

Methods

We performed a multicenter retrospective study of 71 patients with PBL from 3 institutions in China. The Kaplan–Meier method and log-rank tests were used for the survival analysis. Cox regression analysis was performed to evaluate the prognostic factors. Subgroup analysis was performed to assess the prognostic significance of IPI scores, R-IPI scores, and NCCN-IPI scores.

Results

The median follow-up was 4.7 years (0.7–21.8 years). The 5-year progression-free survival (PFS) and overall survival (OS) rates were 90.2% and 96.3%. In the multivariate analysis, only IPI scores and radiotherapy were significantly associated with OS and PFS (P < 0.05). Applying the R-IPI in our patient cohort indicates a significant difference in PFS between the two groups of R-IPI (P = 0.034) but not for OS (P = 0.072). And the NCCN-IPI was prognostic for OS (P = 0.025) but not for PFS (P = 0.066). Subgroup analyses of IPI showed that survival analysis of IPI scores for the PFS and OS of patients using rituximab were not significantly different (P > 0.05).

Conclusions

Our study confirms the prognostic value of IPI in patients with PBL, but the predictive value of IPI proved to be relatively low with the addition of the rituximab. The R-IPI and NCCN-IPI can accurately assess the high and low-risk groups of PBL patients but were insufficient to evaluate the intermediate risk group.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-022-02772-y.

Expression of PD-L1 and YWHAZ in Patients with Diffuse Large B Cell Lymphoma: A Possible Association with the Prognosis of Lymphoma

Diffuse large B cell lymphoma (DLBCL) is the most common pathological subtype of non-Hodgkin lymphoma (NHL) and is the most common type of adult lymphoma. Due to the poor prognosis of relapsed/refractory DLBCL, new drug targets and therapeutic methods are urgently needed. We investigated the expression of programmed death ligand 1 (PD-L1) and 3-monooxygenase/tryptophan 5-monooxygenase activating protein zeta (14-3-3ζ or YWHAZ) in patients with DLBCL. The purpose was to verify the expression levels of YWHAZ and PD-L1 and their relationships with the prognosis of DLBCL and to lay a foundation for further study on the role of YWHAZ and PD-L1 in DLBCL. Immunohistochemistry was used in 140 patients with DLBCL to test protein expression levels of YWHAZ and PD-L1. All patients were followed up in the hospital or by telephone or via WeChat. The positive expression rate of YWHAZ was 62.14% (87/140). The expression was negatively correlated with the positive expression of BAD (r = −0.177, P = 0.036) and positively correlated with the positive expression of BCL-2 (r = 0.180, P = 0.033). When the cut-off value for PD-L1 was established at 5%, 10%, 15%, and 20%, the corresponding positive expression rates of PD-L1 were 79.66% (94/118), 51.69% (61/118), 40.68% (48/118), and 36.44% (43/118). YWHAZ significantly affected the OS of DLBCL (P ≤ 0.001). The prognosis of the patients was related to the positive expression of PD-L1 when the cut-off value of PD-L1 was 5% (P = 0.033). However, positive expression of PD-L1 was not associated with the prognosis when the cut-off values of PD-L1 were 10% (P = 0.404), 15% (P = 0.208), and 20% (P = 0.408). The positive expression of YWHAZ (hazard ratio 6.215; 95% confidence interval 3.214-12.017; P < 0.05) was an independent adverse prognostic factor for OS. YWHAZ may be an important oncogene in the occurrence and development of DLBCL and may be used as a therapeutic target. PD-L1 may be an oncogene or tumor suppressor gene in the occurrence and development of DLBCL. Different cut-off values of PD-L1 may affect the prognosis of DLBCL.

High Red Cell Distribution Width Independently Predicts Adverse Survival in Patients with Newly Diagnosed Skull Base Chordoma

Objective

Accumulating studies report that levels of mean corpuscular volume (MCV) and red cell distribution width (RDW) are associated with outcomes in cancer patients, while studies including MCV and RDW in chordoma are lacking so far. Therefore, our study aims to investigate the prognostic impact of MCV and RDW on survival in skull base chordoma patients.

Methods

Levels of preoperative MCV and RDW in 187 primary skull base chordoma patients were collected. X-tile software was used to find the cutoff values of MCV and RDW. Progression-free survival (PFS) and overall survival (OS) analyses were performed using the Kaplan–Meier methods, Cox analysis, and nomogram model.

Results

Low MCV level (MCV <84.2) was more commonly observed in classical chordoma patients (p=0.022). High RDW level (RDW≥12.7) was correlated with older patient age (p=0.022) and a tough tumor texture (p=0.035). Low MCV level and high RDW level were associated with poor PFS (p=0.045 and 0.007, respectively) and OS (p=0.023 and <0.001, respectively). Multivariate Cox analysis demonstrated that RDW was an independent prognostic indicator for both PFS (p=0.001) and OS (p<0.001). Importantly, a nomogram based on RDW and clinical predictors showed satisfactory performance for PFS and OS prediction (concordance index, C-index: 0.684 and 0.744, respectively).

Conclusion

Our data was first to reveal the prognostic role of RDW in skull base chordoma, and identified the use of RDW may contribute to a more accurate prognosis judgment and personalized treatment decision.

The pretreatment platelet count predicts survival outcomes of diffuse large B-cell lymphoma: An analysis of 1007 patients in the rituximab era

BACKGROUND

The prognostic value of platelet count in diffuse large B-cell lymphoma (DLBCL) has not been extensively investigated. We aimed to examine the association of pretreatment platelet count with disease features, and further examine the prognostic significance of platelet count in DLBCL treated with the R-CHOP regimen.

METHODS

Patients with DLBCL diagnosed between Jan 1 st, 2005 and Dec 31 st, 2018 at Cancer Hospital, Chinese Academy of Medical Sciences were retrospectively analyzed. Propensity score matching (PSM) was used to balance confounding factors.

RESULTS

A total of 1007 eligible patients who received frontline R-CHOP or R-CHOP-like regimens were included in this study. The optimal cutoff value of platelet count was 157 × 10⁹/L, as determined by the Maximally Selected Rank Statistics method. Patients with the platelet count ≤157 × 10⁹/L had significantly inferior overall survival (OS) (5-year OS, 44.4 % vs. 74.9 %, P < 0.001) and progression-free survival (PFS) (5-year PFS, 35.5 % vs. 65.9 %, P < 0.001) than those with the platelet count >157×10⁹/L. Multivariate analyses showed that pretreatment platelet count ≤ 157 × 10⁹/L was an adversely independent prognostic factor for OS (hazard ratio [HR] 1.960, 95 % confidence interval [CI] 1.418-2.709, P<0.001) and PFS (HR 1.443, 95 %CI 1.080-1.927, P = 0.013). The PSM analysis and subgroup analyses further confirmed the significantly negative impact of low platelet count on OS and PFS.

CONCLUSION

The pretreatment platelet count may be a simple, cost-effective and useful prognostic factor in DLBCL patients treated with frontline R-CHOP regimens. Further investigation is warranted to elucidate the biologic mechanism underlying the prognostic significance of platelet count in DLBCL.

Prognostic Role of Blood Markers in Primary Central Nervous System Lymphoma Patients Treated With High-Dose Methotrexate-Based Therapy

Purpose: Primary central nervous system lymphoma (PCNSL) is a rare type of extra-nodal non-Hodgkin lymphoma, but the prognostic value of blood parameters indicating systemic inflammation and nutritional status remains unknown. We aim to explore the prognostic role of blood parameters in PCNSL.

Methods: All PCNSL patients diagnosed at West China Hospital between February 2011 and February 2020 were retrospectively screened. For patients who were initially treated with high-dose methotrexate (HD-MTX)-based therapy, clinical data were collected. Survival analyses were performed using the Kaplan–Meier method and multivariable Cox proportional regression. The accuracies of different multivariate models were assessed by Harrell's C statistical analysis (C-index).

Results: Sixty patients were included. Median overall survival (OS) was 4.8 ± 3.7 years, and median progression-free survival (PFS) was 1.9 ± 1.3 years. In the multivariate analysis, hemoglobin (Hb) (HR 3.940, p = 0.013), neutrophil–lymphocyte ratio (NLR) (HR 10.548, p = 0.034), and total bilirubin (TBIL) (HR 3.429, p = 0.004) had independent prognostic values for PFS, while lymphocyte–monocyte ratio (LMR) (HR 6.195, p = 0.039), systemic immune-inflammation index (SII) (HR 5.144, p = 0.012), and TBIL (HR 3.892, p = 0.009) were independently related to OS. The C-index of the Memorial Sloan-Kettering Cancer Center (MSKCC) score increased from 0.57 to 0.72 when SII and TBIL were combined.

Conclusions: Our study indicated that pretreatment Hb, NLR, SII, LMR, and TBIL were convenient prognostic factors in PCNSL. Adding SII and TBIL to the MSKCC score can better predict the survival of PCNSL based on HD-MTX regimens.

Peripheral blood cell ratios as prognostic factors in canine diffuse large B-cell lymphoma treated with CHOP protocol

Diffuse large B-cell lymphoma (DLBCL) is the most common haematopoietic tumour in dogs and recognized as clinical model for its human counterpart. Recently, neutrophil-to-lymphocyte (NLR) and lymphocyte-to-monocyte (LMR) ratios have been shown to predict time-to-progression (TTP) and lymphoma-specific survival (LSS) in dogs with DLBCL treated with CHOP-based chemotherapy. We retrospectively evaluated in 59 dogs diagnosed with DLBCL the prognostic value of haematological parameters and derived ratios: NLR, LMR, platelet-to-lymphocyte (PLR) and platelet-to-neutrophil (PNR) ratios for TTP, LSS and associated secondary end-points (time-to-progression-rate [TTPR] and lymphoma-specific survival-rate [LSSR]) as rates at 180 and 365 days. PNR is an independent prognostic marker (p ≤ .001) for TTPR/180 and 365 days, dogs with a PNR above 0.032 were more likely to progress before 180 days (sensitivity 46.5%, specificity 87.5%, p = .004). On univariate analysis, NLR showed a prognostic significance for LSSR/180 (p = .006) and LSSR/365 (p = .009). A baseline NLR value below 7.45 was positively associated with survival at 180 days (sensitivity 52%, specificity 85.3%, p = .025). The presence of substage b, was associated with early progression and decreased survival at 180 days (p = .031). Anaemia significantly reduced LSSR at 365 days (p = .028). This is the first study evaluating PLR and PNR in canine DLBCL and demonstrates that PNR could be a predictor of early lymphoma progression. Since peripheral blood cell composition can be affected by several non-oncological causes, the development of larger multicenter studies with homogeneous inclusion criteria could help to better determine the true predictive values of blood cell ratios in dogs' DLBCL treated with CHOP chemotherapy.

Racial and ethnic differences in diffuse large B-cell lymphoma survival among an underserved, urban population

Racial/ethnic differences in diffuse large B-cell lymphoma (DLBCL) survival have focused on non-Hispanic Whites (NHW) and non-Hispanic Blacks (NHB), often excluding Hispanics/Latinos. To further assess these racial/ethnic survival differences, we identified incident DLBCL cases diagnosed between 2005 and 2016 (n = 404; NHW = 136, NHB = 106, Hispanic/Latino = 162) at Montefiore Medical Center (Bronx, NY). All-cause mortality survival curves were assessed by the Kaplan-Meier method and log-rank test. Cox proportional hazards regression assessed the association between demographic/clinical factors and all-cause mortality. Hispanic/Latino patients experienced 52% lower risk of mortality compared to NHWs (HR = 0.48, 95%CI = 0.28-0.83), after adjusting for clinical prognostic factors. This reduced risk experienced by Hispanics/Latinos was similarly observed by age at diagnosis (≤60 years, >60 years), stage (I/II, III/IV), and receipt of chemotherapy. NHBs and NHWs experienced similar risk of mortality (HR = 0.85, 95%CI = 0.52-1.40). Overall, among DLBCL patients, Hispanics/Latinos had improved survival compared to NHWs. Additional research should seek to identify the drivers of this survival benefit.

The prognostic roles of hypogammaglobulinemia and hypocomplementemia in newly diagnosed diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is the most frequent type of lymphoma. Our retrospective study included 553 newly diagnosed DLBCL patients from May 2009 to October 2019. The relationships between hypogammaglobulinemia, hypocomplementemia and progression-free survival (PFS) and overall survival (OS) were assessed. In our center, 19.0% of patients had hypogammaglobulinemia, and 7.7% had hypocomplementemia at diagnosis. Immunoglobulin and complement deficiencies were associated with advanced disease and displayed inferior PFS and OS. Then, we designed a new immunization cumulative prognostic score (ICPS) model to comprehensively clarify the effect of these two variables on prognosis. Multivariate analysis showed that ICPS was an independent prognostic indicator for inferior clinical outcomes (PFS: p = 0.007, OS: p = 0.003). Furthermore, the predictive effect of ICPS combined with the International Prognostic Index (IPI) was superior to that of IPI alone (PFS: p = 0.016, OS: p = 0.037). In conclusion, hypogammaglobulinemia and hypocomplementemia could be regarded as adverse prognostic indicators in DLBCL.

Hypercalcemia at diagnosis of diffuse large B-cell lymphoma is not uncommon and is associated with high-risk features and a short diagnosis-to-treatment interval

Diffuse large B-cell lymphoma (DLBCL) is an aggressive type of non-Hodgkin lymphoma. The prevalence of hypercalcemia in this neoplasm and its prognostic significance is unclear. We retrospectively evaluated the prevalence of hypercalcemia at diagnosis of DLBCL and explored associations of hypercalcemia with clinical factors and outcome. Outcome was assessed using event-free survival at 24 months (EFS24). A total of 305 patients (248 de novo DLBCL and 57 transformed indolent lymphomas) diagnosed between 2006 and 2018 in Reims were analyzed. The prevalence of calcemia >10.5 mg/dL at diagnosis of de novo DLBCL and transformed indolent lymphomas was 23% and 26%, respectively. Hypercalcemia in de novo DLBCL was strongly associated with high-risk features, especially with International Prognostic Index (IPI) components, but also with B symptoms, β2-microglobulin, hemoglobin, and albumin levels. The diagnosis-to-treatment interval was significantly shorter for hypercalcemic patients (P = .001). These associations with adverse prognostic factors translated into lower rates of EFS24 (HR = 1.66; 95% CI, 1.08-2.54) and shorter PFS (P = .0059) and OS (P = .0003) for patients with lymphoma-related hypercalcemia but not independently of IPI parameters. These data suggest that hypercalcemia is rather a biomarker of the underlying biological aggressiveness of DLBCL.

New biomarkers in non-Hodgkin lymphoma and acute leukemias

Biomarkers play a critical role in the medical care of patients with cancer, including in early detection of the disease, diagnostic accuracy, risk stratification, treatment, and follow-up. Biomarkers in hematological malignancies can support the redefinition of the diagnosis and adjustments in the treatment plan. Biomarkers can be classified into 4 categories: (1) protein antigens, (2) cytogenetic abnormalities, (3) genetic polymorphisms, and (4) gene expression. Efforts in genomics, proteomics, and metabolomics to observe new biomarkers that contribute to the development of clinical medicine with greater precision in the strategies that improve prevention, diagnosis, and treatment of patients with malignant hematological disease. New biomarkers should accomplish several issues such as the biological plausibility, methodology used, analytical validation, intellectual property registry, and legal framework of application. This knowledge should be transferred to health professionals who can carry out the process of its implementation in clinical practice.

New prognosis score including absolute lymphocyte/monocyte ratio, red blood cell distribution width and beta-2 microglobulin in patients with diffuse large B-cell lymphoma treated with R-CHOP: Spanish Lymphoma Group Experience (GELTAMO)

The International Prognostic Index (IPI) is the most widely used score for non-Hodgkin lymphoma but lacks the ability to identify a high-risk population in diffuse large B-cell lymphoma (DLBCL). Low absolute lymphocyte count and high monocytes have proved to be unfavourable factors. Red-cell distribution width (RDW) has been associated with inflammation and beta-2 microglobulin (B2M) with tumour load. The retrospective study included 992 patients with DLBCL treated with R-CHOP. In the multivariate analysis, age, Eastern Cooperative Oncology Group performance status (ECOG-PS), stage, bulky mass, B2M, RDW, and lymphocyte/monocyte ratio (LMR) were independently related to progression-free survival (PFS). A new prognosis score was generated with these variables including age categorized into three groups (0, 1, 2 points); ECOG ≥ 3-4 with two; stage III/IV, bulky mass, high B2M, LMR < 2·25 and RDW > 0·96 with one each; for a maximum of 9. This score could improve the discrimination of a very high-risk subgroup with five-year PFS and overall survival (OS) of 19% and 24% versus 45% and 59% of R (revised)-IPI respectively. This score also showed greater predictive ability than IPI. A new score is presented including complete blood cell count variables and B2M, which are readily available in real-life practice without additional tests. Compared to R-IPI, it shows a more precise high-risk assessment and risk discrimination for both PFS and OS.

Pretreatment Hemoglobin Adds Prognostic Information To The NCCN-IPI In Patients With Diffuse Large B-Cell Lymphoma Treated With Anthracycline-Containing Chemotherapy

Background

Hemoglobin (Hgb) concentration at diagnosis is associated with outcome in cancer. In a recently reported simplified 3-factor prognostic score in Hodgkin lymphoma, Hgb, along with age and clinical stage, outperformed the classical International Prognostic Score with seven parameters.

Methods

In the present study, we investigated if pretherapeutic Hgb concentration added prognostic information to the NCCN-IPI in diffuse large B-cell lymphoma. We included patients from the Danish Lymphoma Registry (LYFO; N = 3499) and from the Molecular Epidemiology Resource (MER; N = 1225), Mayo Clinic and University of Iowa. Four sex-specific Hgb groups were defined: below transfusion threshold, from transfusion threshold to below lower limit of normal, from lower limit of normal to the population mean, and above the mean. We used multivariable Cox regression to estimate the hazard rate ratios (HR) and 95% CIs for overall survival (OS) and event-free survival (EFS), adjusting for sex, NCCN-IPI, comorbidity, and rituximab treatment.

Results

Approximately half of the patients had Hgb levels below the lower limit of normal. Compared to patients with Hgb levels above the mean, an inferior OS was directly correlated with lower pretreatment Hgb within the predefined groups (HR=1.23, HR=1.51, and HR=2.05, respectively). These findings were validated in the MER.

Conclusion

Based on multivariable analysis, lower pretreatment Hgb, even within the normal range but below the mean, added prognostic information to established indices such as the NCCN-IPI and the Charlson comorbidity index.

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.

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).

Pretreatment Hemoglobin as an Independent Prognostic Factor in Primary Central Nervous System Lymphomas

BACKGROUND

Primary central nervous system lymphoma (PCNSL) is a rare subtype of extranodal lymphoma. Despite established clinical prognostic scoring such as that of the Memorial Sloan Kettering Cancer Center (MSKCC) and the International Extranodal Lymphoma Study Group, outcome prediction needs to be improved. Several studies have indicated an association between changes in hematologic laboratory parameters with patient outcomes in PCNSL. We sought to assess the association between hematological parameters and overall survival (OS) in patients with PCNSL.

METHODS

Pretreatment blood tests were analyzed in patients with newly diagnosed PCNSL (n = 182), and we divided the analysis into two cohorts (A and B, both n = 91). OS was evaluated using the Cox proportional hazards models and log-rank test. Furthermore, the accuracy of the different multivariate models was assessed by Harrell's concordance index (C-index).

RESULTS

Using prechemotherapy blood tests, anemia was found in 38 patients (41.8%) in cohort A and 34 patients (37.4%) in cohort B. In univariate analysis, anemia (<12 g/dL in women and <13 g/dL in men) was significantly associated with OS. None of the other blood tests parameters (neutrophils, lymphocyte, or platelets counts) or their ratios (neutrophil-to-lymphocyte ratio and neutrophil-to-platelets ratio) were associated with OS. In multivariate analysis, after adjusting by MSKCC score, anemia remained an independent prognostic factor. Interestingly, the prediction accuracy of OS using Harrell's C-index was similar using anemia or MSKCC (mean C-index, 0.6) and was increased to 0.67 when combining anemia and MSKCC.

CONCLUSION

The presence of anemia was associated with poor prognosis in both cohorts of PCNSL. Validation of these results and biologic role of hemoglobin levels in PCNSL requires further investigation.

IMPLICATIONS FOR PRACTICE

The prediction of the outcome of primary central nervous system lymphoma (PCNSL) using the most frequently used scores (i.e., Memorial Sloan Kettering Cancer Center [MSKCC] or International Extranodal Lymphoma Study Group) needs to be improved. We analyzed a large cohort of PCNSL to dissect the potential prognostic value of blood tests in this rare entity. We found anemia as an independent predictor for overall survival in PCNSL. Interestingly, the accuracy to predict PCNSL outcome was improved using hemoglobin level. This improvement was additional to the currently used clinical score (i.e., MSKCC). Finally, none of the other blood tests parameters or their ratios had a prognostic impact in this study.

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.

Comparison of Prognostic Indices in Japanese Patients with Diffuse Large B-cell Lymphoma in the Yonago Area

Background

Several prognostic indices for diffuse large B-cell lymphoma (DLBCL) have been developed. Which index is appropriate for Japanese patients with DLBCL treated in real-world practice is unknown.

Methods

The prognostic performances of the original international prognostic index (IPI), age-adjusted IPI, National Comprehensive Cancer Network-IPI, elderly IPI and revised IPI were compared using patients with DLBCL treated in a single institute in the Yonago area in Japan.

Results

From 2005 through 2015, 182 patients with de novo DLBCL were treated with chemotherapy in Tottori University Hospital; 154 (85%) patients received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) although full dose was administered in 63 (35%) patients. The median age of the patients was 71 years (range 18 to 91). Three-year overall survival rate was 71.8% (95% CI, 64.1% to 78.2%). All indices significantly discriminate risk groups for overall survival of the patients (P < 0.001). Although no statistical difference of performance was found among these indices, the best scores of model fit/discrimination measures were beaten out by age-adjusted IPI, the simplest and three-factor model.

Conclusion

Age-adjusted IPI is still usable in real-world practice while a better predictive model is desired for Japanese patients with DLBCL.

Anemia management in cancer patients with chronic kidney disease

Anemia is a common complication of cancer and chronic kidney disease (CKD) associated with decreased physical performance as well as poor prognosis for life expectancy. Renal and cancer-induced anemia share common features regarding pathogenesis and therapeutic strategies. It is typically treated with iron substitution, erythropoiesis-stimulating agents (ESA) and in refractory cases with red blood cell transfusions. However, studies of the past few years unveiled numerous setbacks in the use of ESAs. These included a higher risk of cerebrovascular events and increased mortality without the improvement of cardiovascular outcomes in patients with CKD. Moreover, particularly negative results were observed in patients with previous cancer history under ESA therapy. These unfavorable findings have forced the clinicians to reevaluate the management of renal anemia. This led to decrease of ESA usage, while iron substitution and alternative therapeutic options gained more significance. Iron supplementation is also accompanied with certain risks ranging from gastrointestinal complications to severe allergic reactions and increased rate of infections. Furthermore, the evaluation of the long-term safety of excessive iron therapy is still lacking, especially in CKD patients with cancer. In the absence of these clinical studies, this review aims to summarize the currently available therapeutic strategies in anemia management of CKD patients with concomitant cancer.

Enhanced international prognostic index in Japanese patients with diffuse large B-cell lymphoma

To evaluate the National Comprehensive Cancer Network (NCCN) International Prognostic Index (IPI), we analyzed 284 patients treated with the combination of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in our institution in Japan. Their 5-year overall survival (OS) by risk level was 80.7%, 74.8%, 55.4% and 67.5% (P=0.005); and their 5-year progression-free survival (PFS) was 76.8%, 78.6%, 63.7% and 58.3% (P=0.0722). The NCCN-IPI is a simple scale that uses conventional clinical factors, but did not reflect survival in our cohort. The NCCN-IPI may require further evaluation for different regions and ethnicities before adopting it for routine clinical use.

•

The NCCN-IPI is developed to predict survival in the rituximab era.

•

The NCCN-IPI failed to predict survival in our cohort.

•

The NCCN-IPI may require further evaluation before routine clinical use.

[Comparison of prognostic models for patients with early-stage diffuse large B-cell lymphoma]

OBJECTIVE

To compare the prognostic value of different models in patients with early-stage diffuse large B-cell lymphoma (DLBCL).

METHODS

Early-stage DLBCL patients diagnosed from January 2000 to December 2012 were analyzed retrospectively. All patients received with at least 2 cycles of immunochemotherapy R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) with or without radiotherapy. The prognostic value of international prognostic index (IPI) , revised IPI (R-IPI) and enhanced IPI (NCCN-IPI) was compared.

RESULTS

Ninety-seven cases of early-stage DLBCL were included in the study. The median age was 58 years (15-88 years) with a median follow-up of 34.7 months (range 7.3-77.4 months). The expected 5-year overall survival (OS) for entire group was 82%. There was no patient in the high risk group according to IPI or NCCN-IPI. According to IPI, the 5-year OS in the low, low intermediate, high intermediate risk groups were 95%, 38% and 60%, respectively. According to R-IPI, the 5-year OS in the very good, good, and poor risk groups were 93%, 75% and 60%, respectively. According to NCCN-IPI, the 5-year OS in the low, low intermediate, high intermediate risk groups were 92%, 85% and 29%, respectively.

CONCLUSION

NCCN-IPI would be of an ideal prognostic model for early-stage DLBCL patients.

The clinical significance of fibrinogen plasma levels in patients with diffuse large B cell lymphoma

BACKGROUND

Fibrinogen plays a crucial role in the pathophysiology of tumour cell growth, invasion and metastasis. The aim of this study was to evaluate the prognostic significance of pretreatment plasma fibrinogen levels in patients with diffuse large B cell lymphoma (DLBCL) METHODS: Data from 372 patients with DLBCL, diagnosed and treated between 2004 and 2013 at two Austrian centres, were evaluated retrospectively. The prognostic influences of plasma fibrinogen levels and other factors, including age, tumour stage and the National Comprehensive Cancer Network-International Prognostic Index, on 5-year overall survival (OS) and 5-year disease-free survival (DFS) were studied using Kaplan-Meier curves as well as univariate and multivariate Cox regression models.

RESULTS

Kaplan-Meier analysis revealed that a high fibrinogen plasma level is associated with decreased 5-year OS and 5-year DFS in patients with DLBCL (p<0.001, log-rank test). Furthermore, in multivariate analysis, elevated serum fibrinogen was found to be an independent marker of poor clinical outcome: 5-year OS (HR=1.69, 95% CI 1.06 to 2.72, p=0.029) and 5-year DFS (HR=1.68, 95% CI 1.08 to 2.61, p=0.021).

CONCLUSIONS

In the current study, we demonstrate that high plasma fibrinogen levels at diagnosis predict poor outcome in patients with DLBCL.

TRIAL REGISTRATION NUMBER

25-434 ex 12713 and 415-EP/73/127-2012.

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.