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Somasundaram E, Abramson JS. Double hit lymphoma: contemporary understanding and practices. Leuk Lymphoma 2024:1-8. [PMID: 39378204 DOI: 10.1080/10428194.2024.2412295] [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: 07/24/2024] [Revised: 09/15/2024] [Accepted: 09/29/2024] [Indexed: 10/10/2024]
Abstract
Double-hit lymphoma (DHL) is a high-risk subtype of large B-cell lymphoma, defined by concurrent rearrangements MYC and BCL2. The diagnosis is confirmed through histologic and immunophenotypic examination and fluorescence in situ hybridization (FISH) to demonstrate the rearrangements. DHL morphology ranges from DLBCL to high-grade B-cell lymphoma which can resemble Burkitt lymphoma and is almost always germinal center B-cell like (GCB). Prognosis is influenced by elevated lactate dehydrogenase (LDH), advanced stage, and extranodal involvement, among other factors. Treatment outcomes vary, but intensive chemotherapy regimens such as dose-adjusted EPOCH-R have shown the most promising results, though low-risk cases do occur and may do well with less intensive treatments. Recent therapeutic advances such as CAR-T cells and bispecific antibodies offer promise for patients with relapsed/refractory disease. This review synthesizes data from recent literature to provide a comprehensive analysis of the molecular underpinnings, diagnostic criteria, prognostic factors, and therapeutic strategies for DHL.
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2
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Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol 2024; 204:1178-1192. [PMID: 38247115 PMCID: PMC7616447 DOI: 10.1111/bjh.19273] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024]
Affiliation(s)
| | - Sridhar Chaganti
- Centre for Clinical Haematology, University Hospitals Birmingham, Birmingham, UK
| | - Graham McIlroy
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Sally F Barrington
- King's College London and Guy's and St Thomas' PET Centre, School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Cathy Burton
- Department of Haematology, The Leeds Teaching Hospitals, Leeds, UK
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London, UK
| | - Toby A Eyre
- Oxford Cancer and Haematology Centre, Oxford University Hospitals, Oxford, UK
| | - Timothy Illidge
- Division of Cancer Sciences, Manchester NIHR Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Nagesh Kalakonda
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
| | - Andrea Kuhnl
- Department of Haematology, King's College Hospital, London, UK
| | - Pam McKay
- Department of Haematology, Beatson West of Scotland Cancer Centre, Glasgow, UK
| | - Andrew J Davies
- Cancer Sciences Division, Centre for Cancer Immunology, University of Southampton, Southampton, UK
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3
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de Jonge AV, Bult JAA, Karssing DFE, Nijland M, Chamuleau MED, Brink M. A MYC-rearrangement is a negative prognostic factor in stage II, but not in stage I diffuse large B-cell lymphoma. Blood Cancer J 2024; 14:2. [PMID: 38177113 PMCID: PMC10766972 DOI: 10.1038/s41408-023-00971-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/08/2023] [Accepted: 12/13/2023] [Indexed: 01/06/2024] Open
Abstract
MYC oncogene rearrangements (MYC-R) negatively affect survival in patients with Ann Arbor stage III-IV diffuse large B-cell lymphoma (DLBCL), but their impact in limited stage (LS) I-II is unclear. Therefore, we assessed the impact of MYC-R on progression-free survival (PFS) and overall survival (OS) in LS DLBCL patients at the population level. We identified 1,434 LS DLBCL patients with known MYC-R status diagnosed between 2014 and 2020, who received R-CHOP(-like) regimens using the Netherlands Cancer Registry, with survival follow-up until February 2022. Stage I patients with (n = 83, 11%) and without (n = 650, 89%) a MYC-R had similar 2-years PFS (89% and 93%, p = 0.63) and OS (both 95%, p = 0.22). Conversely, stage II DLBCL patients with a MYC-R (n = 90, 13%) had inferior survival outcomes compared to stage II patients without a MYC-R (n = 611, 87%) (PFS 70% vs. 89%, p = 0.001; OS 79% vs. 94%, p < 0.0001). Both single MYC-R (single hit, n = 36) and concurrent BCL2 and/or BCL6 rearrangements (double/triple hit, n = 39) were associated with increased mortality and relapse risk. In conclusion, in stage II DLBCL a MYC-R is negatively associated with survival. In stage I DLBCL, however, survival outcomes are excellent irrespective of MYC-R status. This challenges the diagnostic assessment of MYC-R in stage I DLBCL patients.
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Affiliation(s)
- A V de Jonge
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands.
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands.
| | - J A A Bult
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - D F E Karssing
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
| | - M Nijland
- Department of Hematology, University Medical Center Groningen, Groningen, The Netherlands
| | - M E D Chamuleau
- Department of Hematology, Amsterdam UMC Location Vrije Universiteit, Amsterdam, The Netherlands
- Cancer Center Amsterdam, Cancer Biology and Immunology, Amsterdam, The Netherlands
| | - M Brink
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, The Netherlands
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4
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Zeremski V, Kropf S, Koehler M, Gebauer N, McPhail ED, Habermann T, Schieppati F, Mougiakakos D. Induction treatment in high-grade B-cell lymphoma with a concurrent MYC and BCL2 and/or BCL6 rearrangement: a systematic review and meta-analysis. Front Oncol 2023; 13:1188478. [PMID: 37546419 PMCID: PMC10399221 DOI: 10.3389/fonc.2023.1188478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 07/05/2023] [Indexed: 08/08/2023] Open
Abstract
Background and aim High-grade B cell lymphomas with concomitant MYC and BCL2 and/or BCL6 rearrangements (HGBCL-DH/TH) have a poor prognosis when treated with the standard R-CHOP-like chemoimmunotherapy protocol. Whether this can be improved using intensified regimens is still under debate. However, due to the rarity of HGBCL-DH/TH there are no prospective, randomized controlled trials (RCT) available. Thus, with this systematic review and meta-analysis we attempted to compare survival in HGBCL-DH/TH patients receiving intensified vs. R-CHOP(-like) regimens. Methods The PubMed and Web of Science databases were searched for original studies reporting on first-line treatment in HGBCL-DH/TH patients from 08/2014 until 04/2022. Studies with only localized stage disease, ≤10 patients, single-arm, non-full peer-reviewed publications, and preclinical studies were excluded. The quality of literature and the risk of bias was assessed using the Methodological Index for Non-Randomized Studies (MINORS) and National Heart, Lung, and Blood Institute (NHLBI) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Random-effect models were used to compare R-CHOP-(like) and intensified regimens regarding 2-year overall survival (2y-OS) and 2-year progression-free survival (2y-PFS). Results Altogether, 11 retrospective studies, but no RCT, with 891 patients were included. Only four studies were of good quality based on aforementioned criteria. Intensified treatment could improve 2y-OS (hazard ratio [HR]=0.78 [95% confidence interval [CI] 0.63-0.96]; p=0.02) as well as 2y-PFS (HR=0.66 [95% CI 0.44-0.99]; p=0.045). Conclusions This meta-analysis indicates that intensified regimens could possibly improve 2y-OS and 2y-PFS in HGBCL-DH/TH patients. However, the significance of these results is mainly limited by data quality, data robustness, and its retrospective nature. There is still a need for innovative controlled clinical trials in this difficult to treat patient population. Systematic review registration https://www.crd.york.ac.uk/prospero, identifier CRD42022313234.
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Affiliation(s)
- Vanja Zeremski
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Siegfried Kropf
- Department for Biometry and Medical Informatics, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
| | - Michael Koehler
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
- Specialty Practice for Psycho-Oncology, Magdeburg, Germany
| | - Niklas Gebauer
- Department of Hematology and Oncology, University Hospital of Schleswig-Holstein, Luebeck, Germany
| | - Ellen D. McPhail
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, United States
| | - Thomas Habermann
- Division of Hematology, Mayo Clinic, Rochester, MN, United States
| | | | - Dimitrios Mougiakakos
- Department of Hematology and Oncology, Medical Center, Otto-von-Guericke University Magdeburg, Magdeburg, Germany
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5
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Duffield AS, Dogan A, Amador C, Cook JR, Czader M, Goodlad JR, Nejati R, Xiao W, Happ L, Parker C, Thacker E, Thakkar D, Dave SS, Wasik MA, Ott G. Progression of follicular lymphoma and related entities: Report from the 2021 SH/EAHP Workshop. Am J Clin Pathol 2023; 159:aqad042. [PMID: 37167543 PMCID: PMC10233403 DOI: 10.1093/ajcp/aqad042] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/21/2023] [Indexed: 05/13/2023] Open
Abstract
OBJECTIVES The 2021 Society for Hematopathology and European Association for Haematopathology Workshop addressed the molecular and cytogenetic underpinnings of transformation and transdifferentiation in lymphoid neoplasms. METHODS Session 4, "Transformations of Follicular Lymphoma," and session 5, "Transformations of Other B-Cell Lymphomas," included 45 cases. Gene alteration analysis and expression profiling were performed on cases with submitted formalin-fixed, paraffin embedded tissue. RESULTS The findings from session 4 suggest that "diffuse large B-cell lymphoma/high-grade B-cell lymphoma with rearrangements of MYC and BCL2" is a distinct category arising from the constraints of a preexisting BCL2 translocation. TdT expression in aggressive B-cell lymphomas is associated with MYC rearrangements, immunophenotypic immaturity, and a dismal prognosis but must be differentiated from lymphoblastic -lymphoma. Cases in session 5 illustrated unusual morphologic and immunophenotypic patterns of transformation. Additionally, the findings support the role of cytogenetic abnormalities-specifically, MYC and NOTCH1 rearrangements-as well as single gene alterations, including TP53, in transformation. CONCLUSIONS Together, these unique cases and their accompanying molecular and cytogenetic data suggest potential mechanisms for and unusual patterns of transformation in B-cell lymphomas and indicate numerous opportunities for further study.
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Affiliation(s)
- Amy S Duffield
- Department of Pathology and Laboratory Medicine, Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, US
| | - Ahmet Dogan
- Department of Pathology and Laboratory Medicine, Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, US
| | - Catalina Amador
- Department of Pathology and Laboratory Medicine, University of Miami Miller School of Medicine, Miami, FL, US
| | - James R Cook
- Department of Laboratory Medicine, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, US
| | - Magdalena Czader
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN, US
| | - John R Goodlad
- Department of Pathology, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Reza Nejati
- Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA, US
| | - Wenbin Xiao
- Department of Pathology and Laboratory Medicine, Hematopathology Service, Memorial Sloan Kettering Cancer Center, New York, NY, US
| | | | | | | | - Devang Thakkar
- Center for Genomic and Computational Biology and Department of Medicine, Duke University, Durham, NC, US
| | - Sandeep S Dave
- Center for Genomic and Computational Biology and Department of Medicine, Duke University, Durham, NC, US
| | - Mariusz A Wasik
- Department of Pathology, Fox Chase Cancer Center, Philadelphia, PA, US
| | - German Ott
- Abteilung für Klinische Pathologie, Robert-Bosch-Krankenhaus, and Dr Margarete Fischer-Bosch Institut für Klinische Pharmakologie, Stuttgart, Germany
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6
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El-Sharkawi D, Sud A, Prodger C, Khwaja J, Shotton R, Hanley B, Peacock V, Peng YY, Arasaretnam A, Sharma S, Aldridge F, Sharma B, Wotherspoon A, Cheung B, De Lord C, Johnston R, Kassam S, Pettengel R, Linton K, Greaves P, Cook L, Naresh KN, Cwynarski K, Eyre TA, Chau I, Cunningham D, Iyengar S. A retrospective study of MYC rearranged diffuse large B-cell lymphoma in the context of the new WHO and ICC classifications. Blood Cancer J 2023; 13:54. [PMID: 37072385 PMCID: PMC10113386 DOI: 10.1038/s41408-023-00827-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/24/2023] [Accepted: 04/03/2023] [Indexed: 04/20/2023] Open
Affiliation(s)
- Dima El-Sharkawi
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Amit Sud
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
- Division of Genetics and Epidemiology, The Institute of Cancer Research, London, UK
| | - Catherine Prodger
- Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | - Rohan Shotton
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Brian Hanley
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Ying Ying Peng
- St George's University Hospitals NHS Foundation Trust, London, UK
| | | | - Sarkhara Sharma
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Frances Aldridge
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Bhupinder Sharma
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Andrew Wotherspoon
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | | | - Corinne De Lord
- Epsom and St Helier University Hospitals NHS Trust, London, UK
| | | | - Shireen Kassam
- King's College Hospital NHS Foundation Trust, London, UK
| | - Ruth Pettengel
- St George's University Hospitals NHS Foundation Trust, London, UK
| | - Kim Linton
- The Christie Hospital NHS Foundation Trust, Manchester, UK
| | - Paul Greaves
- Barking, Havering and Redbridge University Hospitals NHS Trust, Essex, UK
| | - Lucy Cook
- Imperial College Healthcare NHS Trust, London, UK
| | | | - Kate Cwynarski
- University College Hospitals NHS Foundation Trust, London, UK
| | - Toby A Eyre
- Churchill Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ian Chau
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - David Cunningham
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK
| | - Sunil Iyengar
- The Royal Marsden NHS Foundation Trust and the Institute of Cancer Research, London, UK.
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7
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Bobillo S, Khwaja J, Ferreri AJM, Cwynarski K. Prevention and management of secondary central nervous system lymphoma. Haematologica 2023; 108:673-689. [PMID: 36384246 PMCID: PMC9973486 DOI: 10.3324/haematol.2022.281457] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Indexed: 11/18/2022] Open
Abstract
Secondary central nervous system (CNS) lymphoma (SCNSL) is defined by the involvement of the CNS, either at the time of initial diagnosis of systemic lymphoma or in the setting of relapse, and can be either isolated or with synchronous systemic disease. The risk of CNS involvement in patients with diffuse large B-cell lymphoma is approximately 5%; however, certain clinical and biological features have been associated with a risk of up to 15%. There has been growing interest in improving the definition of patients at increased risk of CNS relapse, as well as identifying effective prophylactic strategies to prevent it. SCNSL often occurs within months of the initial diagnosis of lymphoma, suggesting the presence of occult disease at diagnosis in many cases. The differing presentations of SCNSL create the therapeutic challenge of controlling both the systemic disease and the CNS disease, which uniquely requires agents that penetrate the blood-brain barrier. Outcomes are generally poor with a median overall survival of approximately 6 months in retrospective series, particularly in those patients presenting with SCNSL after prior therapy. Prospective studies of intensive chemotherapy regimens containing high-dose methotrexate, followed by hematopoietic stem cell transplantation have shown the most favorable outcomes, especially for patients receiving thiotepa-based conditioning regimens. However, a proportion of patients will not respond to induction therapies or will subsequently relapse, indicating the need for more effective treatment strategies. In this review we focus on the identification of high-risk patients, prophylactic strategies and recent treatment approaches for SCNSL. The incorporation of novel agents in immunochemotherapy deserves further study in prospective trials.
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Affiliation(s)
- Sabela Bobillo
- Department of Hematology, Vall d'Hebron Institute of Oncology (VHIO), Vall d'Hebron University Hospital, Barcelona
| | - Jahanzaib Khwaja
- Department of Haematology, University College London Hospitals, London
| | - Andrés J M Ferreri
- Lymphoma Unit, Department of Onco-Haematology, IRCCS San Raffaele Scientific Institute, Milan
| | - Kate Cwynarski
- Department of Haematology, University College London Hospitals, London
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8
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Nastoupil LJ, Bartlett NL. Navigating the Evolving Treatment Landscape of Diffuse Large B-Cell Lymphoma. J Clin Oncol 2023; 41:903-913. [PMID: 36508700 DOI: 10.1200/jco.22.01848] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Diffuse large B-cell lymphoma, the most common subtype of non-Hodgkin lymphoma, comprises a heterogenous group of morphologically, genetically, and clinically distinct diseases. Several recent advances have affected the treatment landscape, which had been mostly stagnant for the past few decades. We will review the practice-changing studies in frontline (POLARIX), early relapse (ZUMA-7 and TRANSFORM), and multiple recurrent (ZUMA-1, JULIET, TRANSCEND, L-MIND, and LOTIS-2) stages and discuss how the treatment landscape may evolve with the emergence of bispecific antibodies.
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9
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Gordon MJ, Westin JR. Fitting double-hit lymphoma into the aggressive lymphoma spectrum: a square peg in a round hole? Leuk Lymphoma 2022; 63:1034-1044. [PMID: 34842019 DOI: 10.1080/10428194.2021.2008383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
High-grade B-cell lymphoma with MYC and BCL2 and/or BCL6 rearrangements or both, commonly called double-hit lymphoma (DHL), is an aggressive B-cell lymphoma that is molecularly distinct from diffuse large B-cell lymphoma (DLBCL) and is associated with poor outcomes. Recent advances in the molecular classification of DLBCL have identified distinct subsets, including genetic signatures which correlate with DHL and survival. DHL with concomitant TP53 mutation appears to be associated with a very poor prognosis. Standard chemo-immunotherapy is not an effective treatment for these patients and personalized, innovative strategies are needed. In this review, we summarize recent advances in the subclassification of DLBCL, with a focus on DHL. We also incorporate early, promising clinical trial data using CAR T and targeted therapies. Rationally designed clinical trials for DLBCL are needed to advance the care of patients with DHL and other adverse risk DLBCL subgroups.
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Affiliation(s)
- Max J Gordon
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jason R Westin
- University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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10
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Miura K, Takahashi H, Nakagawa M, Hamada T, Uchino Y, Iizuka K, Ohtake S, Iriyama N, Hatta Y, Nakamura H. Ideal dose intensity of R-CHOP in diffuse large B-cell lymphoma. Expert Rev Anticancer Ther 2022; 22:583-595. [PMID: 35472312 DOI: 10.1080/14737140.2022.2071262] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The standard of care for diffuse large B-cell lymphoma (DLBCL) is rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP). However, its ideal dose intensity varies among cases. AREAS COVERED This review provides the latest insights on the dose intensity of R-CHOP for DLBCL patients. Specifically, we discussed the optimal dose intensity for elderly patients, the optimal number of treatment cycles for limited or advanced-stage diseases, and the role of dose-intensified therapies or adding targeted inhibitors. EXPERT OPINION Performing a comprehensive or simplified geriatric assessment can distinguish elderly DLBCL patients who will likely benefit from curative R-CHOP. Very elderly or medically unfit patients may need dose reduction in R-CHOP; the Age, Comorbidities, and Albumin index may aid decision-making. Four cycles of R-CHOP followed by two rituximab cycles comprise a new standard for low-risk, limited-stage DLBCL patients. Compared to eight cycles, six cycles of R-CHOP have similar efficacy and fewer toxicities for advanced-stage DLBCL. Dose-intensified therapy is not recommended in most DLBCL cases but may be considered for patients with double (or triple)-hit lymphoma. Applying targeted inhibitors and not merely escalating R-CHOP dose intensity through molecular subtyping will improve the treatment outcome for DLBCL.
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Affiliation(s)
- Katsuhiro Miura
- Tumor Center, Nihon University Itabashi Hospital (Director); 2Department of Hematology and Rheumatology, Nihon University School of Medicine (Associate Professor), Tokyo, Japan.,Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hiromichi Takahashi
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan.,Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine (Assistant Professor), Tokyo, Japan
| | - Masaru Nakagawa
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan.,Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine (Assistant Professor), Tokyo, Japan
| | - Takashi Hamada
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshihito Uchino
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Kazuhide Iizuka
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan.,Division of Laboratory Medicine, Department of Pathology and Microbiology, Nihon University School of Medicine (Assistant Professor), Tokyo, Japan
| | - Shimon Ohtake
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Noriyoshi Iriyama
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Yoshihiro Hatta
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
| | - Hideki Nakamura
- Department of Hematology and Rheumatology, Nihon University School of Medicine, Tokyo, Japan
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11
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Zhuang Y, Che J, Wu M, Guo Y, Xu Y, Dong X, Yang H. Altered pathways and targeted therapy in double hit lymphoma. J Hematol Oncol 2022; 15:26. [PMID: 35303910 PMCID: PMC8932183 DOI: 10.1186/s13045-022-01249-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 03/07/2022] [Indexed: 12/20/2022] Open
Abstract
High-grade B-cell lymphoma with translocations involving MYC and BCL2 or BCL6, usually referred to as double hit lymphoma (DHL), is an aggressive hematological malignance with distinct genetic features and poor clinical prognosis. Current standard chemoimmunotherapy fails to confer satisfying outcomes and few targeted therapeutics are available for the treatment against DHL. Recently, the delineating of the genetic landscape in tumors has provided insight into both biology and targeted therapies. Therefore, it is essential to understand the altered signaling pathways of DHL to develop treatment strategies with better clinical benefits. Herein, we summarized the genetic alterations in the two DHL subtypes (DHL-BCL2 and DHL-BCL6). We further elucidate their implications on cellular processes, including anti-apoptosis, epigenetic regulations, B-cell receptor signaling, and immune escape. Ongoing and potential therapeutic strategies and targeted drugs steered by these alterations were reviewed accordingly. Based on these findings, we also discuss the therapeutic vulnerabilities that coincide with these genetic changes. We believe that the understanding of the DHL studies will provide insight into this disease and capacitate the finding of more effective treatment strategies.
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Affiliation(s)
- Yuxin Zhuang
- Department of Lymphoma, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People’s Republic of China
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, People’s Republic of China
| | - Jinxin Che
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, People’s Republic of China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, People’s Republic of China
| | - Meijuan Wu
- Department of Pathology, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People’s Republic of China
| | - Yu Guo
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, People’s Republic of China
| | - Yongjin Xu
- Department of Lymphoma, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People’s Republic of China
| | - Xiaowu Dong
- Hangzhou Institute of Innovative Medicine, Institute of Drug Discovery and Design, College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, People’s Republic of China
- Innovation Institute for Artificial Intelligence in Medicine of Zhejiang University, Hangzhou, People’s Republic of China
- Cancer Center, Zhejiang University, Hangzhou, People’s Republic of China
| | - Haiyan Yang
- Department of Lymphoma, The Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Basic Medicine and Cancer (IBMC), Chinese Academy of Sciences, Hangzhou, People’s Republic of China
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12
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Evolution of therapy for limited stage diffuse large B-cell lymphoma. Blood Cancer J 2022; 12:33. [PMID: 35210407 PMCID: PMC8867133 DOI: 10.1038/s41408-021-00596-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/04/2021] [Accepted: 11/24/2021] [Indexed: 11/11/2022] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common non-Hodgkin lymphoma (NHL), with limited-stage DLBCL defined as stage I or II disease. Risk stratification, initial treatment options, and relapse patterns are distinct from advanced-stage DLBCL, but there is limited data on the impact of biologic features on outcome. Patients have excellent outcomes, with ~90% survival at 2 years. Over the past several years, sequential prospective trials and large registry studies have evaluated the optimal number of chemotherapy cycles and implemented PET-adapted approaches to reduce the need for radiotherapy. Special consideration must still be given to cases of bulky disease, extranodal disease, fully resected scenarios, and adverse biologic features such as high-grade B-cell lymphoma with double/triple hit rearrangements. This review presents the evolution of a modern management approach, with a discussion of recent treatment-defining studies.
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13
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Limited-stage Diffuse Large B-cell Lymphoma. Blood 2021; 139:822-834. [PMID: 34932795 DOI: 10.1182/blood.2021013998] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 12/05/2021] [Indexed: 11/20/2022] Open
Abstract
DLBCL, the most common lymphoma subtype, is localized in 25-30% of patients. Prognosis in patients with limited-stage DLBCL (LS-DLBCL) is excellent with 10-year overall survival of at least 70-80%. Improved insights into the disease biology, the availability of positron-emission tomography (PET) scans and recent dedicated clinical trials within this unique population, have led to evolving treatment paradigms. However, no standard definition of LS-DLBCL exists, and while generally defined as Ann Arbor stages I-II disease with largest mass size <10cm in diameter, variations across studies cause challenges in interpretation. Similar to advanced-stage disease, R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) immunochemotherapy forms the basis of treatment, with combined modality therapy including 3 cycles of systemic treatment and involved-site radiation therapy being a predominant historical standard. Yet the well-described continuous risk of relapse beyond 5 years and established late complications of radiotherapy have challenged previous strategies. More rigorous baseline staging and response assessment with PET may improve decision making. Recent clinical studies have focused on minimizing toxicities while maximizing disease outcomes using strategies such as abbreviated immunochemotherapy alone and PET-adapted radiotherapy delivery. This comprehensive review provides an update of recent literature with recommendations for integration into clinical practice for LS-DLBCL patients.
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14
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Dunleavy K. Double-hit lymphoma: optimizing therapy. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:157-163. [PMID: 34889402 PMCID: PMC8791152 DOI: 10.1182/hematology.2021000247] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Aggressive B-cell lymphoma is a heterogeneous entity with disparate outcomes based on clinical and pathological characteristics. While most tumors in this category are diffuse large B-cell lymphoma (DLBCL), the recognition that some cases have high-grade morphology and frequently harbor MYC and BCL2 and/or BCL6 translocations has led to their separate categorization. These cases are now considered distinct from DLBCL and are named "high-grade B-cell lymphoma" (HGBL). Most are characterized by distinct rearrangements, but others have high-grade morphological features without these and are called HGBL-not otherwise specified. Studies have demonstrated that this group of diseases leads to poor outcomes following standard rituximab, cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone therapy; retrospective and recent single-arm, multicenter studies suggest they should be approached with dose-intense treatment platforms. As yet, this has not been validated in randomized trial settings due to the rarity of these diseases. In the relapsed and refractory setting, novel approaches such as anti-CD19 chimeric antigen receptor T cells and antibodies against CD19 have demonstrated high efficacy in this subgroup. Recently, genomic studies have made much progress in investigating some of the molecular underpinnings that drive their lymphomagenesis and have paved the way for testing additional novel approaches.
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Affiliation(s)
- Kieron Dunleavy
- Correspondence Kieron Dunleavy, Division of Hematology and Oncology, Georgetown Lombardi Comprehensive Cancer Center, Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC 20057; e-mail:
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15
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Habermann TM. Updates in the Management of Early-Stage Diffuse Large B-Cell Lymphoma. J Natl Compr Canc Netw 2021. [DOI: 10.6004/jnccn.2021.5108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Several important updates have emerged in the management of early-stage diffuse large B-cell lymphoma. Three trials resulted in the approval of rituximab + cyclophosphamide/doxorubicin/vincristine/prednisone (R-CHOP) for use in these patients internationally. Furthermore, studies have been initiated to determine whether 4 or 6 cycles of this regimen should be administered without radiation therapy (RT). Six cycles of R-CHOP plus central nervous system (CNS) prophylaxis and prophylactic testicular RT are recommended for patients with extranodal disease occupying the testicles. Although controversial, there is a reasonable consensus in the literature to consider 6 cycles of R-CHOP plus involved-site RT and CNS prophylaxis for patients with extranodal disease of the breast. Patients with primary bone and gastric extranodal disease do not seem to derive a significant survival benefit from RT. Molecular subtype evaluations may change treatment approaches.
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16
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Sonnevi K, Ljungqvist M, Jóelsson JK, Harrysson S, Wästerlid T, Bernell P, Wahlin BE. Excellent survival after R-Hyper-CVAD in hospitalized patients with high-risk large B-cell lymphoma: The Karolinska experience. EJHAEM 2021; 2:774-784. [PMID: 35845206 PMCID: PMC9175941 DOI: 10.1002/jha2.296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/25/2021] [Accepted: 08/27/2021] [Indexed: 11/06/2022]
Abstract
Patients with high-risk aggressive B-cell lymphoma exhibit poor survival after R-CHOP. More intensive regimens yield higher rates of remission but also of complication. We investigated all 401 patients < 70 years with high-risk (age-adjusted [aa] international prognostic index [IPI] ≥2, extranodal, or bulky) aggressive B-cell lymphoma hospitalized at Karolinska for urgent start of immunochemotherapy (129 R-Hyper-CVAD; 261 R-CHOP/R-CHOEP). Patients showed IPI 3-5 (70%), WHO PS ≥2 (49%), bulky disease (70%), extranodal (75%) and CNS (8%) involvement. Five-year overall/progression-free survival (OS/PFS) was better in patients who started R-Hyper-CVAD (84%/77%) compared with R-CHOP/R-CHOEP (66%/55%). Differences were independent in multivariable analysis, seen in all patient categories, and accentuated in extreme high-risk disease: R-Hyper-CVAD vs. R-CHOP/R-CHOEP showed 5-year PFS 69% vs.40% in aaIPI 3 and 88% vs. 38% in CNS involvement. For validation, survival was compared between the two Karolinska sites and calendar periods. Survival was superior 2006-2010 at the site that introduced R-Hyper-CVAD/R-MA 2006, identical at both sites 2011-2017 after the other site adopted R-Hyper-CVAD/R-MA 2011, and excellent 2018-2020 when R-Hyper-CVAD/R-MA use increased to 75% of patients. Despite considerable toxicity, also patients aged 61-69 years showed better survival with R-Hyper-CVAD/R-MA. This is the largest single-centre series of patients treated with R-Hyper-CVAD/R-MA, showing favourable outcome in high-risk aggressive B-cell lymphoma.
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Affiliation(s)
- Kristina Sonnevi
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
| | - Maria Ljungqvist
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Jóel Kristinn Jóelsson
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Sara Harrysson
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Tove Wästerlid
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Per Bernell
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Björn Engelbrekt Wahlin
- Haematology Medical UnitKarolinska University HospitalStockholmSweden
- Division of Haematology, Department of Medicine, HuddingeKarolinska InstitutetStockholmSweden
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17
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Defining and Treating High-grade B-cell lymphoma, NOS. Blood 2021; 140:943-954. [PMID: 34525177 DOI: 10.1182/blood.2020008374] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 09/10/2021] [Indexed: 11/20/2022] Open
Abstract
High-grade B-cell lymphoma, not otherwise specified (HGBL, NOS) is a recently introduced diagnostic category for aggressive B-cell lymphomas. It includes tumors with Burkitt-like or blastoid morphology that do not have double-hit cytogenetics and that cannot be classified as other well-defined lymphoma subtypes. HBCL, NOS are rare and heterogeneous; most have germinal center B-cell phenotype, and up to 45% carry a single-hit MYC rearrangement, but otherwise they have no unifying immunophenotypic or cytogenetic characteristics. Recent analyses utilizing gene expression profiling (GEP) revealed that up to 15% of tumors currently classified as diffuse large B-cell lymphoma display a HGBL-like GEP signature, indicating a potential to significantly expand the HGBL category using more objective molecular criteria. Optimal treatment of HGBL, NOS is poorly defined due to its rarity and inconsistent diagnostic patterns. A minority of patients have early-stage disease which can be managed with standard RCHOP-based approaches with or without radiation. For advanced-stage HGBL, NOS, which often presents with aggressive, disseminated disease, high lactate dehydrogenase, and involvement of extranodal organs (including the central nervous system [CNS]), intensified Burkitt lymphoma-like regimens with CNS prophylaxis may be appropriate. However, many patients diagnosed at age > 60 years are not eligible for intensive immunochemotherapy. An improved, GEP and/or genomic-based pathologic classification that could facilitate HGBL-specific trials is needed to improve outcomes for all patients. In this review, we discuss the current clinicopathologic concept of HGBL, NOS, existing data on its prognosis and treatment, and delineate potential future taxonomy enrichments based on emerging molecular diagnostics.
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18
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Prognostication of Primary Tumor Location in Early-Stage Nodal Diffuse Large B-Cell Lymphoma: An Analysis of the SEER Database. Cancers (Basel) 2021; 13:cancers13163954. [PMID: 34439110 PMCID: PMC8392260 DOI: 10.3390/cancers13163954] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 07/25/2021] [Accepted: 07/29/2021] [Indexed: 12/30/2022] Open
Abstract
The prognostic role of primary tumor location for clinical outcomes of patients with early-stage nodal diffuse large B-cell lymphoma (DLBCL) remains uncertain. We evaluated the relationship between primary tumor site and overall survival (OS) in 9738 early-stage nodal DLBCL patients from the Surveillance, Epidemiology, and End Results (SEER) database. The primary site of the tumors was characterized as supradiaphragm and subdiaphragm according to the definition of lymph node distribution in the Ann Arbor staging. The OS was significantly better for patients of the supradiaphragm group (n = 6038) compared to the ones from the subdiaphragm group (n = 3655) (hazard ratio (HR) 1.24; 95%CI: 1.16-1.33; P < 0.001), and it was preserved after propensity score matching (PSM) (HR 1.15; 95% CI: 1.07-1.24; P < 0.001). Gene enrichment analyses demonstrated that the subdiaphragm group has an upregulated extracellular matrix (ECM)-related signaling, which reportedly can promote growth, invasion, and metastasis of the cancer, and downregulated interferon response, which is considered to have anti-tumor function. Our results indicate the two tumor locations (supradiaphragm and subdiaphragm) presented different prognostic implications for the overall survival, suggesting that the tumor's location could serve as a prognostic biomarker for early-stage nodal DLBCL patients.
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19
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Berger MD, Trelle S, Büchi AE, Jegerlehner S, Ionescu C, de la Chapelle TL, Novak U. Impact on survival through consolidation radiotherapy for diffuse large B-cell lymphoma: a comprehensive meta-analysis. Haematologica 2021; 106:1923-1931. [PMID: 32554560 PMCID: PMC8252950 DOI: 10.3324/haematol.2020.249680] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 06/12/2020] [Indexed: 01/09/2023] Open
Abstract
Rituximab has improved response rates and overall survival in B-cell lymphoma (DLBCL). Radiotherapy is an effective treatment modality for lymphomas, but there is uncertainty on its use as consolidation after chemo-immunotherapy mainly in advanced stages. We evaluated its efficacy with a comprehensive meta-analysis and a systematic search of Pubmed, Embase, Cochrane, and abstracts from ASCO, ASH, ESMO and ASTRO published from June 1966 and December 2018. We identified 11 trials that evaluated consolidation radiotherapy following chemotherapy in a randomized fashion in 4'584 patients. The primary endpoint of this meta-analysis was PFS. As three of the eleven trials were retracted, this data is based on 2414 patients. For the primary endpoint (PFS), we found a hazard ratio (HR) of 0.77 (0.51 to 1.17, pooled (tau2: 0.25; I2: 85%), and a HR of 0.80 (0.53 to 1.21, pooled (bivariate meta-analysis). For overall survival, the HR is 0.93 (0.61 to 1.40; pooled (tau2: 0.25; I2: 74%) and 0.86 (0.58 to 1.27) in a bivariate meta-analysis. The lack of benefit did not change over time (p-value: 0.95 (tau2: 0.32; I2: 88%), and was also absent for PFS when stratifying for chemotherapy, the use of Rituximab, age, the dose of radiotherapy, application to patients in complete remission and with bulky disease. None of the trials used a PET-guided approach. This meta-analysis revealed no survival benefit when consolidation radiotherapy is given to unselected DLBCL patients following chemotherapy. These results need to be considered in future trials in the PET-CT era.
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Affiliation(s)
- Martin D. Berger
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Annina E. Büchi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Sabrina Jegerlehner
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Codruta Ionescu
- Department of Radiation Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | | | - Urban Novak
- Department of Medical Oncology, Inselspital, Bern University Hospital, University of Bern, Switzerland
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20
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Sokol K, McBride A, Binder AF, Porcu P. Treating Early-Stage DLBCL on the FLYER: What Lesson for Radiation Therapy? Front Oncol 2021; 11:686223. [PMID: 34150653 PMCID: PMC8213365 DOI: 10.3389/fonc.2021.686223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/18/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kelsey Sokol
- Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Sidney Kimmel Cancer Center at Jefferson Health, Thomas Jefferson University, Philadelphia, PA, United States
| | - Amanda McBride
- Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Sidney Kimmel Cancer Center at Jefferson Health, Thomas Jefferson University, Philadelphia, PA, United States
| | - Adam Finn Binder
- Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Sidney Kimmel Cancer Center at Jefferson Health, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pierluigi Porcu
- Department of Medical Oncology, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Sidney Kimmel Cancer Center at Jefferson Health, Thomas Jefferson University, Philadelphia, PA, United States
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21
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Susanibar-Adaniya S, Barta SK. 2021 Update on Diffuse large B cell lymphoma: A review of current data and potential applications on risk stratification and management. Am J Hematol 2021; 96:617-629. [PMID: 33661537 PMCID: PMC8172085 DOI: 10.1002/ajh.26151] [Citation(s) in RCA: 146] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 03/02/2021] [Indexed: 12/30/2022]
Abstract
Diffuse large B cell lymphoma (DLBCL), the most common type of Non-Hodgkin lymphoma (NHL), comprises a heterogeneous group of diseases with different biology, clinical presentations, and response to treatment. R-CHOP remains the mainstay of therapy and can achieve long-term disease control in nearly 90% of patients presenting with limited-stage and in up to 60% of those presenting with advanced stages. Advances on the understanding of the genetic landscape and molecular features of DLBCL have identified high-risk subsets with poor outcomes to chemo-immunotherapy that are actively being studied in clinical trials. Novel therapies could potentially improve outcomes for patients with high-risk disease. Studies evaluating risk-adapted therapy based on classification by cell of origin (COO) and molecular features are ongoing. Developments in the fields of immunotherapy, mostly with adoptive T-cell therapy, have significantly improved the outcomes of patients with relapsed refractory disease. In this review, we will summarize the recent data and discuss ongoing efforts to improve DLBCL treatment in the frontline and relapsed refractory settings.
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MESH Headings
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- B-Lymphocyte Subsets/pathology
- Cell Lineage
- Combined Modality Therapy
- Cyclophosphamide/administration & dosage
- DNA, Neoplasm/blood
- Disease Management
- Doxorubicin/administration & dosage
- Genes, bcl-2
- Genes, myc
- Hematopoietic Stem Cell Transplantation
- Humans
- Immunotherapy, Adoptive
- Lymphoma, Large B-Cell, Diffuse/classification
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Neoplasm Staging
- Neoplastic Stem Cells/pathology
- Positron Emission Tomography Computed Tomography
- Prednisone/administration & dosage
- Recurrence
- Risk Assessment
- Rituximab/administration & dosage
- Salvage Therapy
- Treatment Outcome
- Vincristine/administration & dosage
- Exome Sequencing
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Affiliation(s)
| | - Stefan K Barta
- Department of Hematology/Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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22
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Laude M, Lebras L, Sesques P, Ghesquieres H, Favre S, Bouabdallah K, Croizier C, Guieze R, Drieu La Rochelle L, Gyan E, Chin R, Aurran‐Schleinitz T, Marouf A, Deau‐Fischer B, Coppo P, Malot S, Roussel X, Chauchet A, Schwarz M, Bescond C, Lamy de la Chapelle T, Bussot L, Carras S, Burlet B, Rossi C, Daniel A, Morschhauser F, Subtil F, Michallet A. First-line treatment of double-hit and triple-hit lymphomas: Survival and tolerance data from a retrospective multicenter French study. Am J Hematol 2021; 96:302-311. [PMID: 33306213 DOI: 10.1002/ajh.26068] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 12/05/2020] [Accepted: 12/08/2020] [Indexed: 11/12/2022]
Abstract
Historically, double or triple hit lymphoma (DHL and THL) have poor outcomes with conventional chemotherapy, but there is currently no guideline. We report the French experience in managing DHL and THL in first line using collective data on both survival and tolerance. All consecutive patients with newly diagnosis of large B-cell lymphoma with MYC, BCL2, and/or BCL6 rearrangements, as determined by FISH between January 2013 and April 2019 were included. Based on the eligibility criteria, 160 patients were selected among the 184 patients identified. With a median follow-up of 32 months, 2- and 4-year progression free survival (PFS) rates were 40% and 28% with R-CHOP compared with 57% and 52% with intensive chemotherapy (P = .063). There was no difference in overall survival (OS). For advanced stages, PFS was significantly longer with intensive chemotherapy than with R-CHOP (P = .029). There was no impact of autologous stem cell transplantation among patient in remission. For patients with central nervous system (CNS) involvement, the 2-year PFS and OS rate was 21% and 39%, vs 57% and 75% without CNS disease (P = .007 and P < .001). By multivariate analysis, elevated IPI score and CNS disease were strongly and independently associated with a poorer survival, whereas treatment was not significantly associated with OS. This is the largest series reporting the treatment of DHL and THL in Europe. The PFS was significantly longer with an intensive regimen for advanced stage, but no difference in OS, supporting the need for a prospective randomized trial.
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Affiliation(s)
| | - Laure Lebras
- Department of Hematology and Medical Oncology Centre Léon Bérard Lyon France
| | - Pierre Sesques
- Department of Hematology Hospices Civils de Lyon Lyon France
| | | | - Simon Favre
- Department of Hematology and Cell Therapy University Hospital of Bordeaux Bordeaux France
| | - Krimo Bouabdallah
- Department of Hematology and Cell Therapy University Hospital of Bordeaux Bordeaux France
| | - Carolyne Croizier
- Department of Hematology and Cell Therapy Estaing University Hospital Clermont‐Ferrand France
| | - Romain Guieze
- Department of Hematology and Cell Therapy Estaing University Hospital Clermont‐Ferrand France
| | | | - Emmanuel Gyan
- Department of Hematology and Cell Therapy University Hospital of Tours Tours France
| | - Roza Chin
- Department of Hemato‐Oncology Institut Paoli Calmette Marseille France
| | | | - Amira Marouf
- Department of Hematology Cochin Hospital Paris France
| | | | - Paul Coppo
- Department of Hematology and French Reference Center for Thrombotic Microangiopathies Saint‐Antoine Hospital Paris France
| | - Sandrine Malot
- Department of Hematology and French Reference Center for Thrombotic Microangiopathies Saint‐Antoine Hospital Paris France
| | | | - Adrien Chauchet
- Department of Hematology University Hospital of Besançon Besançon France
| | | | - Charles Bescond
- Department of Hematology University Hospital of Angers Angers France
| | | | | | - Sylvain Carras
- Department of Hematology University Hospital of Grenobles Alpes Grenoble France
| | | | - Cédric Rossi
- Department of Clinical Hematology University Hospital of Dijon Dijon France
| | | | | | - Fabien Subtil
- Department of Biostatistics Hospices Civils de Lyon Lyon France
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23
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Binkley MS, Hiniker SM, Younes S, Yoo C, Wignarajah A, Jin M, Guo HH, Gupta NK, Natkunam Y, Advani RH, Hoppe RT. Stage I-II diffuse large B-cell lymphoma treated with rituximab and chemotherapy with or without radiotherapy. Leuk Lymphoma 2021; 62:1840-1849. [PMID: 33622155 DOI: 10.1080/10428194.2021.1876859] [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: 10/22/2022]
Abstract
We set to identify prognostic factors in a retrospective cohort of consecutive patients with stage I-II diffuse large B-cell lymphoma treated with rituximab-chemotherapy with or without radiotherapy from 2001 through 2017 at our institution. We identified 143 patients with median follow-up of 7.7 years. The majority were male (59.4%), had stage II (53.1%), had stage-modified IPI 0-1 (smIPI, 58.1%), and had non-bulky disease (<7 cm, 68.5%). 99 patients (69.2%) received rituximab-chemotherapy followed by radiotherapy, and 44 patients (30.8%) received rituximab-chemotherapy alone. The 5-year progression-free survival (PFS) and overall survival (OS) were 81.2% and 88.9%, respectively. The 5-year PFS for those with smIPI 0-1 versus 2-4 was 89.5% versus 69.7%, respectively (P = 0.005). Bulky disease (≥7 cm) was associated with worse PFS and OS on univariable and multivariable analyses (P < 0.05). Patients with smIPI 0-1 without bulky disease have excellent outcomes. However, patients with smIPI 2-4 or bulky disease have a high risk of progression.
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Affiliation(s)
- Michael S Binkley
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Susan M Hiniker
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Sheren Younes
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Christopher Yoo
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Anjali Wignarajah
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Jin
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - H Henry Guo
- Department of Nuclear Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Neel K Gupta
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasodha Natkunam
- Department of Pathology, Stanford University School of Medicine, Stanford, CA, USA
| | - Ranjana H Advani
- Department of Medicine, Division of Oncology, Stanford University School of Medicine, Stanford, CA, USA
| | - Richard T Hoppe
- Department of Radiation Oncology, Stanford University School of Medicine, Stanford, CA, USA
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24
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Augustyn A, Medeiros LJ, Ludmir EB, Gunther J, Fang P, Li S, Ok CY, Bankston ME, Verma V, Pasalic D, Ahmed S, Nastoupil LJ, Westin JR, Strati P, Neelapu SS, Nair R, Steiner RE, Iyer SP, Rodriguez A, Fayad LE, Flowers CR, Dabaja BS, Pinnix CC. The impact of cell-of-origin, MYC/Bcl-2 dual expression and MYC rearrangement on disease relapse among early stage diffuse large B-cell lymphoma patients treated with combined modality therapy. Leuk Lymphoma 2021; 62:1361-1369. [PMID: 33480830 DOI: 10.1080/10428194.2020.1869965] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We addressed the prognostic impact of cell-of-origin (COO), MYC and Bcl-2 overexpression as well as isolated MYC rearrangement among 111 patients with limited stage diffuse large B-cell lymphoma (DLBCL) treated with consolidative radiation therapy (RT) after a metabolic complete response to immunochemotherapy. With a median follow-up of 31.1 months (95% CI 27.4 - 34.8), 4 relapses occurred. The 3-year progression free survival (PFS), overall survival (OS), and loco-regional relapse free survival (LRFS) for the cohort were 95%, 96%, and 100%, respectively. There were no differences in OS, PFS, or LRFS based on COO or MYC/Bcl-2 dual expression (DE). Similarly, patients with MYC translocations without BCL2 or BCL6 rearrangements did not have worse outcomes. Consolidative RT produced excellent local control, regardless of DLBCL biology, with one late in-field failure.
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Affiliation(s)
- Alexander Augustyn
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ethan B Ludmir
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jillian Gunther
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Penny Fang
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shaoying Li
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chi Young Ok
- Departments of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mikaela E Bankston
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Vivek Verma
- Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Dario Pasalic
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sairah Ahmed
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Loretta J Nastoupil
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jason R Westin
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Paolo Strati
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sattva S Neelapu
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Ranjit Nair
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Raphael E Steiner
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Swaminathan P Iyer
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Alma Rodriguez
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis E Fayad
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christopher R Flowers
- Departments of Lymphoma/Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Bouthaina S Dabaja
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Chelsea C Pinnix
- Departments of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Persky DO, Smith SM, LeBlanc ML, Friedberg JW. Reply to E. Hawkes et al. J Clin Oncol 2020; 38:4222-4223. [PMID: 33104437 DOI: 10.1200/jco.20.02856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Daniel O Persky
- Daniel O. Persky, MD, University of Arizona Cancer Center, Tucson, AZ; Sonali M. Smith, MD, University of Chicago, Chicago, IL; Michael L. LeBlanc, PhD, Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA; and Jonathan W. Friedberg, MD, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | - Sonali M Smith
- Daniel O. Persky, MD, University of Arizona Cancer Center, Tucson, AZ; Sonali M. Smith, MD, University of Chicago, Chicago, IL; Michael L. LeBlanc, PhD, Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA; and Jonathan W. Friedberg, MD, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | - Michael L LeBlanc
- Daniel O. Persky, MD, University of Arizona Cancer Center, Tucson, AZ; Sonali M. Smith, MD, University of Chicago, Chicago, IL; Michael L. LeBlanc, PhD, Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA; and Jonathan W. Friedberg, MD, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | - Jonathan W Friedberg
- Daniel O. Persky, MD, University of Arizona Cancer Center, Tucson, AZ; Sonali M. Smith, MD, University of Chicago, Chicago, IL; Michael L. LeBlanc, PhD, Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA; and Jonathan W. Friedberg, MD, Wilmot Cancer Institute, University of Rochester, Rochester, NY
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Alzahrani M, Al-Mansour MM, Apostolidis J, Barefah A, Dada R, Alhejazi A, Alayed Y, Motabi I, Radwi M, Al-Hashmi H. Saudi Lymphoma Group's Clinical Practice Guidelines for Diagnosis, Management and Follow-up of Patients with Various Types of Lymphoma during the Coronavirus Disease 2019 Pandemic. SAUDI JOURNAL OF MEDICINE & MEDICAL SCIENCES 2020; 8:227-238. [PMID: 32952517 PMCID: PMC7485653 DOI: 10.4103/sjmms.sjmms_457_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 07/09/2020] [Accepted: 07/12/2020] [Indexed: 11/29/2022]
Abstract
The Saudi Lymphoma Group had previously published recommendations on the management of the major subtypes of lymphoma. However, the effect the currently ongoing coronavirus disease 2019 (COVID-19) pandemic has on the management of patients with lymphoma has been paramount. Therefore, the Saudi Lymphoma Group has decided to provide clinical practice guidelines for the diagnosis, management and follow-up of patients with various types of lymphoma during the COVID-19 pandemic.
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Affiliation(s)
- Musa Alzahrani
- Department of Medicine and Oncology Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Mubarak M. Al-Mansour
- Department of Medicine, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- Princess Noorah Oncology Center, King Abdulaziz Medical City, Ministry of National Guard Health Affairs-Western Region, Dammam, Saudi Arabia
| | - John Apostolidis
- Department of Adult Hematology and Stem Cell Transplantation, Oncology Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
| | - Ahmed Barefah
- Department of Hematology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Reyad Dada
- Department of Oncology, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
- Department of Medicine, College of Medicine, Al-Faisal University, Riyadh, Saudi Arabia
| | - Ayman Alhejazi
- Department of Oncology, King Saud bin Abdulaziz University for Health Sciences, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Yasir Alayed
- Radiation Oncology, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ibraheem Motabi
- Department of Adult Hematology and BMT, Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mansoor Radwi
- Department of Hematology, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Hani Al-Hashmi
- Department of Adult Hematology and Stem Cell Transplantation, Oncology Center, King Fahad Specialist Hospital, Dammam, Saudi Arabia
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Kumar A, Persky DO. Treatment of Early (Limited)-Stage DLBCL. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2020; 20 Suppl 1:S34-S36. [PMID: 32862861 DOI: 10.1016/s2152-2650(20)30454-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Abhijeet Kumar
- University of Arizona Cancer Center, 1515 N Campbell Ave, Tucson, AZ, 85724-5025, USA
| | - Daniel O Persky
- University of Arizona Cancer Center, 1515 N Campbell Ave, Tucson, AZ, 85724-5025, USA.
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Persky DO, Li H, Stephens DM, Park SI, Bartlett NL, Swinnen LJ, Barr PM, Winegarden JD, Constine LS, Fitzgerald TJ, Leonard JP, Kahl BS, LeBlanc ML, Song JY, Fisher RI, Rimsza LM, Smith SM, Miller TP, Friedberg JW. Positron Emission Tomography-Directed Therapy for Patients With Limited-Stage Diffuse Large B-Cell Lymphoma: Results of Intergroup National Clinical Trials Network Study S1001. J Clin Oncol 2020; 38:3003-3011. [PMID: 32658627 DOI: 10.1200/jco.20.00999] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
PURPOSE Diffuse large B-cell lymphoma (DLBCL) presents as a limited-stage disease in 25% to 30% of patients, with better overall survival (OS) than that for advanced-stage disease but with continuous relapse regardless of treatment approach. The preferred treatment is abbreviated rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and radiation therapy. On the basis of promising results of positron emission tomography (PET)-directed treatment approaches, we designed a National Clinical Trials Network (NCTN) study to improve outcomes and decrease toxicity. METHODS Patients with nonbulky (< 10 cm) stage I/II untreated DLBCL received 3 cycles of standard R-CHOP therapy and underwent a centrally reviewed interim PET/computed tomography scan (iPET). Those with a negative iPET proceeded with 1 additional cycle of R-CHOP, whereas those with a positive iPET received involved field radiation therapy followed by ibritumomab tiuxetan radioimmunotherapy. RESULTS Of 158 patients enrolled, 132 were eligible and 128 underwent iPET, which was positive in 14 (11%) of the patients. With a median follow-up of 4.92 years (range, 1.1-7.7 years), only 6 patients progressed and 3 died as a result of lymphoma. Eleven patients died as a result of nonlymphoma causes at a median age of 80 years. The 5-year progression-free survival estimate was 87% (95% CI, 79% to 92%) and the OS estimate was 89% (95% CI, 82% to 94%), with iPET-positive and iPET-negative patients having similar outcomes. CONCLUSION To our knowledge, S1001 is the largest prospective study in the United States of limited-stage DLBCL in the rituximab era, with the best NCTN results in this disease subset. With PET-directed therapy, 89% of the patients with a negative iPET received R-CHOP × 4, and only 11% had a positive iPET and required radiation, with both groups having excellent outcomes. The trial establishes R-CHOP × 4 alone as the new standard approach to limited-stage disease for the absolute majority of patients.
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Affiliation(s)
- Daniel O Persky
- Division of Hematology/Oncology, University of Arizona, Tucson, AZ
| | - Hongli Li
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | | | - Steven I Park
- Department of Medicine, Levine Cancer Institute/Atrium Health, Charlotte, NC.,University of North Carolina, Chapel Hill, NC
| | - Nancy L Bartlett
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Lode J Swinnen
- Division of Medical Oncology, Johns Hopkins Cancer Center, Baltimore, MD
| | - Paul M Barr
- Division of Hematology/Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | | | - Louis S Constine
- Department of Radiation Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
| | | | - John P Leonard
- Division of Hematology and Medical Oncology, Weill Cornell Medical Center, New York, NY
| | - Brad S Kahl
- Department of Medicine, Washington University School of Medicine, St. Louis, MO
| | - Michael L LeBlanc
- SWOG Statistical Center, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Joo Y Song
- Department of Pathology, City of Hope, Duarte, CA
| | - Richard I Fisher
- Department of Hematology/Oncology, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
| | - Lisa M Rimsza
- Department of Pathology, Mayo Clinic, Scottsdale, AZ
| | - Sonali M Smith
- Section of Hematology/Oncology, University of Chicago, Chicago, IL
| | - Thomas P Miller
- Division of Hematology/Oncology, University of Arizona, Tucson, AZ
| | - Jonathan W Friedberg
- Division of Hematology/Oncology, Wilmot Cancer Institute, University of Rochester, Rochester, NY
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