Improving survival and preventing recurrence of diffuse large B-cell lymphoma in younger patients: current strategies and future directions

More Pronounced Muscle Loss During Immunochemotherapy is Associated with Worse Clinical Outcomes in Newly Diagnosed Patients with Diffuse Large B-Cell Lymphoma with Unfavorable Features

Introduction

Cancer-induced cachexia is associated with poor prognosis in patients with non-Hodgkin lymphoma, but it is unknown how and to what extent curable lymphoma treatments affect the musculoskeletal system.

Patients and Methods

We retrospectively analyzed 104 newly diagnosed diffuse large B-cell lymphoma (DLBCL) patients with unfavorable disease features treated with the R-DA-EPOCH regimen. Psoas muscle area (PMA) measured at L3 vertebra level was compared between staging (pre-therapy) and revision (end of treatment) computerized tomography (CT) scans.

Results

Small but significant decline in PMA was observed during the immunochemotherapy period (average loss 5%; P=0.016) with 57.7% of patients experiencing muscle loss. Higher body surface area (OR=17.98 for each m²; P=0.034), number of cycles with dose reduction (OR=2.86 for each cycle; P=0.039) and worse response to therapy (OR=3.09 for each response category; P=0.052) were recognized as independent contributors to the PMA loss in multivariate analysis. One quarter of patients had more pronounced PMA loss (≥21%), which was associated with significantly worse overall and progression-free survival. Both ≥21% PMA loss and non-achieving response to therapy remained independently associated with inferior OS (PMA loss HR=2.98; P=0.016 and achieving response HR=0.04; P<0.001) and PFS (PMA loss HR=3.16; P=0.005 and achieving response HR=0.08; P=0.001) in multivariate analyses.

Discussion

Muscle loss occurs in approximately half of newly diagnosed DLBCL patients with unfavorable disease features during R-DA-EPOCH immunochemotherapy. If pronounced, this is associated with worse clinical outcomes irrespectively of achieved response to therapy. Muscle loss seems to be mostly affected by the efficacy and tolerability of the regimen.

Maintenance therapy for untreated diffuse large B-cell lymphoma: a systematic review and network meta-analysis

Background:

Several clinical trials have been conducted to evaluate the role of maintenance therapy in untreated diffuse large B-cell lymphoma (DLBCL) patients with complete response or partial response following standard immunochemotherapy; however, the effect of maintenance therapy remains uncertain, and a suitable maintenance strategy has not been determined because of the lack of direct/indirect comparisons.

Methods:

We performed a systematic review and Bayesian network meta-analysis (NMA) to analyze and compare the effectiveness of different maintenance regimens in newly diagnosed DLBCL patients. We searched the PubMed Medline, Embase, Web of Science, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials for relevant papers from inception to 18 March 2021. Our study was prospectively registered in the International Prospective Register of Systematic Reviews (CRD42020168864). Data on overall survival (OS) were extracted and the treatments were ranked using the surface under the cumulative ranking (SUCRA) curve.

Results:

Eight trials and seven treatments involving 3525 patients were analyzed. OS analysis indicated that none of the drugs showed any benefit compared with non-maintenance therapy. Maintenance therapy with lenalidomide (SUCRA 69.3%) was ranked first in terms of OS.

Conclusion:

Based on the OS results observed in this NMA, we do not recommend maintenance therapy in patients with newly diagnosed DLBLC after first-line therapy.

Incidence and prognostic factors of primary thyroid lymphoma and construction of prognostic models for post-chemotherapy and postoperative patients: a population-based study

BACKGROUND

Primary thyroid lymphoma (PTL) is a rare thyroid malignancy, there are few large sample studies on PTL and no standardized treatment regimen has been established due to the rarity. The aims of this study were to explore the incidence and prognostic factors of PTL and construct visual prognostic prediction models for post-chemotherapy and postoperative patients.

METHODS

The incidence of PTL in 1975-2017 was extracted from the US Surveillance, Epidemiology, and End Results (SEER) database, then assessed using joinpoint regression software. A total of 1616 eligible PTL patients diagnosed in 1998-2016 were brought into prognostic analysis. Multivariate Cox regression analyses were carried out to reveal independent prognostic elements for overall survival (OS) and cancer-specific survival (CSS).

RESULTS

PTL incidence showed a relatively steady increase in 1975-1994, which annual percent change (APC) was 4.0%, and steady decreasing in 1994-2017(APC - 2.4%). Age, marital status, lymphoma Ann Arbor stage, histological subtypes, surgery, chemotherapy, and radiation were significantly correlated to OS and CSS. Nomograms were constructed to predict OS and CSS in post-chemotherapy and postoperative PTL patients separately, and were verified to have good reliability.

CONCLUSIONS

The incidence of PTL increased and subsequently decreased. We revealed the prognostic implications and constructed reliable nomograms for post-chemotherapy and postoperative PTL patients.

Polatuzumab Vedotin: Current Role and Future Applications in the Treatment of Patients with Diffuse Large B-Cell Lymphoma

Diffuse large B-cell lymphoma (DLBCL) is a biologically and clinically heterogeneous disease. Despite good responses to standard of care frontline chemoimmunotherapy, the prognosis of relapsed/refractory (R/R) patients remains obscured by the possible inadequate responses to salvage therapy, eligibility for autologous transplantation, age and comorbidities. Polatuzumab vedotin is an antibody-drug conjugate formed by a CD79b antibody conjugated to the highly cytotoxic agent monomethyl auristatin E by means of a cleavable linker. Following significant clinical efficacy in R/R DLBCL, polatuzumab vedotin was granted accelerated Food and Drug Administration (FDA) approval in combination with bendamustine plus rituximab for patients who have failed at least two prior therapies. Other clinical studies involving polatuzumab vedotin in combination with other therapy regimens are also under evaluation for previously untreated DLBCL patients. In this article, we review the different phases from the preclinical development of polatuzumab vedotin to studies leading to its first approval, and highlight the potential future roles of this molecule in the treatment landscape of DLBCL.

[Efficacy and prognostic analysis of relapsed/refractory diffuse large B-cell lymphoma patients with hepatitis B virus infection]

Objective: To evaluate the clinical and prognostic significance of hepatitis B virus infection on patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). Methods: A retrospective analysis was performed in 81 relapsed/refractory DLBCL cases who were treated with salvage regimens from January 2004 to November 2016. The patients were divided into two group, HBsAg positive and HBsAg negative group, and assessed the clinical features and survival time of two groups. Results: Twenty-four (29.6%) patients were HBsAg positive and 57(70.4%) were negative. HBsAg-positive DLBCL patients showed unique clinical features, including more younger patients (P=0.005), more advanced Ann Arbor stage (P<0.001), high-risk IPI (P=0.010), more hypohemoglobin (P=0.015), especially extra-nodal involvement (P=0.038) and recurrence (P=0.002). Overall response rate (29.2% vs 68.4%, χ(2)=10.720, P=0.001) and median overall survival time [(11.3±2.9) months vs (30.0±7.6) months, χ(2)=28.175, P<0.001] were inferior in HBsAg-positive patients, respectively. Conclusion: To strictly control HBV infection plays an important role on the survival and prognosis of relapsed/refractory lymphoma patients.

Rituximab with dose-adjusted EPOCH as first-line treatment in patients with highly aggressive diffuse large B-cell lymphoma and autologous stem cell transplantation in selected patients

AIM

To assess the benefit of rituximab with dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (R-DA-EPOCH) regimen as a first-line treatment for patients with diffuse large B-cell lymphoma (DLBCL) presenting with unfavorable or aggressive features, and autologous stem cell transplantation (ASCT) as a part of the first-line treatment for selected DLBCL patients with additional aggressive features.

METHODS

We retrospectively analyzed 75 newly diagnosed DLBCL patients with Ki-67+≥80% or International Prognostic Index ≥2 who were treated with R-DA-EPOCH between 2005 and 2015. Of 24 DLBCL patients with additional aggressive features (Ki-67+≥90% or age-adjusted IPI≥2) who were planned to receive consolidation with ASCT, 17 patients underwent the procedure. We determined the overall response rate (ORR), complete remission (CR), partial remission (PR), 5-year overall survival (OS), and progression free survival (PFS) in all DLBCL patients and specifically those planned to receive ASCT.

RESULTS

All 75 patients included in the analysis started one or more cycles of therapy. The ORR, CR, and PR rates were 80%, 55%, and 25%, respectively. The response was non-evaluable in 10 of 75 patients due to treatment discontinuation. The OS and PFS rates for all 75 patients were 70% and 61%, respectively, and 80% and 79%, respectively, for 24 planned-to-receive-ASCT patients. Age (≤65 vs >65 years) had no prognostic impact on OS and PFS (P=0.994 and P=0.827, respectively).

CONCLUSION

Our retrospective analysis of one of the largest DLBCL patient cohorts outside the US National Cancer Institute showed that R-DA-EPOCH is a very effective therapeutic option as a first-line treatment of DLBCL patients with unfavorable prognostic features irrespective of their age. ASCT provided additional benefit for DLBCL patients with additional aggressive features.

Primary thyroid lymphoma: A case report and review of the literature

Introduction

A rapidly enlarging mass of the anterior compartment of the neck with compressive symptoms may represent, among other diagnosis, a neoplasm of the thyroid gland.

Presentation of case

We describe the case of a 59-year-old woman referred to the endocrine surgical unit because of compressive cervical symptoms for 3 months. The cervical ultrasound revealed a sub-sternal goiter with heterogeneous echo structure and the fine-needle aspirating cytology was inconclusive. Given the large impact of symptoms on life quality, she was submitted to a total thyroidectomy. Histological examination of the surgical specimen revealed the presence of a Diffuse Large B Cell Lymphoma of the thyroid.

Discussion

Primary thyroid lymphomas are rare and there are few randomized studies for diagnostic and therapeutic guidance. New immunohistochemical and molecular techniques have improved the diagnostic accuracy with corebiopsy limiting the role of surgery. The treatment should first include the control of local disease with radiotherapy and/or surgery combined with chemotherapy to control obscure or disseminated disease. Palliative surgery may be needed to relieve airway compression symptoms. Under these circumstances, surgery should be performed by a specialized surgeon to decrease the associated morbidity. The prognosis of patients depends on the histological classification of the tumor and the stage of the disease.

Conclusion

Due to the rarity of the disease, each case must be evaluated and treated individually, since there is not a consensual therapeutic approach.

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Primary thyroid lymphomas are very rare.

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New immunohistochemical and molecular techniques have improved the diagnostic accuracy with corebiopsy limiting surgery.

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Surgery has a small role in PTL and when needed it should be performed by a specialized surgeon to decrease morbidity.

ALDH1A1 induces resistance to CHOP in diffuse large B-cell lymphoma through activation of the JAK2/STAT3 pathway

Increasing evidence has shown that aldehyde dehydrogenase 1A1 (ALDH1A1), a detoxifying enzyme, is responsible for chemoresistance in a variety of tumors. Although the majority of patients with diffuse large B-cell lymphoma (DLBCL) can be cured with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), chemoresistance is a common cause of treatment failure. This study aims to investigate the significance of ALDH1A1 expression and the mechanism by which ALDH1A1 is involved in the chemoresistance of DLBCL cells. ALDH1A1 expression was assessed in 88 DLBCL tissues by immunohistochemistry. The association between ALDH1A1 expression and outcome was evaluated. We also investigated the effect of ALDH1A1 on CHOP resistance in DLBCL cells using functional analysis. ALDH1A1 expression levels were upregulated in patients with stable or progressive disease after CHOP and its expression positively correlated with expression of STAT3 and p-STAT3. In keeping with these observations, ALDH1A1 expression was significantly associated with short survival of DLBCL patients who received CHOP chemotherapy. In functional assays in Pfeiffer cells, overexpression of ALDH1A1 conferred resistance to CHOP, while silencing of ALDH1A1 using short hairpin RNA had the opposite effect. Furthermore, we also observed that ALDH1A1 could regulate the JAK2/STAT3 pathway, while inhibition of the JAK2/STAT3 pathway by WP1066 negated the effect of ALDH1A1 overexpression. These observations reveal that ALDH1A1 induces resistance to CHOP through activation of the JAK2/STAT3 pathway in DLBCL, and its targeting provides a potential strategic approach for reversing CHOP resistance.

Outcome of patients with relapsed diffuse large B-cell lymphoma who fail second-line salvage regimens in the International CORAL study

Salvage chemotherapy followed by autologous stem cell transplantation (ASCT) is the standard second-line treatment for relapsed and refractory diffuse large B-cell lymphoma (DLBCL). However, the strategy is less clear in patients who require third-line treatment. Updated outcomes of 203 patients who could not proceed to scheduled ASCT in the Collaborative Trial in Relapsed Aggressive Lymphoma (CORAL) are herein reviewed. In the intent-to-treat analysis, overall response rate to third-line chemotherapy was 39%, with 27% CR or CR unconfirmed, and 12% PR. Among the 203 patients, 64 (31.5%) were eventually transplanted (ASCT 56, allogeneic SCT 8). Median overall survival (OS) of the entire population was 4.4 months. OS was significantly improved in patients with lower tertiary International Prognostic Index (IPI), patients responding to third-line treatment and patients transplanted with a 1-year OS of 41.6% compared with 16.3% for the not transplanted (P<0.0001). In multivariate analysis, IPI at relapse (hazard ratio (HR) 2.409) and transplantation (HR 0.375) independently predicted OS. Third-line salvage chemotherapy can lead to response followed by transplantation and long-term survival in DLBCL patients. However, improvement of salvage efficacy is an urgent need with new drugs.

Thyroid lymphoma: recent advances in diagnosis and optimal management strategies

Primary thyroid lymphoma is rare, composing approximately 5% of all thyroid malignancies and less than 3% of all extranodal lymphomas. It typically presents as a rapidly enlarging goiter with associated compressive symptoms. Thyroid ultrasound and fine needle aspiration cytology, using flow cytometry and immunohistochemistry, remain the main modalities used to confirm the presence of lymphoma. The increasing use of an ultrasound-guided core biopsy to achieve an accurate diagnosis has further limited the role of surgery. An open surgical biopsy may still be required not only for definitive diagnosis but also to confirm the subtype of lymphoma. There are limited numbers of randomized or prospective trials to guide management, and controversy remains over optimal treatment. Treatment and prognosis of this disease can be dichotomized into two separate groups: pure mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBCL) or mixed subtypes. Early stage (stage IE) intrathyroidal MALT lymphomas typically have an indolent course and may be treated with single-modality surgery, radiotherapy, or a combination of both. DLBCLs are more aggressive, and survival outcomes are highest with multimodal therapy incorporating monoclonal antibodies, chemotherapy, and radiotherapy. The prognosis is generally excellent but can be varied because of the heterogeneous nature of thyroid lymphomas. The aim of this paper is to discuss the changes in diagnostic modalities and to focus on the recent alterations in the management of this rare disease, including targeted therapies as well as the more limited role of the endocrine surgeon.