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Shimkus G, Nonaka T. Molecular classification and therapeutics in diffuse large B-cell lymphoma. Front Mol Biosci 2023; 10:1124360. [PMID: 36818048 PMCID: PMC9936827 DOI: 10.3389/fmolb.2023.1124360] [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: 12/15/2022] [Accepted: 01/09/2023] [Indexed: 02/05/2023] Open
Abstract
Diffuse large B-cell lymphoma (DLBCL) encompasses a wide variety of disease states that have to date been subgrouped and characterized based on immunohistochemical methods, which provide limited prognostic value to clinicians and no alteration in treatment regimen. The addition of rituximab to CHOP therapy was the last leap forward in terms of treatment, but regimens currently follow a standardized course when disease becomes refractory with no individualization based on genotype. Research groups are tentatively proposing new strategies for categorizing DLBCL based on genetic abnormalities that are frequently found together to better predict disease course following dysregulation of specific pathways and to deliver targeted treatment. Novel algorithms in combination with next-generation sequencing techniques have identified between 4 and 7 subgroups of DLBCL, depending on the research team, with potentially significant and actionable genetic alterations. Various drugs aimed at pathways including BCR signaling, NF-κB dysfunction, and epigenetic regulation have shown promise in their respective groups and may show initial utility as second or third line therapies to patients with recurrent DLBCL. Implementation of subgroups will allow collection of necessary data to determine which groups are significant, which treatments may be indicated, and will provide better insight to clinicians and patients on specific disease course.
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Affiliation(s)
- Gaelen Shimkus
- School of Medicine, Louisiana State University Health Shreveport, Shreveport, LA, United States
| | - Taichiro Nonaka
- Department of Cellular Biology and Anatomy, Louisiana State University Health Sciences Center, Shreveport, LA, United States,Feist-Weiller Cancer Center, Louisiana State University Health Shreveport, Shreveport, LA, United States,*Correspondence: Taichiro Nonaka,
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2
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DLBCL 1L—What to Expect beyond R-CHOP? Cancers (Basel) 2022; 14:cancers14061453. [PMID: 35326604 PMCID: PMC8946010 DOI: 10.3390/cancers14061453] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/01/2022] [Accepted: 03/03/2022] [Indexed: 11/26/2022] Open
Abstract
Simple Summary Diffuse large B-cell lymphoma (DLBCL) is the most common aggressive non-Hodgkin’s lymphoma. About two-thirds of patients are cured by the first-line (1L) standard of care (SOC), the R-CHOP (Rituximab, Cyclophosphamide, Doxorubicin, Vincristine and Prednisolone) immunochemotherapy protocol. The profound molecular heterogeneity of DLBCL is the underlying reason why many patients, despite improved next-line options, eventually succumb to the disease. Hence, enhancing the efficacy of 1L treatment is critical for improving long-term outcomes in DLBCL. A plethora of novel treatment options with potential in later lines is currently under evaluation in 1L settings. We summarize here the established and emerging strategies for newly diagnosed DLBCL and emphasize the need for individualized treatment decisions. Abstract The R-CHOP immunochemotherapy protocol has been the first-line (1L) standard of care (SOC) for diffuse large B-cell lymphoma (DLBCL) patients for decades and is curative in approximately two-thirds of patients. Numerous randomized phase III trials, most of them in an “R-CHOP ± X” design, failed to further improve outcomes. This was mainly due to increased toxicity, the large proportion of patients not in need of more than R-CHOP, and the extensive molecular heterogeneity of the disease, raising the bar for “one-size-fits-all” concepts. Recently, an R-CHP regimen extended by the anti-CD79b antibody–drug conjugate (ADC) Polatuzumab Vedotin proved superior to R-CHOP in terms of progression-free survival (PFS) in the POLARIX phase III trial. Moreover, a number of targeted agents, especially the Bruton’s tyrosine kinase (BTK) inhibitor Ibrutinib, seem to have activity in certain patient subsets in 1L and are currently being tested in front-line regimens. Chimeric antigen receptor (CAR) T-cells, achieving remarkable results in ≥3L scenarios, are being exploited in earlier lines of therapy, while T-cell-engaging bispecific antibodies emerge as conceptual competitors of CAR T-cells. Hence, we present here the findings and lessons learnt from phase III 1L trials and piloting phase II studies in relapsed/refractory (R/R) and 1L settings, and survey chemotherapy-free regimens with respect to their efficacy and future potential in 1L. Novel agents and their mode of action will be discussed in light of the molecular landscape of DLBCL and personalized 1L perspectives for the challenging patient population not cured by the SOC.
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He MY, Kridel R. Treatment resistance in diffuse large B-cell lymphoma. Leukemia 2021; 35:2151-2165. [PMID: 34017074 DOI: 10.1038/s41375-021-01285-3] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 04/21/2021] [Accepted: 05/05/2021] [Indexed: 01/29/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is a highly heterogeneous disease and represents the most common subtype of lymphoma. Although 60-70% of all patients can be cured by the current standard of care in the frontline setting, the majority of the remaining patients will experience treatment resistance and have a poor clinical outcome. Numerous efforts have been made to improve the efficacy of the standard regimen by, for example, dose intensification or adding novel agents. However, these results generally failed to demonstrate significant clinical benefits. Hence, understanding treatment resistance is a pressing need to optimize the outcome of those patients. In this Review, we first describe the conceptual sources of treatment resistance in DLBCL and then provide detailed and up-to-date molecular insight into the mechanisms of resistance to the current treatment options in DLBCL. We lastly highlight the potential strategies for rationally managing treatment resistance from both the preventive and interventional perspectives.
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Affiliation(s)
- Michael Y He
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Robert Kridel
- Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada. .,Institute of Medical Science, University of Toronto, Toronto, ON, Canada. .,Department of Medical Biophysics, University of Toronto, Toronto, ON, Canada.
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Pasvolsky O, Rozental A, Raanani P, Gafter-Gvili A, Gurion R. R-CHOP compared to R-CHOP + X for newly diagnosed diffuse large B-cell lymphoma: a systematic review and meta-analysis. Acta Oncol 2021; 60:744-749. [PMID: 33734921 DOI: 10.1080/0284186x.2021.1898048] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Treatment with rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is standard of care first line treatment for diffuse large B-cell lymphoma (DLBCL), though outcomes remain suboptimal. METHODS We performed a systemic review and meta-analysis of randomized controlled trials comparing the efficacy and safety of R-CHOP vs. R-CHOP + X (addition of another drug to R-CHOP) as first line treatment for DLBCL. We searched Cochrane Library, PubMed and conference proceedings up to September 2020. RESULTS Our search yielded ten trials including 4206 patients. The added drug was bortezomib or lenalidomide in three trials each, and gemcitabine, bevacizumab and ibrutinib, each drug in one trial. R-CHOP + X was associated with statistically significant improved disease control (HR 0.88, 95% CI 0.78-0.99). The point estimate was in favor of improved overall survival with R-CHOP + X (hazard ratio (HR) 0.87, 95% confidence interval (CI) 0.75-1.00), although this was not statistically significant. Subgroup analysis revealed improved disease control with the addition of lenalidomide and in patients younger than 60 years. R-CHOP + X was associated with an increase in serious adverse events and grade III/IV hematologic toxicity. CONCLUSION The addition of another drug to frontline R-CHOP treatment for DLBCL did not result in a significant improvement in OS, although we did observe improved disease control compared to R-CHOP, perhaps most evident with the addition of lenalidomide. Yet, RCHOP + X was associated with an increased risk for serious and hematological adverse events. Further studies could reveal subgroups that would benefit most from augmentation of standard R-CHOP.
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Affiliation(s)
- Oren Pasvolsky
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Rozental
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Pia Raanani
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Gafter-Gvili
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Medicine A, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
| | - Ronit Gurion
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Beilinson Hospital, Petach Tikva, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Cherng HJJ, Westin J. Why R-CHOP + X is not enough: lessons learned and next steps in the mission to improve frontline therapy for diffuse large B-cell lymphoma. Leuk Lymphoma 2021; 62:1302-1312. [PMID: 33403905 PMCID: PMC9153122 DOI: 10.1080/10428194.2020.1869228] [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: 02/07/2023]
Abstract
Two-thirds of newly diagnosed cases of diffuse large B-cell lymphoma (DLBCL) are cured with R-CHOP, an immunochemotherapy regimen that has been the standard of care for almost two decades. Ongoing molecular characterization of DLBCL has revealed a heterogeneous disease comprised of multiple subtypes based on putative cell of origin or somatic mutations with unique oncogenic signaling pathways. The door has been opened to the use of novel agents that target the specific molecular vulnerabilities of DLBCL, but despite this, multiple randomized studies have not identified a suitable drug 'X' to combine with R-CHOP. This report will review recent attempts to add individual novel agents to R-CHOP in the mission to improve frontline treatment for DLBCL and discuss promising ongoing studies. It will offer potential strategies to explore when designing future clinical trials, including exploiting synergy between multiple novel agents.
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Affiliation(s)
- Hua-Jay J. Cherng
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Jason Westin
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX
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Khurana A, Mwangi R, Nowakowski GS, Habermann TM, Ansell SM, LaPlant BR, Link BK, Cerhan JR, Maurer MJ, Witzig TE. Impact of Organ Function-Based Clinical Trial Eligibility Criteria in Patients With Diffuse Large B-Cell Lymphoma: Who Gets Left Behind? J Clin Oncol 2021; 39:1641-1649. [PMID: 33529046 PMCID: PMC8274741 DOI: 10.1200/jco.20.01935] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
PURPOSE Exclusion of patients needing urgent treatment or requiring novel biomarkers before enrollment has impacted the ability to enroll real-world patients in frontline trials of diffuse large B-cell lymphoma (DLBCL). The impact of baseline organ function-based eligibility criteria on this effect and clinical trial exclusion is less well-understood. METHODS Consecutive patients with newly diagnosed lymphoma were enrolled from 2002 to 2015 into the Molecular Epidemiology Resource (MER) of the University of Iowa and Mayo Clinic Lymphoma Specialized Program of Research Excellence. The current analysis includes 1,265 patients with DLBCL receiving standard immunochemotherapy. Organ function parameters were identified from criteria for hemoglobin, absolute neutrophil count, platelet count, creatinine clearance, and bilirubin, as reported in frontline DLBCL trials. Abstracted laboratory values from MER were used to determine the percent (%) of patients excluded. Outcomes and cause-of-death analyses comparing ineligible and eligible groups in MER were conducted. An interactive online tool was developed to estimate exclusions based on organ function for future trial design. RESULTS Between 9% and 24% of MER patients with DLBCL receiving standard immunochemotherapy were excluded on the basis of baseline organ function alone. Ineligible patients based on organ function had significantly inferior event-free survival (hazard ratios, 1.67-2.16), overall survival (hazard ratios, 1.87-2.56), and event-free survival at 24 months (odds ratio, 1.71-2.16). Ineligible patients were more likely to die from lymphoma progression than increased therapy-related complications. CONCLUSION Current national and international trials exclude up to 24% of patients from participation on the basis of organ function alone. A significant difference in the outcomes, notably lymphoma-related death, suggests issues with generalization and potential exclusion of high-risk patients. These data will help future clinical trial development and meet US Food and Drug Administration and ASCO recommendations to increase trial accrual.
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Affiliation(s)
| | - Raphael Mwangi
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | | | | | - Betsy R. LaPlant
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | - Brian K. Link
- Department of Medicine, University of Iowa, Iowa City, IA
| | - James R. Cerhan
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN
| | | | - Thomas E. Witzig
- Division of Hematology, Mayo Clinic, Rochester, MN,Thomas E. Witzig, MD, Division of Hematology, Mayo Clinic, 200 First Street, Rochester, MN 55905; e-mail:
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Wang L, Li LR, Young KH. New agents and regimens for diffuse large B cell lymphoma. J Hematol Oncol 2020; 13:175. [PMID: 33317571 PMCID: PMC7734862 DOI: 10.1186/s13045-020-01011-z] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Accepted: 11/24/2020] [Indexed: 12/14/2022] Open
Abstract
As a widely recognized standard regimen, R-CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone) is able to cure two-thirds patients with diffuse large B cell lymphoma (DLBCL), and the remaining patients suffer from refractory or relapsed disease due to resistance to R-CHOP and fare poorly. Unsatisfied outcomes for those relapsed/refractory patients prompted efforts to discover new treatment approaches for DLBCL, including chimeric antigen receptor T cells, bispecific T cell engagers, immunomodulatory drugs, immune checkpoint inhibitors, monoclonal antibodies, antibody-drug conjugates, molecular pathway inhibitors, and epigenetic-modifying drugs. Herein, up-to-date data about the most promising treatment approaches for DLBCL are recapitulated, and novel genetic classification systems are introduced to guide individualized treatment for DLBCL.
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MESH Headings
- Animals
- Antineoplastic Agents/pharmacology
- Antineoplastic Agents/therapeutic use
- Antineoplastic Agents, Immunological/pharmacology
- Antineoplastic Agents, Immunological/therapeutic use
- Antineoplastic Combined Chemotherapy Protocols/pharmacology
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Drug Development
- Epigenesis, Genetic/drug effects
- Humans
- Immune Checkpoint Inhibitors/pharmacology
- Immune Checkpoint Inhibitors/therapeutic use
- Immunoconjugates/pharmacology
- Immunoconjugates/therapeutic use
- Immunologic Factors/pharmacology
- Immunologic Factors/therapeutic use
- Immunotherapy/methods
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/immunology
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/therapy
- Signal Transduction
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Affiliation(s)
- Liang Wang
- Department of Hematology, Beijing TongRen Hospital, Capital Medical University, Beijing, 100730, China.
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, Beihang University & Capital Medical University, Beijing TongRen Hospital, Beijing, 100730, China.
| | - Lin-Rong Li
- Peking Union Medical College Hospital, Beijing, 100560, China
| | - Ken H Young
- Division of Hematopathology, Department of Pathology, Duke University Medical Center and Cancer Institute, Durham, NC, 27710, USA.
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Lue JK, O'Connor OA. A perspective on improving the R-CHOP regimen: from Mega-CHOP to ROBUST R-CHOP, the PHOENIX is yet to rise. LANCET HAEMATOLOGY 2020; 7:e838-e850. [PMID: 33091357 DOI: 10.1016/s2352-3026(20)30222-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/01/2020] [Accepted: 07/02/2020] [Indexed: 12/15/2022]
Abstract
The integration of rituximab (R) into cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) by Coiffier and colleagues was the first, and last, successful modification of this backbone regimen, which has endured now for almost 20 years. Countless attempts to redefine R-CHOP for patients with diffuse large B-cell lymphoma (DLBCL) have migrated from a focus on dose-intense and dose-dense regimens, to the use of maintenance therapies, and most recently the addition of novel agents. To date, none have changed the basic formula. Although there are many reasons for the absence of success, the incredible molecular heterogeneity of DLBCL is likely to be a major complicating factor. It is clear that as the scientific field's understanding of the genetic heterogeneity of DLBCL deepens, a precision medicine approach should be accounted for and might be one of several paths that could lead to improved outcomes. The rapid identification of poor prognostic groups within the evolving diverse molecular landscape of DLBCL will create new opportunities to produce the next generation of studies with targeted agents against specific pathological drivers. It is conceivable that targeting these driver pathways will require more than one agent, and of course, splitting the pool of patients with DLBCL into smaller groups on the basis of molecular characteristics, will reduce the number of eligible patients for clinical trial investigation. The integration of immunological agents might afford new opportunities to develop treatments agnostic to the complex molecular diversity, while adding minimal toxicity to the regimen. With each of these iterations, the hope is to ultimately shift away from a one-size-fits-all chemotherapy mentality to one predicated on an individualised approach, whether that be through the use of a targeted small molecule or a biological drug. In this Viewpoint, we explore the history of the collective efforts to improve upon R-CHOP, and underscore those lessons that might help to reshape our future plans.
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Affiliation(s)
- Jennifer K Lue
- Center for Lymphoid Malignancies, Division of Hematology-Oncology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Owen A O'Connor
- Emily Couric Clinical Cancer Center, Department of Medicine and Department of Microbiology, Immunology, and Cancer Biology, University of Virgina, Charlottesville, VA, USA
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Frontline therapy with R-CHOP for diffuse large B-cell lymphoma: Where have we come (or not come)? A Perspective. J Geriatr Oncol 2020; 12:320-325. [PMID: 32972884 DOI: 10.1016/j.jgo.2020.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 07/10/2020] [Accepted: 09/16/2020] [Indexed: 11/24/2022]
Abstract
A major evolution in the treatment of patients with diffuse large B-cell lymphoma (DLBCL) occurred almost two decades ago, with clinical trials demonstrating that the addition of rituximab (R) to cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP), which had been the "gold standard" of therapy since 1976, significantly improved outcome, including response rate and disease-free survival, of these patients. Since the adoption of R-CHOP, subsequent clinical trials have attempted to improve upon outcomes achieved with R-CHOP, with a variety of approaches examined. These have included dose intensification, which may be applicable in younger patients, but not in the many older or frailer patients with a disease with median age at diagnosis in the 60's. Newer anti-CD20 monoclonal antibodies have been substituted for rituximab in frontline regimens. A series of new agents, with unique mechanisms of action, have been added to the R-CHOP backbone. Rituximab-based, non-anthracycline regimens have been studied for older, more frail patients. The utility of maintenance therapy in responding patients has been re-examined, despite the lack of benefit found in the US Intergroup trial. Advances in molecular and genetic aspects of DLBCL have emerged since the seminal R-CHOP trials, demonstrating the DLBCL is not a single entity, but instead a spectrum of multiple disease subtypes. Attempts have been made to identify those patients at baseline who have poorer outcomes with standard approaches, utilizing laboratory and imaging findings. Moving forward, different risk-adapted treatment approaches will be studied to in an effort to improve overall outcome beyond R-CHOP.
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10
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Lin N, Song Y, Zhu J. Immune checkpoint inhibitors in malignant lymphoma: Advances and perspectives. Chin J Cancer Res 2020; 32:303-318. [PMID: 32694896 PMCID: PMC7369179 DOI: 10.21147/j.issn.1000-9604.2020.03.03] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2020] [Accepted: 05/24/2020] [Indexed: 01/01/2023] Open
Abstract
Classical Hodgkin lymphoma (cHL) has been identified with universal genetic alterations of chromosome 9p24.1, which contains PD-L1/PD-L2 genes. The amplification of 9p24.1 is associated with the increased expression of PD-L1 and PD-L2 on RS cells, which promotes their immune evasion, and subsequently makes cHL sensitive to PD-1 blockade. Several PD-1 inhibitors have shown significant efficacies with overall response rate (ORR) of 70%-90% in relapse/refractory (r/r) cHL and have acquired the approvals for this indication. Recently, more and more studies are conducted to investigate PD-1 blockade in earlier disease course and in combination with neo-agents or chemotherapy. Unlike cHL, non-Hodgkin lymphoma (NHL) consists of numerous subtypes harboring highly biological heterogeneity. Only a few subtypes have been shown to have genetic alteration of9p24.1 including primary mediastinal B cell lymphoma (PMBL), gray zone lymphoma (GZL) with features intermediate between diffuse large B cell lymphoma (DLBCL) and cHL, primary central nervous system lymphoma (PCNSL) and primary testicular lymphoma (PTL). Epstein-Barr virus (EBV)-associated lymphomas have a virally mediated overexpression of PD-L1, also making them sensitive to PD-1 blockade. Therefore, PD-1 inhibitors are less effective in most r/r NHL than in r/r cHL. Further understanding of the biological features of NHL and immune checkpoint inhibitors (ICPi) combined therapy is the research focus in the future. In this review, we outlined the recent progress of ICPi in lymphoma originating from clinical studies.
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Affiliation(s)
- Ningjing Lin
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Lymphoma, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Yuqin Song
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Lymphoma, Peking University Cancer Hospital & Institute, Beijing 100142, China
| | - Jun Zhu
- Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education/Beijing), Department of Lymphoma, Peking University Cancer Hospital & Institute, Beijing 100142, China
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11
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Nowakowski GS, Zhu J, Zhang Q, Brody J, Sun X, Maly J, Song Y, Rizvi S, Song Y, Lansigan F, Jing H, Cao J, Lue JK, Luo W, Zhang L, Li L, Han I, Sun J, Jivani M, Liu Y, Heineman T, Smith SD. ENGINE: a Phase III randomized placebo controlled study of enzastaurin/R-CHOP as frontline therapy in high-risk diffuse large B-cell lymphoma patients with the genomic biomarker DGM1. Future Oncol 2020; 16:991-999. [PMID: 32250167 DOI: 10.2217/fon-2020-0176] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
While combination of rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP) cures most patients with diffuse large B-cell lymphoma (DLBCL), those with high-risk international prognostic index disease have inferior survival. Enzastaurin as a potent inhibitor of PKC-β and PI3K/AKT pathway suppressor has been tested in many clinical trials including two key studies in DLBCL: Phase III maintenance study (Preventing Relapse in Lymphoma Using Daily Enzastaurin [PRELUDE]) and a first-line Phase II study (S028). DNA extracted from PRELUDE patients' blood samples was retrospectively genotyped identifying a novel genetic biomarker, DGM1 that showed high correlation with response to enzastaurin. A similar finding observed in the S028 study suggested that addition of enzastaurin to R-CHOP may significantly improve outcomes as frontline therapy for high-risk DGM1 positive DLBCL patients. ENGINE is a global, multicenter, placebo-controlled and randomized study to compare the effect of R-CHOP/enzastaurin as frontline treatment in high-risk DLBCL patients. The primary end point for this study is overall survival in patients who are DGM1 positive. Clinical Trial Registration Identifier: NCT03263026.
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MESH Headings
- Female
- Humans
- Male
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biomarkers, Tumor/genetics
- Cyclophosphamide/adverse effects
- Cyclophosphamide/therapeutic use
- Doxorubicin/adverse effects
- Doxorubicin/therapeutic use
- Genetic Association Studies
- Genetic Predisposition to Disease
- Indoles/administration & dosage
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/mortality
- Prednisone/adverse effects
- Prednisone/therapeutic use
- Research Design
- Rituximab/adverse effects
- Rituximab/therapeutic use
- Vincristine/adverse effects
- Vincristine/therapeutic use
- Randomized Controlled Trials as Topic
- Clinical Trials, Phase III as Topic
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Affiliation(s)
| | - Jun Zhu
- Peking University Cancer Hospital & Institute, Beijing, PR China
| | - Qingyuan Zhang
- Harbin Medical University Cancer Hospital, Harbin, PR China
| | - Joshua Brody
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Xiuhua Sun
- The Second Hospital of Dalian Medical University, Dalian, PR China
| | - Joseph Maly
- Norton Cancer Institute, Louisville, KY, USA
| | - Yuqin Song
- Peking University Cancer Hospital & Institute, Beijing, PR China
| | - Syed Rizvi
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Yongping Song
- Affliliated Cancer Hospital of Zhengzhou University, Zhengzhou, PR China
| | | | - Hongmei Jing
- Peking University Third Hospital, Beijing, PR China
| | - Junning Cao
- Fudan University Shanghai Cancer Center, Shanghai, PR China
| | | | - Wen Luo
- Denovo Biopharma LLC, San Diego, CA, USA
| | - Lei Zhang
- Denovo Biopharma LLC, San Diego, CA, USA
| | - Ling Li
- Denovo Biopharma LLC, San Diego, CA, USA
| | - Isabel Han
- Denovo Biopharma LLC, San Diego, CA, USA
| | - Joan Sun
- Denovo Biopharma LLC, San Diego, CA, USA
| | | | - Young Liu
- Denovo Biopharma LLC, San Diego, CA, USA
| | | | - Stephen D Smith
- University of Washington/Fred Hutchinson Cancer Center, Seattle, WA, USA
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12
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Smith SD, Till BG, Shadman MS, Lynch RC, Cowan AJ, Wu QV, Voutsinas J, Rasmussen HA, Blue K, Ujjani CS, Shustov A, Cassaday RD, Fromm JR, Gopal AK. Pembrolizumab with R‐CHOP in previously untreated diffuse large B‐cell lymphoma: potential for biomarker driven therapy. Br J Haematol 2020; 189:1119-1126. [DOI: 10.1111/bjh.16494] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Accepted: 12/24/2019] [Indexed: 01/12/2023]
Affiliation(s)
- Stephen D. Smith
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Brian G. Till
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Mazyar S. Shadman
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Ryan C. Lynch
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Andrew J. Cowan
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Qian V. Wu
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Jenna Voutsinas
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Heather A. Rasmussen
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
| | - Katherine Blue
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
| | - Chaitra S. Ujjani
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
| | - Andrei Shustov
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
- Division of Hematology Department of Internal Medicine University of Washington Seattle WA USA
| | - Ryan D. Cassaday
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
- Division of Hematology Department of Internal Medicine University of Washington Seattle WA USA
| | - Jonathan R. Fromm
- Division of Hematopathology Department of Laboratory Medicine University of Washington Seattle WA USA
| | - Ajay K. Gopal
- Division of Medical Oncology Department of Internal Medicine University of Washington Seattle WA USA
- Clinical Research Division Fred Hutchinson Cancer Research Center Seattle WA USA
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13
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Sun F, Fang X, Wang X. Signal Pathways and Therapeutic Prospects of Diffuse Large B Cell Lymphoma. Anticancer Agents Med Chem 2020; 19:2047-2059. [PMID: 32009599 DOI: 10.2174/1871520619666190925143216] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/18/2019] [Accepted: 07/18/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diffuse Large B Cell Lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma which is heterogeneous both clinically and morphologically. Over the past decades, significant advances have been made in the understanding of the molecular genesis, leading to the identification of multiple pathways and molecules that can be targeted for clinical benefit. OBJECTIVE The current review aims to present a brief overview of signal pathways of DLBCL, which mainly focus on B-cell antigen Receptor (BCR), Nuclear Factor-κB (NF-κB), Phosphatidylinositol-3-Kinase (PI3K) - protein kinase B (Akt) - mammalian Target of Rapamycin (mTOR), Janus Kinase (JAK) - Signal Transducer and Activator (STAT), Wnt/β-catenin, and P53 pathways. METHODS Activation of signal pathways may contribute to the generation, development, chemotherapy sensitivity of DLBCL, and expression of pathway molecules is associated with the prognosis of DLBCL. Some agents targeting these pathways have been proved effective and relevant clinical trials are in progress. These agents used single or combined with chemotherapy/each other might raise the possibility of improving clinical outcomes in DLBCL. CONCLUSION This review presents several signal pathways of DLBCL and targeted agents had a tendency to improve the curative effect, especially in high-risk or relapsed/refractory DLBCL.
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Affiliation(s)
- Feifei Sun
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, No.324, Jingwu Road, Jinan, Shandong 250021, China
| | - Xiaosheng Fang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, No.324, Jingwu Road, Jinan, Shandong 250021, China
| | - Xin Wang
- Department of Hematology, Shandong Provincial Hospital Affiliated to Shandong University, No.324, Jingwu Road, Jinan, Shandong 250021, China.,Shandong University School of Medicine, Jinan, Shandong 250012, China
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Miao Y, Medeiros LJ, Li Y, Li J, Young KH. Genetic alterations and their clinical implications in DLBCL. Nat Rev Clin Oncol 2019; 16:634-652. [PMID: 31127191 DOI: 10.1038/s41571-019-0225-1] [Citation(s) in RCA: 119] [Impact Index Per Article: 23.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diffuse large B cell lymphoma (DLBCL) is a highly heterogeneous lymphoid neoplasm with variations in gene expression profiles and genetic alterations, which lead to substantial variations in clinical course and response to therapy. The advent of high-throughput genome sequencing platforms, and especially whole-exome sequencing, has helped to define the genetic landscape of DLBCL. In the past 10 years, these studies have identified many genetic alterations in DLBCL, some of which are specific to B cell lymphomas, whereas others can also be observed in other types of cancer. These aberrations result in altered activation of a wide range of signalling pathways and other cellular processes, including those involved in B cell differentiation, B cell receptor signalling, activation of the NF-κB pathway, apoptosis and epigenetic regulation. Further elaboration of the genetics of DLBCL will not only improve our understanding of disease pathogenesis but also provide further insight into disease classification, prognostication and therapeutic targets. In this Review, we describe the current understanding of the prevalence and causes of specific genetic alterations in DLBCL and their role in disease development and progression. We also summarize the available clinical data on therapies designed to target the aberrant pathways driven by these alterations.
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Affiliation(s)
- Yi Miao
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yong Li
- Department of Cancer Biology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ken H Young
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA. .,Graduate School of Biomedical Sciences, University of Texas Health Science Center, Houston, TX, USA.
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15
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Iacoboni G, Zucca E, Ghielmini M, Stathis A. Methodology of clinical trials evaluating the incorporation of new drugs in the first-line treatment of patients with diffuse large B-cell lymphoma (DLBCL): a critical review. Ann Oncol 2019; 29:1120-1129. [PMID: 29659676 DOI: 10.1093/annonc/mdy113] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background The first-line treatment of diffuse large B-cell lymphoma (DLBCL) is the combination of rituximab with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy, curing approximately 60% of patients. Many clinical trials have been carried out over the last 10 years trying to improve the results of this treatment, but the appropriateness of their planning strategies could be rediscussed. Patients and methods Reports of phase III trials evaluating the addition of molecularly targeted agents or new monoclonal antibodies to the classic R-CHOP backbone in first-line induction or maintenance treatment were reviewed. The trial design, primary end point, number of patients enrolled, patient selection criteria, treatment schedule and results were registered for each one. In addition, the phases I and II trials which preceded these phase III trials were also reviewed. Results Among six phase III trials with results, only one trial evaluating lenalidomide maintenance after response to R-CHOP induction was positive and reached its primary end point. The other five trials did not show an improved outcome with the addition of the new agent. The preceding phases I and II trials were very heterogeneous in their end points and design. Even though most of these trials were considered positive, thus encouraging further investigation, so far they failed to predict the results of the subsequent phase III trials. Conclusion The standard of care for DLBCL is still R-CHOP. Phase I/II trials failed to predict the results of subsequent phase III trials evaluating non-chemotherapeutic agents added to R-CHOP. The methodology of phase II trials evaluating new agents in DLBCL needs to be better defined in the future.
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Affiliation(s)
- G Iacoboni
- Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - E Zucca
- Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - M Ghielmini
- Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland
| | - A Stathis
- Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland.
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16
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Morrison VA, Hamilton L, Ogbonnaya A, Raju A, Hennenfent K, Galaznik A. Treatment approaches for older and oldest patients with diffuse large B-cell lymphoma - Use of non-R-CHOP alternative therapies and impact of comorbidities on treatment choices and outcome: A Humedica database retrospective cohort analysis, 2007-2015. J Geriatr Oncol 2019; 11:41-54. [PMID: 31416716 DOI: 10.1016/j.jgo.2019.07.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/27/2019] [Accepted: 07/30/2019] [Indexed: 12/27/2022]
Abstract
INTRODUCTION We characterized real-world treatment patterns in older (65-74 years) and oldest (75-85 years) patients with diffuse large B-cell lymphoma (DLBCL) receiving initial therapy (R-CHOP, non-R-CHOP regimens). Impact of comorbidities on treatment choice, and overall and progression-free survival (OS, PFS) were assessed by age. PATIENTS AND METHODS Using the Humedica database, we identified 1436 newly diagnosed patients with DLBCL who received frontline therapy from 1/07-9/15. The 885 patients ≥65 years of age were further evaluated for baseline demographics, comorbidities, initial therapy, and PFS/OS. RESULTS Of 885 patients, 406 (45.9%) were age 65-74, and 479 (54.1%) age 75-85, years. First line therapy was R-CHOP (61.8%) or non-R-CHOP (38.2%). Although Charlson Comorbidity Index (CCI) scores were similar at baseline, congestive heart failure and myocardial infarction were more common in those receiving non-R-CHOP regimens. Survival outcomes were superior for those receiving initial R-CHOP, versus non-R-CHOP, therapy (median PFS 53.9 versus 27.8 months; two-year PFS 71.2% versus 51.6%, p < .0001; median OS not reached versus 45 months; two-year OS 81.3% versus 62.9%, p < .0001, respectively). Only 10.4% (R-CHOP) and 12.1% (non-R-CHOP) of patients received second line therapies. Two-year OS by age (65-74, 75-85 years) was 66.4% and 39.1%, respectively with R-CHOP (p = .0045), and 74.3% and 54.5%, respectively with non-R-CHOP (p = .004), therapy. Age ≥ 75 years and CCI of 2+ were associated with shorter OS and PFS. CONCLUSIONS This study identified real-world first line treatment patterns for older patients with DLBCL. Our findings support the feasibility of administering standard R-CHOP therapy, even to oldest patients with DLBCL.
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Affiliation(s)
- Vicki A Morrison
- Hematology/Oncology, Hennepin County Medical Center, University of Minnesota, 715 8th St, Minneapolis, MN 55404, USA.
| | - Laurie Hamilton
- Xcenda LLC, 4114 Woodlands Parkway, Suite 500, Palm Harbor, FL 34685, USA.
| | | | - Aditya Raju
- Xcenda LLC, 4114 Woodlands Parkway, Suite 500, Palm Harbor, FL 34685, USA.
| | - Kristin Hennenfent
- Xcenda LLC, 4114 Woodlands Parkway, Suite 500, Palm Harbor, FL 34685, USA.
| | - Aaron Galaznik
- Millennium Pharmaceuticals, Inc., 40 Landsdowne St, Cambridge, MA 02139, USA(1).
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17
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Miao Y, Medeiros LJ, Xu-Monette ZY, Li J, Young KH. Dysregulation of Cell Survival in Diffuse Large B Cell Lymphoma: Mechanisms and Therapeutic Targets. Front Oncol 2019; 9:107. [PMID: 30881917 PMCID: PMC6406015 DOI: 10.3389/fonc.2019.00107] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/05/2019] [Indexed: 12/23/2022] Open
Abstract
Diffuse large B cell lymphoma (DLBCL) is the most common type of lymphoma worldwide, representing 30-40% of non-Hodgkin lymphomas, and is clinically aggressive. Although more than half of patients with DLBCL are cured by using standard first-line immunochemotherapy, the remaining patients are refractory to the first-line therapy or relapse after complete remission and these patients require novel therapeutic approaches. Understanding the pathogenesis of DLBCL is essential for identifying therapeutic targets to tackle this disease. Cell survival dysregulation, a hallmark of cancer, is a characteristic feature of DLBCL. Intrinsic signaling aberrations, tumor microenvironment dysfunction, and viral factors can all contribute to the cell survival dysregulation in DLBCL. In recent years, several novel drugs that target abnormal cell survival pathways, have been developed and tested in clinical trials of patients with DLBCL. In this review, we discuss cell survival dysregulation, the underlying mechanisms, and how to target abnormal cell survival therapeutically in DLBCL patients.
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Affiliation(s)
- Yi Miao
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Zijun Y Xu-Monette
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jianyong Li
- Department of Hematology, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province Hospital, Nanjing, China
| | - Ken H Young
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.,Graduate School of Biomedical Sciences, The University of Texas Health Science Center at Houston, Houston, TX, United States
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Maintenance Therapy in Diffuse Large B Cell Lymphoma and Mantle Cell Lymphoma. Curr Treat Options Oncol 2018; 19:45. [DOI: 10.1007/s11864-018-0561-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Chiappella A, Santambrogio E, Castellino A, Nicolosi M, Vitolo U. Integrating novel drugs to chemoimmunotherapy in diffuse large B-cell lymphoma. Expert Rev Hematol 2017; 10:697-705. [DOI: 10.1080/17474086.2017.1350164] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Annalisa Chiappella
- Città della Salute e della Scienza Hospital and University, Hematology, Turin, Italy
| | - Elisa Santambrogio
- Città della Salute e della Scienza Hospital and University, Hematology, Turin, Italy
| | - Alessia Castellino
- Città della Salute e della Scienza Hospital and University, Hematology, Turin, Italy
| | - Maura Nicolosi
- Città della Salute e della Scienza Hospital and University, Hematology, Turin, Italy
| | - Umberto Vitolo
- Città della Salute e della Scienza Hospital and University, Hematology, Turin, Italy
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20
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Prêtre V, Wicki A. Inhibition of Akt and other AGC kinases: A target for clinical cancer therapy? Semin Cancer Biol 2017; 48:70-77. [PMID: 28473255 DOI: 10.1016/j.semcancer.2017.04.011] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 04/04/2017] [Accepted: 04/25/2017] [Indexed: 01/27/2023]
Abstract
AGC kinases have been identified to contribute to cancer development and progression. Currently, most AGC inhibitors in clinical development are Akt inhibitors such as MK-2206 or GDC-0068, which are known to promote cell growth arrest and to sensitize cancer cells to radiotherapy. Response rates in clinical trials with single agent Akt inhibitors are typically low. The observed adverse events are within the expected limits for compounds inhibiting the PI3K-mTOR axis. Preclinical and early clinical data for combination therapies are accumulating. Based on these data, several Akt inhibitors are about to enter phase 3 trials. Besides drugs that target Akt, p70S6K inhibitors have entered clinical development. Again, the response rates were rather low. In addition, relevant toxicities were identified, including a risk for coagulopathies with these compounds. Multi-AGC kinase inhibitors are also in early clinical development but the data is not sufficient yet to draw conclusions regarding their efficacy and side-effect profile. PKC inhibitors have been tested in the phase 3 setting but were found to lack efficacy. More trials with isoform-specific PKC inhibitors are expected. Taken together, therapies with AGC kinase inhibitors as single agents are unlikely to meet success. However, combination therapies and a precise stratification of patients according to the activation of signaling axes may increase the probability to see relevant efficacy with these compounds. The emergence of onco-immunotherapies holds some new challenges for these agents.
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Affiliation(s)
- Vincent Prêtre
- Department of Biomedicine, University of Basel, 4031 Basel, Switzerland
| | - Andreas Wicki
- Department of Biomedicine, University of Basel, 4031 Basel, Switzerland; Department of Medical Oncology, University Hospital Basel, 4031 Basel, Switzerland.
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21
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A phase II randomized study of lenalidomide or lenalidomide and rituximab as maintenance therapy following standard chemotherapy for patients with high/high-intermediate risk diffuse large B-cell lymphoma. Leukemia 2016; 31:241-244. [PMID: 27654851 PMCID: PMC5214342 DOI: 10.1038/leu.2016.255] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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