Prognostic value of event-free survival at 12 and 24 months and long-term mortality for non-Hodgkin follicular lymphoma patients: A study report from the Spanish Lymphoma Oncology Group

BACKGROUND

Relatively few studies have analyzed the mortality of follicular lymphoma (FL) patients in comparison with a sex- and age-matched general population. This study analyzed the overall survival (OS) of patients with FL and compared their survival with the expected survival of a general population.

METHODS

Patients diagnosed with FL were prospectively enrolled from 1980 to 2013. Standardized mortality ratios (SMRs) were obtained from yearly sex- and age-specific mortality rates in Spain, and OS was compared with age- and sex-matched general population data.

RESULTS

A total of 1074 patients with newly diagnosed FL were enrolled. The median OS was 231 months (95% confidence interval [CI], 195-267 months). Event-free survival at 12 months (EFS12) and event-free survival at 24 months (EFS24) were associated with an increased probability of early death, with an SMR of 10.27 (95% CI, 8.26-12.77) for EFS12. The overall SMR, including all causes of death, was 2.55 (95% CI, 2.23-2.92), and it was higher for women (SMR, 3.02; 95% CI, 2.48-3.67) and young adults (SMR, 6.01; 95% CI, 3.13-11.55). More than 10 years after the diagnosis, mortality rates for FL patients were lower than those for the general population (SMR, 0.47; 95% CI, 0.28-0.78). When FL was excluded as a cause of death, the overall SMR was 1.35 (95% CI, 1.11-1.65) without a statistically significant mortality increase in the >60-year-old group in comparison with age- and sex-matched general population data. More than 15% of the patients included in the study (n = 158) had more than 10 years of follow-up.

CONCLUSIONS

EFS12 and EFS24 predict an early increase in mortality. The long-term SMR, over the course of 10 years of follow-up, shows that patients with FL have a risk of dying similar to that of a sex- and age-matched general population. Cancer 2017;123:3709-3716. © 2017 American Cancer Society.

Impact of treatment in long-term survival patients with follicular lymphoma: A Spanish Lymphoma Oncology Group registry

BACKGROUND

Follicular lymphoma is the second most common non-Hodgkin lymphoma in the United States and Europe. However, most of the prospective randomized studies have very little follow-up compared to the long natural history of the disease. The primary aim of this study was to investigate the long-term survival of our series of patients with follicular lymphoma.

PATIENTS AND METHODS

A total of 1074 patients with newly diagnosed FL were enrolled. Patients diagnosed were prospectively enrolled from 1980 to 2013.

RESULTS

Median follow-up was 54.9 months and median overall survival is over 20 years in our series. We analyzed the patients who are still alive beyond 10 years from diagnosis in order to fully assess the prognostic factors that condition this group. Out of 166 patients who are still alive after more than 10 years of follow-up, 118 of them (73%) are free of evident clinical disease. Variables significantly associated with survival at 10 years were stage < II (p <0.03), age < 60 years (p <0.0001), low FLIPI (p <0.002), normal β2 microglobulin (p <0.005), no B symptoms upon diagnosis (p <0.02), Performance Status 0-1 (p <0.03) and treatment with anthracyclines and rituximab (p <0.001), or rituximab (p <0.0001).

CONCLUSIONS

A longer follow-up and a large series demonstrated a substantial population of patients with follicular lymphoma free of disease for more than 10 years.

mRNA in exosomas as a liquid biopsy in non-Hodgkin Lymphoma: a multicentric study by the Spanish Lymphoma Oncology Group

PURPOSE

To determine the feasibility of mRNAs (C-MYC, BCL-XL, BCL-6, NF-κβ, PTEN and AKT) in exosomes of plasma as a liquid biopsy method for monitoring and prognostic evolution in B-cell lymphomas.

PATIENTS AND METHODS

Exosomes were isolated from 98 patients with B-cell Lymphoma and 68 healthy controls. mRNAs were analyzed by quantitative PCR. An additional 31 post-treatment samples were also studied.

RESULTS

In the general and follicular lymphoma series, the presence of AKT mRNA was associated with poor response to rituximab-based treatment. Patients with first relapse or disease progression showed a lower percentage of PTEN and BCL-XL mRNA. The presence of BCL-6 mRNA was associated with a high death rate. The absence of PTEN mRNA in the general series, and presence of C-MYC mRNA in follicular lymphomas, were associated with short progression-free survival. BCL-6 and C-MYC mRNA were independent prognostic variables of overall survival. C-MYC mRNA may provide prognostic information with respect to overall survival. BCL-XL mRNA and increase of BCL-6 mRNA in post-treatment samples could serve as molecular monitoring markers.

CONCLUSIONS

This is the first large study to evaluate the prognostic and predictive values of pretreatment tumor-associated mRNA in exosomes. BCL-6 and C-MYC mRNA positivity in pretreatment samples were predictors of worse PFS compared to patients with mRNA negativity. C-MYC mRNA positivity was also a statistically significant predictor of inability to obtain complete response with first-line therapy.

MicroRNA signatures and treatment response in patients with advanced classical Hodgkin lymphoma

Although specific microRNA (miRNA) signatures in classical Hodgkin lymphoma (cHL) have been proposed, their relationship with clinical outcome remains unclear. Despite treatment advances, a substantial subset of patients with advanced cHL are refractory to standard therapies based on adriamycin and its variants. Global miRNA expression data of 29 advanced cHL patients and five cHL-derived cell lines were used to identify profiles from Hodgkin-Reed-Sternberg (HRS) cells and their non-tumoural microenvironment. A cHL-miRNA signature was identified with 234 miRNAs differentially expressed. A subset of these miRNAs was associated with outcome and selected for study in an independent set of 168 cHL samples using quantitative reverse transcription polymerase chain reaction. Multivariate Cox regression analyses including cross-validation with failure-free survival (FFS) as clinical endpoint revealed a miRNA signature with MIR21, MIR30E, MIR30D and MIR92B* that identified two risk-groups with significant differences in 5-year FFS (81% vs. 35.7%; P < 0.001). Additionally, functional silencing of MIR21 and MIR30D in L428 cells showed increased sensitivity to doxorubicin-induced apoptosis, pointing towards abnormalities of mitochondrial intrinsic and TP53-CDKN1A pathways as related to miRNA deregulation in cHL. These results suggest that clinical outcome in cHL is associated with a specific miRNA signature. Moreover, functional analyses suggest a role for MIR21 and MIR30D in cHL pathogenesis and therapeutic resistance.

First efficacy assessment of a phase II study with cyclophosphamide, vincristine, liposomal doxorubicin, and prednisone plus rituximab, administered every two weeks (R-COMP-14) as primary treatment for NHL

18519

Background: R-CHOP is the standard treatment for CD20+ aggressive B-cell non-Hodgkin lymphoma (DLBCL). Dose dense regimens have shown better outcome and acceptable tolerability compared to standard. Liposomal doxorubicin has demonstrated significant less cardiotoxicity and acute toxicity when compared with standard doxorubicin. The aim of the study is to assess the efficacy and safety of the R- COMP-14 (Myocet™-modified CHOP) in newly diagnosed aggressive DLBCL. Pegfilgrastim was used to provide prophylactic bone marrow support. Methods: Patients (Pts) with stages III, IV or I, II (IPI = 1) were included in this single arm, multicentric, 2-step (Simon design) phase II trial. Treatment: eight biweekly cycles of liposomal doxorubicin 50 mg/m2, cyclophosphamide 750mg/m2, vincristine 1.4 mg/m2 (max. 2mg), rituximab 375 mg/m2 and prednisone 100 mg/d d1–5. Pegfilgrastim was administered on day 2 at standard dose. Interim analysis shows: Twenty-six out of 28 Pts were evaluable for efficacy. Median age: 51 y (28 - 64). Ann Arbor stage: I-II (IPI = 1) 42%, III 29%, IV 29%. Extranodal involvement: 50%. Median basal LVEF was 66% (range 44 - 80). Results: The overall response rate was 84% (CR 64% and PR 20%). Three (12%) Pts had PD and 1 (4%) SD. Median n° cycles was 8 (2-8); the median relative dose intensity per week was 93.5%. Only 4.8% of cycles were delayed and 4.2% of the cycles were administered with dose reduction due to related adverse events. Grade 3–4 neutropenia and thrombocytopenia were observed in 4.0% and 0.6% of cycles respectively. Febrile neutropenia experienced in 3.3% of cycles. Non-hematological G3–4 toxicities per cycles were hepatic (1.7%), emesis (1.2%) and G3 neurotoxicity, asthenia and infection (0.6% each). No other relevant toxicities were observed. Median LVEF after completion of treatment was 63% (range 52 - 76), there was no cardiac clinical event related to the treatment, nor irreversible toxicities. Conclusions: This Interim analysis confirmed the efficacy and safety of the dose-dense regimen in order to continue with the second step of the study. R-COMP-14 treatment with pegfilgrastim bone marrow support warrants further exploration.

No significant financial relationships to disclose.

Tumor microenvironment and mitotic checkpoint are key factors in the outcome of classic Hodgkin lymphoma

Around 20% to 30% of patients with Hodgkin lymphoma (HL) do not benefit from standard therapies and finally succumb to their disease. The factors that influence the outcome of HL have not been elucidated, underscoring the demand for the identification of biologic risk factors and new therapeutic targets. We analyzed the gene expression profiles of samples from 29 patients with advanced classic HL treated with standard therapy and compared the expression profiles of patients with favorable and unfavorable clinical outcome. Using supervised methods, we identified 145 genes associated with outcome, which were grouped into 4 signatures representing genes expressed by either the tumoral cells (genes involved in the regulation of mitosis and cell growth/apoptosis) or the tumor microenvironment. The relationship between the expression of 8 representative genes and survival was successfully validated in an independent series of 235 patients by quantification of protein expression levels on tissue microarrays. Analysis of centrosomes and mitotic checkpoint confirmed the existence of an abnormal transition through mitosis in HL cells. Therefore, genes related to tumor microenvironment, cell growth/apoptosis, and regulation of mitosis are associated with treatment response and outcome of patients with HL.

Normal protein diet for episodic hepatic encephalopathy: results of a randomized study

BACKGROUND/AIMS

Protein-restricted diets are usually prescribed for cirrhotic patients with hepatic encephalopathy. However, protein restriction may worsen the nutritional status without resulting in an improvement of hepatic encephalopathy. We designed a study to assess the effects of the amount of protein in the diet on the evolution of episodic hepatic encephalopathy.

METHODS

Cirrhotics admitted to the hospital because of an episode of encephalopathy (n=30) were randomized to receive a low-protein diet with progressive increments or a normal protein diet for 14 days, in addition to standard measures to treat hepatic encephalopathy. Protein synthesis and breakdown were studied at day 2 and day 14 with the glycine-N(15) infusion method.

RESULTS

The outcome of hepatic encephalopathy was not significantly different between both groups of treatment. Protein synthesis was similar for low and normal protein diet, but those of the low-protein diet group showed higher protein breakdown.

CONCLUSIONS

Diets with a normal content of protein, which are metabolically more adequate, can be administered safely to cirrhotic patients with episodic hepatic encephalopathy. Restriction of the content of protein of the diet does not appear to have any beneficial effect for cirrhotic patients during an episode of encephalopathy.

[Infections related to parenteral nutrition catheter]

Infectious complications related to total parenteral nutrition (TPN) catheters were prospectively evaluated during a four-month period in a third level teaching hospital in which a protocol on parenteral nutrition is implemented. The study included 102 catheters inserted for a total of 1,448 days (mean 12.06 day/catheter). Local pain, redness, and fever were recorded among 1.9%, 9.8% and 10.7% of cases, respectively. In no case were the defined criteria for catheter related sepsis fulfilled. Catheter tips were cultured in 72.5% of the studied catheters. Tip colonization was observed in 4.1% of cultured tips whereas infection was detected in 8% of them according to microbiological criteria. During the same time period in the hospital, 15 episodes of catheter bacteremia among 6,874 inpatients were observed which were not related to parenteral nutrition, which represents 0.22% of inpatients. The conclusion of our study is that adhering to a parenteral nutrition protocol, with special emphasis in catheter and connection management involves a very low incidence of infectious complications related to parenteral nutrition.

Early curbing of protein hypercatabolism in postoperative patients by nutritional support with glucose plus amino acids, but not with glucose alone

This work attempts to determine if there are differences in protein metabolism in post-surgical patients who receive parenteral nutrition with amino acids plus glucose (G+AA) or conventional gluco-salinal solution (GS). Eighteen patients submitted to gastrointestinal surgery were randomized and double-blindly administered either G+AA (1 g AA/kg x d and 28 kJ/kg x d), or GS (28 kJ/kg x d). Protein metabolism was determined 12 h after surgery (day 0) and after 5 days of nutritional support. On day 0, protein breakdown was similarly elevated, with respect to reference values, in both groups (GS: 4.62 +/- 0.25; G+AA: 5.25 +/- 0.50 g prot/kg x d) as a result of surgical stress. These values increased significantly at day 5 (P < 0.03) with the administration of GS to 6.93 +/- 1.00 g prot/kg x d, while they decreased (P < 0.002, 3.30 +/- 0.42 g prot/kg x d) with G+AA. Protein synthesis was increased (5.69 +/- 0.86 g prot/kg x d) with GS (P < 0.02), and was decreased (2.79 +/- 0.44 g prot/kg x d) with G+AA (P < 0.0002). Both synthesis and breakdown were inside normal reference values after 5 days for group G+AA. In both groups, nitrogen balance did not change significantly at day 5 compared to day 0. G+AA is effective in curbing the hypermetabolism produced by postoperative stress, achieving normal protein metabolism in 5 days, while GS increases the protein breakdown and synthesis. Nitrogen balance does not detect these modifications of the protein metabolism. Undernutrition on prognosis is not yet fully recognized.

[Parenteral nutrition: a utilization study in a general hospital]

A follow-up of 116 patients initiating parenteral nutrition was performed from December 1990 to March 1991 (average of 18 patients on parenteral nutrition per day, which accounted for a prevalence of 2% compared to total patients admitted), in order to determine a series of characteristics related to the use of parenteral nutrition in our hospital, by means of obtaining concrete, updated information. With regard to the patients, it was observed that 37% of these were suffering from chronic ailments, with more or less incapacitating pathologies. The nutritional state prior to parenteral nutrition was normal in 53% of cases, and the most common reasons for admittance to hospital were neoplasias (27%) and digestive pathology (18%). 42% of the patients were admitted to the ICU and 34% to General Surgery. Indication for parenteral nutrition was intestinal pathology in 23% of cases, followed by pancreatic pathology in 16% of cases and pathology of the oesophagus in 10%; in 45% of cases, it was commenced during the postoperative period. With regard to the composition of the parenteral nutrition, we should mention the use of polyols instead of glucose in 80% of diabetic patients and 75% of patients with pancreatitis, the widespread use of mixture of 50% medium and long chain triglycerides and the use of amino acid solutions with 20% branched chain in most patients, both in situations of stress and maintenance.

Stability of ranitidine hydrochloride in total nutrient admixtures

The stability of ranitidine hydrochloride in total nutrient admixtures (TNAs) containing 5% intravenous fat emulsion was studied. A TNA containing lipids and glucose was prepared aseptically in three ethylene-vinyl acetate bags. Ranitidine hydrochloride 100 mg and 200 mg was added to two of the bags to yield concentrations of 50 micrograms/mL and 100 micrograms/mL, respectively. The third bag served as a control. At 0, 12, 24, 48, and 72 hours, the ranitidine content was measured by high-performance liquid chromatography, the pH of the admixtures was determined, and the bags were visually inspected for signs of color changes, creaming, or precipitates. Particle-size distribution was measured at 72 hours and compared with that in the control bag at time zero. No appreciable changes in pH occurred over 72 hours, and no visual changes were observed. At concentrations of 50 and 100 micrograms/mL of admixture, ranitidine hydrochloride activity declined approximately 80% during the study period. Approximately 10% of the initial concentration was lost in 12 hours. In both cases, there was no variation in particle-size distribution compared with that in the control bag at time zero. Ranitidine hydrochloride appears to be stable for up to 12 hours at room temperature in the admixtures studied, and the lipid emulsion apparently was not altered during this period by ranitidine.

Valuation of protein metabolism and albumin in patients submitted to peripheral parenteral nutrition (PPN)

A protein breakdown study was carried out in ten post-operative patients, 24 hours after operation and after five days of peripheral parenteral nutrition; five of these patients were in a good nutritive condition (group A) and five were suffering from malnutrition and were critically ill (group B). Results indicate that the administration of amino-acids achieved a decrease in the degree of protein breakdown in the two groups under study, and also it was observed that better use was made of the nitrogen administered, particularly by the liver when the nitrogenous supply is completed with carbohydrates such as glucose. The difference obtained in values between the oxidized leucine and the leucine administered suggests that there is an endogenous donor pool, and the differences existing between breakdown and leucine oxidation values indicate that in group A, nourished solely with amino-acids, breakdown is lesser and oxidation greater than in group B, nourished with amino-acids and glucose, which suggests that there is more stimulation to re-use the amino-acids in this group.