Autologous and Allogeneic Hematopoietic Cell Transplantation in Peripheral T/NK-cell Lymphomas: A Histology-Specific Review

Estimating long-term progression-free and overall survival in patients with peripheral T-cell lymphoma: A US population-based oncology simulation model based on 5-year results from the ECHELON-2 trial

BACKGROUND: The ECHELON-2 5-year update showed continued clinically meaningful improvements in progression-free survival (PFS) and overall survival with frontline (1L) A+CHP (brentuximab vedotin in combination with cyclophosphamide, doxorubicin, prednisone) vs CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) in CD30-expressing peripheral T-cell lymphomas (PTCLs). OBJECTIVE: To estimate PTCL annual prevalence in the United States in 2031 without and with A+CHP using data from the ECHELON-2 5-year update. METHODS: Population-level outcomes were estimated using a dynamic oncology simulation model. Utilization of 1L CHOP (65% utilization) and CHOP plus etoposide (35% utilization) were varied over time and compared with scenarios incorporating 1L A+CHP (20%-50% utilization; base case: 40% utilization) per expert clinicians' opinion. Additional inputs included PTCL incidence and PFS for consolidation and post-1L therapies from published sources. PFS (51.4% [95% CI = 42.8%-59.4%] vs 43.0% [35.8%-50.0%]) and overall survival (hazard ratio = 0.72 [0.53-0.99]) for A+CHP and CHOP came from ECHELON-2. RESULTS: In 2031, an estimated 2,082 patients will be diagnosed with PTCL. Approximately 1,412 additional patients will be alive and progression free, and 106 fewer patients will require second-line therapy with 40% A+CHP utilization vs no A+CHP utilization. Varying 1L A+CHP utilization from 20%-50% vs no 1L A+CHP utilization added 732 to 1,752 patients alive and progression free. CONCLUSIONS: In this oncology simulation model, the improvements in survival outcomes seen with A+CHP vs CHOP in the ECHELON-2 5-year results translated into more estimated patients with PTCL progression free and alive for at least 5 years following 1L A+CHP vs CHOP and a decreased need for post-1L therapy. DISCLOSURES: This study was funded by Seagen Inc. Dr Liu and Dr Yu are employees and shareholders of Seagen Inc. Mr Bloudek is and Dr Mordi was an employee of Curta Health, which received funding from Seagen Inc. for the conduct of this study. Dr Burke received consulting fees from Genentech/Roche, AbbVie, Seattle Genetics, Bayer, AstraZeneca, Adaptive Biotechnologies, Verastem, MorphoSys, Kura, Epizyme, BeiGene, Kymera, Novartis, Bristol Myers Squibb, TG Therapeutics, Lilly, and Nurix; and received payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events in speakers bureaus for BeiGene and Seagen Inc. Dr Phillips received consulting fees from AstraZeneca, MorphoSys, Epizyme, Roche/Genentech, Epizyme Eli Lilly, AbbVie, BeiGene, Pharmacyclics, Bristol Myers Squibb, Xencor, Seagen Inc., TG Therapeutics, Bayer, Incyte, and Gilead; and received payment for honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Epizyme and Seagen Inc.

Anaplastic Large Cell Lymphoma: Molecular Pathogenesis and Treatment

Simple Summary

Anaplastic large cell lymphoma is a rare type of disease that occurs throughout the world and has four subtypes. A summary and comparison of these subtypes can assist with advancing our knowledge of the mechanism and treatment of ALCL, which is helpful in making progress in this field.

Abstract

Anaplastic large cell lymphoma (ALCL) is an uncommon type of non-Hodgkin’s lymphoma (NHL), as well as one of the subtypes of T cell lymphoma, accounting for 1 to 3% of non-Hodgkin’s lymphomas and around 15% of T cell lymphomas. In 2016, the World Health Organization (WHO) classified anaplastic large cell lymphoma into four categories: ALK-positive ALCL (ALK+ALCL), ALK-negative ALCL (ALK−ALCL), primary cutaneous ALCL (pcALCL), and breast-implant-associated ALCL (BIA-ALCL), respectively. Clinical symptoms, gene changes, prognoses, and therapy differ among the four types. Large lymphoid cells with copious cytoplasm and pleomorphic characteristics with horseshoe-shaped or reniform nuclei, for example, are found in both ALK+ and ALK−ALCL. However, their epidemiology and pathogenetic origins are distinct. BIA-ALCL is currently recognized as a new provisional entity, which is a noninvasive disease with favorable results. In this review, we focus on molecular pathogenesis and management of anaplastic large cell lymphoma.

Recent advances in T-cell lymphoid neoplasms

T Cells comprise many subtypes of specified lymphocytes, and their differentiation and function take place in different tissues. This cellular diversity is also observed in the multiple ways T-cell transformation gives rise to a variety of T-cell neoplasms. This review covers the main types of T-cell malignancies and their specific characteristics, emphasizing recent advances at the cellular and molecular levels as well as differences and commonalities among them.

Allogeneic Hematopoietic Stem Cell Transplantation in Extranodal Natural Killer/T-cell Lymphoma

Objective

Extranodal NK/T-cell lymphoma (ENKL) is aggressive and resistant to chemotherapy and radiotherapy. Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a potentially curative treatment for high-risk lymphomas owing to its associated graft-versus-lymphoma (GVL) effect. However, its application to ENKL is limited. We aim to summarize the characteristics of allo-HSCT for ENKL and, more importantly, evaluate whether allo-HSCT could offer any benefits for ENKL.

Materials and Methods

A systematic review and data analysis were performed to evaluate the performance of allo-HSCT in the treatment of ENKL using studies obtained from PubMed, Medline, and Embase from January 2000 to December 2019 in the English language.

Results

A total of 136 cases from 17 eligible publications were included in this study. It was found that after allo-HSCT, with an average follow-up time of 34 months (range: 1-121 months), 37.5% (52) of 136 patients had acute graft-versus-host disease (GVHD) and 31.6% (43) had chronic GVHD. Furthermore, 35.3% (48) of the patients were reported to have relapsed, but 2 of those relapsed only locally and achieved complete remission (CR) again with additional irradiation, chemotherapy, and donor lymphocyte infusions for one and rapid tapering and discontinuation of cyclosporine for the other, earning more than one year of extra survival. Finally, of the 136 patients, 51.5% (70) died because of primary disease progression (42.9%), infection (20.0%), GVHD (11.4%), organ failure (7.1%), hemorrhage (4.3%), and other causes (not specified/unknown) (14.3%).

Conclusion

Allo-HSCT may be a treatment option for advanced or relapsed/refractory ENKL, but its role still requires more rigorous future studies.

Exploring the Risks of Genetic Similarity Between Donor and Recipient in Human Leukocyte Antigen-Matched Transplantation

OBJECTIVE

Successful allogeneic hematopoietic stem cell transplantation (HSCT) relies on human leukocyte antigen (HLA) matching. However, whether HLA-matching between donors and recipients increases recipients' risk of genetic disease remains unclear.

METHODS

We investigated whether HLA-matched donor cells used for HSCT have similar microsatellite DNA polymorphisms to HSCT recipients at 19 randomly selected loci including CSF1PO, D12S391, D13S317, D16S539, D18S51, D19S433, D21S11, D2S1338, D3S1358, D5S818, D6S1043, D7S820, D8S1179, FGA, PentaD, PentaE, TH01, TPOX, and VWA. We analyzed allele matching at each short tandem repeat (STR) loci in HLA-matched and mismatched (control) groups using binary outcomes and a quantitative numerical method.

RESULTS

The frequencies were similar between the HLA-matched group and the mismatched group for D6S1043. However, the allele matching rate was higher in the HLA-matched group than that in the mismatched group at 14 of the 19 STR loci. Overall, a significant increase in the rate of STR matching was observed in the HLA-matched group compared to the mismatched group (P = .004).

CONCLUSION

It would be interesting to know if the HLA matched pairs came more often in question than their mismatched counterparts as candidates for fully HLA-matched unrelated HSCT. The actual risk for HSCT donors developing these diseases needs further evaluation.

[Outcomes of 33 patients with anaplastic large cell lymphoma treated after hematopoietic stem cell transplantation]

目的

探讨造血干细胞移植治疗间变大细胞淋巴瘤（ALCL）的疗效及预后。

方法

回顾性分析全国八家三甲医院2005年1月至2017年12月收治的33例接受造血干细胞移植（HSCT）的ALCL患者临床资料，评价自体造血干细胞移植（auto-HSCT）和异基因造血干细胞移植（allo-HSCT）治疗ALCL的生存率、复发率和影响预后的相关因素。

结果

33例接受HSCT的ALCL患者的中位发病年龄为31（12~57）岁，男23例，女10例，间变性淋巴瘤激酶阳性（ALK⁺）和阴性（ALK⁻）分别为24例（72.7%）和9例（27.3%）。25例患者接受auto-HSCT（ALK⁺患者19例，ALK⁻患者6例），8例患者接受allo-HSCT（ALK⁺患者5例，ALK⁻患者3例）。移植后中位随访时间18.7（4.0~150.0）个月。移植前疾病缓解状态：完全缓解6例（均行auto-HSCT），部分缓解16例（auto-HSCT组14例，allo-HSCT组2例），复发难治11例（auto-HSCT组5例，allo-HSCT组6例）。疾病进展死亡7例，其中auto-HSCT组5例（20.0%），allo-HSCT组2例（25.0%）。移植相关死亡（TRM）5例，其中auto-HSCT组2例（8.0%），allo-HSCT组3例（37.5%）。auto-HSCT后中位无进展生存（PFS）和总生存（OS）时间均为15个月，allo-HSCT后中位PFS时间为3.7（1.0~90.0）个月，中位OS时间为4.6（1.0~90.0）个月，两组生存曲线差异无统计学意义（OS及PFS P值分别为0.247和0.317）。auto-HSCT和allo-HSCT组的2年OS率分别为72%和50%，5年OS率分别为36%和25%。

结论

ALCL化疗反应率高，有不良预后因素的情况下化疗后序贯auto-HSCT为重要治疗措施，高危患者或可从allo-HSCT中获益。

Brentuximab vedotin in the treatment of CD30+ PTCL

In this timely Blood Spotlight, Barta et al summarize for the practicing hematologist the strengths and limitations of current data on brentuximab vedotin–based treatment in peripheral T-cell lymphoma (PTCL).

Nasal-type extranodal natural killer/T-cell lymphoma presenting with a mass on the buttock: A case report

RATIONALE

Nasal-type extranodal natural killer (NK)/T-cell lymphoma is a highly unusual disease with no standard curative managements yet. Our focus is to emphasize a very rare case of nasal-type extranodal NK/T-cell lymphoma with onset of the mass on the buttock successfully operated by combination of surgical excision together with chemotherapy. The management of these unique cases is of great clinical guiding significance.

PATIENT CONCERNS

A 20-year-old woman presented with a 2-month history of continuous and progressive severe pain on her left buttock. Since December 2017, the patient developed nasal congestion, accompanied with mild pain in the left eye, and new subcutaneous nodules on both cheeks.

DIAGNOSIS

Postoperative pathology confirmed the diagnosis of extranodal NK/T cell lymphoma. This is an extremely rare presentation of nasal-type NK/T-cell lymphoma.

INTERVENTIONS

The patient underwent enlarged resection of the tumor on the buttock. After the diagnosis of extranodal NK/T-cell lymphoma was established, the patient received chemotherapy and autologous hematopoietic stem cell transplantation.

OUTCOMES

The patient's symptoms improved significantly after the surgery, and the postoperative period was uneventful at the 1-year follow-up visit. There were no complications associated with the operation and adjuvant therapies during the follow-up period.

LESSONS

Taken together, the lesion's clinical features, imaging results, and pathological characteristics are unique. Extranodal NK/T-cell lymphoma, although rare, should be part of the differential diagnosis when the patient presents with the mass on the buttock. We recommend enlarged excision of the extranodal lymphoma. Combined of surgical excision of the extranodal lymphoma, chemotherapy and autologous hematopoietic stem cell transplantation are good choice for proper treatment.

Innovative analysis of predictors for overall survival from systemic non-Hodgkin T cell lymphoma using quantile regression analysis

Background:

Non-Hodgkin T/NK cell lymphoma is a rare and widely variable type of lymphoma with the most dismal prognosis. This study aimed to investigate varied impact of the clinical indicators to the overall survival (OS).

Methods:

We conducted a retrospective study to identify the non-invasive clinical features of T cell lymphoma that can predict prognosis with an innovative analysis method using quantile regression. A total of 183 patients who visited a top-tier hospital in Beijing, China, were enrolled from January 2006 to December 2015. Demographic information and main clinical indicators were collected including age, erythrocyte sedimentation rate (ESR), survival status, and international prognostic index (IPI) score.

Results:

The median age of the patients at diagnosis was 45 years. Approximately 80% of patients were at an advanced stage, and the median survival time after diagnosis was 5.1 months. Multivariable analysis of the prognostic factors for inferior OS associated with advanced clinical staging [HR=3.16, 95%CI (1.39–7.2)], lower platelet count [HR = 2.57, 95%CI (1.57–4.19), P < 0.001] and higher IPI score [HR = 1.29, 95%CI (1.01–1.66), P = 0.043]. Meanwhile, T cell lymphoblastic lymphoma [HR = 0.40, 95%CI (0.20–0.80), P = 0.010], higher white blood cell counts [HR = 0.57, 95%CI (0.34–0.96), P = 0.033], higher serum albumin level [HR = 0.6, 95%CI (0.37–0.97), P = 0.039], and higher ESR [HR = 0.53, 95%CI (0.33–0.87), P = 0.011] were protective factors for OS when stratified by hemophagocytic lymphohistiocytosis (HLH). Multivariable quantile regression between the OS rate and each predictor at quartiles 0.25, 0.5, 0.75, and 0.95 showed that the coefficients of serum β2-microglobulin level and serum ESR were statistically significant in the middle of the coefficient curve (quartile 0.25–0.75). The coefficient of IPI was negatively associated with OS. The coefficients of hematopoietic stem cell transplantation (HSCT) and no clinical symptoms were higher at the middle of the quartile level curve but were not statistically significant.

Conclusions:

The IPI score is a comparatively robust indicator of prognosis at 3 quartiles, and serum ESR is stable at the middle 2 quartiles section when adjusted for HLH. Quantile regression can be used to observe detailed impacts of the predictors on OS.

Anaplastic Large Cell Lymphoma: Contemporary Concepts and Optimal Management

Anaplastic Large Cell Lymphomas (ALCL) are clinically aggressive and pathologically distinct lymphoid neoplasms that originate from a mature post-thymic T-cell. The contemporary World Health Organization (WHO) Classification of Haematologic Malignancies recognizes two distinct subtypes of systemic ALCL: Anaplastic Lymphoma Kinase (ALK)-negative, and ALK-positive. An additional unique subtype of ALCL is known to arise after prolonged exposure to breast implants, known as Breast Implant Associated ALCL (BIALCL). While histologic features of ALCL subtypes have significant overlap, genomic studies suggest the unique pathophysiology and molecular events of tumorigenesis. As a group, ALCLs are rare among non-Hodgkin lymphomas comprising 1-3% overall. There seems to be age and geographic predilection with ALK-positive ALCL affecting younger individuals and being diagnosed more frequently in North America than Europe. Both subtypes are quite uncommon in Hispanic and Asian populations. ALK-positive ALCL patients have a better overall prognosis than those with ALK-negative ALCL, and clinical features at presentation (i.e., International Prognostic Index, IPI) define the outcome in both subtypes. Molecular events affecting DUSP22 and TP63 have been reported to predict survival outcomes as well, with former being favorable, and the latter an unfavorable prognostic marker. Multiagent CHOP-like chemotherapy remains a standard of care for newly diagnosed ALCL patients treated with curative intent and provide a chance of cure for the majority of ALK-positive ALCL patients, and at least half of the ALK-negative ALCL patients. The role of consolidative high-dose therapy and autologous hematopoietic stem cell transplantation remains unclear. Novel targeted agents are actively being investigated for their role in initial therapy. New immunoconjugates, targeted kinase inhibitors, and transgenic autologous T-cells are being studied in patients with relapsed and refractory disease. This review will discuss contemporary concepts in pathogenesis and management of systemic ALCL. The biology and management of primary cutaneous ALCL will be discussed elsewhere.

Peripheral T-Cell Lymphoma, not Otherwise Specified (PTCL-NOS)

Peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) is a World Health Organization (WHO)-defined diagnostic category within the highly heterogeneous group of mature post-thymic T-cell neoplasms. It is the most common subtype of mature post-thymic T-cell neoplasms globally, accounting for up to 35% of PTCL cases in Europe and North America. PTCL-NOS is a diagnosis of exclusion, comprising several disease entities that differ in biology, clinical presentation, and outcome. The diagnosis of PTCL-NOS is made based on the presence of typical histopathological features of lymphoma, an aberrant T-cell immunophenotype, often with a loss of CD5 and CD7, and a clonal T-cell receptor (TCR) gene rearrangement, in the appropriate clinical context. Unlike other types of T-cell lymphoma, recurrent mutations to assist with the diagnosis have not been identified. Patients often present with advanced stage. Prognosis is poor, with a 5-year overall survival (OS) of 20-30%. Anthracycline-based combination chemotherapy remains the most frequently used frontline strategy, with overall response rates (ORR) of 50-60%, and complete response rates (CRR) of 20-30%. Prospective studies with intent-to-treat analyses have shown that consolidation with high-dose chemotherapy and autologous stem cell transplant (ASCT) results in progression-free survivals (PFS) that compare favorably with historical cohorts and may improve OS in selected patient populations. However, randomized data are still lacking. Over the past decade, therapeutic agents approved in the relapsed and refractory setting have produced response rates of up to 33% and median PFS up to 18 months. Overall, outcomes remain poor and there is a dire need for more effective treatments. This review discusses the latest information on the diagnosis and treatment of PTCL-NOS.