Low absolute lymphocyte count is a poor prognostic factor in diffuse-large-B-cell-lymphoma

Prognostic indices in diffuse large B-cell lymphoma: a population-based comparison and validation study of multiple models

Currently, the International Prognostic Index (IPI) is the most used and reported model for prognostication in patients with newly diagnosed diffuse large B-cell lymphoma (DLBCL). IPI-like variations have been proposed, but only a few have been validated in different populations (e.g., revised IPI (R-IPI), National Comprehensive Cancer Network IPI (NCCN-IPI)). We aimed to validate and compare different IPI-like variations to identify the model with the highest predictive accuracy for survival in newly diagnosed DLBCL patients. We included 5126 DLBCL patients treated with immunochemotherapy with available data required by 13 different prognostic models. All models could predict survival, but NCCN-IPI consistently provided high levels of accuracy. Moreover, we found similar 5-year overall survivals in the high-risk group (33.4%) compared to the original validation study of NCCN-IPI. Additionally, only one model incorporating albumin performed similarly well but did not outperform NCCN-IPI regarding discrimination (c-index 0.693). Poor fit, discrimination, and calibration were observed in models with only three risk groups and without age as a risk factor. In this extensive retrospective registry-based study comparing 13 prognostic models, we suggest that NCCN-IPI should be reported as the reference model along with IPI in newly diagnosed DLBCL patients until more accurate validated prognostic models for DLBCL become available.

PD-L1 Is Involved in the Development of Non-Hodgkin's Lymphoma by Mediating Circulating Lymphocyte Apoptosis

Lymphocyte apoptosis plays a crucial role in tumor-induced immunosuppression. Programmed death ligand-1 (PD-L1) blocks lymphocyte activation via its receptor, PD-1. However, PD-L1/PD-1 expression and its role in enhancing immune suppression in non-Hodgkin lymphoma (NHL) have not been identified. The purpose of the study was to assess PD-L1/PD-1 expression in circulating lymphocytes in NHL and its role in immunosuppression. Twenty newly diagnosed NHL patients and twenty normal volunteers were enrolled in the study. PD-L1/PD-1 expression in circulating lymphocytes and the apoptosis of lymphocyte subsets were assessed using flow cytometry. The findings revealed that the PD-L1 expression in circulating CD3+, CD3+CD4+, CD3+CD8+, and CD20+ lymphocytes were dramatically upregulated in NHL patients (p < 0.001), whereas peripheral lymphocytes expressed low levels of PD-1. Compared with normal volunteers, a significant increase in lymphocyte apoptosis was revealed by annexin-V binding on T and B lymphocytes (p < 0.001). Peripheral lymphocytes expressing PD-L1 were four times more vulnerable to apoptosis than those expressing PD-1. Our findings imply that PD-L1 upregulation contributes to NHL development by promoting circulating lymphocyte apoptosis. This research adds to our understanding of the function of the PD-L1/PD-1 pathway in tumor evasion, establishing a novel therapeutic target in NHL. The results offer additional evidence for the immunomodulatory role of PD-L1 in circulating lymphocytes, providing a rationale for further investigations into immunological dysfunctions resulting from NHL. PD-L1+ lymphocytes could be employed as a biomarker to assess the effectiveness of immune systems and predict illness in patients with NHL.

Prognostic value of prognostic nutritional index on extranodal natural killer/T-cell lymphoma patients: A multicenter propensity score matched analysis of 1022 cases in Huaihai Lymphoma Working Group

Prognostic nutritional index (PNI), comprised of serum albumin level and lymphocyte count, is associated with the prognosis of several malignant diseases, while the prognostic value of PNI in extranodal natural killer/T cell lymphoma, nasal type (ENKTL) remains unclear. This retrospective multicenter study aimed to investigate the value of PNI in predicting the prognosis of newly diagnosed ENKTL patients by using propensity score matched analysis (PSM). A total of 1022 newly diagnosed ENKTL patients were retrieved from Huaihai Lymphoma Working Group and clinicopathological variables were collected. MaxStat analysis was used to calculate the optimal cut-off points of PNI and other continuous variables. The median age at diagnosis was 47 years and 69.4% were males, with the 5-year OS of 71.7%. According to the MaxStat analysis, 41 was the optimal cut-off point for PNI. The Pseudo R2 before matching was 0.250, and it decreased to less than 0.019 after matching. Confounding factors of the two groups were well balanced after PSM. Multivariable analysis revealed that PNI, Korean Prognostic Index (KPI), eastern cooperative oncology group performance status (ECOG PS), the prognostic index of natural killer lymphoma (PINK) and hemoglobin were independent prognostic factors for ENKTL. The results of subgroup analysis demonstrated that patients with low PNI could predict worse prognosis and re-stratify patients in ECOG PS ≥ 2, EBER-positive, the International Prognostic Index (IPI) (HIR + HR), and PINK (HR) groups. PNI combined with IPI, PINK and KPI could improve the prediction efficiency. In conclusion, PNI could accurately stratify the prognosis of ENKTL by PSM analysis and patients with low PNI had poorer prognosis.

Iterated cross validation method for prediction of survival in diffuse large B-cell lymphoma for small size dataset

Efforts have been made to improve the risk stratification model for patients with diffuse large B-cell lymphoma (DLBCL). This study aimed to evaluate the disease prognosis using machine learning models with iterated cross validation (CV) method. A total of 122 patients with pathologically confirmed DLBCL and receiving rituximab-containing chemotherapy were enrolled. Contributions of clinical, laboratory, and metabolic imaging parameters from fluorine-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scans to the prognosis were evaluated using five regression models, namely logistic regression, random forest, support vector classifier (SVC), deep neural network (DNN), and fuzzy neural network models. Binary classification predictions for 3-year progression free survival (PFS) and 3-year overall survival (OS) were conducted. The 10-iterated fivefold CV with shuffling process was conducted to predict the capability of learning machines. The median PFS and OS were 41.0 and 43.6 months, respectively. Two indicators were found to be independent predictors for prognosis: international prognostic index and total metabolic tumor volume (MTVsum) from FDG PET/CT. For PFS, SVC and DNN (both with accuracy 71%) have the best predictive results, of which outperformed other algorithms. For OS, the DNN has the best predictive result (accuracy 76%). Using clinical and metabolic parameters as input variables, the machine learning methods with iterated CV method add the predictive values for PFS and OS evaluation in DLBCL patients.

Targeted sequencing reveals the relationship between mutations and patients' clinical indicators, blood cell counts and early progression in diffuse large-B cell lymphoma

In the current study, we assessed the relationship between mutations and the blood cell counts and early progression of patients with diffuse large-B cell lymphoma (DLBCL). A total of 109 patients with newly diagnosed DLBCL were included in this study. UBE2A mutation was only found in patients with bone marrow involvement. The mutations of ZNF608, SF3B1, DTX1, and NCOR2 were related to blood cell counts. NCOR2 mutations were only detected in patients of the noncomplete response group (PR + SD + PD). In addition, the mutations of ATM, BTG2, TBL1XR1, and TP53 were linked to lower PFS/OS rate, while SGK1, SCOS1, and NFKBIE were related to higher PFS/OS rate. Importantly, we identified that Ann Arbor stage (III-IV), B symptoms, absolute lymphocyte count (ALC) abnormity, and MTOR mutation were the four independent influencing factors of the 12-month progression of DLBCL patients. Overall, this study revealed that mutations were associated with the early progression of DLBCL.

The pretreatment platelet count predicts survival outcomes of diffuse large B-cell lymphoma: An analysis of 1007 patients in the rituximab era

BACKGROUND

The prognostic value of platelet count in diffuse large B-cell lymphoma (DLBCL) has not been extensively investigated. We aimed to examine the association of pretreatment platelet count with disease features, and further examine the prognostic significance of platelet count in DLBCL treated with the R-CHOP regimen.

METHODS

Patients with DLBCL diagnosed between Jan 1 st, 2005 and Dec 31 st, 2018 at Cancer Hospital, Chinese Academy of Medical Sciences were retrospectively analyzed. Propensity score matching (PSM) was used to balance confounding factors.

RESULTS

A total of 1007 eligible patients who received frontline R-CHOP or R-CHOP-like regimens were included in this study. The optimal cutoff value of platelet count was 157 × 10⁹/L, as determined by the Maximally Selected Rank Statistics method. Patients with the platelet count ≤157 × 10⁹/L had significantly inferior overall survival (OS) (5-year OS, 44.4 % vs. 74.9 %, P < 0.001) and progression-free survival (PFS) (5-year PFS, 35.5 % vs. 65.9 %, P < 0.001) than those with the platelet count >157×10⁹/L. Multivariate analyses showed that pretreatment platelet count ≤ 157 × 10⁹/L was an adversely independent prognostic factor for OS (hazard ratio [HR] 1.960, 95 % confidence interval [CI] 1.418-2.709, P<0.001) and PFS (HR 1.443, 95 %CI 1.080-1.927, P = 0.013). The PSM analysis and subgroup analyses further confirmed the significantly negative impact of low platelet count on OS and PFS.

CONCLUSION

The pretreatment platelet count may be a simple, cost-effective and useful prognostic factor in DLBCL patients treated with frontline R-CHOP regimens. Further investigation is warranted to elucidate the biologic mechanism underlying the prognostic significance of platelet count in DLBCL.

Normal Absolute Monocyte Count in Combination with Normal/High Absolute Lymphocyte Count at the Time of Relapse is Associated with Improved Survival in Patients with Early Relapsed Acute Myeloid Leukemia

This study aimed to examine the prognostic significance of peripheral absolute monocyte count (AMC) in combination with absolute lymphocyte count (ALC) at the time of relapse in a cohort of 57 patients with early relapsed (first complete remission <12 months) acute myeloid leukemia (AML). Both univariate and multivariate Cox proportional hazard regression analyses revealed that normal AMC in combination with normal/high ALC (versus low/high AMC in combination with low ALC) was significantly associated with improved OS. We concluded that the combination of AMC and ALC could be used as a prognostic marker for survival outcomes in early relapsed AML.

Dynamic changes in peripheral blood lymphocyte subset counts and functions in patients with diffuse large B cell lymphoma during chemotherapy

Background

This study aimed to analyze the lymphocyte subsets, their activities and their dynamic changes during immunochemotherapy in patients newly diagnosed with diffuse large B cell lymphoma (DLBCL).

Methods

Patients with DLBCL (n = 33) were included in the present study. Their peripheral lymphocyte subsets, phenotypes and functions were detected using flow cytometry. The dynamic results of lymphocyte activities were available for 18 patients.

Results

Compared with healthy controls (HCs), the counts of CD3⁺, CD4⁺, and CD8⁺ T cells as well as those NK cells decreased in patients newly diagnosed with DLBCL, mainly attributed to patients with high risk of prognosis assessed by International Prognostic Index (IPI) score. Lymphocyte counts didn’t present significant difference between high risk (IPI scores 3–5) and low risk patients (IPI scores 0–2), but CD4⁺ T cells and CD8⁺ T cells expressed higher levels of CD28 and HLA-DR, respectively, in patients with IPI score ranging from 3 to 5. Patients at high risk harbored higher percentage of regulatory T cells (Tregs), and their CD4⁺ and CD8⁺ T cells produced lower levels of IFN-γ, reflecting an impaired cellular immune response. The dynamic changes of lymphocyte numbers and functions during treatment were further investigated. Total counts of CD3⁺, CD4⁺, CD8⁺ T and NK cells progressively decreased because of the cytotoxicity of chemotherapy and then gradually recovered after six cycles treatment (rituximab combined with cyclophosphamide, doxorubicin, vincristine and prednisone, R-CHOP). The functions of CD4⁺ and CD8⁺ T cells recovered by the end of two cycles R-CHOP treatment, although NK cell function was not significantly affected throughout treatment. These results suggest that the counts and functions of lymphocytes are significantly decreased in patients with DLBCL, particularly those of CD4⁺ and CD8⁺ T cells.

Conclusions

The absolute counts and functions of CD4⁺, CD8⁺ T cells, which were significantly lower in patients with DLBCL, gradually recovered after effective treatment. Therefore, combined detection of T cell counts and functions are critically important for administering effective personalized immunotherapy as well as for identifying new prognostic markers or DLBCL.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12935-021-01978-w.

Prognostic models in primary central nervous system lymphoma patients: A systematic review

Over the last decade, several prognostic models have been proposed for primary central nervous system lymphoma (PCNSL), but consensus on the optimal model for these patients is absent or lacking. This study aims to review available prognostic models for PCNSL and discuss their prognostic features. A comprehensive literature search performed in Pubmed/Embase identified ten studies with a variable number of analysed patients (range 32-3453), which proposed 12 prognostic models. Age and performance status were the most important prognostic factors in PCNSL and an integral part of the majority of the proposed models. However, there is no universally accepted prognostic model for PCNSL owning to a number of limitations such as a small number of patients, limited samples obtained for genetic analysis, retrospective nature of studies, single centre studies, and lack of validation. Future multicentre studies are necessary to determine the optimal prognostic model for PCNSL by combining different prognostic markers of significance.

Validation and comparison of prognostic values of GNRI, PNI, and CONUT in newly diagnosed diffuse large B cell lymphoma

Diffuse large B cell lymphoma (DLBCL) is the most common type of aggressive non-Hodgkin lymphoma. Emerging evidence indicates that poor nutritional status determined with nutritional indices such as geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI), and controlling nutritional status score (CONUT) was associated with poor prognosis of DLBCL. We conducted this multicenter retrospective study to validate and compare prognostic values of the three indices in 615 newly diagnosed DLBCL patients. The overall survival (OS) in patients with poor nutritional status determined with each of these nutritional indices were significantly inferior compared with that in those without nutritional risks (5-year OS in patients with GNRI < 95.7 and GNRI ≥ 95.7 were 56.4% and 83.5%, P < 0.001; PNI < 42.4 and PNI ≥ 42.4 were 56.1% and 81.0%, P < 0.001; CONUT > 4 and CONUT ≤ 4 were 53.1% and 77.1%, P < 0.001). GNRI and CONUT were independent prognostic predictors for OS (GNRI < 95.7, hazard ratio [HR] 1.83, 95% confidence interval [CI] 1.22-2.74, P = 0.0032; CONUT > 4, HR 1.53, 95% CI 1.05-2.23, P = 0.028) after multivariate analyses. Nutritional status determined with GNRI affected OS more strongly in the patients with nongerminal center B cell-like (nonGCB) DLBCL compared with that in those with GCB-type DLBCL. In conclusion, baseline poor nutritional status determined based on GNRI or CONUT was an independent risk factor of newly diagnosed DLBCL, and GNRI was also useful as an independent prognostic factor for patients with nonGCB-type DLBCL.

A low lymphocyte-to-monocyte ratio is an independent predictor of poorer survival and higher risk of histological transformation in follicular lymphoma

The lymphocyte-to-monocyte ratio (LMR) is a prognostic factor in different neoplasms, but its potential importance in follicular lymphoma (FL) is not well defined. We studied 384 FL patients for which the LMR was available at diagnosis. Baseline features and outcomes were compared between patients with an LMR ≤/>2.5. The 76 patients (20%) who had an LMR ≤2.5 were older and had a higher tumor burden. A low LMR was predictive of a lower 10-y progression-free survival (32 vs. 55%, p = .001) and overall survival (35 vs. 78%, p < .0001; HR = 2.3, p = .003 in a 6-element multivariable model). A low LMR was also an independent risk factor for histological transformation (11 vs. 6% at 10 years, p = .01). Likewise, patients with a low LMR had a higher rate of second malignancies. The potential utility of this widely available parameter and its contribution to well-established prognostic scores need to be explored in independent, prospective series.

Statistical Challenges in Development of Prognostic Models in Diffuse Large B-Cell Lymphoma: Comparison Between Existing Models - A Systematic Review

Background and Aim

Based on advances in the diagnosis, classification, and management of diffuse large B-cell lymphoma (DLBCL), a number of new prognostic models have been proposed. The aim of this study was to review and compare different prognostic models of DLBCL based on the statistical methods used to evaluate the performance of each model, as well as to analyze the possible limitations of the methods.

Methods and Results

A literature search identified 46 articles that proposed 55 different prognostic models for DLBCL by combining different clinical, laboratory, and other parameters of prognostic significance. In addition, six studies used nomograms, which avoid risk categorization, to create prognostic models. Only a minority of studies assessed discrimination and/or calibration to compare existing models built upon different statistical methods in the process of development of a new prognostic model. All models based on nomograms reported the c-index as a measure of discrimination. There was no uniform evaluation of the performance in other prognostic models. We compared these models of DLBCL by calculating differences and ratios of 3-year overall survival probabilities between the high- and the low-risk groups. We found that the highest and lowest ratio between low- and high-risk groups was 6 and 1.31, respectively, while the difference between these groups was 18.9% and 100%, respectively. However, these studies had limited duration of follow-up and the number of patients ranged from 71 to 335.

Conclusion

There is no universal statistical instrument that could facilitate a comparison of prognostic models in DLBCL. However, when developing a prognostic model, it is recommended to report its discrimination and calibration in order to facilitate comparisons between different models. Furthermore, prognostic models based on nomograms are becoming more appealing owing to individualized disease-related risk estimations. However, they have not been validated yet in other study populations.

Improving the international prognostic index score using peripheral blood counts: Results of a large multicenter study involving 520 patients with diffuse large B cell lymphoma

The main purpose of this study was to assess whether it is possible to improve the prognostic impact of international prognostic index (IPI) score by combining it with peripheral blood counts. Thus, we evaluated the prognostic power of lymphocyte, neutrophil, and monocyte counts in 520 patients with diffuse large B cell lymphoma treated with R‐CHOP, confirming that these parameters have a strong impact on overall survival (OS). Using revised IPI (R‐IPI), 44% of patients were categorized as poor‐risk and showed an OS at 5 years of 46%. As OS at 5 years of the 520 patients is 67%, it is clearly evident that R‐IPI tends to overestimate the proportion of patients with poor prognosis. Accordingly, in an attempt to improve the discriminating power of R‐IPI, we evaluated and compared three different scores by combining the neutrophil lymphocyte ratio (NLR) and absolute monocyte count (AMC) with the following values: (a) IPI score 3‐5, (b) age > 60 years and performance status, (c) age  ≥ 65 years and LDH > ULN. The three indexes studied, had a similar 5 years OS for the high‐risk group (46%‐52%), but the proportion of patients classified as poor‐risk were 37%, 20%, and 32%, respectively, which are lower than 44% identified with R‐IPI. Thus, while R‐IPI overestimates the number of high‐risk patients, after applying our models, it is possible to recognize patients who are truly at high‐risk. Of the three scores, the most accurate appears to be that based on NLR, AMC, LDH > ULN and age ≥ 65 years, which identifies 32% of high‐risk patients, correlating well with what is seen in clinical practice.

Prognostic Significance of Absolute Lymphocyte Count, Absolute Monocyte Count, and Absolute Lymphocyte Count to Absolute Monocyte Count Ratio in Follicular Non-Hodgkin Lymphoma

INTRODUCTION

Recently, the lymphocyte to monocyte ratio (LMR) has been proposed as an easily determinable prognostic factor in patients with cancer, including lymphomas. The objective of this study was the evaluation of the impact of baseline absolute lymphocyte count (ALC), absolute monocyte count (AMC), and the LMR on the treatment response and prognosis in follicular lymphoma (FL).

PATIENTS AND METHODS

The data of 100 patients with a FL variant, admitted and treated between January 2009 and June 2018, were analyzed.

RESULTS

The area under the receiver operator characteristic curve and cutoff values of ALC, AMC, and LMR for discrimination between survival times using receiver operating characteristic curves showed 0.57 × 10⁹/L as the most discriminative ALC cutoff value, 1.235 ×10⁹/L as the most discriminative AMC cutoff value, and 1.63 as the most discriminative LMR cutoff value. Progressive disease and stable disease after first-line therapy and mortality rate were significantly associated with lower ALC, higher AMC, and higher LMR. Shorter overall survival (OS) was significantly associated with patients with lower ALC when compared with those having higher ALC. Shorter OS and progression-free survival (PFS) were significantly associated with higher AMC when compared with those having lower AMC. Shorter OS and PFS were significantly associated with lower LMR when compared with those having higher LMR. High-risk Follicular Lymphoma International Prognostic Index as well as low LMR were considered as risk factors for prediction of OS in all the studied patients with FL in univariate analysis and multivariate analysis.

CONCLUSION

ALC, AMC, and LMR at diagnosis are simple indices, which reflect the host systemic immunity and can predict the clinical outcomes in FL.

New prognosis score including absolute lymphocyte/monocyte ratio, red blood cell distribution width and beta-2 microglobulin in patients with diffuse large B-cell lymphoma treated with R-CHOP: Spanish Lymphoma Group Experience (GELTAMO)

The International Prognostic Index (IPI) is the most widely used score for non-Hodgkin lymphoma but lacks the ability to identify a high-risk population in diffuse large B-cell lymphoma (DLBCL). Low absolute lymphocyte count and high monocytes have proved to be unfavourable factors. Red-cell distribution width (RDW) has been associated with inflammation and beta-2 microglobulin (B2M) with tumour load. The retrospective study included 992 patients with DLBCL treated with R-CHOP. In the multivariate analysis, age, Eastern Cooperative Oncology Group performance status (ECOG-PS), stage, bulky mass, B2M, RDW, and lymphocyte/monocyte ratio (LMR) were independently related to progression-free survival (PFS). A new prognosis score was generated with these variables including age categorized into three groups (0, 1, 2 points); ECOG ≥ 3-4 with two; stage III/IV, bulky mass, high B2M, LMR < 2·25 and RDW > 0·96 with one each; for a maximum of 9. This score could improve the discrimination of a very high-risk subgroup with five-year PFS and overall survival (OS) of 19% and 24% versus 45% and 59% of R (revised)-IPI respectively. This score also showed greater predictive ability than IPI. A new score is presented including complete blood cell count variables and B2M, which are readily available in real-life practice without additional tests. Compared to R-IPI, it shows a more precise high-risk assessment and risk discrimination for both PFS and OS.

A better prediction of progression-free survival in diffuse large B-cell lymphoma by a prognostic model consisting of baseline TLG and %ΔSUVmax

In the era of rituximab, the International Prognostic Index (IPI) has been inefficient in initial risk stratification for patients with R‐CHOP‐treated diffuse large B‐cell lymphoma (DLBCL). To estimate the predictive values of PET/CT quantitative parameters and three prognostic models consisting of baseline and interim parameters for three‐year progression‐free survival (PFS), we conducted an analysis of 85 patients in China with DLBCL underwent baseline and interim PET/CT scans and treated at the Department of Hematology of Peking University Third Hospital from November 2012 to November 2017. The PET/CT parameters, viz. the baseline and interim values of standardized uptake value (SUV_max), total metabolic tumor volume (TMTV), and total lesion glycolysis (TLG), and their rates of change, were analyzed by a receiver operating characteristics curve, Kaplan‐Meier analysis, and log‐rank test. Besides, the National Comprehensive Cancer Network International Prognostic Index (NCCN‐IPI) was also included in the multivariate Cox hazards model. Owing to the strong correlation between TMTV and TLG at baseline and interim (Pearson's correlation coefficient, r = 0.823, P‐value = 0.000, and 0.988, P‐value = 0.000, respectively), only TLG was included in the multivariate Cox hazards model, where TLG₀ > 1036.61 g and %ΔSUV_max < 86.02% showed predictive value independently (HR = 10.42, 95% CI 2.35‐46.30, P = 0.002, and HR = 4.86, 95% CI 1.27‐18.54, P = 0.021, respectively). Replacing TLG in the equation, TMTV₀ and TMTV₁ both showed significantly predictive abilities like TLG (HR = 8.22, 95% CI 1.86‐32.24, P = 0.005, and HR = 2.96, 95% CI 1.16‐7.54, P = 0.023, respectively). After dichotomy, NCCN‐IPI also gave a significant performance (P = 0.035 and P = 0.010, respectively, in TLG and TMTV models). The baseline variables, that is, TMTV₀, TLG₀ and dichotomized NCCN‐IPI, and the interim variables TMTV₁ and %ΔSUV_max, presented independent prognostic value for PFS. In prognostic model 2 (TLG₀ + %ΔSUV_max), the group with TLG₀ > 1036.61 g and %ΔSUV_max < 86.02% recognized 19 (82.6%) of the relapse or progression events, which showed the best screening ability among three models consisting of baseline and interim PET/CT parameters.

The neutrophil/lymphocyte ratio ≥3.5 is a prognostic marker in diffuse large B-cell lymphoma: a retrospective analysis from the database of the Italian regional network 'Rete Ematologica del Lazio per i Linfomi' (RELLI)

In solid tumors and lymphomas, the neutrophil/lymphocyte (N/L) ratio at diagnosis has been shown to be a prognostic factor. The aim of our study was to validate the originally reported N/L ratio cut-point of 3.5 in patients with diffuse large B-cell lymphoma (DLBCL) registered in an Italian real-life database. The prognostic role of the N/L ratio at diagnosis on event-free survival (EFS) and overall survival (OS) was assessed in 505 patients with DLBCL. Patients with an N/L ratio <3.5 (n = 249) had a 4-year EFS probability of 76% and OS probability of 86%, significantly higher than the 4 year EFS rate of 48% and OS rate of 64% in patients with N/L ratio ≥3.5 (n = 256, both p<.0001). The N/L ratio was an independent prognostic factor in the multivariate analysis including the IPI score, and could separate patients with a low/intermediate risk IPI (IPI <3).

Peripheral blood lymphocyte subsets of newly diagnosed DLBCL patients and their dynamic changes with rituximab based immunochemotherapy

The purpose of this study was to explore lymphocyte subsets of newly diagnosed DLBCL patients, and dynamics along with treatment of R-CHOP. A total of 40 DLBCL patients were enrolled. ALC of grade III-IV DLBCL patients was significantly lower than that of health controls (1.33*10E9/L vs 1.89*10E9/L, p = 0.003), mostly attributing to decreased CD4+ cells (p = 0.012). And serum LDH level of patients was negatively correlated with ALC (p = 0.033). ALC progressively decreased along with treatment, so as to CD3+, CD4+ and CD19+ cells, while proportion of CD4+ and CD8+ cells increased significantly after two cycles' treatment (p < 0.05). CR of ALC low (<1.18*10E9/L) group was lower than that of ALC high group (37.5% vs 73.3%), though not statistically significant (p = 0.179).

Lymphopenia in Cancer Patients and its Effects on Response to Immunotherapy: an opportunity for combination with Cytokines?

Quantitative lymphocyte alterations are frequent in patients with cancer, and strongly impact prognosis and survival. The development of cancers in immunosuppressed patients has demonstrated the contribution of different T cell populations, including CD4⁺ cells, in the control of cancer occurrence.Whereas absolute numbers of neutrophils, platelets and red blood cells are routinely monitored in clinic following treatments, because of possible short-term complications, absolute lymphocyte counts (ALC), their subpopulations or diversity (phenotype, TCR) are rarely analyzed and never used to choose therapy or as prognostic criteria. The recent identification of immune checkpoint inhibitors (ICPi) as powerful therapeutic agents has revitalized immunotherapy of cancer in a broader group of diseases than anticipated. The status of the immune system is now recognized as an important biomarker for response to these novel treatments. Blood ALC values, along with tumor infiltration by CD8⁺T cells, and ICPi and ICPi-ligand expression, are likely to be a potential marker of sensitivity to anti-ICPi therapy.In this article, we review the current knowledge on the incidence and significance of lymphopenia in cancer patients, and discuss therapeutic strategies to restore lymphocyte numbers.

Prognostic nomogram incorporating inflammatory cytokines for overall survival in patients with aggressive non-Hodgkin's lymphoma

BACKGROUND

This study aimed to investigate the association of pre-treatment inflammatory status with survival time and to develop a prognostic nomogram incorporating inflammatory cytokines in non-Hodgkin's lymphoma.

METHODS

A total of 228 patients with diffuse large B-cell lymphoma (DLBCL) received R-CHOP-based regimens from a prospective randomized study (NCT01852435) were included as a training cohort. Other cohorts of 886 lymphoma patients were served as validation cohorts. Lymphocyte-monocyte ratio (LMR), serum levels of soluble interleukin s(IL)-2R, IL-6, IL-8, IL-10 and tumor necrosis factor-α (TNF-α), were assessed before treatment. Least absolute shrinkage and selection operator (LASSO) regression were used to select variables for nomogram of overall survival (OS). The predictive accuracy of the nomogram was determined by concordance index (C-index).

FINDINGS

The nomogram included lactate dehydrogenase (LDH), sIL-2R, TNF-α and decreased LMR. The C-index of the nomogram for OS prediction were range from 0.61 to 0.86 for training cohort of DLBCL and validation cohorts of DLBCL, PTCL, NKTCL and ASCT, which were superior to the predictive power of International Prognostic Index (IPI, 0.67 to 0.84) or NCCN-IPI (0.59 to 0.78), but not in those of indolent lymphoma like FL and MALT.

INTERPRETATIONS

The nomogram incorporating inflammatory cytokines provides a useful tool for risk stratification in aggressive non-Hodgkin's lymphomas. FUND: National Natural Science Foundation of China, the Shanghai Commission of Science and Technology, Multicenter Clinical Research Project by Shanghai Jiao Tong University School of Medicine, Clinical Research Plan of SHDC, and Chang Jiang Scholars Program.

The prognostic role of end of treatment FDG-PET-CT in patients with diffuse large B cell lymphoma can be improved by considering it with absolute monocyte count at diagnosis

It is well established that some patients with diffuse large B-cell lymphoma (DLBCL) and the negative end of treatment PET-CT (EOT-PET-CT) will relapse, while a proportion with positive uptake can still obtain long-term EFS. We reviewed data of 200 consecutive, previously untreated patients with DLBCL recorded in Italy and Israel between 2007 and 2015. We found that patients with negative EOT-PET-CT with AMC > 630/mmc have a 3-years EFS of 72%, compared to those with AMC ≤ 630/mmc that have an EFS of 84%. Furthermore, considering patients with positive EOT-PET-CT, those with AMC > 630/mmc have a 3-years EFS of 8%, while those with AMC ≤ 630/mmc have an EFS of 38%. Thus, it appears that combining the gold standard for response evaluation EOT-PET-CT with a simple and inexpensive parameter like AMC at diagnosis, further improves prognostication in DLBCL. Applying this simple method can be useful for all doctors working in lymphoma clinical practice.

Prognostic Significance of Pretreatment Neutrophil/Lymphocyte Ratio and Platelet/Lymphocyte Ratio in Patients with Diffuse Large B-Cell Lymphoma

It is generally believed that there is correlation between cancer prognosis and pretreatment PLR and NLR. However, there are limited data about their role in diffuse large B cell lymphoma (DLBCL). This study aims to determine the prognostic value of pretreatment PLR and NLR for patients who have DLBCL. The associations between clinical characteristics and NLR and PLR were evaluated among 182 DLBCL patients from January 2005 to June 2016. The optimal cutoff values for high PLR (⩾150) and NLR (⩾2.32) in prognosis prediction were determined. The effect of NLR and PLR on survival was evaluated through multivariate Cox regression analysis, univariate analysis, and log-rank test. According to the evaluation results, patients with high NLR and PLR had significantly shorter OS (P=0.026 and P=0.035) and PFS (P=0.024 and P=0.022) compared with those who have low PLR and NLR. On multivariate analyses, IPI>2, elevated LDH, and PLR⩾2.32 were prognostic factors for OS and PFS in DLBCL patients. Therefore, we demonstrated that high PLR and NLR predicted adverse prognostic factors in DLBCL patients.

Available prognostic models for risk stratification of diffuse large B cell lymphoma patients: a systematic review

The International Prognostic Index (IPI) has been used for risk stratification for a long time in diffuse large B cell lymphoma (DLBCL). Based on new clinical and biological prognostic markers, many new prognostic models have been described. This review aims to present the progress in development and validation of these prognostic models. A comprehensive literature review was performed to identify studies that proposed a new prognostic model in DLBCL. A total of 38 studies met the inclusion criteria. The IPI, revised IPI (R-IPI), and National Comprehensive Cancer Network (NCCN)-IPI were the most studied prognostic indexes, externally validated and commonly used to compare to other models. Despite an increasing number of prognostic models have been proposed lately, most of them lack external validation. Further studies, that combine biological and clinical markers with prognostic significance, are needed to determine the optimal prognostic tool for more personalized treatment approach to DLBCL patients.

[Efficacy and prognostic analysis of 98 cases of relapsed/refractory diffuse large B-cell lymphoma treated with second-line regimens]

Objective: To evaluate the efficacy and prognostic factors of second-line regimens for patients with relapsed/refractory diffuse large B-cell lymphoma (DLBCL). Methods: A retrospective analysis was performed in 98 patients with relapsed/refractory DLBCL who were treated with salvage regimens in Rui Jin Hospital from July 2004 to June 2016. Overall response rate (ORR) was evaluated after all treatment finished. Overall survival (OS) was analyzed by Kaplan-Meier method and multivariate by Cox proportional hazards models. Results: There were 60 males and 38 females with a median age of 55.5 (15-77) years. 48 (49.0%) patients responded to chemotherapy, and 32 (32.7%) patients achieved complete remission (CR). Factors affecting ORR were progression disease or refractory/relapse status less than 12 months after diagnosis (χ(2)=5.878, P=0.015) , IPI intermediate-high/high risk (χ(2)=5.930, P=0.015) and NCCN-IPI intermediate-high/high risk (χ(2)=4.961, P=0.026). No significance difference was observed in ORR between germinal-center B-cell type (GCB) and non-GCB (χ(2)=0.660, P=0.417). One-year and 2-year OS rates were 51.0% and 31.5%, with median OS at 13.17 months, respectively. Multivariate analysis indicated NCCN-IPI intermediate-high/high risk[HR=2.176 (95%CI 1.338-3.538) , P=0.002] and response to chemotherapy [HR=0.273 (95%CI 0.165-0.452) , P<0.001] were independent prognostic factors for survival. Conclusion: NCCN-IPI is a valid predictor of outcome for patients with relapse/refractory DLBCL. Response to chemotherapy is an independent prognostic factor for better survival.

Prognostic implication of leucocyte subpopulations in diffuse large B-cell lymphoma

BACKGROUND

Recent studies have suggested that variables related to host adaptive immunity and the tumor microenvironment may predict the outcome in patients with non-Hodgkin's lymphoma. This study was undertaken to determine the prognostic value of peripheral blood leucocyte subpopulations in diffuse large-B-cell lymphoma patients.

METHODS

We prospectively analyzed the 16 leukocyte subpopulations using Cytodiff flow cytometric technique in a cohort of 45 diffuse large-B-cell lymphoma patients at a single institution between February and December 2014. The Cox proportional hazards model was used to evaluate prognostic factors for overall survival and progression free survival.

RESULTS

Diffuse large-B-cell lymphoma patients had decreased cytotoxic and non-cytotoxic NK&T cells as well as increased CD16+ monocytes, CD16- monocytes and mature neutrophils. The decreased CD16- monocyte/CD16+ monocyte ratio and increased mature neutrophil/cytotoxic NK&T cell ratio were related to poor progression-free and overall survival outcome in single and multivariate analysis. The co-constructed model using International Prognostic Index and mature neutrophil/cytotoxic NK&T cell ratio can also help discriminate the clinical outcome.

CONCLUSIONS

The decreased CD16-monocyte/CD16+monocyte ratio and increased mature neutrophil/cytotoxic NK&T cell ratio predict poor prognosis in diffuse large-B-cell lymphoma patients. This finding provides a strong rationale for the study of cellular immunotherapy in B-cell lymphoma.

Prognostication of diffuse large B-cell lymphoma in the molecular era: moving beyond the IPI

Diffuse large B-cell lymphoma (DLBCL) is a heterogeneous disease with variable outcomes. Despite the majority of patients being cured with combination chemoimmunotherapy, up to 30% eventually succumb to the disease. Until recently, baseline prognostic assessment has centred on the International Prognostic Index (IPI), although this index is yet to impact strongly on treatment choice. Molecular features such as cell of origin, MYC and BCL-2 genetic alterations and protein overexpression were identified over a decade ago, yet their prognostic value is still not fully elucidated. Adding complexity are the plethora of new clinical, biological and molecular prognostic markers described in the recent literature, most of which lack independent validation, likely act as surrogate markers for those already in common use and have yet to substantially impact on therapeutic decision making. This review comprehensively assesses the value of individual prognostic markers in the clinical setting and their potential to predict response to novel agents, and ways to optimise their use in future research.

Prognostic value of expression of nuclear factor kappa-B/p65 in non-GCB DLBCL patients

Purpose

We estimated the expression of nuclear factor kappa B/p65 in non-germinal center B-cell-like subtype diffuse large B-cell lymphoma, to investigate its relationship to clinicopathological features, and to further evaluate its prognostic value and clarify its impact on survival.

Results

Among the 49 patients enrolled in this study, 14 (28.6%) had positive p65 expression. The negative p65 group had significantly better survival compared to the positive p65 group in terms of both the 3-year estimated OS (91.2% vs. 39.3%, p = 0.003) and PFS (75.6% vs. 26.5%, p = 0.002). In patients with 4 or more risk factors, p65 was an independent prognostic factor of OS (HR 5.99, 95%CI=1.39-25.75, p=0.016) and PFS (HR 4.01, 95%CI=1.15-14.00, p=0.029).

Materials and Methods

The expression of the NF-κB/p65 protein was deteremined by immunohistochemistry in 49 non-GCB DLBCL. Survival was assessed by the Kaplan–Meier method and Cox multivariate analysis. The median patient follow-up period was 24 months.

Conclusions

The expression of NF-κB/p65 has prognostic value in high risk non-GCB DLBCL, and it is a suitable target for the development of new therapies.

Absolute lymphocyte counts at end of induction correlate with distinct immune cell compartments in pediatric B cell precursor acute lymphoblastic leukemia

Several retrospective studies in children with B cell precursor (BCP) acute lymphoblastic leukemia (ALL) provided clinical evidence that higher absolute lymphocyte counts (ALC) early into treatment significantly correlated with improved relapse-free and overall survival. It still remains unknown, however, whether the predictive role of higher ALCs reflects general bone marrow recovery or a more specific attribute of immune function. To investigate this question, we implemented a prospective observational cohort study in 20 children with BCP ALL on day 29 (D29) of induction chemotherapy and immunophenotyped their lymphoid (T, B and natural killer cells) and myeloid (neutrophils, monocytes, dendritic cells) compartments. In a first evaluation of a cohort treated with Children's Oncology Group-based induction chemotherapy, the immune cell compartments were differentially depleted at D29. Neither gender, risk status, minimal residual disease, nor bone marrow recovery markers correlated with D29 ALC. In contrast, both CD3+ T cell and dendritic cell compartments, which did not correlate with age, significantly correlated with D29 ALC (p < 0.0001). In addition, subset complexity of cellular immune compartments was preserved at D29. This study reveals that D29 ALC significantly correlates with distinct immune cell compartments but not with bone marrow recovery markers, suggesting that higher D29 ALCs may contribute to leukemia control by inducing specific host immune activity.

Peripheral blood T cell alterations in newly diagnosed diffuse large B cell lymphoma patients and their long-term dynamics upon rituximab-based chemoimmunotherapy

The importance of T cell-dependent immune responses in achieving long-term cure of chemoimmunotherapy-treated cancer patients is underscored by the recently described "vaccinal effect" exerted by therapeutic mAbs. In accordance, pre- and post-therapy peripheral blood lymphopenia represents a well-established negative prognostic factor in DLBCL. We analyzed the phenotypic and functional (IFNγ production, and Granzyme B (GrzB) cytotoxic granule marker expression) profile of peripheral blood T lymphocyte subsets ("conventional" CD4+ and CD8+, FOXP3+CD25bright Treg, and "innate-like" CD56+) in DLBCL patients at diagnosis, and assessed the long-term impact of R-CHOP chemoimmunotherapy, in a prospective study. At diagnosis, DLBCL patients showed lower lymphocyte counts, due to selective decrement of CD4+ T (including Treg) and B lymphocytes. While all T cell subsets transiently decreased during therapy, CD4+ T cell and Treg remained significantly lower than controls, up to 1 year after R-CHOP. Phenotypically skewed profile of CD4+ and CD8+ T cell subsets associated with higher frequencies of IFNγ+ and GrzB+ cells at diagnosis, that transiently decreased during therapy, and re-attained persistently elevated levels, till up to 1 year after therapy. Differently, the pre-therapy elevated levels of circulating monocytes, and of plasma IL-6 and IL-10 rapidly normalized upon R-CHOP. In sum, we describe a quantitatively and functionally altered status of the peripheral blood T cell compartment in DLBCL patients at diagnosis, that persists long-term after tumor eradication, and it is only transiently perturbed by R-CHOP chemoimmunotherapy. Moreover, data suggest the association of selected T cell functional features with DLBCL phenotype, and with therapy outcome.

Prognostic significance of total metabolic tumor volume on 18F-fluorodeoxyglucose positron emission tomography/ computed tomography in patients with diffuse large B-cell lymphoma receiving rituximab-containing chemotherapy

Purpose

The purpose of this study was to determine the prognostic significance of metabolic parameters on pre-treatment ¹⁸F-fluorodeoxyglucose positron emission tomography/ computed tomography (FDG PET/CT), in patients with diffuse large B-cell lymphoma (DLBCL) receiving rituximab-containing therapy.

Materials and Methods

From September 2009 to December 2014, DLBCL patients who had received FDG PET/CT scans for staging were enrolled. The maximal standardized uptake value of tumor (SUVt) was recorded. The metabolic tumor volume (MTV) was the volume of lesion with an elevated SUV greater than 2.5. The total lesion glycolysis (TLG) was the sum of the products of MTV and mean SUV in all measured lesions. Univariate and multivariate analyses were used to assess the prognostic significance of maximal SUVt, total MTV, TLG and other clinical parameters.

Results

There were 118 patients enrolled in this study. The median follow-up time was 28.7 months. The 5-year progression-free survival (PFS) for patients with higher and lower total MTV was 32.3% and 66.0% respectively (p = 0.0001). The 5-year overall survival (OS) for patients with higher and lower total MTV was 34.3% and 69.9% respectively (p < 0.0001). Multivariate analysis revealed, besides IPI, that total MTV was independently predictive for PFS (HR: 2.31, 95% CI: 1.16 - 4.60, p = 0.0180) and OS (HR: 2.38, 95% CI: 1.12 - 5.04, p = 0.024). TLG and maximal SUV of tumor were not independent prognostic factors.

Conclusions

An elevated total MTV was a predictor for shorter PFS and OS in patients with DLBCL receiving rituximab-containing therapy, independent of IPI.

Associations between elevated pre-treatment serum cytokines and peripheral blood cellular markers of immunosuppression in patients with lymphoma

Higher ratios of the pre-treatment peripheral blood absolute lymphocyte (ALC) to absolute monocyte counts (AMC) are associated with improved outcomes in lymphoma. Conversely, elevated pre-treatment serum cytokines are associated with inferior outcomes. The relationship between pre-treatment serum cytokines and ALC/AMC ratios remains unknown. We studied twelve serum cytokines and the ALC/AMC ratios in 390 patients with untreated diffuse large B-cell, follicular, mantle cell, T-cell, and Hodgkin lymphoma. Different pre-treatment serum cytokine concentrations correlated with ALC, AMC, and ALC/AMC ratios depending on the lymphoma type. In the entire cohort (n = 390) lower ALC/AMC ratios modestly correlated with higher IL-2R (r = -0.36), IL-12 (r = -0.17), IP-10 (r = -0.23), and MIG (r = -0.32) concentrations (p < 0.001). Elevated IL-2R was independently associated with suppressed ALC (OR 2.69, 95% CI 1.77-4.07, p < 0.001), elevated AMC (OR 2.05, 95% CI 1.34-3.14, p < 0.001), and suppressed ALC/AMC ratios (OR 3.51, 95% CI 2.31-5.34, p < 0.001). Both elevated IL-2R (HR 2.27, 95% CI 1.48-3.49, p < 0.001) and suppressed ALC/AMC ratios (HR 1.53, 95% CI 1.03-2.28, p = 0.037) were independently associated with inferior overall survival. These data support the notion that elevated serum cytokines are immunosuppressive and provide further rationale to target the tumor microenvironment for therapeutic benefit.

High serum levels of soluble interleukin-2 receptor (sIL2-R), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF) are associated with adverse clinical features and predict poor outcome in diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma with heterogeneous outcomes. To improve accuracy of the international prognostic index score, new biological variables are being investigated. The aim of this study was to determine the prognostic significance of serum levels of different cytokines, namely soluble interleukin-2 receptor (sIL2-R), interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF). We analyzed 197 de novo DLBCL patients (91 M/106 F; median age 66 years) treated with immunochemotherapy in a single institution. Serum cytokine determination was performed with ELISA, using the upper normal values as cut-offs. sIL-2R, IL-6 and TNF were elevated in 133, 130 and 144 cases, respectively. Elevation of each of these cytokines correlated with worse performance status, presence of B symptoms, advanced stage, elevated LDH and β2-microglobulin (P<0.03) and lower complete remission rate (P<0.001). Elevated levels of serum sIL-2R and TNF were significantly associated with shorter progression-free (PFS) and overall survival (OS), while elevated IL-6 only with shorter PFS. Early death (<4months from diagnosis) strongly correlated with elevated cytokines. Determination of serum cytokines levels is simple and adds information regarding risk of early death, response to therapy, and outcome.

Pretreatment neutrophil/lymphocyte ratio but not platelet/lymphocyte ratio has a prognostic impact in multiple myeloma

BACKGROUND

We evaluated the prognostic significance of neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) in patients with multiple myeloma (MM).

METHODS

In total, we retrospectively analyzed 315 newly diagnosed MM patients and calculated NLR and PLR from the complete blood count of the untreated patients. We further assessed the role of pretreatment NLR and PLR on overall survival (OS) and progression-free survival (PFS).

RESULTS

Multiple myeloma patients with high NLR (≥2) experienced shorter OS (P=.02) and PFS (P=.01) compared with patients with low NLR (<2). Furthermore, among the patients with conventional chemotherapy, elderly patients, or patients with advanced stages, high NLR (≥2) was found to have a negative prognostic impact on OS and PFS. In the multivariate Cox analysis, we confirmed that the NLR was an independent prognostic factor for both OS and PFS (P=.000). But the differences in OS or PFS by PLR were not found in MM patients.

CONCLUSIONS

Our study suggests that NLR not PLR can be acted as an independent prognostic factor for analyzing the clinical outcome of MM patients.

Red blood cell distribution width as a simple negative prognostic factor in patients with diffuse large B-cell lymphoma: a retrospective study

Aim

To determine the prognostic value of baseline red blood cell distribution width (RDW) in diffuse large B cell lymphoma (DLBCL) patients.

Methods

Data from 81 DLBCL patients diagnosed from 2006 to 2013 at the University Hospital Center Osijek, Osijek, Croatia, were reviewed. We evaluated disease outcome, overall survival (OS) and event-free survival (EFS), and demographic, clinical and laboratory factors affecting outcome. Univariate analysis and Cox regression analysis were used.

Results

Median age of patients was 64 years, 29 were men (35.8%). Higher RDW levels (%) were found in patients with advanced Ann Arbor clinical stage (14.94 ± 1.82 vs 13.55 ± 1.54, P = 0.001) and in those with poor response to therapy (14.94 ± 1.82 vs 13.55 ± 1.54, P = 0.001). Patients with RDW>15% (cut-off was calculated by receiver operating characteristics) had significantly worse OS (median [range], 33 months [20-46] vs 74 months [65-82], P < 0.001) and EFS (27 months [15-40] vs 68 months [59-77], P < 0.001). Cox regression analysis showed that RDW>15% was an independent prognostic factor for OS (HR 3.654, 95% CI 1.128-11.836) and EFS (HR 2.611, 95% CI 1.012-6-739).

Conclusion

High baseline RDW is an independent prognostic marker of poor outcome in patients with DLBCL. RDW could be an easily available and inexpensive marker for the risk stratification in patients with DLBCL.

High levels of regulatory T cells in blood are a poor prognostic factor in patients with diffuse large B-cell lymphoma

OBJECTIVES

Host immunity likely plays a role in preventing progression of diffuse large B-cell lymphoma (DLBCL). Analysis of host immune cells may provide useful information for assessing prognosis or possibly clinical management.

METHODS

Peripheral blood samples from 77 patients with DLBCL and 30 healthy volunteers were analyzed using flow cytometry immunophenotyping. CBC counts, T-cell subsets, and dendritic cells (DCs) were detected, and the results were correlated with clinicopathologic characteristics.

RESULTS

Compared with healthy volunteers, patients with DLBCL had significantly higher leukocyte and monocyte counts (P < .001); higher percentages of neutrophils (P < .001), "natural" regulatory T cells (Tregs; CD3+Foxp3+, P < .001), and immature DCs (CD83-CD1a+, P = .005); and lower percentages of lymphocytes (P < .001) and helper T cells (P = .038). In univariate analysis, high neutrophil counts (≥6,000/μL, P = .014) and "induced" Tregs (CD4+CD25+, P = .026) were poor survival factors along with high International Prognostic Index scores (P < .001) and other high-risk clinical parameters. In multivariate analysis, high Tregs retained significance. Suppression of lymphocytes correlated with poor clinical factors; higher natural Tregs correlated with a lower CD4+/CD8+ ratio (P = .035) and more immature DCs (P = .055).

CONCLUSIONS

Changes in blood immune cells occur in patients with DLBCL. The results also support a suppressive role of Tregs in adaptive immunity and correlate with poor-risk prognostic factors.

[Usefulness of Clinicobiological Data Obtained Prior to Cervical Lymph Node Biopsy]

INTRODUCTION

We commonly use data obtained prior to cervical lymph node biopsy for the diagnosis of malignant lymphoma. Based on such data, we can confirm whether a biopsy should be performed in some cases. Currently, the parameters used to indicate a presurgery examination prior to biopsy have been very few. So, we retrospectively analyzed cases of cervical lymph node biopsy. Moreover, we examined the usefulness of clinicobiological data obtained prior to cervical lymph node biopsy to evaluate various factors related to the diagnosis of malignant lymphoma.

METHODS

This study included 77 patients for whom the initial diagnostic impression was malignant lymphoma before surgery. Of the 77 cases, 40 were diagnosed as having malignant lymphoma and 37 were diagnosed as having non-malignant lymphoma. We performed a case-controlled study to evaluate the differences in clinicobiological data between malignant and non-malignant lymphoma in terms of the following parameters: (1) age, (2) sex, (3) number of white blood cells, (4) white blood cell lymphocyte count, (5) percentage of white blood cell lymphocytes, (6) percentage of eosinophils (%), (7) percentage of monocytes (%), (8) atypical lymphocytes (%), (9) hemoglobin level, (10) lactate dehydrogenase level, (11) C-reactive protein level, (12) soluble interleukin-2 receptor (IL-2R) level, and (13) cytological findings. We used multivariate and univariate analyses to study the data statistically.

RESULTS

The following 5 factors were found to be significant in a Wilcoxon t-test for malignant lymphoma: percentage of white blood cell lymphocytes, sIL-2R level, age, white blood cell lymphocyte count, and cytological findings; these factors were also significant when examined using a Pearson χ2 test. The other factors did not differ significantly between the malignant and non-malignant lymphomas. The percentage of white blood cell lymphocytes and the cytological findings were identified as significant independent factors for the diagnosis of malignant lymphoma in a multivariate analysis, whereas the other factors were not found to be significant.

CONCLUSION

Based on the results of the univariate and multivariate analyses performed in the present study, the decline in the percentage of white blood cell lymphocytes and the cytological findings obtained prior to cervical lymph node biopsy are significant indicators of malignant lymphoma.

Neutrophil/Lymphocyte Ratio, Lymphocyte/Monocyte Ratio, and Absolute Lymphocyte Count/Absolute Monocyte Count Prognostic Score in Diffuse Large B-Cell Lymphoma: Useful Prognostic Tools in the Rituximab Era

The neutrophil/lymphocyte ratio (NLR), lymphocyte/monocyte ratio (LMR), and absolute lymphocyte count/absolute monocyte count prognostic score (ALC/AMC PS) have been described as the most useful prognostic tools for patients with diffuse large B-cell lymphoma (DLBCL). We retrospectively analyzed 148 Taiwanese patients with newly diagnosed diffuse large B-cell lymphoma under rituximab (R)-CHOP-like regimens from January 2001 to December 2010 at the Tri-Service General Hospital and investigated the utility of these inexpensive tools in our patients. In a univariate analysis, the NLR, LMR, and ALC/AMC PS had significant prognostic value in our DLBCL patients (NLR: 5-year progression-free survival [PFS], P = 0.001; 5-year overall survival [OS], P = 0.007. LMR: PFS, P = 0.003; OS, P = 0.05.

ALC/AMC PS

PFS, P < 0.001; OS, P < 0.001). In a separate multivariate analysis, the ALC/AMC PS appeared to interact less with the other clinical factors but retained statistical significance in the survival analysis (PFS, P = 0.023; OS, P = 0.017). The akaike information criterion (AIC) analysis produced scores of 388.773 in the NLR, 387.625 in the LMR, and 372.574 in the ALC/AMC PS. The results suggested that the ALC/AMC PS appears to be more reliable than the NLR and LMR and may provide additional prognostic information when used in conjunction with the International Prognostic Index.

Absolute Lymphocyte Count Recovery Independently Predicts Outcome in Childhood Acute Lymphoblastic Leukemia: Experience From a Tertiary Care Cancer Center of a Developing Country

BACKGROUND

Accurate risk stratification is essential for successful treatment outcome in childhood acute lymphoblastic leukemia. Early recovery of absolute lymphocyte count (ALC) during induction therapy is emerging as a reliable favorable prognostic indicator that may hold its relevance in resource-constraint settings.

MATERIALS AND METHODS

This is a retrospective chart review of medical records of 212 patients of acute lymphoblastic leukemia, aged less than 18 years, treated between January 1996 and December 2009. Time to lymphocyte recovery was analyzed with respect to various prognostic factors and survival and Martingale residuals were used to define ALC cut-offs.

RESULTS

High-risk disease characteristics including older age (10 y and older), National Cancer Institute high risk, and central nervous system disease at diagnosis were associated with delayed lymphocyte recovery. The 5-year event-free, relapse-free, and overall survival of patients with day 15 ALC of ≥ 500 cells/µL and day 29 ALC of ≥ 1000 cells/µL was 81.7% ± 4%, 86.4% ± 2.8%, 91.0% ± 3%, respectively, compared with those with delayed recovery (16.6% ± 5.6%, 19.3% ± 6.4%, 32.8% ± 7.2%, P < 0.001). In multivariate analysis both these ALC cut-offs retained their significance as prognostic variables of survival.

CONCLUSION

Our analysis revealed ALC to be an important independent predictor of treatment outcome and may provide key prognostic information in settings where minimal residual disease-based risk stratification is not feasible.

Prognostic roles of absolute monocyte and absolute lymphocyte counts in patients with advanced-stage follicular lymphoma in the rituximab era: an analysis from the FOLL05 trial of the Fondazione Italiana Linfomi

Recently, in an attempt to improve the discrimination power of the international prognostic index (IPI), patients with diffuse large B-cell lymphoma were evaluated to determine the prognostic roles of peripheral blood absolute monocyte count (AMC) and absolute lymphocyte count (ALC). Here, we analysed data of 428 patients with follicular lymphoma (FL) enrolled in a prospective, randomized trial (FOLL05 study) conducted by Fondazione Italiana Linfomi, to assess the impact of AMC and ALC on progression-free survival (PFS). All patients had been treated with one of three treatment combinations: (i) rituximab (R) plus cyclophosphamide, vincristine and prednisone; (ii) R plus cyclophosphamide, doxorubicin, vincristine and prednisone or (iii) R plus mitoxantrone and fludarabine. We showed that only AMC was a powerful predictor of PFS, and possibly overall survival, in patients with FL treated with combination chemotherapy regimens that contained R. The AMC can be used alone as a novel, simple factor that can predict survival outcome in patients with FL, independent of the immunochemotherapy regimen. It may therefore be widely used by clinicians, due to its simplicity and broad applicability. Additionally, it can be combined with other factors that determine the IPI or FLIPI, to increase the discriminating ability of these indices.

Diffuse large B-cell lymphoma: sites of extranodal involvement are a stronger prognostic indicator than number of extranodal sites in the rituximab era

The National Comprehensive Cancer Network (NCCN) International Prognostic Index (IPI) is an enhanced prognostic tool that has identified some specific extranodal sites as a poor prognostic factor. We retrospectively analyzed 148 Taiwanese patients with newly diagnosed diffuse large B-cell lymphoma receiving rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP)-like regimens from January 2001 to December 2010 at the Tri-Service General Hospital. In univarate analysis, ≥ 2 extranodal involved sites had no significant prognostic relevance (p = 0.108), although extranodal involvement of the lung/pleura, liver, lower urinary tract or bone marrow was a statistically significant poor prognostic factor (p < 0.001). In multivariate analysis, specific extranodal sites had a stronger predictive value for poor prognosis (relative risk 3.654, 95% confidence interval 1.514-8.815, p = 0.004) compared with the number of extranodal sites involved. This finding suggests that specific extranodal involved sites have prognostic value in the R era.

Tumor-associated and immunochemotherapy-dependent long-term alterations of the peripheral blood NK cell compartment in DLBCL patients

Natural Killer (NK) cells are a key component of tumor immunosurveillance and thus play an important role in rituximab-dependent killing of lymphoma cells via an antibody-dependent cellular cytotoxicity (ADCC) mechanism. We evaluated the phenotypic and functional assets of peripheral blood NK cell subsets in 32 newly-diagnosed diffuse large B-cell lymphoma (DLBCL) patients and in 27 healthy controls. We further monitored long-term modifications of patient NK cells for up to 12 months after rituximab-based immunochemotherapy. At diagnosis, patients showed a higher percentage of CD56^dim and CD16⁺ NK cells, and a higher frequency of GrzB⁺ cells in CD56^dim, CD56^bright, and CD16⁺ NK cell subsets than healthy controls. Conversely, DLBCL NK cell killing and interferon γ (IFNγ) production capability were comparable to those derived from healthy subjects. Notably, NK cells from refractory/relapsed patients exhibited a lower "natural" cytotoxicity. A marked and prolonged therapy-induced reduction of both "natural" and CD16-dependent NK cytotoxic activities was accompanied by the down-modulation of CD16 and NKG2D activating receptors, particularly in the CD56^dim subset. However, reduced NK cell killing was not associated with defective lytic granule content or IFNγ production capability. This study firstly describes tumor-associated and therapy-induced alterations of the systemic NK cell compartment in DLBCL patients. As these alterations may negatively impact rituximab-based therapy efficacy, our work may provide useful information for improving immunochemotherapeutic strategies.

Diffuse large B-cell lymphoma: optimizing outcome in the context of clinical and biologic heterogeneity

Although the majority of patients with diffuse large B-cell lymphoma (DLBCL) can be cured with standard rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), patients who fail R-CHOP have a dismal outcome. Thus, optimization of front-line therapy, as well as the development of more effective salvage strategies, remains an important objective. Advances in molecular genetics have vastly improved our understanding of the biological diversity of DLBCL and have led to the discovery of key oncogenic pathways. In addition to the major molecular designations of germinal center B-cell and activated B-cell subtypes, next-generation sequencing technologies have unveiled the remarkable complexity of DLBCL and identified unique molecular targets that may be differentially exploited for therapeutic benefit. These findings have translated into a growing list of promising novel agents. Moving forward, it is of paramount importance to recognize the heterogeneity of DLBCL and to investigate these targeted agents within patient populations who are most likely to benefit. It will be necessary to prioritize drugs that affect key driver pathways and to combine them rationally to optimize their benefit. Improved prognostication and the availability of predictive biomarkers will be crucial to allow for the possibility of individualized risk-adapted therapy.

Prognostic factors for diffuse large B-cell lymphoma in the R(X)CHOP era

BACKGROUND

The introduction of rituximab (R) to conventional CHOP chemotherapy for newly diagnosed diffuse large B-cell lymphoma (DLBCL) led to an unequivocal improvement in survival, establishing RCHOP as the standard of care. Still, nearly 40% of DLBCL patients will eventually die of relapsed disease. Efforts to improve outcomes by addition of new biologic agents (X) to the RCHOP backbone are underway. In this era of R(X)CHOP, it is imperative to develop prognostic and predictive markers, not only to identify patients who will suffer a particularly aggressive course, but also to accurately select patients for clinical trials from which they will most benefit.

DESIGN

The following review was undertaken to describe prognostic factors in DLBCL, with emphasis on markers that are accurate, relatively available, and clinically applicable in 2014.

RESULTS

The International Prognostic Index retains its validity in the era of RCHOP, although with limited ability to predict those with <50% chance of long-term survival. Gene expression profiling has provided novel insights into the biology of DLBCL and led to the development of immunohistochemistry (IHC) algorithms that are in routine practice. Identification of a 'double-hit' (DH) lymphoma by fluorescent in situ hybridization with aberrations involving MYC and/or BCL2 and BCL6 genes has important implications due to its extremely dismal prognosis with RCHOP. Other markers such as the absolute lymphocyte count (ALC), serum immunoglobulin free light chains, vitamin D levels, serum cytokines/chemokines, and imaging with positron emission tomography (PET) have all shown promise as future predictive/prognostic tests.

CONCLUSIONS

The future for new treatment options in DLBCL is promising with current clinical trials testing novel targeted agents such as bortezomib, lenalidomide, and ibrutinib as the 'X' in R(X)CHOP. Predictive factors are required to select and randomize patients appropriately for these trials. We envision the day when 'X' will be chosen based on the biological characteristics of the tumor.

Lymphopenia during routine follow-up may predict relapse in patients with extranodal NK/T cell lymphoma

Recently, absolute lymphocyte count (ALC) at diagnosis, as a surrogate marker of host immunity, has been reported to be a prognostic factor for clinical outcomes in extranodal NK/T cell lymphoma (ENKTL). In this retrospective study, we set out to investigate whether ALC at the time of confirmed relapse or at last follow-up is a marker for relapse after chemoradiotherapy in 84 patients with stage I/II ENKTL. Receiver operating characteristics (ROC) curve and area under the curve (AUC) analysis showed that ALC at follow-up was a significant marker for relapse (AUC = 0.883, P < 0.001). Using 1.215 × 10(9)/L as the optimal cutoff value of ALC, 44 patients (52.4%) were in lower ALC group and 40 patients (47.6%) were in higher ALC group. The sensitivity and specificity for ALC at the time of confirmed relapse or at last follow-up was 94.1 and 76.0%, respectively. The relative risk of relapse with an ALC < 1.215 × 10(9)/L was 14.5. The positive predictive value with an ALC < 1.215 × 10(9)/L was 72.7%, and the negative predictive value with an ALC ≥ 1.215 × 10(9)/L was 95.0%. The 4-year cumulative incidence rate for an ALC < 1.215 × 10(9)/L was 73.2% compared with 3.2% for an ALC ≥ 1.215 × 10(9)/L (P < 0.001). In a multivariate regression analysis, ALC at the time of confirmed relapse or last follow-up remained to be a significant factor for relapse (P < 0.001). In conclusion, lymphopenia observed during routine follow-up can predict relapse in patients with ENKTL, which needs further validation in prospective trials.

Expansion of NK cells and reduction of NKG2D expression in chronic lymphocytic leukemia. Correlation with progressive disease

The immune system may mediate anti-tumor responses in chronic lymphocytic leukemia (CLL) which may affect disease progression and survival. In this study, we analyzed the immune characteristics of 99 consecutive previously diagnosed CLL patients and 50 healthy controls. The distribution of lymphocyte subsets at diagnosis was retrospectively analyzed. Compared with controls, leukemia patients showed an expansion of NK and CD8 T cells at diagnosis. The relative number of CD8 T cells at diagnosis was associated with time to treatment, suggesting that CD8 T cells may modify disease progression. The distribution of lymphocyte subsets was analyzed again when patients were enrolled in this study. The median time since these patients were diagnosed was 277 weeks. Compared with diagnosis, the absolute number of CD8 T cells significantly decreased in these patients, reaching similar values to healthy controls; however NK cells kept significantly elevated overtime. Nevertheless, NK cells showed an impaired expression of NKG2D receptor and a defective cytotoxic activity. This down-regulation of NKG2D expression was further enhanced in patients with advanced and progressive disease. Additionally, membrane NKG2D levels significantly decreased on CD8 T cells, but a significant increase of NKG2D+CD4+ T cells was observed in CLL patients. The cytotoxic activity of NK cells was diminished in CLL patients; however the treatments with IL-2, IL-15, IL-21 and lenalidomide were able to restore their activity. The effect of IL-2 and IL-15 was associated with the increase of NKG2D expression on immune cells, but the effect of IL-21 and lenalidomide was not due to NKG2D up-regulation. The expansion of NK cells and the reversibility of NK cell defects provide new opportunities for the immunotherapeutic intervention in CLL.