Prognostic assessment in patients with indolent B-cell lymphomas

Prognostic Factors in Patients with Low-Grade Nonhodgkin Lymphoma

Low-grade Nonhodgkin lymphoma (LG-NHL) is characterized by indolent clinical course, which consist of marginal zone lymphoma (MZL), follicular lymphoma (FL), chronic lymphocytic leukemia/small lymphocytic lymphoma, lymphoplasmacytic lymphoma, waldenstrom macroglobulinemia (WM) as the most common subtypes. Factors affecting prognosis and treatment need in these patients have long been the subject of research. A retrospective study was conducted with patients diagnosed with LG-NHL in Hematology Departments of two centres between 2010 and 2018. At the time of diagnosis, demographic and disease characteristics, hematological and biochemical parameters were examined. Using these data, treatment requirements, response and survival rates were calculated. The effect of parameters on survival and need to treatment were analyzed. 93 LG-NHL patients were included in this study. 40 (43%) of these patients were MZL, 28 (30.1%) were FL and 25 (26.8%) were others. In comparison of patients required treatment with patients without treatment, there was significant difference among the number of comorbidity, platelet count, neutrophil count, disease subgroups and ferritin levels. Logistic regression analysis revealed that disease subgroup (other than MZL and FL) and ferritin levels were independent risk factors for need to treatment. Only ferritin level was found to be associated with overall survival. The current study demonstrated an association between serum ferritin levels and prognosis in patients with LG-NHL. Given that it is easily available and low-cost, the initial ferritin level can be used as a prognostic marker for patients with indolent lymphoma.

Analysis of Japanese patients from the AUGMENT phase III study of lenalidomide + rituximab (R2) vs. rituximab + placebo in relapsed/refractory indolent non-Hodgkin lymphoma

Patients with indolent non-Hodgkin lymphoma (iNHL) typically respond to first-line immunochemotherapy, but relapse is common. Treatment options for relapsed iNHL include chemotherapy ± rituximab and rituximab monotherapy. Lenalidomide plus rituximab (R²) is an immunomodulatory regimen that enhances rituximab-mediated cytotoxicity and improves clinical activity in iNHL. AUGMENT was a double-blind phase III randomized trial of R² vs. rituximab + placebo (R-placebo) in patients with relapsed/refractory follicular lymphoma or marginal zone lymphoma who were not refractory to rituximab. The primary endpoint was progression-free survival (PFS). Data reported here focus on Japanese patients from AUGMENT and reflect 36 patients (n = 18, each group). PFS was superior in the R² group, HR = 0.32 (95% CI 0.11-0.96). Median PFS was not reached (95% CI 19.7-NE) in the R² group vs. 16.5 months (95% CI 11.3-30.6) in the R-placebo group. Grade 3/4 adverse events were more frequent in patients treated with R² (67%) than with R-placebo (22%), primarily attributable to increased neutropenia (50% vs 17%). R² resulted in significantly longer median PFS than R-placebo in Japanese patients with R/R iNHL, and the efficacy and the safety profile of R² were similar to those reported in the global population.

Early progression as a predictor of survival in marginal zone lymphomas: an analysis from the FIL-NF10 study

Marginal zone lymphomas (MZLs) are indolent nonfollicular B-cell lymphomas (INFLs) and have heterogeneous clinical behavior. Recently, time to progression of disease at 24 months (POD24) was identified to stratify overall survival (OS) in follicular non-Hodgkin lymphoma and in INFL. Here, we examined the ability of POD24 to predict subsequent OS in a large, international cohort of MZL as part of the NF10 prospective international registry headed by Fondazione Italiana Linfomi (FIL). POD24 was only calculated for MZL patients requiring immediate therapy and was defined as experiencing lymphoma progression within 24 months from diagnosis. Among the 1325 patients enrolled in the NF10 study, we identified 321 patients with MZL for whom immediate therapy was planned right after lymphoma diagnosis. Overall, POD24 was confirmed in 59 patients (18%). Three-year OS for patients with POD24 was 53% with a hazard ratio of 19.5 (95% confidence interval, 8.4-45) compared with patients without POD24 (3-year OS, 95%). Association of POD24 with OS was confirmed for the subgroup of splenic and extranodal MZLs. Assessment of POD24 stratifies subsequent outcome in MZL and identifies a high-risk population. This trial was registered at www.clinicaltrials.gov as #NCT02904577.

Increased Risk of Infectious Complications in Older Patients With Indolent Non-Hodgkin Lymphoma Exposed to Bendamustine

Background

Bendamustine is a potent chemotherapy agent increasingly used to treat indolent non-Hodgkin lymphoma (iNHL). While effective, it causes significant T-cell lymphopenia, which may increase risk of infection. We examined infectious complications associated with bendamustine-containing regimens among older patients with iNHL.

Methods

For this Surveillance, Epidemiology, and End Results (SEER)-Medicare cohort study, we identified 9395 patients with iNHL (follicular, marginal zone, Waldenström macroglobulinemia) treated with chemotherapy from 2006 to 2013. Thirteen percent received bendamustine-containing regimens. We compared baseline characteristics and infection incidence rates between patients treated with and without bendamustine. We conducted multivariate Cox proportional hazards regression (adjusting for demographics, comorbidities, disease and treatment characteristics, risk factors for infection, and antimicrobial prophylaxis) to determine infectious risks associated with bendamustine.

Results

Bendamustine was associated with an increased risk of both common infections such as bacterial pneumonia (hazard ratio [HR], 1.50 [95% confidence interval {CI}, 1.21-4.85]) and opportunistic infections such as cytomegalovirus (HR, 3.98 [95% CI, 1.40-11.26]), varicella zoster virus (HR, 1.49 [95% CI, 1.18-1.89]), histoplasmosis (HR, 3.55 [95% CI, 1.10-11.42]), and Pneumocystis jirovecii pneumonia (when administered as third-line therapy: HR, 3.32 [95% CI, 1.00-11.11]). Risk of infections was more prominent in patients receiving bendamustine as part of later (third-line and above) regimens, and independently associated with well-established factors such as neutropenia and corticosteroid exposure.

Conclusions

Bendamustine is associated with an increased risk of common and opportunistic infections in patients with iNHL. Further prospective investigation into the potential role of antimicrobial prophylaxis is needed in these patients.

Reduced Dose Intensities of Doxorubicin in Elderly Patients with DLBCL in Rituximab Era

Purpose

The dose intensity of doxorubicin (DID) is important to the survival of diffuse large B cell lymphoma (DLBCL) patients. However, due to expected toxicities, most elderly patients cannot receive full doses of anthracyclines. The purpose of this study was to evaluate the effect of DID on the survival of elderly DLBCL patients (age ≥ 70 years) in the rituximab era.

Materials and Methods

We analyzed 433 DLBCL patients who were treated with R-CHOP between December 2003 and October 2011 at the Seoul National University Hospital. Of these patients, 19.2% were aged ≥ 70 years. We analyzed the survival outcomes according to DID.

Results

Significantly poorer overall survival (OS) was observed for patients aged ≥ 70 years (2-year OS rate: 59.9% vs. 84.2%; p < 0.001). DID ≤ 10 mg/m²/wk had a significant effect on the OS and progression-free survival (PFS) in elderly patients (2-year OS rate: 40.0% in DID ≤ 10 mg/m²/wk vs. 62.6% in DID > 10 mg/m²/wk; p=0.031; 2-year PFS: 35.0% vs. 65.7%; p=0.036). The OS on each 1.7 mg/m²/wk doxorubicin increment above 10 mg/m²/wk in elderly patients was not significant among the groups (2-year OS rate: 75.0% in DID 10.0-11.7 mg/m²/wk vs. 66.7% in DID 15.0-16.7 mg/m²/wk; p=0.859). Treatment related mortality was not related to DID.

Conclusion

DID can be reduced up to 10 mg/m²/wk in elderly DLBCL patients in the rituximab era. Maintenance of DID > 10 mg/m²/wk and judicious selection of elderly patients who are tolerant to DID is necessary.