Comparison of first-line treatment with bendamustine plus rituximab versus R-CHOP for patients with follicular lymphoma grade 3A: Results of a retrospective study from the Fondazione Italiana Linfomi

Comparison of Real-World Outcomes in Patients With Follicular Lymphoma Treated With BR Versus RCHOP-Like Regimens

BACKGROUND

Patients with follicular lymphoma (FL) grade (G) 1-3A who meet treatment criteria are commonly treated with chemo-immunotherapy regimens such as bendamustine plus rituximab (BR) or rituximab plus cyclophosphamide, doxorubicin, vincristine, prednisone (RCHOP). Two prospective trials have compared BR to RCHOP-like regimens and showed improved progression free survival with BR in FL G1-2 patients. However, in real-world practice, there is clinical variability in utilization of BR versus RCHOP-like regimens. Additionally, the optimal treatment for patients with FL G3A remains unclear.

METHODS

We used a nationwide electronic health record-derived de-identified database to compare outcomes in 2089 patients with FL G1-3A treated with frontline BR versus RCHOP-like regimens.

RESULTS

We demonstrated clinical improvement in time to next treatment or death (TTNTD) with BR (median 96 vs. 78 months, HR 1.15, 95% CI 0.986-1.332, P = .086), albeit not statistically significant. No difference in overall survival (OS) was observed. Maintenance rituximab was associated with improved TTNTD and OS. Among G3A patients (N = 304), TTNTD was comparable between the 2 regimens, however OS was significantly improved with RCHOP-like regimens in univariate analysis (median 138 vs. 96 months, HR 0.51, 95% CI 0.313-0.834, P = .007).

CONCLUSIONS

In conclusion, this study of real-world patients supports the use of BR and rituximab maintenance for front-line treatment of FL. Further prospective studies are needed to determine the ideal treatment for FL G3A.

The real-world efficacy and safety of frontline therapy of obinutuzumab plus bendamustine for untreated high-tumor-burden follicular lymphoma

BACKGROUND

While R-CHOP has been one of the standard therapies for untreated high-tumor-burden (HTB) follicular lymphoma (FL) for over 2 decades, obinutuzumab plus bendamustine (OB) is also currently regarded as the standard of care since its approval in 2018 in Japan; however, the long-term efficacy and safety of OB in the daily clinical practice has not been thoroughly evaluated.

METHODS

We conducted a multicenter retrospective study for the clinical outcome of 53 patients with HTB FL treated by OB as the frontline therapy between 2018 and 2021 in the Kyoto Hematology Clinical Study Group (KOTOSG). All patients had at least 2-year follow-up period.

RESULTS

The median age was 67, and 60.4% were classified as high risk according to the Follicular Lymphoma International Prognostic Index. The overall and complete response rates after induction therapy with OB were 98% and 83%, respectively. With a median follow-up of 38.5 months, the 3-year progression-free survival (PFS) and overall survival (OS) were 77.3% and 91.2%, respectively. Grade 3-4 hematological adverse events (AEs) were common, including neutropenia (58.5%) and lymphopenia (98.1%). Non-hematological AEs included infections, such as lung infections, coronavirus disease 2019, and sepsis, with two cases (3.8%) being fatal. Finally, propensity score-matched analysis showed no significant difference in PFS between 46 FL patients treated by the frontline OB and 46 FL patients treated by R-CHOP between 2001 and 2019 in KOTOSG.

CONCLUSION

This study highlighted the need for careful treatment selection based on patient background and disease condition in real-world practice with more elderly patients.

[Clinical characteristics and prognosis analysis in patients with bone marrow invasive follicular lymphoma]

Objective: This study aimed to summarize the clinical characteristics and prognosis of patients with bone marrow invasive follicular lymphoma (FL) and discuss the treatment modalities. Methods: This study included 183 consecutive patients with FL accompanied by bone marrow invasion and receiving regular treatment at the Hospital of Hematology, Chinese Academy of Medical Sciences, from January 2013 to December 2022. Clinical data were retrospectively collected and analyzed, and single and multifactorial analyses of survival prognosis were conducted with the Kaplan-Meier method and Cox regression model. Results: The median age was 48 (range: 19 - 78) years, and the male-to-female ratio was 0.9∶1. All of the patients had bone marrow invasion, 27.8% had increased lactate dehydrogenase levels, 42.1% had lymphocyte counts of >5×10(9)/L, 18.4% had abnormal chromosomal karyotypes, and 48.6% had Ki-67 index of ≥30% in lymphoid tissue. Comparison of different subgroups: lymphocyte counts of >5×10(9)/L, number of lymph nodes of ≥5 involved, and proportion of bone marrow chromosomal abnormalities occurring were higher in the anthracycline-intensive treatment group than in the rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) protocol and the nucleoside analog (including CD20 monoclonal antibody in combination with fludarabine and bendamustine) groups (all P<0.05). The complete remission rate was 39.1% in the conventional R-CHOP group, which was lower and statistically significant than that in the intensive treatment group (55.1%) and the nucleoside analog group (62.5%) (P=0.042). The multivariate analysis for survival analysis revealed high risk of FLIPI (HR= 1.910, 95% CI 1.036 - 3.522, P=0.036), chromosomal abnormalities karyotype (HR=2.666, 95% CI 1.333-5.331, P=0.006), and conventional R-CHOP treatment (HR=2.287, 95% CI 1.140-4.591, P=0.020) were the independent adverse prognostic factors affecting progression-free survival (PFS), whereas POD24 was the only independent adverse prognostic factor affecting overall survival (OS) adverse prognostic factor (HR=9.581, 95% CI 3.000 - 30.593, P<0.001) . Conclusions: The clinical presentations of patients with bone marrow invasive FL were easy to combine the clinical features, including increased lymphocyte count, chromosomal abnormalities, and Ki-67 index in lymphoid tissues. The FLIPI score, chromosomal abnormal karyotype, and high-lymphoid-tissue Ki-67 index were the poor prognostic factors influencing PFS. R-CHOP therapy demonstrated a poor prognosis in this group of patients.

Comparing R-Bendamustine vs. R-CHOP Plus Maintenance Therapy as First-Line Systemic Treatment in Follicular Lymphoma: A Multicenter Retrospective GELTAMO Study

Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) and R-bendamustine (R-B) are the most common frontline treatment strategies for advanced-stage follicular lymphoma (FL). After R-CHOP induction therapy, using rituximab for maintenance therapy notably improves outcomes; however, whether this can be achieved by using the same approach after R-B therapy is still being determined. This retrospective analysis compared 476 FL patients from 17 GELTAMO centers who received R-based regimens followed by rituximab maintenance therapy for untreated advanced-stage FL. The complete response rate at the end of induction was higher with R-B and relapses were more frequent with R-CHOP. During induction, cytopenias were significantly more frequent with R-CHOP and so was the use of colony-stimulating factors. During maintenance therapy, R-B showed more neutropenia and infectious toxicity. After a median follow-up of 81 months (95% CI: 77-86), the 6-year rates of progression-free survival (PFS) were 79% (95% CI: 72-86) for R-bendamustine vs. 67% (95% CI: 61-73) for R-CHOP (p = 0.046), and 6-year overall survival (OS) values were 91% (95% CI: 86-96) for R-B vs. 91% (95% CI: 87-94) for R-CHOP (p = 0.49). In conclusion, R-B followed by rituximab maintenance therapy in patients with previously untreated FL resulted in significantly longer PFS than R-CHOP, with older patients also benefiting from this treatment without further toxicity. Adverse events during maintenance were more frequent with R-B without impacting mortality.