Prognostic significance of the immunophenotype versus the International Prognostic Index in aggressive non-Hodgkin's lymphoma

Prognostic Analysis of Patients with Primary Extranodal Lymphoma: A Retrospective Study

Background

Originating from extranodal organs or tissues, primary extranodal lymphoma (PENL) acts in different primary sites with diverse clinical performances and PENL has remarkable geographical differences and lacks the relevant reports in each region.

Patients and Methods

Two hundred and twenty PENL patients were enrolled, and the relevant clinical and laboratory indicators were analyzed. In addition, statistical methods were applied to analyze the effects of different factors on overall survival (OS) and progression-free survival (PFS) of patients.

Results

The three most frequent primary sites of PENL are the digestive system, head and neck, and central nervous system. The patients were classified into groups based on their risk status, resulting in low-risk, medium-low-risk, medium-high-risk, and high-risk, and their respective 3-year OS values were calculated, which showed that 121 patients (55%) were in the low-risk group and 3-year OS was 85.2% (25.9% medium-low-risk, 3-year OS 66.6%; 15% medium-high-risk, 3-year OS 61.9%; 4.09% high risk, 3-year OS 45.7%). A multivariate analysis of the Cox regression demonstrated that serum beta 2-microglobulin (β₂-MG) and lactate dehydrogenase (LDH) were independent prognostic factors for OS and PFS, respectively. Both the performance status and pathological subtypes were independent prognostic factors for OS and PFS.

Conclusion

The correlated independent risk factors such as β₂-MG, LDH, performance status, and pathological subtypes, were helpful for effectively determining the prognosis of PENL patients and guiding treatment.

A 54-year-old male with diabetic nephropathy and suspected disseminated tuberculosis: Clinicopathologic correlation in a rare diagnosis

Tuberculosis (TB) and Non-Hodgkins lymphoma (NHL) share similar clinical and radiological features, which make diagnosis a challenge. It is often difficult to rule out a diagnosis of extrapulmonary and/or disseminated TB because of its paucibacillary nature and difficulty in accessing the involved organs. In countries with high prevalence of TB like ours, empirical antitubercular treatment (ATT) is started, and the patient is followed up closely for response. We present a rare case of a 54-year old diabetic male who was suspected to be a case of disseminated TB but had a rapid downhill course despite ATT. A postmortem revealed features of a rare, aggressive T-cell NHL masquerading as disseminated TB.

Peripheral T-cell lymphoma unspecified type presenting with a pneumothorax as the initial manifestation: A case report and literature review

The present study describes the case of a 51-year-old male presenting with a pneumothorax, in whom a final diagnosis of peripheral T-cell lymphoma unspecified type (PTCL-u) was determined. As the patient had experienced a shortness of breath subsequent to exercise for a period of 2 months, a fiber bronchoscopy was performed; however, no abnormalities were initially identified. Following the bronchoscopy, the patient suffered a recurrent pneumothorax with symptoms of emaciation, night sweats and a fever. The combination of computed tomography and interstitial lung pathology results suggested a high probability of malignant lymphoma. Further test results confirmed this diagnosis, including the fiber bronchoscopy biopsy report, which indicated a large amount of lymphocyte aggregation, and an ultrasound that identified several supraclavicular and left submandibular enlarged lymph nodes (largest size, 2.3×1.3 cm), with an absent hilar lymph node. A biopsy of the left cervical lymph node was performed, with post-operative pathological analysis confirming a diagnosis of peripheral T-cell lymphoma unspecified (stage IVB). The patient received two cycles of CHOP chemotherapy, and the symptoms alleviated following completion of the treatment, with chest radiography indicating that the pneumothorax had disappeared. The patient subsequently refused further treatment due to financial difficulty, and succumbed to the disease 6 months later.

T-cell lymphoma masquerading as extrapulmonary tuberculosis: case report and review of literature

It is often difficult to establish confirmatory diagnosis in cases of extrapulmonary tuberculosis (TB) because of its paucibacillary nature and difficulty in accessing the involved organs. In several cases, empirical anti-tubercular treatment is started, and the patient is followed-up closely for response. In countries with high prevalence of TB, it is a reasonably good strategy and works most of the times. However, catastrophe may occur when aggressive lymphomas masquerade as TB.

Autologous stem cell transplantation as the first-line treatment for peripheral T cell lymphoma: results of a comprehensive meta-analysis

OBJECTIVE

In view of the poor prognosis of most peripheral T cell lymphoma (PTCL) subtypes treated with conventional chemotherapy such as CHOP/CHOP-like regimens, high-dose chemotherapy followed by autologous stem cell transplantation (HDT/ASCT) seems a reasonable option in eligible patients. Nevertheless, owing to the small size of the study and the heterogeneity of most published series, a consensus on the role of ASCT as the first-line consolidation therapy for high-risk PTCL patients has not been reached so far.

STUDY DESIGN

We searched MEDLINE, EMBASE, EBSCO, Web of Science, clinicaltrials.gov and the Cochrane Library. Hazard ratio (HR) and 95% confidence intervals (CIs) were calculated by a fixed/random effect model.

RESULTS

Twenty-one studies were eligible. Although no statistical significance was observed in these studies, there was a trend toward survival advantage for the HDT/ASCT group as compared to the historical control group (HR 0.81, 95% CI 0.31-2.13). Statistical differences were confirmed in terms of overall survival (OS) between complete remission (CR) and non-CR patients (HR 3.17, 95% CI 0.92-5.42), patients with good and poor risk according to the International Prognostic Index (IPI; HR 0.36, 95% CI 0.22-0.60, I(2) 49%) and Prognostic Index for PTCL (PIT; HR 0.31, 95% CI 0.17-0.58; HR 0.31, 95% CI 0.18-0.54).

CONCLUSION

The clear and convincing proof of the effects of up-front HDT/ASCT still depends on sufficient large PTCL-restricted randomized trials in the future. Patients who failed to attain CR before transplant exhibited a worse prognosis; patients with good risk of IPI or PIT had a substantially better OS after ASCT.

Rituximab-CHOP-ESHAP vs CHOP-ESHAP-high-dose therapy vs conventional CHOP chemotherapy in high-intermediate and high-risk aggressive non-Hodgkin's lymphoma

With currently available combination chemotherapy regimens, the outcome of the patients newly diagnosed with aggressive non-Hodgkin's lymphoma (NHL) identified as 'high' and 'high-intermediate' risk groups according to the international prognostic index (IPI) is still unsatisfactory and a more innovative therapy is urgently required to improve the survival of the patients. The purpose of this study was to compare the efficacy of rituximab given in combination with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) and ESHAP (etoposide, methylprednisolone, high-dose Ara-C, cisplatin) vs CHOP-ESHAP and upfront high-dose therapy (HDT) and autologous stem cell transplantation (ASCT) vs standard CHOP in patients aged < or = 65 years old newly diagnosed with 'high' and 'high-intermediate' risk aggressive lymphoma enrolled onto two consecutive treatment trials at the institute. Between May 1995 - July 2002, 84 patients, aged 15 - 65 years old, with newly diagnosed aggressive NHL and an age-adjusted IPI of 2 or 3 were enrolled. The median age of the patients was 38 years (range 15 - 65). The baseline demographic features, in particular the major prognostic variables, were similar between the treatment groups. Patients treated with rituximab-CHOP-ESHAP received eight cycles of rituximab (375 mg m(-2) on day 1 of cycles 1 - 6 and days 21 and 28 of cycle 7) plus CHOP (day 3 of cycles 1, 3 and 5) and ESHAP (day 3 of cycles 2, 4 and 6 and day 1 of cycle 7) at 21-day intervals. Patients enrolled onto the CHOP-ESHAP-HDT arm (n = 23) were treated with three courses of CHOP and then switched to two or four cycles of ESHAP followed by HDT. Patients treated with CHOP alone (n = 25) were treated with the standard eight cycles of CHOP. The rate of complete remission was significantly improved with rituximab-CHOP-ESHAP compared with either CHOP-ESHAP-HDT or CHOP alone (67% compared with 44% and 36%, respectively; p = 0.043). With a median follow-up time of 53 months, the 5-year overall survival (OS) was improved by the addition of rituximab-61% with rituximab-CHOP-ESHAP, compared with 43% for CHOP-ESHAP-HDT and 24% for CHOP alone (p = 0.088). Significant increases in failure-free survival (FFS) and disease-free survival (DFS) (61% and 96%), compared with CHOP-ESHAP-HDT (34% and 90%) and CHOP (16% and 44%; p = 0.002 and p < 0.001, respectively) were observed. Compared to CHOP, rituximab-CHOP-ESHAP yielded significantly superior OS (p = 0.014), FFS (p < 0.001) and DFS (p < 0.001). The survivals, however, were not significantly different from patients treated with CHOP-ESHAP-HDT. It is concluded that rituximab-ESHAP-CHOP is superior over standard CHOP and fares comparably to upfront HDT/ASCT in previously untreated patients with aggressive lymphoma. A prospective randomized controlled trial is warranted to confirm these results.

High-dose chemotherapy with autologous stem cell transplantation in the first line treatment of aggressive non-Hodgkin lymphoma (NHL) in adults

BACKGROUND

High-dose chemotherapy with autologous stem cell support (HDT) has been proven effective in relapsed aggressive non-Hodgkin lymphoma (NHL). However, conflicting results of HDT as part of first-line treatment have been reported in randomised controlled trials (RCTs). We undertook a systematic review and meta-analysis to assess the effects of such treatment.

OBJECTIVES

To determine whether high-dose chemotherapy with autologous stem cell transplantation as part of first-line treatment improves survival in patients with aggressive non-Hodgkin lymphoma.

SEARCH STRATEGY

MEDLINE, EMBASE, Cancer Lit, the Cochrane Library and smaller databases, Internet-databases of ongoing trials, conference proceedings of the American Society of Clinical Oncology and the American Society of Hematology were searched. We included full-text, abstract publications and unpublished data.

SELECTION CRITERIA

Randomised controlled trials comparing conventional chemotherapy versus high-dose chemotherapy in the first-line treatment of adults with aggressive non-Hodgkin lymphoma were included in this review.

DATA COLLECTION AND ANALYSIS

Eligibility and quality assessment, data extraction and analysis were done in duplicate. All authors were contacted to obtain missing data and asked to provide individual patient data.

MAIN RESULTS

Fifteen RCTs including 3079 patients were eligible for this meta-analysis. Overall treatment-related mortality was 6.0% in the HDT group and not significantly different compared to conventional chemotherapy (OR 1.33 [95% CI 0.91 to 1.93], P=0.14). 13 studies including 2018 patients showed significantly higher CR rates in the group receiving HDT (OR 1.32, [95% CI 1.09 to 1.59], P=0.004). However, HDT did not have an effect on OS, when compared to conventional chemotherapy. The pooled HR was 1.04 ([95% CI 0.91 to 1.18], P=0.58). There was no statistical heterogeneity among the trials. Sensitivity analyses underlined the robustness of these results. Subgroup analysis of prognostic groups according to IPI did not show any survival difference between HDT and controls in 12 trials (low and low-intermediate risk IPI: HR 1.41[95% CI 0.95 to 2.10], P=0.09; high-intermediate and high risk IPI: HR 0.97 [95% CI 0.83 to 1.13], P=0.71. Event-free survival (EFS) also showed no significant difference between HDT and CT (HR 0.93, [95% CI 0.81 to 1.07], P=0.31). Other possible risk factors such as the proportion of patient with diffuse large cell lymphoma, protocol adherence, HDT strategy, response status before HDT, conditioning regimens and methodological issues were analysed in sensitivity analyses. However, there was no evidence for an association between these factors and the results of our analyses.

AUTHORS' CONCLUSIONS

. Despite higher CR rates, there is no benefit for high-dose chemotherapy with stem cell transplantation as a first line treatment in patients with aggressive NHL.

Autologous transplantation for relapsed or primary refractory peripheral T-cell lymphoma

Autologous transplantation (ASCT) is the standard of care for chemosensitive relapsed or primary refractory aggressive lymphoma, but little is known about its efficacy in the subset of patients with peripheral T-cell lymphoma (PTCL). We undertook a retrospective review of patients with PTCL who underwent ASCT for relapsed or refractory disease after responding to second-line therapy, excluding patients with indolent histologies and those with anaplastic lymphoma kinase (ALK) expressing anaplastic large cell lymphoma. The results of 24 patients with PTCL were compared with those of 86 consecutive patients with chemosensitive relapsed or primary refractory diffuse large B-cell lymphoma (DLBCL). With a median follow-up time of 6 years for surviving patients with PTCL and DLBCL, the 5-year progression-free survival (PFS) rates for PTCL and DLBCL patients were 24% and 34% respectively (P = 0.14); the corresponding overall survival (OS) rates were 33% and 39% respectively. There were no significant differences between the two groups with respect to time to disease progression or survival after progression. The second-line age-adjusted international prognostic index was the only variable prognostic for PFS and OS in a multivariate analysis. The outcome of ASCT for patients with chemosensitive relapsed or primary refractory PTCL is similar to that for patients with DLBCL.