Treatment-specific risk of subsequent malignant neoplasms in five-year survivors of diffuse large B-cell lymphoma

BACKGROUND

The introduction of rituximab significantly improved the prognosis of diffuse large B-cell lymphoma (DLBCL), emphasizing the importance of evaluating the long-term consequences of exposure to radiotherapy, alkylating agents and anthracycline-containing (immuno)chemotherapy among DLBCL survivors.

METHODS

Long-term risk of subsequent malignant neoplasms (SMNs) was examined in a multicenter cohort comprising 2373 5-year DLBCL survivors treated at ages 15-61 years in 1989-2012. Observed SMN numbers were compared with expected cancer incidence to estimate standardized incidence ratios (SIRs) and absolute excess risks (AERs/10 000 person-years). Treatment-specific risks were assessed using multivariable Cox regression.

RESULTS

After a median follow-up of 13.8 years, 321 survivors developed one or more SMNs (SIR 1.5, 95% CI 1.3-1.8, AER 51.8). SIRs remained increased for at least 20 years after first-line treatment (SIR ≥20-year follow-up 1.5, 95% CI 1.0-2.2, AER 81.8) and were highest among patients ≤40 years at first DLBCL treatment (SIR 2.7, 95% CI 2.0-3.5). Lung (SIR 2.0, 95% CI 1.5-2.7, AER 13.4) and gastrointestinal cancers (SIR 1.5, 95% CI 1.2-2.0, AER 11.8) accounted for the largest excess risks. Treatment with >4500 mg/m2 cyclophosphamide/>300 mg/m2 doxorubicin versus ≤2250 mg/m2/≤150 mg/m2, respectively, was associated with increased solid SMN risk (hazard ratio 1.5, 95% CI 1.0-2.2). Survivors who received rituximab had a lower risk of subdiaphragmatic solid SMNs (hazard ratio 0.5, 95% CI 0.3-1.0) compared with survivors who did not receive rituximab.

CONCLUSION

Five-year DLBCL survivors have an increased risk of SMNs. Risks were higher for survivors ≤40 years at first treatment and survivors treated with >4500 mg/m2 cyclophosphamide/>300 mg/m2 doxorubicin, and may be lower for survivors treated in the rituximab era, emphasizing the need for studies with longer follow-up for rituximab-treated patients.

A rare case of Waldenström's macroglobulinaemia-associated cryoglobulinaemia vasculitis

This case report presents a patient with vasculitis as a presenting symptom of type I cryoglobulinaemia due to lymphoproliferative disease. This is an uncommon cause of vasculitis, but important to recognise, as it influences treatment decisions. We discuss the differential diagnosis and extensive diagnostic approach of vasculitis. Above all, this case emphasizes that even a limited quantity of paraproteins can cause severe symptoms.

Lenalidomide added to standard intensive treatment for older patients with AML and high-risk MDS

More effective treatment modalities are urgently needed in patients with acute myeloid leukemia (AML) of older age. We hypothesized that adding lenalidomide to intensive standard chemotherapy might improve their outcome. After establishing a safe lenalidomide, dose elderly patients with AML were randomly assigned in this randomized Phase 2 study (n = 222) to receive standard chemotherapy ("3 + 7") with or without lenalidomide at a dose of 20 mg/day 1-21. In the second cycle, patients received cytarabine 1000 mg/m² twice daily on days 1-6 with or without lenalidomide (20 mg/day 1-21). The CR/CRi rates in the two arms were not different (69 vs. 66%). Event-free survival (EFS) at 36 months was 19% for the standard arm versus 21% for the lenalidomide arm and overall survival (OS) 35% vs. 30%, respectively. The frequencies and grade of adverse events were not significantly different between the treatment arms. Cardiovascular toxicities were rare and equally distributed between the arms. The results of the present study show that the addition of lenalidomide to standard remission induction chemotherapy does not improve the therapeutic outcome of older AML patients. This trial is registered as number NTR2294 in The NederlandsTrial Register (www.trialregister.nl).

Is the 15∆ Base in Prism Test Reliable for Detection of Amblyopia in Anisometropic Patients?

PURPOSE

The 15∆ base in prism test (15∆BIPT) introduced by Gobin is often used in The Netherlands to detect fixation preference, especially in young and preverbal children in whom a reliable measurement of the visual acuity (VA) is difficult. It is assumed that the fixation preference detected by the 15∆BIPT can be used to predict the presence of amblyopia. The aim of this retrospective case note review was to investigate the accuracy of the 15∆BIPT in detection of amblyopia in anisometropic patients.

METHODS

Four hundred and twelve files of anisometropic patients visiting the orthoptic department of The Rotterdam Eye Hospital were analyzed. Amblyopia was defined as an intraocular difference in VA of 2 or more Snellen lines. The sensitivity, specificity, and positive and negative predictive values of the 15∆BIPT were calculated and the receiver operating characteristic (ROC) curve was plotted.

RESULTS

One hundred and fifty-two patients ranging from 3.3-13.1 years of age (median 5.4 years) met the inclusion criteria. One hundred and two patients were diagnosed with amblyopia. Best-corrected median VA of the best eye was 1.0 (range 0.5-1.2) and the worst eye 0.70 (range 0.05-1.2). Sensitivity of the 15∆BIPT (based on detecting amblyopia) was 34.3%. Specificity was 88.0%. The positive predictive value was 85.4% versus a negative predictive value of 39.6%. The area under the ROC curve (AUC) was 0.65 (95% CI 0.56-0.74).

CONCLUSION

The low sensitivity, large number of false negatives and the AUC show that the 15∆BIPT can be considered a poor test for detecting amblyopia in anisometropic patients.

Human metapneumovirus in haematopoietic stem cell transplantation recipients: a case series and review of the diagnostic and therapeutic approach

Human metapneumovirus (hMPV) is a paramyxovirus that causes respiratory tract infections ranging from mild upper airway infection to severe pneumonia. Patients with haematological disease, especially haematopoietic stem cell transplantation (HSCT) recipients, are more likely to develop more severe infections. We describe three cases of hMPV infection in HSCT patients. The most reliable diagnostic procedure for hMPV is multiplex ligation-dependent probe amplification (MLPA) on a nasopharyngeal swab. Sensitivity and specificity of MLPA to detect hMPV is high and time to diagnosis is short. A number of other respiratory pathogens can be tested in one test run. Treatment is mainly supportive and only a few antiviral agents are available for treating paramyxovirus infections. Ribavirin and immunoglobulins were reported to be effective in cases of HSCT patients with hMPV pneumonia but their efficacy has not been studied in randomised trials.

Abstract P6-11-08: A Comparison of Chemotherapeutic Treatment Practice in Metastatic Breast Cancer (MBC) in Belgium (BE) and The Netherlands (NL)

Introduction: Current treatment recommendations provide limited guidance for chemotherapy (CT) of MBC, while physicians have many options to choose from. We undertook a retrospective survey to describe and compare actual CT approaches to MBC in clinical practice in two neighboring European countries, BE and NL.

Methods: 20 BE and 18 NL hospitals collected data for 490 and 434 patients (pts), respectively, diagnosed with MBC in 2003-2009 and treated with ≥1 CT regimen. Demographic, disease and treatment data of the last 25 consecutively treated pts per hospital were included in each survey. The NL survey required age ≥70 yrs at MBC diagnosis, the BE survey had no upper age limit. We compared patient characteristics and treatment policies between both cohorts (BE vs. NL, for all comparisons). Results: BE patients were older at MBC diagnosis (median 60 vs. 56 yrs) and had M1 tumor status at primary diagnosis more frequently (26 vs. 20%). Average year of MBC diagnosis was 2005 for both countries. There were no striking differences in ER/PR positivity (61/50 vs. 64/47%), HER2/neu overexpression (27 vs. 31%), triple negative status (12 vs. 15%), or cardiac co-morbidity. Prior hormonal (22 vs. 12%), hormonal + adjuvant CT (32 vs. 26%), and total adjuvant CT (58 vs. 51%) had been given more frequently in the BE cohort. In pts receiving adjuvant CT, anthracyclines had been used more frequently in the NL cohort (61 vs. 78%). Pts in the BE and NL cohort received up to 10 and 6 lines of CT, respectively. 79 vs. 73% and 55 vs. 43% of pts received 2 and 3 lines of CT, respectively. BE pts received far more monotherapy in first line (46 vs. 25%), but not in second (66 vs. 65%) and third line (65 vs. 63%). Drugs used most frequently for monotherapy in lines 1-3 were the same in BE and NL: docetaxel (40 vs. 38%) and capecitabine (13 vs. 26%) in line 1; docetaxel (27 vs. 38%) and capecitabine (23 vs. 16%) in line 2; capecitabine (30 vs. 30%) and vinorelbine (16 vs. 19%) in line 3. The most frequently used CT combinations were very different: FEC (40%)vs. FAC (24%) in first line, FEC (7%) vs. CMF (14%) in second line, and non-pegylated liposomal doxorubicin/cyclophosphamide (6%) vs. CMF (15%) in third line.

Many different CT regimens for MBC were used throughout all lines (e.g. > 20 regimens in first line) in both countries. Overall, 81 vs. 71% of pts received a taxane and/or an anthracycline in first line, 57 vs. 60% in second line, and 43 vs. 29% in third line. 33 vs. 36% were re-challenged with an anthracycline after having received anthracycline-based (neo) adjuvant CT.

Physician-assessed response (52 vs. 53%) and stable disease rates (22 vs. 26%) to first-line CT were similar.

Conclusions: Daily treatment practice of MBC differs considerably between BE and NL, in particular with respect to monotherapy vs. combination CT in first line, specific combination regimens used in lines 1-3, and the number of subsequent lines employed. More adjuvant treatment appeared to have been given to Belgian pts. Despite these differences, reported response rates were remarkably similar. Although a wide variety of CT regimens are used in MBC in BE and NL, anthracyclines and taxanes are the cornerstones in both countries.

Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P6-11-08.