Utility of routine post-therapy surveillance imaging in diffuse large B-cell lymphoma

PURPOSE

We examined the utility of post-therapy surveillance imaging in a large, prospectively enrolled cohort of patients with diffuse large B-cell lymphoma (DLBCL) from the United States and confirmed our results in an independent cohort of patients from France.

METHODS

Patients with newly diagnosed DLBCL and treated with anthracycline-based immunochemotherapy were identified from the Molecular Epidemiology Resource (MER) of the University of Iowa/Mayo Clinic Lymphoma Specialized Program of Research Excellence and the Léon Bérard Cancer Center, Lyon, France. In those with relapse, details at relapse and outcomes were abstracted from records.

RESULTS

680 individuals with DLBCL were identified from the MER, 552 (81%) of whom achieved remission after induction. 112 of the 552 patients (20%) suffered a relapse. The majority (64%) of relapses were identified before a scheduled follow-up visit. Surveillance imaging detected DLBCL relapse before clinical manifestations in nine out of 552 patients (1.6%) observed after therapy. In the Lyon cohort, imaging identified asymptomatic DLBCL relapse in four out of 222 patients (1.8%). There was no difference in survival after DLBCL relapse in patients detected at scheduled follow-up versus before scheduled follow-up in both the MER (P = .56) and Lyon cohorts (P = .25).

CONCLUSION

The majority of DLBCL relapses are detected outside of planned follow-up, with no difference in outcome in patients with DLBCL detected at a scheduled visit compared with patients with relapse detected outside of planned follow-up. These data do not support the use of routine surveillance imaging for follow-up of DLBCL.

Impact of the introduction of rituximab in first-line follicular lymphoma: a retrospective study of 247 unselected patients referred to a single institution with a long-term follow-up

Rituximab was approved in France in 2004, following randomized trials that demonstrated efficacy in newly diagnosed high tumour burden follicular lymphoma (FL). This retrospective study compared the management and outcome of FL in unselected patients treated in a single institution before and after rituximab approval. Two hundred and forty-seven adult patients were referred with first-line FL between 1996 and 2010 and are included in this study. The 103 pre-rituximab patients comprising cohort 1 were diagnosed between January 1996 and December 2003; cohort 2 includes the 144 patients diagnosed after the approval of rituximab between January 2004 and December 2010. Baseline clinical and biological data, type of therapy, treatment response, progression-free survival (PFS) and overall survival (OS) rates were compared. There were no statistically significant differences between the two cohorts with respect to baseline clinical and disease characteristics, including FL International Prognostic Index score. The major difference between the two cohorts is the use of rituximab in first line. Seventy-one per cent of patients in cohort 2 received rituximab (19% alone, 52% with chemotherapy) versus 10% in cohort 1 (2% alone, 8% with chemotherapy; p < 0.0001). The objective response rate (ORR) was significantly higher for cohort 2 (ORR 84% compared with 72% for cohort 1; p = 0.03). The PFS and OS rates were also significantly better: 3-year PFS 72% [95% confidence interval (CI) 64-80%] versus 55% (95% CI 45-64%), p = 0.0039 and 3-year OS 98% (95% CI 94-99%) versus 83% (95% CI 74-90%), p = 0.0007. Effect of period of study is significant when using multivariate analysis on PFS and OS and lactate dehydrogenase level (PFS and OS) and age (OS). These data from everyday practice confirm the benefit for patients with FL treated in the last decade through availability of rituximab in first line used alone or in association with various chemotherapy regimens.

Body weight change in women receiving adjuvant chemotherapy for breast cancer: a French prospective study

BACKGROUND & AIMS

Adjuvant chemotherapy has frequently been associated with weight gain after breast cancer diagnosis. We aimed to prospectively evaluate body weight variations in French patients with early breast cancer.

METHODS

This prospective observational study included 272 breast cancer patients who were candidates for adjuvant chemotherapy. Weight and body mass index were measured at baseline visit, then at 9 and 15 months from baseline (6 and 12-month post-chemotherapy). At baseline visit, information on the benefits of weight gain prevention and healthy diet was given by a dietician. Univariate logistic regression was performed to test the association between weight gain and potential predictive factors.

RESULTS

Thirty percent of patients gained weight during the year before diagnosis, 26% were overweight and 15% were obese. At one year, the mean weight change was +1.5kg (SD=4.1) and +2.3% (SD=6.0); 60% of the cohort had gained weight, with a median increase of 3.9kg (SD=3.0) and 5.9% (SD=4.4). Reported weight gain during the year before diagnosis appears to be the only factor associated with the absence of post-chemotherapy weight gain (OR=0.54, 95% CI [0.31-0.95], p=0.034).

CONCLUSION

Body weight increased in the post-chemotherapy period in French breast cancer survivors, even when given dietary recommendations. Appropriate weight management interventions with nutritional follow-up and physical activity programs are needed.

First step in management of weight gain induced by chemotherapy for early breast cancer

Abstract #6139

Adjuvant therapies for breast cancer are often associated with weight gain (WG). Overweight, obesity and WG have deleterious consequences for quality of life and probably for breast cancer evolution.&#x2028; This french monocentric prospective study aimed to determine the incidence of overweight, obesity and WG during and one year after adjuvant chemotherapy (CT) for early breast cancer. Secondary goals were to examine the observance of national nutritional recommendations for healthy living, to observe their effects on WG prevention and to estimate patients needs for dietetic management.&#x2028; Method : Patients younger than 66 years candidates for adjuvant CT for early breast cancer underwent dietary evaluation at the beginning of CT and were informed of the benefits of WG prevention, healthy diet and living habits. Written recommendations are given. A dietetic follow-up was systematically proposed. Weight, Body Mass Index (BMI) and nutritional habits over the last year before diagnosis, and at 6 and 12 months after chemotherapy were recorded. Statistical analysis is performed to test the association between WG and initial parameters (alpha level 5%).&#x2028; Results: Of 272 consecutive patients recruited from Oct 2004 to Oct 2006, 242 are evaluated at 6 months and 233 after 1 year. The mean age was 51 years ; 44.1% were not menopausal before chemotherapy. TNM classification was as follows: T0: 15%, T1: 41%, T2: 32%, T3: 9%, T4: 3% and N+: 68%. Chemotherapy regimes were based on doxorubicin for 40% of cases, on taxanes for 1.5% and both for 58.5% . Hormonal therapy was provided to 74.85% of the patients. The average weight before chemotherapy was 65.9 kg (44-117); 25.7% of patients were overweight (25&lt;BMI&lt;30) and 15.1% obese (BMI&gt;30). A third experienced WG during the year before diagnosis. Six months after CT, 52.1% patients had gained weight (&lt;5% body weight for 59%, but &gt;10% for 7.1%) and 29.8 % had lost weight. At one year, WG affected 59.7% of the patients. The average of WG is 5.88% of body weight and 14.4% of the patients gained more than 10%. WG before diagnosis seems to be the only factor associated with post CT absence of weight gain (OR 0.542, IC 95% [0.308-0.954], p= 0.0338). Only 43 women (16%) asked for dietetic follow-up, which induced weight loss for 57%. Health recommendations of the national program of nutrition and health (PNNS in France) were observed by 36.1% of the patients at the beginning of treatment, versus 43.5% at 6 months and 52.1% at one year.&#x2028; Discussion and conclusions :&#x2028; This study confirms the high rate of patients gaining weight after chemotherapy. Nutritional information alone is not sufficient, and appropriate healthy program (nutritional follow up and physical activities) must be proposed to limit weight gain and avoid possible consequences on disease free survival and further co morbidities.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 6139.

Combination of rituximab with chemotherapy in diffuse large B-cell lymphoma. Evaluation in daily practice before and after approval of rituximab in this indication

Randomized trials have demonstrated improved outcome from adding rituximab to CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) for patients with diffuse large B-cell lymphoma (DLBCL). This retrospective study compared the outcomes of 224 patients with DLBCL treated in our institution before (Period 1, 1996-2002) and after (Period 2, 2002-2005) approval of rituximab in this indication to evaluate the impact of the drug in daily practice in unselected patients receiving different types of chemotherapy. We treated 131 patients in Period 1 versus 93 in Period 2 (median follow-up, 75 and 29 months, respectively) with no difference in patient characteristics between the two periods. Event-free and overall survivals (EFS and OS) were significantly improved in Period 2 for elderly patients and a significant shift in the selection of regimens was observed at the time when rituximab became available. More patients received the CHOP regimen in Period 2 than in Period 1 (82 vs. 57%, p < 0.007) with CHOP being substituted for epirubicin-based regimens. In younger patients treated mostly with the ACVBP regimen (doxorubicin, cyclophosphamide, vindesine, bleomycin, prednisone) these differences were not observed, suggesting that combination of rituximab with dose-dense chemotherapy may deserve further evaluation in this age group.

Development of a rule based prognostic tool for HER 2 positive breast cancer patients

A three stage development process for the production of a hierarchical rule based prognosis tool is described. The application for this tool is specific to breast cancer patients that have a positive expression of the HER 2 gene. The first stage is the development of a Bayesian classification neural network to classify for cancer specific mortality. Secondly, low-order Boolean rules are extracted form this model using an Orthogonal Search based Rule Extraction (OSRE) algorithm. Further to these rules additional information is gathered from the Kaplan-Meier survival estimates of the population, stratified by the categorizations of the input variables. Finally, expert knowledge is used to further simplify the rules and to rank them hierarchically in the form of a decision tree. The resulting decision tree groups all observations into specific categories by clinical profile and by event rate. The practical clinical value of this decision support tool will in future be tested by external validation with additional data from other clinical centres.

Time-to-event analysis with artificial neural networks: an integrated analytical and rule-based study for breast cancer

This paper presents an analysis of censored survival data for breast cancer specific mortality and disease-free survival. There are three stages to the process, namely time-to-event modelling, risk stratification by predicted outcome and model interpretation using rule extraction. Model selection was carried out using the benchmark linear model, Cox regression but risk staging was derived with Cox regression and with Partial Logistic Regression Artificial Neural Networks regularised with Automatic Relevance Determination (PLANN-ARD). This analysis compares the two approaches showing the benefit of using the neural network framework especially for patients at high risk. The neural network model also has results in a smooth model of the hazard without the need for limiting assumptions of proportionality. The model predictions were verified using out-of-sample testing with the mortality model also compared with two other prognostic models called TNG and the NPI rule model. Further verification was carried out by comparing marginal estimates of the predicted and actual cumulative hazards. It was also observed that doctors seem to treat mortality and disease-free models as equivalent, so a further analysis was performed to observe if this was the case. The analysis was extended with automatic rule generation using Orthogonal Search Rule Extraction (OSRE). This methodology translates analytical risk scores into the language of the clinical domain, enabling direct validation of the operation of the Cox or neural network model. This paper extends the existing OSRE methodology to data sets that include continuous-valued variables.

High survival rate with the LMT-89 regimen in lymphoblastic lymphoma (LL), but not in T-cell acute lymphoblastic leukemia (T-ALL)

The most appropriate treatment for lymphoblastic lymphomas (LL) remains uncertain. We treated 27 patients with newly diagnosed LL according to an LMT-89 protocol, which is a modified version of the LMT-81 protocol previously reported in pediatric patients. The median age was 31 years. Mediastinal enlargement was present in 25/27 patients, with pleural effusion in 12. Four patients had central nervous system involvement and 12 had bone marrow involvement and 24/27 (89%) had advanced Ann Arbor stage III-IV disease. Complete remission (CR) was achieved in 20/27 patients, unconfirmed complete remission in three patients (residual mediastinal lesion on computed tomography scan) and four failed induction therapy (ORR: 85%). Twelve patients (44%) remained in continuous CR with a median follow-up of 95 months. Survival at 3 years (when all the events occurred in our series) was 63%. Bone marrow involvement was associated with a poor outcome. Overall survival was 85+/-20% in patients without bone marrow involvement compared to 37+/-30% in patients with bone marrow involvement. The Ann Arbor stage, age and serum lactate dehydrogenase level did not influence outcomes. This LMT-89 protocol is a safe regimen and is highly effective in advanced LL without bone marrow involvement.