The 5th Edition of the World Health Organization (WHO) Classification of Hematolymphoid Tumors: What's New in Pediatrics?

The World Health Organization (WHO) has revised the classification of hematolymphoid tumors (WHO-HAEM5) in August 2022 to incorporate certain recent changes in understanding of disease biology. This article highlights the important changes, with particular reference to those most relevant to children.

Chronic active Epstein-Barr virus infection mimicking tuberculosis - A diagnostic enigma

ABSTRACT

Chronic active EBV infection is a rare disorder prone for misdiagnosis. They present with a wide range of symptoms from indolent to aggressive clinical course. Clinico-pathological correlation with confirmation by ancillary techniques is inevitable to diagnose this disease. We present a case of a 29-year-old male with fever, weight loss, and lymphadenopathy for 6 months. Lymph node biopsy showed occasional granuloma with preserved architecture. Suspected to have tuberculosis, he received antitubercular treatment (ATT) with no response for 3 months. Subsequently, additional workup showed many EBV-positive cells in sinusoids with high serum EBV titer, confirming the difficult diagnosis of CAEBV. The present case highlights the difficulty in the diagnosis of this entity and also emphasizes the necessity to recognize this disorder in countries endemic for tuberculosis, as it is no longer bound by ethnicity and geographical boundaries.

Prospective Cohort Study to Evaluate Toxicity and Cosmesis between Interstitial APBI and Ultra-Hypo-Fractionated Whole Breast Irradiation in Patients with Early Breast Cancer

PURPOSE/OBJECTIVE(S)

Both interstitial multi-catheter brachytherapy based accelerated partial breast irradiation (APBI) and ultra-hypo-fractionated whole breast irradiation (WBI) with 5 fractions can complete treatment in a short time and result in lower treatment-related costs. Although data are available on their toxicity compared with conventional and hypo-fractionated regimens, there are few data directly comparing these two techniques.

MATERIALS/METHODS

This prospective cohort study enrolled early breast cancer patients with negative ink margin, T1 or T2 stage, and tumor size of 3 cm or less, with 0 to 3 positive lymph nodes after adequate axillary dissection or negative sentinel lymph node biopsy (N0-1), regardless of receptor status (ER, PR, HER2neu). Of the total 31 patients, 15 received APBI with multi-catheter interstitial brachytherapy (35 Gy in10 fractions over 5 days with a minimum interval of 6 hours between fractions) and 16 patients received WBI (27 Gy in 5 fractions over 5 days) with either 3DCRT or VMAT technique. Acute toxicity was assessed using the RTOG toxicity grading and breast cosmesis was assessed using the Harvard breast cosmesis score. Toxicity and cosmesis were assessed immediately after treatment, after one month, and after three months of treatment. Results were compared between groups using the Mann Whitney U test.

RESULTS

All patients completed a 3-month follow-up after completion of treatment. There was no statistically significant difference between the 2 groups in terms of highest grade toxicity (p = 0.97) and acute toxicity immediately after RT (p = 1.0) and after 1 month of RT (p = 0.91). However, at 3 months, more patients in the WBI group had a residual skin reaction than in the APBI group (p = 0.03). There was no statistically significant difference in breast cosmesis scores at any time point. 53.3%, 6.6% had grade 1 and 2 skin toxicities respectively immediately after RT in the APBI group and 62.5% of patients had grade 1 skin toxicity in WBI group. After 1 month 26.6%, 26.6% & 13.3% patients had grade 2, grade 1 and grade 3 toxicities respectively. In the WBI group, at 1 month, 50%, 18.7% and 12.5% patients had grade 1, 3 and 2 skin toxicities respectively. At 3 months, 42.8% and 7.1% of patients in the APBI group had grade 1 and grade 2 toxicities, respectively. In the WBI group, 78.5% and 7.1% of patients had grade 1 and 2 skin toxicities respectively.

CONCLUSION

In this study, no difference in acute toxicity or breast cosmesis was demonstrated between APBI-based interstitial brachytherapy and ultra-hypo-fractionated WBI. Since both regimens can be administered within 5 days, the decision between them is challenging for both physicians and patients. This study can be considered hypothesis-generating and used for further planning of equivalence or noninferiority studies.

Clinical Outcome and Patterns of Failure in Patients with Solitary Plasmacytoma Treated with Radical Radiotherapy

PURPOSE/OBJECTIVE(S)

We intended to assess the patterns of care and failure in patients with solitary plasmacytoma (SP), treated at our institute from 2011-21.

MATERIALS/METHODS

Data pertaining to the management of patients with SP was abstracted by retrospective chart review. Progression free survival (PFS) and overall survival (OS) were defined as the time intervals from the date of diagnosis to the date of progression (local, systemic or both) and death or last follow up, respectively. PFS and OS were analyzed by Kaplan Meier method.

RESULTS

Atotal of 72 patients were diagnosed with SP (61-bone plasmacytoma; 11-extramedullary plasmacytoma) in between 2011 and 2021. The median age at diagnosis was 52 years. The male: female ratio was 2.27. The ECOG PS were 0, 1, 2, 3, and 4 in 1, 46, 11, 10, and 3 patients, respectively. The median diameter of the lesion was 6.7 cm (range 2.3-18.4 cm). The median M protein was 0.375 g/dl (range 0.63-5.3 g/dl). On bone marrow examination, 8 and 64 patients had no and minimal marrow involvement, respectively (median bone marrow plasma cells 4%). Radical radiotherapy (RT) was administered in 71 patients, the techniques being 2D-conventional in 35, 3D-conformal in 14, IMRT in 8 and VMAT in 5 patients (details not available in 9). The median RT dose was 45 Gy in 25 fractions over 5 weeks (range 45-50 Gy). In addition, 5(7%) patients underwent surgery prior to RT and 6(8.5%) patients received systemic chemotherapy. After RT, the median quantum of symptom relief was 75% (range 0-100%). The best response to RT was CR, PR, SD and PD in 41(57.7%),18(25.4%),3(4.2%) and 4(5.6%) patients, respectively (response assessment could not be done in 5). Local control with primary RT was achieved in 58(81.7%) patients. No RT related grade 3/4 acute or late toxicity was reported. The median follow up was 48.3 months (range 1.3-141.6 months). A total of 28(39.4%) patients experienced disease progression (systemic in 15, local in 7 and both in 6), out of which 13 could be successfully salvaged with further systemic chemotherapy (mostly bortezomib, lenalidomide/pomalidomide and dexamethasone based) with or without local treatment. On progression to multiple myeloma, 9 patients underwent high dose chemotherapy(melphalan) followed by autologous stem cell transplant. Nine (12.7%) patients died, the causes being COVID-19 infection in 1, surgical complications in 1, PD in 2, second malignancies in 3 and unknown in 2. The actuarial rates of PFS & OS were 58.4% & 92.5% at 3 years and 50.3% & 89.4% at 5 years, respectively. Metachronous second malignancies were noted in 4 patients (B-ALL-1, lung cancer-1, metastatic carcinoma cervix-1, metastatic carcinoma gall bladder-1).

CONCLUSION

In patients with SP, radical RT with a modest dose (45-50 Gy) leads to satisfactory symptom relief, response and local control. Close to 40% patients eventually progress to multiple myeloma, out of which 50% can be successfully salvaged with further systemic chemotherapy. The 5-year OS approaches 90% in this cohort.

Optimum Radiation Dose for Palliation in Head and Neck SCC: A Phase III Randomized Controlled Trial (OPRAH)

PURPOSE/OBJECTIVE(S)

Palliative radiotherapy has been used to alleviate symptoms in locally advanced (T4b) head and neck Squamous cell carcinoma, but optimum dose is still debated. The trial has been designed to determine if high palliative radiation dose (30 Gy/ 5#/ 5 days) improves progression free survival compared to low palliative dose (20 Gy/ 5# 5 days). The secondary objective was to compare toxicity rates profile between the two radiation doses (CTCAE version 5) and compare Quality of life between the two arms with QOL - HN35 questionnaire.

MATERIALS/METHODS

This is a prospective randomized phase III randomized controlled trial. We hypothesized that by increasing the dose per fraction and total dose there would be an improvement in PFS without difference in late toxicity and QOL. The present study will also perform an exploratory analysis of effect of palliative radiotherapy on immune function and its effect on survival. Considering median PFS 2.5 months in 20 Gy arm we assumed that PFS will improve by 1.25 months (total PFS 3.75 months) in 30 Gy arm. To reach the hypothesis with 90% power and alpha error of 0.05, attrition rate of 10% sample size calculated was 286. Patients with cT4b disease of larynx/ Hypopharynx/ Oropharynx/ Oral cavity not amenable to surgery, Carotid encasement > 180 degree, histologically proven squamous cell carcinoma, Age > 18 years and < 75 years ECOG PS 0-2 were eligible.

RESULTS

Until December 2022, we completed accrual of 239 patients. Median age: 53 years (Range: 29-70 years); Gender: Male: Female = 9: 1 (214: 25). 145 patients had history of smoking, 87 had additional history of tobacco chewing. 67 patients had history of alcohol consumption, 13 patients had history of smoking, tobacco and alcoholism. All patients had stage IVA or Stage IVB disease. Primary site was oral cavity in 58%, Oropharynx in 19%, larynx in 10% and hypopharynx in 8% cases. 72.3% patients had a PS of 1, 21.7% had PS 2 at presentation. Prior to RT requirement of analgesic was: No pain medicine: 5; WHO step I:173, WHO step II: 52, WHO step III:14. All patients received conformal radiation with 6 MV linear accelerator. Target volume was GTV plus 1 cm margin to form CTV and 5 mm expansion to generate PTV. Out of 239 patients 67 patients had a disease progression. Mucositis is the commonest side effect affecting most of the patients and improve with best supportive care.

CONCLUSION

High dose palliation appears to be equally well tolerated. However, the impact of such dose escalation will be established if final analysis reaches the pre-defined endpoint.

Empirical Antitubercular Treatment for Lymphadenopathy: Are We Missing Lymphoma?

OBJECTIVE

To evaluate the proportion of patients who received empirical treatment with antitubercular therapy (ATT) prior to the diagnosis of Hodgkin lymphoma (HL) in the first multicentric, prospective study on HL from India, and to assess its impact on extent of disease at diagnosis and outcomes.

METHODS

Children < 18 y with biopsy proven HL were enrolled in InPOG-HL-15-01. Along with other clinical and epidemiological data, history of prior treatment with ATT was documented. All patients received treatment as per a risk-stratified, response-adapted strategy.

RESULTS

Out of 396, 115 (29%) children had received ATT prior to establishing a definitive diagnosis of HL. This cohort presented with advanced-stage disease (p = 0.001) and B symptoms (p = 0.001) in a higher proportion of cases. Consequently, those children were more likely to receive 6 rather than 4 cycles of chemotherapy (p = 0.001). They were more likely to have infradiaphragmatic involvement (p = 0.001). Overall survival and event-free survival were not different.

CONCLUSION

Empirical treatment with ATT in children presenting with lymphadenopathy continues to be practiced widely in India. The delay in diagnosis may contribute to children presenting with advanced-stage disease warranting more intensive treatment for successful outcomes.

Rosai Dorfman Disease with malignant transformation to Histiocytic Sarcoma: A diagnostic conundrum

ABSTRACT

Histiocytic disorders mostly occur as de-novo nodal or extranodal benign masses with rare secondary malignant transformation. A 10-year-old female presented with 10-cm cervical swelling since 9 months associated with fever. Computed tomography revealed left cervical lymphadenopathy and bilateral lung nodules. Lymph node excision biopsy showed effacement of architecture by atypical histiocytes with marked nuclear pleomorphism and frequent mitosis. Focal areas showed mature histiocytes with emperipolesis. The cells were immunopositive for CD68, CD163, and S100 (focal), whereas they were negative for Langerin and CD1a. The Ki67 proliferative index was 30%. A diagnosis of histiocytic sarcoma in a background of Rosai-Dorfman disease was made.

Primary extranodal NK/T cell lymphoma of stomach: A case report and review of literature

ABSTRACT

Extranodal Natural killer/T (NK/T) cell lymphoma nasal type is an aggressive non-Hodgkin lymphoma and has a constant association with Epstein-Barr virus (EBV) infection. Approximately more than 75% cases are located in upper aero-digestive tract, of which stomach is a very rare site. Very few cases of gastric extranodal NK/T cell lymphoma have been reported in the literature. A 22-year-old male patient presented with complaints of abdominal pain and hematemesis. Endoscopy showed a large ulcer in the stomach. Partial gastrectomy done and histopathology showed transmural infiltration by intermediate size atypical lymphoid cells which are immunopositive for CD3, CD56, TIA, EBV-encoded RNA (EBER) and negative for CD4, CD8, CD20. A diagnosis of extranodal NK/T cell lymphoma nasal type was made.

Splenic Lymphomas: A Tertiary Care Center Experience and Review of Literature

Primary splenic lymphomas are rare with the majority of lymphomas in spleen being secondary to an extra-splenic lymphoma. We aimed to analyze the epidemiological profile of the splenic lymphoma and review the literature. This was a retrospective study including all splenectomies and splenic biopsies from 2015 to September 2021. All the cases were retrieved from Department of Pathology. Detailed histopathological, clinical and demographic evaluation was done. All the lymphomas were classified according to WHO 2016 classification. A total of 714 splenectomies were performed for a variety of benign causes, as part of tumor resections and for the diagnosis of lymphoma. Few core biopsies were also included. A total of 33 lymphomas diagnosed in the spleen, primary splenic lymphomas constituted 84.84% (n = 28) of the cohort with 5 (15.15%) having the primary site elsewhere. The primary splenic lymphomas constituted 0.28% of all the lymphomas arising at various sites. Adult population (19-65 years) formed the bulk (78.78%) with a slight male preponderance. Splenic marginal zone lymphomas (n = 15, 45.45%) comprised of major proportion of cases followed by primary splenic diffuse large B-cell lymphoma (n = 4, 12.12%). Splenectomy was the main course of treatment for SMZL with a good overall outcome, with chemotherapy ± radiotherapy forming the mainstay in other lymphomas. Lymphomas in spleen can be infiltrative or a primary, hence proper clinic-radiological and pathological evaluation is required. Appropriate management is guided by the precise and detailed evaluation by the pathologist, requiring understanding of the same.

Acute myeloid leukemia with RAM immunophenotype: A new underdiagnosed entity

INTRODUCTION

Acute myeloid leukemia (AML) with RAM immunophenotype is a distinct subtype of AML, as described by the Children's Oncology Group (COG), with characteristic morphological and immunophenotypic properties. It is characterized by strong CD56 expression with dim to negative CD45, HLA-DR, and CD38 expression. It is an aggressive leukemia with a poor response to induction chemotherapy and/or frequent relapses.

METHODS

Seven cases with the characteristic RAM immunophenotype were identified in this retrospective analysis of newly diagnosed pediatric AML cases from January 2019 to December 2021. Herein, we have critically analyzed their clinical, morphological, cytochemical, immunophenotyping, cytogenetic, and molecular profiles. The patients were traced and followed for their current disease and treatment status.

RESULTS

Of 302 cases of pediatric AML (age <18 years), seven cases (2.3%) with the distinct RAM phenotype were observed, with age ranging from 9 months to 5 years. Two patients were misdiagnosed earlier as small round cell tumor because of the strong CD56 positivity and the absence of leukocyte common antigen (LCA), but they were later correctly identified as granulocytic sarcoma. The bone marrow aspirate showed blasts with unusual cohesiveness and clumping with nuclear moulding, mimicking non-hematologic malignancies. Flow cytometry revealed blasts with low side scatter, dim to negative CD45 and CD38, negative cMPO, CD36, and CD11b; moderate to bright CD33, CD117, and bright CD56. The Mean fluorescence intensity (MFI) of CD13 expression was significantly lower as compared to the internal controls. Cytogenetic and molecular studies did not show any recurrent abnormalities. Reverse transcription polymerase chain reaction for CBFA2T3-GLIS2 fusion was performed in 5/7 cases, with one positive result. On clinical follow-up, two patients were refractory to chemotherapy. Six of the seven cases had succumbed to death (duration of survival: 3-343 days after initial diagnosis).

CONCLUSION

AML with RAM immunophenotype, a distinct form of pediatric AML with a poor prognosis, may pose a diagnostic challenge if presented as a soft tissue mass. A comprehensive immunophenotypic evaluation, including stem cell and myeloid markers, is critical for an accurate diagnosis of myeloid sarcoma with the RAM-immunophenotype. Our data demonstrated weak CD13 expression as an additional immunophenotypic finding.

Follicular Helper T-Cell-derived Nodal Lymphomas: Study of Histomorphologic, Immunophenotypic, Clinical, and RHOA G17V Mutational Profile

The study was designed to review the demographic, clinical, and pathologic characteristics of follicular helper T cells (TFH)-derived nodal PTCL in India including angioimmunoblastic T-cell lymphoma (AITL), peripheral T-cell lymphoma (PTCL) with follicular helper T cell phenotype (P-TFH), and follicular T-cell lymphoma with additional immunohistochemistry (IHC) and RHOAG17V mutational analysis, as well as their impact on survival. This retrospective study included 88 cases of PTCL that were reclassified using IHC for TFH markers (PD1, ICOS, BCL6, and CD10) and dendritic-meshwork markers (CD21, CD23). Cases of TFH cell origin were evaluated for RHOAG17V mutation using Sanger sequencing and amplification-refractory mutation system-polymerase chain reaction (PCR) (validated using cloning and quantitative PCR) with detailed clinicopathologic correlation. Extensive re-evaluation with added IHC panel resulted in a total of 19 cases being reclassified, and the final subtypes were AITL (37 cases, 42%), PTCL-not otherwise specified (44, 50%), P-TFH (6, 7%), and follicular T-cell lymphoma (1, 1%). The presence of at least 2 TFH markers (>20% immunopositivity) determined the TFH origin. AITL patients tended to be male and showed increased presence of B-symptoms and hepatosplenomegaly. Histomorphology revealed that 92% of AITL cases had pattern 3 involvement. Sanger sequencing with conventional PCR did not yield any mutation, while RHOAG17V was detected by amplification-refractory mutation system-PCR in AITL (51%, P =0.027) and P-TFH (17%), which was validated with cloning followed by sequencing. Cases of RHOAG17V-mutant AITL had a worse Eastern Cooperative Oncology Group performance status initially but fared better in terms of overall outcome ( P =0.029). Although not specific for AITL, RHOAG17V mutation shows an association with diagnosis and requires sensitive methods for detection due to low-tumor burden. The mutant status of AITL could have prognostic implications and translational relevance.

Response assessment by positron emission tomography-computed tomography as compared with contrast-enhanced computed tomography in childhood Hodgkin lymphoma can reduce the need for radiotherapy in low- and middle-income countries

INTRODUCTION

The InPOG-HL-15-01, a multicentric prospective study, used a risk-stratified and response-based approach with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) backbone to treat children and adolescents with newly diagnosed Hodgkin lymphoma (HL) and reduce the use of radiation therapy (RT). Children/adolescents with bulky disease or inadequate response at early response assessment (ERA) after two cycles of chemotherapy were assigned to receive RT. For ERA, positron emission tomography computed tomography (PET-CT) was recommended but not mandatory in view of limited access. This study aimed to compare the impact of using contrast-enhanced computed tomography (CECT) and PET-CT on treatment decisions and outcomes.

METHODOLOGY

396 patients were enrolled and 382 had an ERA at the assigned time point. Satisfactory response was defined as Deauville score 3 or less for patients undergoing PET-CT and complete response (CR)/very good partial response (VGPR) for patients undergoing CECT. Outcomes of interest incorporate 5 year event-free survival (EFS), EFS including abandonment (EFSa), and overall survival (OS).

RESULTS

At ERA, satisfactory response was documented in 277 out of 382 (72.5%) participants and this was significantly higher in PET-CT (151 out of 186, 81.2%) as compared with CECT-based assessments (126 out of 196, 64.3%) respectively (p value < .001). Amongst the 203 patients with nonbulky disease (wherein the indication for RT was entirely dependent on ERA), 96 out of 114 (84.2%) and 61 out of 89 (68.5%) patients achieved a satisfactory response according to the PET-CT and CECT (p value = .008) respectively and hence a lesser proportion of patients in the PET-CT arm received RT. Despite a lower usage of RT the 5 year OS of both groups, ERA based on CECT (91.8%) versus PET-CT (94.1%) was comparable (p value = .391) and so was the 5 year EFS (86.7 vs. 85.5%, p value = .724).

CONCLUSION

Use of PET-CT as the modality for ERA is more likely to indicate a satisfactory response as compared with CECT and thereby decreases the need for RT in response-based treatment algorithm for HL-afflicted children. The reduction in the application of RT did not impact the overall outcome and plausibly would lower the risk of delayed toxic effects.

Safety and Efficacy of Bendamustine and Rituximab (BR) Regimen in Indian Chronic Lymphocytic Leukaemia Patients

We investigated the safety and efficacy of bendamustine-rituximab (BR) in previously untreated symptomatic and advanced CLL patients, as there is no data available on BR from the Indian subcontinent.This retrospective study included 120 consecutive treatment naïve patients with CLL without del (17p), who were registered at the Department of Medical Oncology, AIIMS between January 2010 and July 2018. Bendamustine was given at a dose of 90 mg/m2 on days 1 and 2, combined with rituximab 375 mg/m2 rituximab on day 1, every 28 days for up to 6 courses. Event-free survival (EFS) was defined as the date of treatment to date of relapse, disease progression, or death due to any cause.The median age was 57 years (range: 30-75 years). As per the clinical Rai stage, 30 (25%) patients were in stage II, 42 (35%) were in stage III and 48 (40%) were in stage IV. ZAP70 was positive (> 20%) in 50%, CD 38 was positive (> 30%) in 33%, and CD49d was positive (> 30%) in 49% of cases. Beta-2 microglobulin (B2M) was elevated (≥ 3.5 mg/L) in 80% of cases. Fifty-five cases (50%, n = 110) were IGHV mutated. The mean number of cycles was 5 (1-6). The overall response rate (ORR) seen with BR was 90% and complete response was 45%. Median progression-free survival was 24 months with a median follow-up period of 29 months. Haemoglobin (< 10 g/dL), elevated B2 M, unmutated IGHV had a statistically significant adverse impact on EFS on univariate analysis but on multivariate analysis, only IGHV mutation status was found to had significance on EFS. The median EFS was 27 months in IGHV mutated versus 18 months in IGHV unmutated-CLL patients (p = 0.001). Grade 3/4 neutropenia, thrombocytopenia, anemia, and infections were observed in 30.6%, 8%, and 12% respectively. The most common non-hematological toxicity was skin rash which was grade 1/2 in 24 (20%) cases and grade 3/4 in 12 (10%) cases. This is the largest study from India to demonstrate the safety and efficacy of BR in symptomatic CLL patients. BR is an effective and safe regimen in the first-line treatment of CLL. Unmutated-CLL patients have inferior EFS than mutated-CLL patients. Skin toxicity was the most common adverse effect seen in our population which was observed in around one-third of cases.

Cytology of Castleman's disease (hyaline-vascular type) masquerading as Hodgkin's lymphoma

Castleman disease (CD) is a rare benign disorder presents as a lymph nodal mass in mediastinum, cervical, axillary or abdomen. Due to the presence of dysplastic dendritic cell in a background mature lymphocyte and plasma cell, it mimics Hodgkin disease (HD). Synchronous and metachronous occurrence in HD and CD can also occur. An 11-year-old male presented with cervical lymphadenopathy (3.5 × 3.5 cm). Fine needle aspiration shows atypical binucleate cell in a background of small lymphocytes, a diagnosis of Hodgkin disease is suggested. Excisional biopsy showed classical features of Hyaline vascular Castleman disease. Careful cytological evaluation and clinical correlation is required for definitive diagnosis.

Blastic plasmacytoid dendritic cell neoplasm: A clinicopathological diagnostic dilemma report of three cases with review of literature

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a highly aggressive hematologic neoplasm and classified under acute myeloid leukemia. Here, we describe the clinicopathological features of three cases of BPDCN: two with classical and one uncommon immunophenotype. A-35-year-old female (case 1) presented with complaint of nasal mass and generalized lymphadenopathy. Biopsy from axillary lymph node showed infiltration by cells with scant cytoplasm which were immunopositive for LCA, CD4, CD43, and ALK1. Flowcytometry showed positivity for CD45, CD4, CD33, and CD123 while negative for rest all markers. The other two cases have classical immunophenotype. In clinical practice, nasal mass with lymphadenopathy suggests natural killer T-cell/peripheral T-cell lymphoma. Again immunohistochemical positivity for CD4, CD43, and ALK while negativity for CD3 suggests anaplastic large cell lymphoma. In this case, morphology and extensive bone marrow involvement raise the suspicion. Fowcytometry positivity for HLADR, CD123, and CD33 helps in making diagnosis.

A Comparative Review of ICMR, WHO, and EMA Guidelines for Good Clinical Laboratory Practices

With the advancement of clinical research and the increased burden on laboratory services, there is an unmet need for guidelines regarding proper laboratory functioning and reliable data generation. Several organizations from all over the world have published guidelines for these clinical and research laboratories. Good Clinical Laboratory Practices (GCLP) are stepwise procedures aimed at strengthening the quality of test results produced by all clinical laboratories engaged in human sample analysis. In this article, we attempt a comparison of the GCLP guidelines recently issued by the Indian Council of Medical Research with the guidelines released by the World Health Organization and the European Medicines Agency. Also, we have included and discussed several suggestions that, if included, will lead to the strengthening of the laboratory practices used for both research and patient care for overall improvement in the Indian healthcare system.

TCL-306 Application of the Proposed Immunohistochemistry Algorithm for the Prognostication of GATA3 and TBX21 Subtypes of Peripheral T-Cell Lymphoma, Not Otherwise Specified

CONTEXT

Recent molecular studies have indicated the varied oncogenic pathways resulting in the subtypes of peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS), which affect prognosis and may have predictive value.

OBJECTIVE

To evaluate the immunohistochemistry (IHC) algorithm (Amador et al.) for the subtyping of PTCL, NOS and ascertain their relevance with correlation to the clinicopathological profile.

DESIGN

This 7-year (2015-2021) ambispective study included 43 patients with diagnoses of PTCL, NOS from the archives of the Department of Pathology (AIIMS, New Delhi). IHC for transcription factors GATA3 (>50% immunopositivity considered positive) and TBX21 (>20%) and their target proteins CCR4 (>50%) and CXCR3 (>20%) was performed followed by subtyping by two pathologists. Detailed clinicopathological correlation was done.

MAIN OUTCOME MEASURES

The association between the subtypes and clinical factors (demographics, performance status, organomegaly, IPI/PIT score, stage, marrow involvement), histologic features (monomorphous/polymorphous population), and survival (overall and progression-free survival) was analyzed.

RESULTS

With the application of the algorithm by Amador et al., the cases were categorized into the subtypes GATA3 (18), TBX21 (13), and unclassifiable (7). There was no significant association observed with the clinical parameters of the subtypes. Though an increased proportion of TBX21-subgroup cases showed a polymorphous population compared to the GATA3 subgroup with monomorphous population, no significant P-value was found. Two of the Lennert lymphomas were categorized in the GATA3 subgroup. On multivariate analysis, no significant difference was present for overall survival (P-value=0.149) and progression-free survival (P-value=0.066) amongst the IHC-defined subtypes; the trends suggest that the GATA3 subgroup has worse overall and progression-free survival.

CONCLUSIONS

The IHC-derived subtypes of GATA3 and TBX21 may have a role in prognostication and may guide further therapeutics aiding in better patient management of this aggressive group of lymphomas. The algorithm is reproducible, however some of the cases may be left unclassifiable and require further work up and gene expression profiling. The results trend toward the GATA3 subgroup having a monomorphous population with a worse overall prognosis, requiring a larger sample size for validation. The application of this algorithm in routine practice can help in risk stratification of the patients.

FUNDING

Thanks to Science-Engineering-Research-Board and AIIMS-Research section (SERB-EEQ/2016/402, AIIMS-A-653).

Current trends in diagnosis and management of follicular lymphoma

Follicular lymphoma (FL) originates from germinal center B cells, is the most prevalent form of indolent non-Hodgkin's lymphoma. Upfront management is based on stage, grade, and disease burden. Radiotherapy may be curative in limited disease while chemoimmunotherapy is preferred in advanced disease. Maintenance therapy is routinely administered but its role is debatable. Relapses are common and interval from initial therapy to relapse is most important prognostic factor for relapsed FL. Management of relapsed patients is based on the initial management, the interval from prior therapies, and the toxicity of available therapies. Multiple agents are available for patients after two or more lines of therapy, but sequencing remains poorly defined.

Small cell variant anaplastic large cell lymphoma presenting as leukemia: A case report and review of Literature

Anaplastic large cell lymphoma (ALCL) is a subcategory of the mature T-cell neoplasm characterized by sheets of cluster of differentiation (CD)30-positive pleomorphic large cells mostly present as lymphadenopathy. Here, we describe a case of Small cell variant ALCL with leukemic presentation without lymphadenopathy. A 68-year-old male presented with fatigue and weakness; examination revealed a total leukocyte count of 295,000/uL. The peripheral smear showed cells having cerebriform nuclei comprising 90% of the leukocytes. The flow cytometry showed that the cells were immunopositive for CD3 (weak), CD4, CD7, and negative for the rest of the markers. The cell blocks from the peripheral blood showed cells with immunopositivity for CD30, anaplastic lymphoma kinase (ALK), and Epithelial membrane antigen (EMA). A diagnosis of the small cell variant of ALK-positive ALCL was made. Due to the presence of atypical pleomorphic cells without lymphadenopathy, the case has a diagnostic dilemma with differential diagnosis of Sezary syndrome, T-cell prolymphocytic leukemia, and adult T-cell leukemia/lymphoma. Karyotyping and additional immunohistochemistry help for the confirmation of the diagnosis.

Neoplasms of follicular helper T-cells: an insight into the pathobiology

T-follicular helper cells (TFH) are a unique subset of T-cells with varied transcriptional profiles and functions. In the last 2016 WHO classification, lymphomas arising from TFH were included as a broad category and emphasis was given to separating them from other peripheral T cell lymphomas. The neoplasms derived from these mainly comprise angioimmunoblastic T-cell lymphoma, peripheral T-cell lymphoma with T-follicular helper cell phenotype, follicular T-cell lymphoma, and cutaneous CD4+ small-medium sized lymphoproliferative disorders. The TFH lymphomas comprise both indolent and aggressive forms. Additional immunohistochemistry to identify TFH cells like CD10, BCL6, ICOS, PD1, CXCL13 and mutations like RHOA, IDH2 is required for diagnosis and prognostication. The understanding of these has evolved over the years, and currently we review the updates and pathobiology of the above.

Safety and efficacy of Ibrutinib in Indian patients with chronic lymphocytic leukemia

e19585

Background: Ibrutinib, an oral Bruton's tyrosine kinase inhibitor, is approved for the treatment of chronic lymphocytic leukemia (CLL) in both upfront and relapsed/refractory. The prevalence of CLL is very low in India compared to western countries. Hence, the real-world data regarding efficacy and safety of Ibrutinib among the Indian population is very scarce. In this study, we aim to examine the toxicity profile, treatment response, and survival outcomes among Indian patients with CLL treated with Ibrutinib. Methods: In this retrospective study, we recruited all consecutive patients diagnosed with CLL, both treatment naïve (TN) and relapsed/refractory (R/R) CLL, on Ibrutinib (daily dose of 420 mg), registered at the Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India between April 2016 and December 2021. Diagnosis of CLL, an indication of treatment, and response assessment were based on the recent guidelines (2018) from the International Workshop on CLL (iwCLL). Results: A total of 90 patients were recruited in this study, of which 33 were newly diagnosed and 57 had R/R CLL. Median age of the cohort was 60 years (range, 35–80 years) and male to female ratio was 3:1. The median total leukocyte count was 55x109/L and Del 17p was detected in 18% of cases. The R/R cases had received a median of 1(1-3) prior line of therapy. Overall response rate was observed in 76(84.4%), complete response was in 18 (20%) cases, partial response (PR) was in 49 (54.4%) cases, and in 9 (10%) cases PR with lymphocytosis (PR-L) was observed. With a median follow-up period of 15 months (4-60), 2-year progression-free survival (PFS) was 80% for the whole cohort. The median PFS was not reached in TN cases and was 18 months in R/R cases. Grade-3/4 adverse events (A/E) were seen in 17 (29.8%, n = 57) of R/R cases and in 3 (9.1%,n = 33) of TN cases. The most common Grade-3/4 A/E were infections in 19 (21.1%), (Varicella: 7, Pneumocystis: 6, Aspergilosis: 2, Mucormycosis: 1, Disseminated tuberculosis: 1, Encephalitis: 1, Others: 1) and cytopenias in 9 (10%) of cases. Other A/E were fatigue in 6 cases, arthralgia in 3, bleeding in 2, cutaneous rash in 2, reactivation of hepatitis-B in 2, diarrhea in 2, arrhythmia in 2, and autoimmune hemolytic anemia in one case. Ten patients (11.1%) had a dose reduction due to AE. The discontinuation rate was 27 (30%), due to progressive disease in 18 patients and due to adverse events in 9 patients. Twenty patients died, 14 due to disease progression or Richter's transformation, 5 due to infections, and 2 due to other reasons. Conclusions: This is the largest study of ibrutinib from India. Ibrutinib is safe and effective in upfront and R/R cases of CLL. Infections are the most common adverse event in R/R cases. Acyclovir and Co-trimoxazole prophylaxis can be considered in R/R cases of CLL in routine clinical practice . Arrhythmias were rare A/E as compared with the available literature.

The Expression of the RUVBL1 Component of the R2TP Complex Correlates with Poor Prognosis in DLBCL

INTRODUCTION

Diffuse large B-cell lymphoma (DLBCL) is the most prevalent subtype of non-Hodgkin's lymphoma (NHL) accounting for 30% of adult NHL worldwide and 50% in developing countries like India. DNA damage and Myc-induced transformation are well-known contributing factors towards development of DLBCL. A recently identified HSP90 co-chaperone complex R2TP has been shown to contribute towards DNA damage and Myc-induced transformation. This study aimed to analyse the immunohistochemical (IHC) expression of R2TP complex components RUVBL1, PIH1D1, and RPAP3 in DLBCL patients and correlate with prognosis.

METHODS

DLBCL (n = 54) histological slides were retrieved from archives, and detailed histomorphological and clinical features were noted. IHC staining of R2TP complex components RUVBL1, PIH1D1, and RPAP3 was performed on 54 cases (FFPE) of DLBCL. Expression data were correlated with survival and clinical features.

RESULTS

Out of the 54 DLBCL cases, 59.26% (n = 32) stained positive for RUVBL1. The RUVBL1 expression was associated with poor prognosis in both progression-free survival (PFS) (p = 0.0146) and overall survival (OS) (p = 0.0328). The expression was positively correlated with bone marrow involvement (p = 0.0525). The expression of PIH1D1 was observed in 68.51% (n = 32) of DLBCL cases, and positive correlation was observed with international prognostic index score (p = 0.0246); however, no correlation was observed with PFS or OS. Finally, RPAP3 was found immunopositive in only 1 case of DLBCL.

CONCLUSIONS

Immunopositivity for RUVBL1 is associated with poor prognosis along with a higher relapse rate amongst the DLBCL patients. PIH1D1 immunopositivity correlated with a higher IPI score.

ALK-Negative Primary Cutaneous Anaplastic Large Cell Lymphoma With Systemic Involvement or Systemic ALCL With Cutaneous Lesion. A Diagnostic Dilemma

ABSTRACT

Primary cutaneous anaplastic large-cell lymphoma (C-ALCL) is a cutaneous CD30-positive lymphoproliferative disorder. The patients usually present with single or multiple cutaneous nodules or papules and about 10% cases present with extracutaneous manifestations, which are predominantly in the form of regional lymph nodal involvement. Visceral involvement especially pulmonary or hepatic involvement in C-ALCL is only rarely described in the scientific literature. Approximately 20%-42% cases show spontaneous regression, about 50% cases may recur; however, C-ALCL generally carries a good prognosis. We present a rare case of primary C-ALCL in a 66-year-old man with regional lymph nodal and hepatic involvement. Differential diagnostic entities are discussed in this report with the review of the literature.

Differential expression of miRNA in histological subtype of Wilms tumor

INTRODUCTION

Wilms tumor is the most common renal malignancy in children and difficult to differentiate from other paediatric abdominal tumors radiologically, necessitating an invasive procedure for diagnosis. Previous studies have shown the potential role of miRNA as biomarkers for diagnosis, histological subtyping and prognosis. In this study, we are exploring the role of miRNA in the histological subtyping of Wilms tumor in the Indian population.

MATERIALS AND METHODS

A total of 15 cases of Wilms tumor were evaluated for global miRNA expression analysis by microarray. Total RNA was extracted from fresh frozen tumor and miRNA expression analysis was performed using Agilent platform. Unsupervised clustering was done to analyse the data.

RESULTS

Using unpaired student T test, top 10 significantly differentially expressed miRNA were selected which could differentiate among different histological subtypes by unsupervised hierarchical clustering and principal component analysis. The presence of necrosis, heterologous differentiation led to change in miRNA expression profile and led to a distinct cluster formation.

CONCLUSIONS

A panel of 5 miRNAs (miR1, 133b, 299-3p, 499a-5p, 491-3p) could differentiate among different histological subtypes of Wilms tumor, thus avoiding an invasive procedure in children, however, further confirmation using real time PCR analysis will be needed.

Impact of Cell-of-Origin on Outcome of Patients With Diffuse Large B-Cell Lymphoma Treated With Uniform R-CHOP Protocol: A Single-Center Retrospective Analysis From North India

Introduction

There is a scarcity of data from India on the impact of cell of origin (COO) on outcomes of diffuse large B-cell lymphoma (DLBCL). This study was conducted to evaluate the impact of COO on outcomes of DLBCL patients treated with uniform rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (RCHOP) protocol.

Materials and Methods

This retrospective analysis included patients who received uniform RCHOP chemoimmunotherapy during the study period (2014–2020) at the Department of Medical Oncology at All India Institute of Medical Sciences (AIIMS), New Delhi, India. The patients were classified as germinal center B-cell like (GCB) or activated B-cell (ABC) type using the Hans classification.

Results

Four hundred seventeen patients with median age of 48 years (range, 18–76) and a male-female ratio of 2:1 were included in the analysis. B symptoms and bulky disease were seen in 42.9% and 35.5%. Extranodal involvement was seen in 50.8% of cases. ECOG performance status (0-2) was present in 65%, and 51% presented with advanced disease. GCB subtype was seen in 43%, and 47% were ABC type. Low- and intermediate-risk international prognostic index (IPI) score was seen in 76% of cases. The overall response rate to RCHOP was 85.8%, including a complete response rate of 74.8%. After a median follow-up of 30 months, the 3-year event-free survival (EFS) and overall survival (OS) were 80% and 88%, respectively. The presence of B symptoms and poor ECOG performance status (3-4) was associated with inferior CR rate. Low albumin (p < 0.001), age >60 years (p = 0.001), bulky disease (p < 0.001), and extranodal involvement (p = 0.001) were associated with inferior EFS, whereas a high IPI risk score was associated with an inferior OS (p < 0.001). EFS and OS were not significantly different between the GCB and ABC subtypes. Grade III/IV anemia, neutropenia, and thrombocytopenia were seen in 7.6%, 13.6%, and 2.7% of patients, respectively. Febrile neutropenia was seen in 8.9% of patients, and there were four treatment-related deaths.

Conclusions

Cell of origin for DLBCL has no impact on CR, EFS, and OS if patients are appropriately treated with standard doses and frequency of RCHOP. RCHOP is well tolerated in our patients, and results are comparable with the Western data.

Testicular fixation and its effect on ipsilateral and contralateral testis in prepubertal rat model

Background

While performing orchidopexy, various suture materials or fibrin glues are used to achieve testicular fixation. This study was designed to assess the histological changes in testis after orchidopexy using fibrin glue and suture material.

Methods

Male Wistar rats (n = 80) were divided randomly into four groups. Group I, (n = 20): sham operation, Group II (n = 20): Dartos Pouch (DP), Group III (n = 20): Transtunical fixation (TF), Group IV (n = 20): Tissue Adhesive (TA). Ipsilateral and contralateral testicular histology was assessed at 70 and 120 days of life after sacrificing animals by using thiopental sodium intraperitoneally at a dose of 100 mg/kg.

Results

Morphologically, at day 70, contralateral testis in Group III had a significant (p value 0.046) decrease testicular width (0.92 ± 0.01 vs 1.24 ± 0.39 cm). At 120 of life, Group I, II, III, and IV had a significant (p value < 0.001 each) decrease testicular width and weight in ipsilateral and decrease testicular length (p value 0.002) in contralateral testis. Histologically, mean seminiferous tubular diameter and DNA flow cytometry had a significant (p value < 0.001) decrease in size in Group I, II, III, and IV both ipsilateral as well as contralateral testis. Intergroup comparison at 70 and 120 days of life showed a significant decrease in seminiferous tubular diameter in Group II, III and IV and in Johnsen maturation score, seminiferous tubular diameter, DNA flow cytometry in Group I, II, III, and IV.

Conclusions

Dartos Pouch is most suitable procedure for treatment of orchidopexy. Suture fixation must be avoided and if the need arises then instead of suture materials, fibrin glue should be used for testicular fixation.

Combined Modality Treatment with “Dexamethasone, Methotrexate, Ifosfamide, L-Asparaginase, and Etoposide ” Chemotherapy and Involved Field Radiotherapy for Early Stage Natural Killer/T Cell Lymphoma with Local Tumor Invasiveness: A Single-institution Study from India

Context: Patients with early stage extranodal natural killer/T-cell lymphoma, nasal type (ES-NKTCL) and local tumor invasiveness (LTI) show poor treatment outcomes with standard approaches. Dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) is an intensive, highly active protocol mainly studied in advanced/recurrent disease. No prior study has utilized this protocol in high-risk ES-NKTCL. Methods: Between 2011 and 2016, all patients with ES-NKTCL with LTI at presentation were uniformly treated at our institute with a combination of SMILE chemotherapy for 5–6 cycles, and involved-field radiotherapy (IFRT). Records of these patients were retrospectively reviewed. Results: Sixteen patients were identified, 69% stage IE and 31% stage IIE. The majority of patients had B-symptoms (75%), paranasal sinus (PNS) invasion (81%), facial skin invasion (56%), palatal perforation (69%), or orbital extension (56%). 12/16 had B-symptoms, and 6/16 had elevated lactate dehydrogenase. All patients received the entire planned 5–6 cycles. IFRT was delivered after a mean 4 cycles. Complete remission was achieved in 13/15 (87%) patients. At a median follow up of 18.5 months, 1-year progression-free survival and overall survival was 84% and 94%, respectively. Grade 3–4 toxicity was seen in 81%, most commonly neutropenia (75%), anemia (44%), and thromobocytopenia (31%). Six patients required dose adjustments (predominantly in the first 1 or 2 cycles). No treatment-related mortality was noted. Conclusion: SMILE with RT is a toxic but tolerable protocol for ES-NKTCL with LTI with high efficacy. Prospective studies are warranted.

Hypercalcaemia, renal failure, anaemia and osteolytic lesions (CRAB) in chronic lymphocytic leukaemia mimicking multiple myeloma

Classical CRAB features (hypercalcaemia, renal failure, anaemia, osteolytic lesions) have been traditionally defined in patients with plasma cell dyscrasia. But these can be rare and uncommon presentations of other chronic lymphoproliferative disorders (CLPD). The pathophysiological basis of CRAB features in other CLPD need to be explored further for better outcomes and therapeutic interventions. These can present a diagnostic dilemma and requires extensive workup to rule out coexisting malignancy and myeloma. Here, we report an unusual case of B CLPD in a middle-aged male who presented with classical CRAB features along with a brief literature review. After detailed investigations, he was diagnosed as chronic lymphocytic leukaemia, without any second malignancy and responded well to ibrutinib-based therapy.

An elderly male with nonresolving consolidation

An 81-year-old male presented with a background history of progressive shortness of breath for 3 years with recent worsening in the past 6 months. Clinicoradiological investigations were consistent with a nonresolving consolidation involving predominantly right lung. This clinicopathologic conference discusses the differential diagnoses of pneumonia of long-standing duration and their management options.

The concatenation of association between gastroesophageal reflux and obstructive adenotonsillar hypertrophy

OBJECTIVES

Gastroesophageal reflux (GER) is frequently seen in patients with adenotonsillar hypertrophy. However, the sequential association between GER and adenotonsillar hypertrophy is unknown. This leads to unpredictable outcomes while treating patients of adenotonsillar hypertrophy with GER. The objective of this study is to evaluate the prevalence of GER and gastroesophageal reflux disease (GERD) in paediatric patients with obstructive adenotonsillar hypertrophy (OATH), and to assess the effect of adenotonsillectomy (AT) on GER as well as GERD.

METHODS

In this prospective cohort study, consecutive pediatric patients with grade III/IV hypertrophy of adenoid or/and tonsillar tissue who were planned for AT were recruited after excluding comorbidities predisposing to GER. Symptoms of GERD using Gastro Esophageal Reflux Questionnaire for Young Children (GERQ-YC) and Reflux Indices (RI) obtained from 24-h ambulatory esophageal pH monitoring were evaluated in all patients pre-operatively and 12 weeks following AT.

RESULTS

A total of 49 patients with OATH with average age of 6 years were included in this study. With a RI of >4.3% as the threshold for making the diagnosis of GER on esophageal pH monitoring, the prevalence of GER was 20.4%. The average RI preoperatively was 15.7% which reduced to 1.7% following AT (p = 0.004). Among the 10 patients with preoperative GER, 80% of the patients had no evidence of GER after surgery. New incidences of GER was not observed post operatively in this cohort. As per the GER symptom scoring system, 31% of the parents reported GERD pre-operatively which resolved completely in all patients following surgery.

CONCLUSIONS

- In this study, the prevalence of GER proven by 24 h ambulatory esophageal pH monitoring is 20% in pediatric patients with OATH. Following AT, GER resolved in 80% of cases and was reduced substantially in the remaining cases in the subset of patients with pre-operative GER. The symptoms of GERD based on parents' recall of child's previous symptoms may not accurately represent presence of GER. Our results suggest that OATH can result in GER due to increased negative intra-thoracic pressure as a result of breathing against an obstructed upper airway and hence, GER subsides following surgical removal of the obstructive pathology. To establish this concatenational association of OATH and GER, larger studies are mandated.

Pediatric mediastinal lymphoma

The mediastinum is the visceral compartment of thoracic cavity divided into the superior and inferior mediastinum, further inferior compartmentalize into anterior, middle, and posterior mediastinum. Lymphoma in the mediastinum may be primary or secondary to systemic disease. Lymphoma may arise from lymphoid organs-like thymus, mediastinal lymph nodes or other mediastinal organs like heart, lung, pleura, and pericardium. It comprises about 12% of all the mediastinal tumors in adults however, it constitutes 50% of the pediatric mediastinal mass. Anatomically lymphoma most commonly involves anterior mediastinum. Among the pediatric mediastinal lymphomas, lymphoblastic lymphoma (LBL) predominate followed by Hodgkin lymphoma (HL), primary mediastinal large B cell lymphoma (PMBCL) and very rarely Grey zone lymphoma. Other types of non-HLs (NHLs) are rare among pediatric population. Radiologically and clinically present as an anterior mediastinal mass with symptoms of dyspnea, cough, and superior vena cava syndrome. Also, clinically and radiologically all the pediatric mediastinal mass shares the overlapping features, hence, for treatment and prognostic points of view its essential to differentiate the three entities, i.e., LBL, HL and PMBCL. The pathological diagnosis of pediatric mediastinal lymphomas is quite challenging for general histopathologists. In this review, we describe the pathology, genetics, differential diagnosis, treatment, prognosis, and a simplified histopathological and immunophenotypical approach to differentiate the pediatric mediastinal lymphomas.

Multiple Myeloma-Effect of Induction Therapy on Transplant Outcomes

BACKGROUND

Patients with multiple myeloma (MM) aged ≤ 65 to 70 years, with a good Eastern Cooperative Oncology Group performance status and no major comorbid conditions, are considered potential candidates for autologous stem cell transplant (ASCT) and will be treated with novel agent-based induction therapy for 4 to 6 cycles before ASCT.

PATIENTS AND METHODS

We analyzed the data from 326 patients with MM who had received novel agent-based induction before ASCT at our center to evaluate the effect of induction therapy on ASCT response, stem cell mobilization, engraftment characteristics, and survival. The median age was 52 years (range, 29-72 years), 216 patients were men (66.3%), 32.7% had stage III using the Revised Multiple Myeloma International Staging System, and 15.8% had high-risk cytogenetics. Of the 326 patients, 75 (23.0%) had undergone ASCT in second remission after salvage therapy for relapse. Also, 194 patients (59.5%) had received doublet induction therapy and 132 (40.5%) had received triplet induction therapy.

RESULTS

Triplet-based induction therapy was superior to doublet-based therapy for response (95.4% vs. 84.02%; P < .003), stem cell mobilization (CD34⁺ ≥ 2 × 10⁶/kg; 88.6% vs. 76.8%; P < .005), and lower 100-day transplant-related mortality (P < .001). The ≥100 day post-ASCT overall response (97.4% vs. 91.7%; P = .124) and complete response (72.5% vs. 68.0%; P = .38) rates were similar. At a median follow-up of 62.5 months, the overall survival (97.5 months vs. 100.0 months; P = .606) and progression-free survival (54.5 months vs. 57 months; P = .515) were similar between the triplet and doublet induction groups.

CONCLUSION

An initial response (chemosensitivity) to induction therapy will prepare patients better for subsequent consolidation therapy and ASCT, leading to favorable outcomes.