Venetoclax plus dose-adjusted R-EPOCH (VR-DA-EPOCH) or G-EPOCH bridging to subsequent cellular therapy for the patients with transformed lymphoma a single center clinical experience

Indolent lymphoma, including chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and follicular lymphoma (FL), can undergo histological transformation into an aggressive subtype, typically diffuse large B-cell lymphoma (DLBCL). The prognosis of transformed lymphoma is poor. In this study, we reported the efficacy and toxicity of a combination of venetoclax, dose-adjusted rituximab or obinutuzumab, etoposide, prednisone, vincristine, doxorubicin, and cyclophosphamide (VR-DA-EPOCH or VG-DA-EPOCH) in 11 patients with biopsy-proven histology transformation into DLBCL, including 8 patients with RT and 3 with transformed FL (tFL). The study was conducted between October 2019 and March 2023 at our single center. The median age of participants at enrolment was 53 years. Six patients (85.7%, 6/7) achieved complete remission (CR) at the end of treatment. The best overall response rate (ORR) and CR rate were both 72.7%, respectively. Two patients received autologous hemopoietic stem cell transplant (ASCT) while two patients received ASCT concurrently with CAR-T therapy for consolidation. With a median follow-up of 13.5 (range, 2.4-29.8) months after enrollment, the median event-free survival, progression-free survival, and overall survival were 9.4, 11.5, and 17.5 months, respectively. Hematologic toxicities of grade ≥3 consisted of neutropenia (90.9%, 10/11), thrombocytopenia (63.6%, 7/11), and febrile neutropenia (54.5%, 6/11). In conclusion, VR-DA-EPOCH or VG-DA-EPOCH was a promising strategy to achieve an early remission, bridging to cellular therapy within this population.

Chimeric Antigen Receptor T-Cells in Indolent Lymphoma, Mantle Cell Lymphoma, Chronic Lymphocytic Leukemia

The advent of chimeric antigen receptor (CAR)-T cell therapy has revolutionized the treatment of several hematological malignancies. Although the initial benefit was mainly observed in aggressive leukemias and lymphomas, recent data have resulted in the approval of multiple CAR-T therapies in indolent lymphomas, with ongoing research showing great promise for further improvements and therapeutic optimizations. In this article, we review the published data and approved therapies for CAR-T cell therapy for indolent lymphomas focusing on mantle cell lymphoma and follicular lymphoma while describing the work in chronic lymphocytic leukemia and future strategies.

Extreme lymphocytosis in a dog with T-zone lymphoma

Background

Canine T-zone lymphoma (TZL) is recognized as an indolent CD45-T cell lymphoma, with low aggressiveness and high overall survival. The diagnosis is obtained by histopathology and immunohistochemistry, but also by cytological examination of the lymph node associated with immunophenotyping. Lymphocytosis is commonly identified as around 10,000 cells/µl and may reach 30,760 cells/µl.

Case Description

The present report describes a case of a female Golden Retriever, nine years old, with generalized lymphadenopathy. In the cytological examination of the superficial cervical lymph node, a monomorphic population of small, "clear cells" and "hand mirror" lymphocyte shape was suggestive of TZL. The leukogram showed intense leukocytosis (160,050 cells/μl) due to small clear cell lymphocytosis (152,048 cells/μl). The myelogram showed a myeloid:erythroid ratio of 2:3; with a pyramidal distribution of cell types and the presence of 22.8% of lymphocytes in the differential count. Bone marrow, peripheral blood, and lymph node immunophenotyping resulted in lymphocyte gates with 97.3% to 99.5% CD5+, predominantly CD4-, CD8-, and CD45- confirming the diagnosis of TZL with associated leukemia. Treatment with chlorambucil and prednisolone was started. During the first month, the lymphocytosis remained above 200,000 cells/uL. After four months of treatment, there was a decrease in lymphocytes, which progressively reached a count of 10,800 cells/ul in the eleventh month.

Conclusion

In the literature, lymphocytosis above 30,760 cells/μl has not been observed in TZLs. Thus, it is believed that this is the first report of extreme lymphocytosis with a slow response to chemotherapy.

Health-related quality of life and chronic fatigue in long-term survivors of indolent lymphoma - a comparison with normative data

The aims of this study are to describe health-related quality of life (HRQoL, SF-36) and fatigue in long-term indolent lymphoma survivors, compared to normative data, and to examine factors related to impaired HRQoL among the survivors. The participants (N = 136, median follow-up after first line therapy 9.8 years) were included from a follow-up study of two clinical trials, with chemo-free first-line therapy. The present survey included questionnaire based data. Compared to the normative data, the mean total fatigue score were higher, and HRQoL lower in 4 of 8 domains among the lymphoma survivors. Among the survivors, somatic comorbidities, not being in paid work and chronic fatigue were significantly associated with reduced physical HRQoL. Anxiety and depressive symptoms were associated with reduced mental HRQoL. Our findings highlight the need for awareness of HRQoL and fatigue in long term follow up in lymphoma survivors, as there are treatments and rehabilitation options.

MYD88 L265P Mutation Detection by ddPCR: Recommendations for Screening and Minimal Residual Disease Monitoring : ddPCR for Highly Sensitive Detection of MYD88 L265P Mutation

MYD88^L265P is a gain-of-function mutation, arising from the missense alteration c.794T>C, that frequently occurs in B-cell malignancies such as Waldenstrom macroglobulinemia and less frequently in IgM monoclonal gammopathy of undetermined significance (IgM-MGUS) or other lymphomas. MYD88^L265P has been recognized as a relevant diagnostic flag, but also as a valid prognostic and predictive biomarker, as well as an investigated therapeutic target. Up until now, allele-specific quantitative PCR (ASqPCR) has been widely used for MYD88^L265P detection providing a higher level of sensitivity than Sanger sequencing. However, the recently developed droplet digital PCR (ddPCR) shows a deeper sensitivity, compared to ASqPCR, that is necessary for screening low infiltrated samples. Actually, ddPCR could represent an improvement in daily laboratory practice since it allows mutation detection in unselected tumor cells, allowing to bypass the time-consuming and costly B-cell selection procedure. ddPCR accuracy has been recently proved to be suitable also for mutation detection in "liquid biopsy" samples that might be used as a noninvasive and patient-friendly alternative to bone marrow aspiration especially during the disease monitoring. The relevance of MYD88^L265P, both in daily management of patients and in prospective clinical trials investigating the efficacy of novel agents, makes crucial to find a sensitive, accurate, and reliable molecular technique for mutation detection. Here, we propose a protocol for MYD88^L265P detection by ddPCR.

Treatment of indolent lymphoma

Treatment of indolent lymphoma has improved significantly in recent decades since the advent of rituximab (anti-CD20 monoclonal antibody). Although, some patients with limited disease can be cured with radiation therapy alone, most patients experience disease progression and recurrence during follow-up despite early initiation of treatment. Thus, watch-and-wait is still regarded the standard for asymptomatic patients. Patients with indolent lymphoma have a significant heterogeneity in terms of tumor burden, symptoms (according to anatomical sites) and the need for instant therapy. Therefore, the initiation of treatment and treatment option should be decided with a clear goal in each patient according to the need for therapy and clinical benefits with the chosen treatment. In this review, we cover the current treatment of follicular lymphoma and marginal zone lymphoma.

Clinical Characteristics, Treatment and Evolution of Splenic and Nodal Marginal Zone Lymphomas-Retrospective and Multicentric Analysis of Portuguese Centers

INTRODUCTION

Treatment of Splenic (SMZL) and Nodal (NMZL) Marginal Zone Lymphoma is not consensual. Histologic transformation (HT) to aggressive lymphoma is a poorly understood event, with an unfavorable outcome.

OBJECTIVES

Describe the clinical characteristics, treatment, outcomes and incidence of HT.

METHODS

Characteristics of patients with SMZL and NMZL consecutively diagnosed in 8 Portuguese centers were retrospectively reviewed. Endpoints were overall survival (OS), time to first systemic treatment (TTFST), frequency of HT and time to transformation (TTT).

RESULTS

This study included 122 SMZL and 68 NMZL, most of them received systemic treatment: 55.4% and 76.5%, respectively. Splenectomy was performed in 58.7% of patients with SMZL. Different treatment protocols were used. OS or TTFST did not differ significantly according to treatments. Given the small sample size, no conclusion can be made concerning the role of Rituximab in the treatment of NMZL and SMZL based in these results. HT was documented in 18 patients, mainly in SMZL, with a cumulative incidence at 5 years of 4.2%. We confirmed that age is a prognostic factor.

CONCLUSION

Randomized prospective trials are needed to standardize treatment in MZL. Patients with HT did appear to have shorter OS in comparison with those who did not experience HT (OS 5 years of 68.4% vs. 80.4%), but the number of HT was too small to reach statistical significance.

Unmet need for mental health services in indolent lymphoma: age differences over one-year post-diagnosis

This study examined distress and mental health service use in patients with newly diagnosed indolent lymphoma over the first-year post-diagnosis, as well as differences by age. Patients with indolent lymphoma completed online self-report measure of distress and whether they accessed mental health services (Yes/No) every four months for a total of four surveys. The baseline sample consisted of 74 patients; 41.9% were age 65 years and older, 24.3% endorsed elevated distress, and 16.2% accessed mental health services. Across time, less than half (36.4-46.7%) of distressed patients accessed mental health services. In patients younger than 65 years, a greater proportion of distressed than non-distressed patients accessed mental health services. However, distress was not associated with mental health service use in older adults. Future research should evaluate issues driving distress and access to mental health care in patients with indolent lymphomas, including age-based approaches.

Assessment of naive indolent lymphoma using whole-body diffusion-weighted imaging and T2-weighted MRI: results of a prospective study in 30 patients

Background

We prospectively evaluated the diagnostic utility of whole-body diffusion-weighted imaging with background body signal suppression and T2-weighted short-tau inversion recovery MRI (WB-DWIBS/STIR) for the pretherapeutic staging of indolent lymphoma in 30 patients.

Methods

This prospective study included 30 treatment-naive patients with indolent lymphomas who underwent WB-DWIBS/STIR and conventional imaging workup plus biopsy. The pretherapeutic staging agreement, sensitivity, and specificity of WB-DWIBS/STIR were investigated with reference to the multimodality and multidisciplinary consensus review for nodal and extranodal lesions excluding bone marrow.

Results

In the pretherapeutic staging, WB-DWIBS/STIR showed very good agreement (κ = 0.96; confidence interval [CI], 0.88–1.00), high sensitivity (93.4–95.1%), and high specificity (99.0–99.4%) for the whole-body regions. These results were similar to those of ¹⁸F-FDG-PET/CT, except for the sensitivity for extranodal lesions. For extranodal lesions, WB-DWIBS/STIR showed higher sensitivity compared to ¹⁸F-FDG-PET/CT for the whole-body regions (94.9–96.8% vs. 79.6–86.3%, P = 0.058).

Conclusion

WB-DWIBS/STIR is an effective modality for the pretherapeutic staging of indolent lymphoma, and it has benefits when evaluating extranodal lesions, compared with ¹⁸F-FDG-PET/CT.

How we treat mature B-cell neoplasms (indolent B-cell lymphomas)

Mature B cell neoplasms, previously indolent non-Hodgkin lymphomas (iNHLs), are a heterogeneous group of malignancies sharing similar disease courses and treatment paradigms. Most patients with iNHL have an excellent prognosis, and in many, treatment can be deferred for years. However, some patients will have an accelerated course and may experience transformation into aggressive lymphomas. In this review, we focus on management concepts shared across iNHLs, as well as histology-specific strategies. We address open questions in the field, including the influence of genomics and molecular pathway alterations on treatment decisions. In addition, we review the management of uncommon clinical entities including nodular lymphocyte-predominant Hodgkin lymphoma, hairy cell leukemia, splenic lymphoma and primary lymphoma of extranodal sites. Finally, we include a perspective on novel targeted therapies, antibodies, antibody-drug conjugates, bispecific T cell engagers and chimeric antigen receptor T cell therapy.

Oncological outcome and recurrence pattern analysis after involved-field irradiation in combination with rituximab for early-stage nodal and extranodal follicular lymphoma

Purpose

Combined radioimmunotherapy (RIT) in follicular lymphomas (FL) has shown promising treatment efficacy in the Mabthera® and Involved field Radiation (MIR) study. Aim of this study was to analyze treatment efficacy and recurrence patterns after RIT in early-stage nodal and extranodal FL.

Methods

We reviewed 107 patients who were treated with combined RIT in two centers. Treatment consisted of 4 × rituximab followed by RIT with 4 × rituximab and involved field (IF) radiotherapy with 30/40 Gy. Median follow-up period was 71 months. In contrast to the MIR study, extranodal involvement and grade 3A histology were included in the analysis.

Results

Extranodal involvement and grade 3A histology were present in 21.8% and 13.1%, respectively. Overall response rate (ORR) after 4 × rituximab, after completion of RIT, and after 6 months was 78.1%, 98.8%, and 98.8%, respectively, with increasing rates of complete remissions (CR). Predictive factors associated with superior PFS were tumor size, completely excised lymphomas, and response to first 4 × rituximab. 5‑year PFS rate was 87.3%, with mostly outfield recurrences (94.1%). Second-line treatment was effective, with 53.3% CR and 46.7% partial remissions (PR). 5‑year OS was 98.1%. RIT was tolerated well, with mainly grade 1–2 acute side effects.

Conclusion

The real-world efficacy of RIT is comparable with the results of the MIR study. Additionally, this analysis shows that extranodal involvement and grade 3A histology are not associated with inferior PFS.

The AUGMENT study: Lenalidomide in indolent lymphoma … balance the imbalance!

Follicular lymphoma is the most common form of indolent Non-Hodgkin Lymphoma and characterized by repeated relapses. Follicular lymphoma (FL) tissue was found to have association between malignant cells and benign immune cells represented in the surrounded microenvironment. Lenalidomide, an immunomodulator, is affecting this microenvironment and demonstrated relevant clinical activity in phase III trials in patients with FL lymphoma. The AUGMENT trial resulted in a better PFS with lenalidomide and rituximab than rituximab and placebo in patients with relapsed/refractory FL and marginal zone lymphoma. However, there are some concerns around the study. The following article is discussing some of these concerns.

Tumor long-axis diameter and SUVmax predict long-term responders in 90Y-ibritumomab tiuxetan monotherapy

90Y-ibritumomab tiuxetan (90Y-IT) is widely used, but the factors responsible for its optimal treatment effects are unknown. We enrolled 34 patients with relapsed indolent lymphoma treated with 90Y-IT monotherapy at Gunma University Hospital between 2003 and 2014 in the present study. Clinical data including computed tomography and 18-Fluoro-deoxyglucose positron emission tomography were retrospectively analyzed. The overall response rate and complete response rate were 91% and 82%, respectively. The median progression-free survival (PFS) and overall survival were 32 months and not reached, respectively. In univariate analysis, tumor long-axis diameter ≤ 2.5 cm, maximum standardized uptake value (SUVmax) ≤ 6.5, localized disease, normal levels of serum soluble interleukin-2 receptor, and the number of involved nodal sites ≤ 3 immediately prior to 90Y-IT were associated with median PFS greater than 6 years. However, in multivariate analysis, only tumor long-axis diameter ≤ 2.5 cm and SUVmax ≤ 6.5 affected PFS [hazard ratio (HR) 0.130, P = 0.0021 and HR 0.283, P = 0.0311, respectively]. Patients with only one prior regimen needed less granulocyte colony-stimulating factor and platelet transfusion. Thus, 90Y-IT treatment should be considered for patients with indolent lymphoma in first relapse who have tumor long-axis diameter ≤ 2.5 cm and SUVmax ≤ 6.5.

Application of Quantitative Indexes of FDG PET to Treatment Response Evaluation in Indolent Lymphoma

Purpose

Although ¹⁸F-fluorodeoxyglucose (FDG) positron emission tomography (PET) is a standard imaging modality for response evaluation in FDG-avid lymphoma, there is a controversy using FDG PET in indolent lymphoma. The purpose of this study was to investigate the effectiveness of quantitative indexes on FDG PET in response evaluation of the indolent lymphoma.

Methods

Fifty-seven indolent lymphoma patients who completed chemotherapy were retrospectively enrolled. FDG PET/computed tomography (CT) scans were performed at baseline, interim, and end of treatment (EOT). Response was determined by Lugano classification, and progression-free survival (PFS) by follow-up data. Maximum standardized uptake value (SUV_max), metabolic tumor volume (MTV), and total lesion glycolysis (TLG) were measured in the single hottest lesion (target A) or five hottest lesions (target B). Their efficacies regarding response evaluation and PFS prediction were evaluated.

Results

On EOT PET, SUV_max, and MTV of both targets were well associated with visual analysis. Changes between initial and EOT PET were not significantly different between CR and non-CR groups. On interim PET, SUV_max, and %ΔSUV_max in both targets were significantly different between CR and non-CR groups. For prediction of PFS, most tested indexes were significant on EOT and interim PET, with SUV_max being the most significant prognostic factor.

Conclusion

Quantitative indexes of FDG PET are well associated with Lugano classification in indolent lymphoma. SUV_max measured in the single hottest lesion can be effective in response evaluation and prognosis prediction on interim and EOT PET.

Follicular Lymphoma: Past, Present, and Future

OPINION STATEMENT

Even in the modern era, follicular lymphoma (FL) remains largely an incurable but treatable disease with both standard and novel treatment modalities. Despite the abundance of efficacious treatment modalities currently available, there is no universally agreed upon standard approach to treatment for patients with FL, particularly in the relapsed/refractory (R/R) setting. There is an increasing need for better tools to risk-stratify patients and to identify those likely to experience relapse early. Additionally, the use of gene expression profiling and next-generation sequencing techniques in recent years has led to a wealth of knowledge regarding the molecular drivers of lymphomagenesis; however, much of this knowledge is not currently applicable on a day to day basis in the clinic setting. Further studies are needed to determine a validated, clinically relevant predictive model that incorporates patient factors and molecular factors that will guide clinicians on the most effective treatment strategy. With many questions left unanswered, it is our opinion that the treatment of FL and sequencing of therapy in the R/R setting should be a personalized approach that balances patient-specific factors such as preferences and comorbidities with treatment-related factors such as known response rates and toxicity profiles.

Review of targeted therapy in chronic lymphocytic leukemia: what a radiologist needs to know about CT interpretation

The last 5 years have been marked by profound innovation in the targeted treatment of chronic lymphocytic leukemia (CLL) and indolent lymphomas. Using CLL as a case study, we present a timeline and overview of the current treatment landscape for the radiologist, including an overview of clinical and radiological features of CLL, discussion of the targeted agents themselves, and the role of imaging in response and toxicity assessment. The goal is to familiarize the radiologist with multiple Food and Drug Administration (FDA)-approved targeted agents used in this setting and associated adverse events which are commonly observed in this patient population.

Maintenance Therapies in Indolent Lymphomas: should Recent Data Change the Standard of Care?

OPINION STATEMENT

The overall benefit of maintenance therapy for patients with an indolent lymphoma continues to go unanswered. A myriad of variables contribute to the lack of clear clinical guidance. First, the disease course is slow and treatment may not be required for years, requiring a long follow-up to prospectively study. Second, due to the long lag time from study initiation to conclusion, many of the induction therapies used at the onset of the study may not be favored at present, providing a conclusion that cannot be reconciled with current clinical practice. For example, bendamustine and rituximab are typically the favored initial treatment agents in follicular lymphoma, which was not true when many maintenance trials were initiated. Third, several studies' inclusion criteria allow for patient enrollment at both initial diagnosis as well as at disease recurrence. In some studies, patients who are asymptomatic are started on therapy, counter to the accepted watch and wait approach. This contributes to the difficulty of generalizing results. The question of the benefit of maintenance therapy has been studied enough, and there may not be a smoking gun in the foreseeable future. However, what does hold promise is focusing on the patients with minimum residual disease after conclusion of chemotherapy. This may be a population that could receive benefit from a prolonged treatment approach. In the meantime, maintenance therapy should not be used in all patients, and the rationale for use should be data-driven, as well as an assessment of a patient's potential intolerability of cytotoxic chemotherapy.

Splenic marginal zone lymphoma: a literature review of diagnostic and therapeutic challenges

Splenic marginal zone lymphoma (SMZL) is a low-grade B-cell non-Hodgkin's lymphoma characterized by massive splenomegaly, moderate lymphocytosis with or without villous lymphocytes, rare involvement of peripheral lymph nodes and indolent clinical course. As a rare disease, with no randomized prospective trials, there is no standard of care for SMZL so far. Splenectomy has been done for many years as an attempt to control disease, but nowadays it has not been encouraged as first line because of new advances in therapy as rituximab, that are as effective with minimal toxicity. Facing these controversies, this review highlights advances in the literature regarding diagnosis, prognostic factors, treatment indications and therapeutic options.

Prognostic factors and indications for treatment of Waldenström's Macroglobulinemia

Waldenström's Macroglobulinemia (WM) is characterized by the presence of an IgM monoclonal protein regardless of its size, 10% or more bone marrow infiltration by small lymphocytes with a plasmacytoid or plasma cell differentiation. These cells usually have the following markers: IgM+, CD5^-, CD10^-, CD19⁺, CD20⁺ and CD23^-. Chronic lymphocytic leukemia as well as other lymphoproliferative disorders such as mantle cell, marginal zone and mucosa-associated lymphoid tissue (MALT) lymphoma must be excluded. Weakness or fatigue from anemia, fever, night sweats, or weight loss represent the most common symptoms. Hepatosplenomegaly may be a major feature. Anemia, thrombocytopenia, hyperviscosity or peripheral neuropathy may be prominent features. Systemic amyloidosis, renal insufficiency and cryoglobulinemia may also be seen. WM must be differentiated from smoldering Waldenström's Macroglobulinemia (SWM) which is an intermediate disease state characterized by an IgM protein ≥3 g/dL and/or a bone marrow containing ≥10% bone marrow lymphoplasmacytic infiltration but no end-organ damage such as symptomatic anemia, constitutional symptoms, hyperviscosity, symptomatic hepatosplenomegaly or lymphadenopathy.

Bendamustine plus rituximab versus R-CHOP as first-line treatment for patients with indolent non-Hodgkin's lymphoma: evidence from a multicenter, retrospective study

The optimal first-line treatment for advanced low-grade non-Hodgkin lymphomas (LG-NHL) is still highly debated. Recently, the StiL and the BRIGHT trials showed that the combination of rituximab and bendamustine (R-B) is non-inferior to rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) with a better toxicity profile. Utilizing a retrospective analysis, we compared the efficacy and safety of both regimens in clinical practice. From November 1995 to January 2014, 263 LG-NHL patients treated with either R-B or R-CHOP were retrospectively assessed in seven European cancer centers. Ninety patients were treated with R-B and 173 with R-CHOP. Overall response rate was 94 and 92 % for the R-B and the R-CHOP group, respectively. The percentage of complete response was similar for both groups (63 vs. 66 % with R-B and R-CHOP, respectively; p = 0.8). R-B was better tolerated and less toxic than R-CHOP. The median follow-up was 6.8 and 5.9 years for the R-CHOP and the R-B group, respectively. Overall, no difference in progression-free survival (PFS) (108 vs. 110 months; p = 0.1) was observed in the R-B group compared to the R-CHOP cohort. Nevertheless, R-B significantly prolonged PFS in FL patients (152 and 132 months in the R-B and R-CHOP group, respectively; p = 0.05). However, this result was not verified in multivariate analysis probably due to the limits of the present study. We confirm that the R-B regimen administered in patients with LG-NHL is an effective and less toxic therapeutic option than R-CHOP in clinical practice.

Enhanced therapeutic effect of APAVAC immunotherapy in combination with dose-intense chemotherapy in dogs with advanced indolent B-cell lymphoma

The aim of this non-randomized controlled trial was to compare time to progression (TTP), lymphoma-specific survival (LSS), and safety of an autologous vaccine (consisting of hydroxyapatite ceramic powder and Heat Shock Proteins purified from the dogs' tumors, HSPPCs-HA) plus chemotherapy versus chemotherapy alone in dogs with newly diagnosed, clinically advanced, histologically confirmed, multicentric indolent B-cell lymphoma. The vaccine was prepared from dogs' resected lymph nodes and administered as an intradermal injection. Forty-five client-owned dogs were enrolled: 20 dogs were treated with dose-intense chemotherapy, and 25 received concurrent immunotherapy. Both treatment arms were well tolerated, with no exacerbated toxicity in dogs also receiving the vaccine. TTP was significantly longer for dogs treated with chemo-immunotherapy versus those receiving chemotherapy only (median, 209 versus 85 days, respectively, P=0.015). LSS was not significantly different between groups: dogs treated with chemo-immunotherapy had a median survival of 349 days, and those treated with chemotherapy only had a median survival of 200 days (P=0.173). Among vaccinated dogs, those mounting an immune response had a significantly longer TTP and LSS than those with no detectable response (P=0.012 and P=0.003, respectively). Collectively these results demonstrate that vaccination with HSPPCs-HA may produce clinical benefits with no increased toxicity, thereby providing a strategy for enhancing chemotherapy in dogs with advanced indolent lymphoma.

Chemoimmunotherapy for Mucosa-Associated Lymphoid Tissue-Type Lymphoma: A Review of the Literature

BACKGROUND

Biological treatments, chemoimmunotherapy, and radiotherapy are associated with excellent disease control in both gastric and extragastric mucosa-associated lymphoid tissue (MALT) lymphomas. Systemic treatment approaches with both oral and i.v. agents are being increasingly studied, not only for patients with disseminated MALT lymphoma, but also for those with localized disease. To date, however, recommendations for the use of available systemic modalities have not been clearly defined.

MATERIALS AND METHODS

The present report reviews the current data on systemic treatment options for patients with MALT lymphoma and provides recommendations for their use in everyday practice.

RESULTS

Different chemotherapeutic agents, including anthracyclines, alkylators, and purine analogs, have been successfully tested in patients with MALT lymphoma. Reducing side effects while maintaining efficacy should be the main goal in treating these indolent lymphomas. From the data from the largest trial performed to date, the combination of chlorambucil plus rituximab (R) appears to be active as first-line treatment. Similarly, R-bendamustine also seems to be highly effective, but a longer follow-up period is needed. R-monotherapy results in lower remission rates, but seems a suitable option for less fit patients. New immunotherapeutic agents such as lenalidomide (with or without rituximab) or clarithromycin show solid activity but have not yet been validated in larger collectives.

CONCLUSION

Patients with MALT lymphoma should be treated within prospective trials to further define optimal therapeutic strategies. Systemic treatment is a reasonable option with potentially curative intent in everyday practice. Based on the efficacy and safety data from available studies, the present review provides recommendations for the use of systemic strategies.

Waldenström macroglobulinemia: What a hematologist needs to know

Waldenström macroglobulinemia (WM) is a distinct hematologic malignancy characterized by a lymphoplasmacytic bone marrow infiltration and the presence of immunoglobulin (Ig)M monoclonal protein. Patients typically present at an advanced age, and a substantial proportion are asymptomatic at diagnosis. A unifying diagnosis of WM may be missed by an unsuspecting hematologist, as symptomatic patients present with a multitude of non-specific manifestations. Although constitutional and neuropathy-related symptoms predominate, concomitant IgM-induced hyperviscosity-associated features can provide useful diagnostic clues. There are specific indications for initiation of therapy. This review focuses on the most up-to-date management strategies of WM, in addition to highlighting the recent discoveries of MYD88 and CXCR4 mutations that have shed unprecedented light on the complex signaling pathways, and opened avenues for novel therapeutic targeting. Although WM remains incurable, with the rapid emergence and integration of effective novel therapies, its clinical course appears poised to improve in the foreseeable future.

Long-term outcomes of patients with persistent indolent B cell malignancies undergoing nonmyeloablative allogeneic transplantation

Relapse is least common in patients with indolent B cell (iB) malignancies (ie, iB non-Hodgkin lymphoma [NHL]) who undergo nonmyeloablative allogeneic transplantation (NMAT) in complete remission (CR). However, for the many patients unable to achieve this state, outcomes are poorly described and methods to improve results are unknown. We sought to describe the long-term follow-up and predictive factors for these poor-risk patients unable to achieve CR before NMAT. We identified and evaluated patients with iB-NHL including chronic lymphocytic leukemia treated with fludarabine/total body irradiation-based NMAT that had evidence of persistent disease before NMAT. From December 1998 to April 2009, 89 patients were identified, most commonly with small/chronic lymphocytic lymphoma (n = 62) and follicular lymphoma (n = 24). Pretransplant anti-CD20 radioimmunotherapy (RIT) using standard yttrium-90-ibritumomab tiuxetan was administered to 18 patients (20%) who more frequently had chemoresistant disease (81% versus 39%, P = .003), disease bulk > 5 cm (61% versus 15%, P < .001), thrombocytopenia < 25k/μL (33% versus 7%, P = .002), and Hematopoietic Cell Transplant Comorbidity Index scores ≥ 3 (72% versus 37%, P = .006). After adjusting for these imbalances, RIT-treated patients had improved rates of progression-free survival (PFS) (hazard ratio [HR] = .4; 95% confidence interval [CI], .2 to .9, P = .02) and overall survival (OS) (HR = .3; 95% CI, .1 to .8, P = .008) compared with the non-RIT group. The 3-year adjusted estimates of PFS and OS for the RIT and non-RIT groups were 71% and 87% versus 44% and 59%, respectively. The use of RIT was the only factor independently associated with improved PFS and OS. Rates of nonrelapse mortality and graft-versus-host disease (GVHD) were similar between the 2 groups, although over 70% of patients developed clinically significant acute or chronic GVHD. In conclusion, despite relatively high rates of GVHD, patients with persistent iB-NHL can derive durable benefit from NMAT.

Follicular lymphoma grade 3: review and updates

Follicular lymphoma (FL), Grade 3, is recognized as a distinct entity in the World Health Organization classification of lymphoma. It is further classified into Grade 3a and Grade 3b depending on the Bernard cell counting system and percentage of centroblasts. Grade 3 has molecular and genetic characteristics that distinguish it from other grades of FL. There is confusion and misunderstanding about the natural history and clinical course of Grade 3a and 3b because some studies indicate them as having indolent behavior and others describe more aggressive biology. The purpose of this article is to understand the concept of Grade 3 FL, especially the fundamental differences between Grade 3a and Grade 3b FL. Grade 3 FL is still an evolving subclass in FL and the practicing physician should understand the aggressive nature of Grade 3b, which typically requires timely attention, compared with Grade 3a. Grade 3a FL has more indolent characteristics but can possibly progress to Grade 3b and/or transform to diffuse large B-cell lymphoma at a future time. Nevertheless, large prospective studies are missing for an optimal evidence-based management approach for patients with Grade 3 FL at this time.

Indolent peripheral T-cell lymphoma involving the gastrointestinal tract

We describe an unusual case of indolent peripheral T-cell lymphoma with multifocal involvement of the gastrointestinal tract. The patient, a 42-year-old Asian man, has been followed up for more than 10 years without chemotherapy and multiple gastrointestinal biopsies showing similar findings. Histologically, the neoplasm expanded into the lamina propria and/or focally extended into the submucosa and was composed of small- to medium-sized lymphocytes with slightly irregular nuclear contours and clear cytoplasm and rare large lymphocytes. The tumor cells were positive for CD3, CD8, granzyme B, and TIA-1 (subset) and negative for CD5, CD56, and Epstein-Barr virus-encoded RNA. Molecular studies for T-cell receptor γ and/or β chain gene rearrangement demonstrated the same clone at different sites and times during the course of the disease. Rare cases of indolent peripheral T-cell lymphoma of the gastrointestinal tract have been previously described and need to be further characterized to avoid the use of aggressive chemotherapy.

Clinical characteristics and outcome in dogs with splenic marginal zone lymphoma

BACKGROUND

Splenic marginal zone lymphoma (MZL) is a form of indolent B-cell lymphoma that is not well characterized in dogs.

HYPOTHESIS/OBJECTIVES

The purpose of this study was to describe clinical characteristics and outcome in dogs with splenic MZL confirmed by histopathology, immunophenotyping, and molecular clonality assessment. We hypothesized that affected dogs would have prolonged survival time with splenectomy alone.

ANIMALS

Thirty-four dogs were included. Twenty-nine dogs were diagnosed after splenectomy, and 5 dogs were diagnosed at necropsy.

METHODS

Pathology records were searched for dogs with histologically confirmed splenic MZL. Clinical and outcome data were retrospectively collected by medical record review, and prognostic factors were evaluated. Histopathology was reviewed by a board-certified pathologist, and tissue sections were subjected to immunophenotyping and molecular clonality assessment by PCR.

RESULTS

Immunohistochemistry confirmed a B-cell phenotype for all dogs. Molecular clonality assessment was performed in 33 of 34 dogs, of which 24 had clonal rearrangement of immunoglobulin (Ig) loci, 3 had pseudoclonal rearrangement, and 6 had polyclonal rearrangement. The overall median survival time (MST) for the 29 dogs that underwent splenectomy was 383 days. The MST for 14 of 29 asymptomatic dogs that underwent splenectomy for MZL was 1,153 days as compared to 309 days for 15/29 dogs with clinical signs referable to splenic MZL (P = .018). Lymph node involvement, hemoabdomen, anemia, chemotherapy, and concurrent malignancy did not affect survival outcome.

CONCLUSIONS AND CLINICAL IMPORTANCE

Dogs diagnosed with splenic MZL can have prolonged survival with splenectomy alone, without the use of adjuvant chemotherapy. Asymptomatic dogs may have a better survival outcome.

Hepatitis C virus-related B cell subtypes in non Hodgkin's lymphoma

AIM

To evaluate if indolent B cell-non Hodgkin's lymphoma (B-NHL) and diffuse large B-cell lymphoma (DLBCL) in hepatitis C virus (HCV) positive patients could have different biological and clinical characteristics requiring different management strategies.

METHODS

A group of 24 HCV related B-NHL patients (11 indolent, 13 DLBCL) in whom the biological and clinical characteristics were described and confronted. Patients with DLBCL were managed with the standard of care of treatment. Patients with indolent HCV-related B-NHL were managed with antiviral treatment pegylated interferon plus ribavirin and their course observed. The outcomes of the different approaches were compared.

RESULTS

Patients with DLBCL had a shorter duration of HCV infection and a higher prevalence of HCV genotype 1 compared to patients with indolent B-NHL in which HCV genotype 2 was the more frequent genotype. Five of the 9 patients with indolent HCV-related B-NHL treated with only antiviral therapy, achieved a complete response of their onco-haematological disease (55%). Seven of the 13 DLBCL patients treated with immunochemotheraphy obtained a complete response (54%).

CONCLUSION

HCV genotypes and duration of HCV infection differed between B-NHL subtypes. Indolent lymphomas can be managed with antiviral treatment, while DLBCL is not affected by the HCV infection.