Age-adjusted International Prognostic Index Research Articles

Impact of Intended and Relative Dose Intensity of RCHOP in a Large, Consecutive Cohort of Elderly DLBCL Patients: No Difference in DFS for 70-80 Years Versus >80 Years and Idi Independently Predicts Survival

Introduction The impact of RCHOP dose attenuation in elderly patients (pts) with DLBCL is poorly understood. 1% of DLBCL 1st line pts in trials are ≥80 years (y). Attenuated R-CHOP (25mg/m2 doxorubicin (DOX); 400mg/m2 cyclophosphamide (CYCLO), 1mg vincristine) cure 50-60% in phase II trials (Peyrade et al, 2011, 2017). Full dose RCHOP compared to attenuated RCHOP does not improve outcome in ≥80y (Juul et al, 2018) or may worsen survival via toxicity (Eyre et al, 2016, Carson et al 2015). Methods We systematically collected data on IDI (cycle (C)1 dose) and RDI of CYCLO/DOX in consecutively treated pts ≥70ys across 6 UK centres (2009-18). Untreated de novo DLBCL and untreated transformation (HGT) of indolent NHL (iNHL) receiving ≥C1 were included. RCHOP was given at a minimum interval of 21 days. G-CSF was routine. The following were excluded: HIV+, prior solid organ transplant, isolated leg type DLBCL, pre-treated HGT, central nervous system involvement with DLBCL, and pts unfit for anthracycline. Data were collected on Cumulative Illness Rating Scale for Geriatrics (CIRS-G), CIRS-G severity index (total/no. categories), age-adjusted international prognostic index ((aa)IPI), Hb, albumin, LDH, B symptoms, bulk ≥10cm, major operation at diagnosis, and extranodal sites (ENS). Predictors of progression free (PFS), disease free (DFS), and overall survival (OS), were determined using univariable (UVA) and multivariable (MVA) Cox regression. Factors were analysed as continuous (denoted *); additionally IDI (full dose: ≥80% of weight based dose vs attenuated: Results 511 pts received R-CHOP with curative intent. 49% were male and 51% were female. Median follow up was 1.67y. Median age was 77y. 32% had stage I-II and 68% stage III/IV. 14% had concurrent iNHL, 20% bulk, 33% >1 ENS, and 66% IPI 3-5. 46% had CIRS-G ≥6. When comparing age/IDI categories, in 70-80y, pts with IDI 80% (2-4; 30%), higher IPI 3-5 (71% vs 64%), higher CIRS-G≥6 (59% vs 40%), and higher CIRS-G severity index. ≥80y receiving IDI>80% had better ECOG (0-1 67% vs IDI For all pts, median PFS was 5.4y (95% confidence interval (CI) 4.1 - 6.9), median DFS was not reached, and median OS 5.5y (95% CI 4.5 - 6.7). When analysed by 70-80 vs ≥80y: 2y PFS was 71.8% (95% CI 66.4-76.4%) vs 60.3% (95% CI 51.5-68.0%), 2y DFS 79.4% (95% CI 74.3-83.6%) vs 76.7% (95% CI 68.4-83.1%) (p = 0.23) and 2y OS 74.6% (95% CI 69.4-79.1%) vs 60.2% (95% CI 51.2-68.1%). Unlike OS and PFS, DFS was not significantly different when 70-80y vs ≥80y were compared, suggesting >80y have a worse outcome due to toxicity and/or unrelated causes of death. 15 deaths in >80y with IDI>80 were: infection (n=5), systemic progressive disease (PD) (n=7), CVA leading to stopping RCHOP post C1 (subsequent PD) (n=1), unknown (in remission) (n=1), dementia (n=1). In 70-80y, IDI>80% had significantly improved PFS, DFS and OS. In ≥80y, there was no difference in PFS, DFS or OS according to IDI 80% (Fig A-F). UVA Univariable predictors of worse PFS and OS included age*, ECOG PS*, DOX IDI*, CYCLO IDI*, combined IDI*, IPI 3-5, aaIPI 2-3, raised LDH, male gender and B symptoms (all p MVA IDI* remained an independent predictor of PFS, DFS and OS. Using 70-80y IDI>80 (HR 1.0) as the comparator, the following were associated with significantly increased risk of PD and / or death in PFS and OS in MVA: 70-80y IDI 80. Compared to 70-80y IDI>80 (HR 1.00), the HR for DFS in ≥80y IDI>80 approached significance (p = 0.07) vs PFS and OS, suggesting that causes other than PD account in part for inferior OS and PFS (Table 1). Conclusions To our knowledge, this is the largest series that has systematically analysed RDI, IDI (DOX, CYCLO and combination) and co-morbidities in consecutive unselected DLBCL ≥70y. Consistent with recent literature (Juul et al, 2018), there is no clear benefit to PFS, DFS or OS in dose intensifying (IDI>80) in ≥80y. IDI is a clear independent predictor of outcome across all pts. Pts 70-80y with IDI Disclosures Eyre:Janssen: Consultancy, Other: travel support; Roche: Consultancy; Abbvie: Consultancy, Other: travel support; Gilead: Consultancy, Other: travel support; Celgene: Other: travel support. Fox:Celgene: Consultancy, Other: Travel, Speakers Bureau; Sunesis: Consultancy; Abbvie: Consultancy, Other: Travel, Research Funding, Speakers Bureau; Janssen: Consultancy, Other: Travel, Speakers Bureau; Gilead: Consultancy, Other: Travel, Research Funding, Speakers Bureau; Roche: Consultancy, Other: Travel, Research Funding, Speakers Bureau. McMillan:Celgene: Honoraria, Other: travel support; BMS: Honoraria; Amgen: Honoraria; Takeda: Other: travel support; Roche: Consultancy, Honoraria, Other: travel support; Pfizer: Research Funding; MSD: Honoraria. Bishton:Abbvie: Research Funding; Roche: Research Funding; Takeda: Other: travel support to ASH; Gilead: Research Funding. Collins:Celleron: Consultancy, Honoraria; Roche: Consultancy, Honoraria, Speakers Bureau; Gilead: Consultancy, Honoraria, Speakers Bureau; BMS: Consultancy, Honoraria, Research Funding; Takeda: Consultancy, Honoraria, Speakers Bureau; ADC Therapeutics: Consultancy, Honoraria, Research Funding; Celgene Corporation: Research Funding; MSD: Consultancy, Honoraria; Amgen: Research Funding; Pfizer: Consultancy, Honoraria.

Results from a Phase Ib Evaluation of Tazemetostat (EPZ-6438) in Combination with R-CHOP in Poor Prognosis Newly Diagnosed Diffuse Large B Cell Lymphoma (DLBCL): a Lysa Study

Results from a Phase Ib Evaluation of Tazemetostat (EPZ-6438) in Combination with R-CHOP in Poor Prognosis Newly Diagnosed Diffuse Large B Cell Lymphoma (DLBCL): a Lysa Study

Ritumixab in Combination with Adapted-Dose of Ifosfamide and Etoposide As Salvage Treatment in Elderly Refractory/Relapsed Diffuse Large B-Cell Lymphoma Patients Non-Candidate for High Dose Therapy: A Retrospective Study of Lyon Hospital University

Introduction: standard treatment for relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) is high-dose chemotherapy followed by autologous stem-cell transplantation (ASCT) but this strategy is not appropriate for elderly DLBCL patients (pts) related to a high risk of toxicities. Multiple chemotherapy regimens had been developed for heavily pretreated elderly DLBCL patients such as R-bendamustine, R-gemcitabine-oxaliplatin (R-GEMOX) and pixantrone; the median progression free survival (PFS) of these regimens were 2, 4 and 3.5 months, respectively in prospective phase II studies for patients previously treated with R (Sehn 2017, Mounier 2013, Pettengel 2016). Adapted dose of ifosfamide and etoposide was firstly developed as sequential consolidation regimen after high-dose CHOP (ACVBP regimen) in first line therapy of young DLBCL patients (Tilly 2003). This regimen with a safe toxicity profile was then used in combination with R in Lyon University Hospital in elderly R/R DLBCL ineligible to intensive strategy.Methods: we retrospectively reviewed the efficacy and the safety profile of this regimen performed in two Lyon University Hospitals (Centre Hospitalier Lyon Sud and Leon Berard Cancer Center). Between June 2004 and March 2017, 75 pts with R/R DLBCL (63 de novo DLBCL, 12 transformed DLBCL) received R (375 mg/m2) in combination etoposide (300 mg/m2) and ifosfamide (1500 mg/m2) on day 1 (N=72, 96%) and on days 1-2 (N=3, 4%) at 2 (N=46, 61%) or 3-week (N=29, 39%) intervals. All medical records were reviewed for clinical and biological characteristics, modality of treatment and supportive care, toxicities, responses and outcome.Results: the median age was 79 years (range, 64-92) at the beginning of R-ifosfamide/VP16 treatment with 46% of the patients over 80 years. 13% of pts had a CIRS-G grade 3 or 4 >2 categories and 35% had a cumulative CIRS-G score more than 6. The performance status according to EORTC scale was 2-4 in 37% of the pts and 93% had III-IV Ann Arbor stages. Age-adjusted IPI were 0-1 in 20 pts (27%) and 2-3 in 55 pts (73%). All patients were previously treated in first-line therapy by R in combination with chemotherapy (CHOP, N=56, 75%, low-dose CHOP, N=14, 19%, other, N=5, 6%). The patients received a median number of 1 previous line (range, 1-8) and no patient was previously treated by ASCT. The median time between initial diagnosis and R-ifosfamide/VP16 was 20 months (range 4-187). The median time between the last treatment and R-ifosfamide/VP16 was 5 months (range 0-181). A refractory disease to first-line treatment was showed in 14 pts (19%). 31% of the patients had a refractory disease to the last regimen performed before R-ifosfamide/VP16. Patients received a median of 6 cycles (1-12). At the end of treatment, the overall response rate (ORR), defined by the rate of complete response (CR) and partial response (PR) was 37%, with 18% of CR. Evaluations were assessed for 29% of the pts by TEP scanner. For toxicity, among the 387 cycles, 10 patients developed febrile neutropenia (2.6%); 15 (20%) a grade 3-4 neutropenia; 7 (9%) a grade 3-4 thrombocytopenia; 5 patients needed platelet units and 16 patients received packed red blood cell units. No grade 3-4 non-hematological toxicity was observed and no toxic death occurred. With a median follow up of 31.3 months (range, 5.0-202.8), the median progression-free survival (PFS) was 4.3 months with a 1-year PFS rate of 26.0% (95%CI, 17.7-38.3) (Figure 1A). The median overall survival (OS) was 8.2 months with a 1-year OS rate of 40.8% (95%CI, 30.9-54.0) (Figure 1B). The median duration of response was 4 months (range 1-97). The median PFS was adversely affected by response (refractory versus CR/PR) to the last treatment (3.0 months versus 5.5 months, P=0.001) (Figure 1C).Conclusions: in this retrospective study, R-Ifosfamide/VP16 regimen provided effective results in R/R DLBCL transplant-ineligible pts with 37% of ORR and a median of PFS of 4.3 months with a safe toxicity profile. This regimen could also be considered as a platform for combinations with novel targeted agents in these categories of patients. [Display omitted] DisclosuresKarlin:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Other: travel support; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Sarkozy:ROCHE: Consultancy. Bachy:Gilead Sciences: Honoraria; Takeda: Research Funding; Sandoz: Consultancy; Amgen: Honoraria; Roche: Research Funding; Celgene: Consultancy; Janssen: Honoraria. Salles:Abbvie: Honoraria; Epizyme: Honoraria; Amgen: Honoraria; F. Hoffmann-La Roche Ltd: Consultancy, Honoraria, Research Funding; Gilead: Honoraria, Other: Advisory Board; Acerta: Honoraria; Novartis: Consultancy, Honoraria; Servier: Honoraria; Servier: Honoraria, Other: Advisory Board; Takeda: Honoraria; BMS: Honoraria, Other: Advisory Board; Celgene: Honoraria, Other: Advisory Board, Research Funding; Janssen: Honoraria, Other: Advisory Board; Merck: Honoraria; Morphosys: Honoraria; Pfizer: Honoraria. Ghesquieres:Sanofi: Consultancy; Gilead: Consultancy; Celgene: Consultancy.

DA-EPOCH Was Not Better Than CHOP for Acquired Immunodeficiency Syndrome-Related Diffuse Large B Cell Lymphoma Patients Treated in a South Brazilian University Hospital

Introduction: Lymphomas are an important complication of HIV infection where they occur with high frequency and are a significant cause of morbidity and mortality.The most prevalent lymphoma subtype in HIV positive population is the diffuse large B cell lymphoma (DLCBL). Antiretroviral therapy (ART) and intensive chemotherapy have been introduced to these patients aiming to increase their response to treatment. Recently, dose adjusted-EPOCH (DA-EPOCH) was associated with better outcome when compared with CHOP. Since these publications, many centers in the world started treating HIV DLBCL patients with EPOCH. In Brazil, Rituximab is not allowed for the treatment of HIV lymphomas (any subtype) in the public health system, so HIV DLBCL patients usually are treated with CHOP or DA-EPOCH.Objective:To compare the progression free survival and overall survival in HIV DLBCL patients treated with CHOP and DA-EPOCH at Hospital de Clínicas de Porto Alegre (HCPA), Porto Alegre, a university public hospital from the southern part of Brazil.Material and Methods:A retrospective cohort of all HIV positive patients and DLBCL, treated from 2007 to 2017 at HCPA. The medical records were reviewed to collect clinical data, reports on pathology, immunohistochemistry, computed tomography (TC) and/or FDG-PET scan from diagnosis and after treatment. Overall survival and progression free survival was determined by the Kaplan-Meier method, and statistical significance was determined by a log-rank test. The study was approved by the institutional review board and complied with the Declaration of Helsinki. All patients gave written informed consent.Results:Forty-three HIV positive patients with untreated DLBCL were enrolled. The median age was 44 years, and 93% had a intermediate or high age-adjusted international prognostic index (aa-IPI). Specific adverse prognostic features included elevated LDH in 84%, B symptoms in 82%, Ann Arbor stage III or IV in 70% and extra-nodal disease in 81%. Central nervous system involvement was found in 9% of patients before treatment. Patients had a median CD4 cell count of 113 cells/mm3 with 21% having a CD4 cell count less than 50 cells/mm3 and 16% of patients were ART naive. Until 2014, CHOP was the chosen treatment for 34 patients. After 2014, DA-EPOCH was the prefered chemotherapy for HIV DLBCL patients and 9 patients were treated with this protocol. The progression free survival at 24 months was 69% in the CHOP group and 83% in DA-EPOCH (p=0.68). Overall survival at same period was 34.5% for CHOP vs 37% for EPOCH (p=0.74). CHOP and DA-EPOCH treatment groups presented similar features regarding the lymphoma and HIV infection, except for higher LDH level and aa-IPI score in the CHOP arm (p=0.02 and p=0.03, respectively).Discussion:The acquired immunodeficiency syndrome-related to DLBCL in this subgroup of patients was associated with a very high-risk prognostic score group. Moreover, 21% of them presented a low count of CD4 cells (less than 50 cells/mm3) at diagnosis. The overall survival was lower than expected for both groups and DA-EPOCH was not associated with better outcome when compared to CHOP. This unexpected finding could be explained in part by the small sample of patients treated with DA-EPOCH, the population prognostic features and the unavailability of rituximab in the treatment of these patients. The follow up study will provide more informations about the impact of DA-EPOCH in our HIV patients. The access to rituximab in HIV DLBCL treatment should be an important point of discussion with public health care providers in Brazil. DisclosuresNo relevant conflicts of interest to declare.

Low-dose trofosfamide plus rituximab is an effective and safe treatment for diffuse large B-cell lymphoma of the elderly: a single center experience

BackgroundRituximab plus combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is broadly accepted as standard for the treatment of diffuse large B-cell lymphoma (DLBCL). Nevertheless, there is sparsely data concerning the management of elderly patients.MethodsWe performed a retrospective study of treatment with rituximab and low-dose trofosfamide in elderly patients (≥ 75 years) with DLBCL who were not suitable for R-CHOP or R-CHOP-like regimens or who did not consent to aggressive treatment. The choice regarding the qualification for R-CHOP or R-CHOP-like regimen was left to the estimation of the treating physicians.ResultsEleven patients with a median age of 83 years (range, 75–90 years) were included. The age-adjusted international prognostic index was low risk in one patient, low-intermediate in four patients, high-intermediate in three patients, and high risk in 3 patients. All patients were evaluable for response. Five patients (45%) achieved a complete response, three (27%) a partial response, one (9%) stable disease, and two (18%) progressive disease. The estimated 1-yr overall survival was 54.5%, and the estimated 1-yr progression-free survival 45.5%, however, three patients (27%) were alive without evidence of disease at 16–20 months from start of treatment. Main toxicity was leukopenia (36% grade III or IV), whereas grade III/IV non-hematological adverse events did not occur.ConclusionsDue to its potency and low toxicity, trofosfamide/rituximab might represent an alternative therapy for DLBCL of elderly patients not suitable for R-CHOP. This observation, however, should be confirmed in a larger patient population within a prospective clinical trial.

The prognostic value of the international prognostic index, the national comprehensive cancer network IPI and the age-adjusted IPI in diffuse large B cell lymphoma

目的比较IPI、美国国家综合癌症网络IPI（NCCN-IPI）及年龄调整的IPI（aa-IPI）三种预后分层模型在弥漫大B细胞淋巴瘤（DLBCL）患者中的预后分层能力。方法回顾性分析2003年1月至2012年12月311例初治DLBCL患者资料，根据治疗方案将患者分为CHOP（环磷酰胺、多柔比星、长春新碱、泼尼松）方案及利妥昔单抗（R）-CHOP方案组，分别采用IPI、NCCN-IPI及aa-IPI对DLBCL患者进行危险度分层。采用Harrell's C统计评价不同模型的预后分层能力。结果①311例患者中接受CHOP方案治疗者128例，接受R-CHOP方案治疗者183例。②CHOP方案组患者的5年总生存（OS）率结果显示，aa-IPI（71.0%对25.0%，P<0.001）、NCCN-IPI（59.7%对26.8%，P<0.001）和IPI（47.6%对36.6%，P=0.003）均能区分中低危和中高危组患者，但前两者区分效果似乎更佳；而R-CHOP方案组，NCCN-IPI拥有更好的预后分层能力，其低危、中低危、中高危患者的5年OS率分别为96.0%、83.0%、66.5%（P=0.009）。③Harrell's C分析结果显示，IPI、NCCN-IPI及aa-IPI预测接受CHOP方案者OS的一致性指数（C-index）分别为0.546、0.667、0.698；预测接受R-CHOP方案者OS的C-index分别为0.611、0.654、0.695。④在≤60岁患者中，IPI、NCCN-IPI、aa-IPI预测接受CHOP方案者OS的C-index分别为0.534、0.675、0.698；预测接受R-CHOP方案者OS的C-index分别为0.584、0.648、0.695。结论NCCN-IPI对于接受利妥昔单抗联合化疗的DLBCL患者有较好的预后分层能力，而aa-IPI对于较年轻的DLBCL患者预后分层能力可能更佳。

Long-term survival and loss in expectancy of life in a population-based cohort of 7114 patients with diffuse large B-cell lymphoma.

Survival has improved among patients with diffuse large B-cell lymphoma (DLBCL) with the addition of anti-CD20 antibody therapy. We aimed to quantify trends and remaining loss in expectation of life (LEL) due to DLBCL at a national population-based level. Patients diagnosed with DLBCL 2000-2013 (N = 7114) were identified through the Swedish Lymphoma Registry and classified according to the age-adjusted International Prognostic Index (aaIPI). The novel measure LEL is the difference between remaining life years among patients and the general population and was predicted using flexible parametric models from diagnosis and among 2-year survivors, by age and sex. Median age at DLBCL-diagnosis was 70 (18-105) years and 54.8% presented with stage III-IV disease. On average, LEL due to DLBCL decreased from 8.0 (95% CI: 7.7-8.3) to 4.6 (95% CI: 4.5-4.6) years over the study period. By risk group, LEL was most reduced among patients with aaIPI ≥2 aged 50-60 years. However, these patients were still estimated to lose >8 years in 2013 (eg, LELmales50years 8.6 years (95% CI: 5.0-12.3)). Among 2-year survivors, LEL was reduced from 6.1 years (95% CI: 5.6-6.5) (aaIPI ≥ 2) and 3.8 years (95% CI: 3.6-4.1) (aaIPI < 2) to 1.1 (95% CI: 1.1-1.2) and 1.0 year (95% CI: 0.8-1.1), respectively. The reduction was observed across all ages. Results for females were similar. By using LEL we illustrate the improvement of DLBCL survival over time. Despite adequate immunochemotherapy, substantial LEL among patients with IPI ≥ 2 points to remaining unmet medical needs. We speculate that observed reduced losses among 2-year survivors indicate a reduction of late relapses.

Refractory diffuse large B-cell lymphoma after first-line immuno-CT: Treatment options and outcomes.

In the rituximab era, one-third of diffuse large B-cell lymphoma patients experience relapse/refractory disease after first-line anthracycline-based immunochemotherapy. Optimal management remains an unmet medical need. The aim of this study was to report the outcomes of a cohort of refractory patients according to their patterns of refractoriness and the type of salvage option. We performed a retrospective analysis, which included 104 diffuse large B-cell lymphoma patients treated at Lyon Sud University Hospital (2002-2017) who presented with refractory disease. Refractoriness was defined as progressive/stable disease during first-line treatment (primary refractory, N=47), a partial response after the end of first-line treatment that required subsequent treatment (residual disease, N=19), or relapse within 1year of diagnosis after an initial complete response (CR) (early relapse, N=38). The 2-year overall survival (OS) rates for primary refractory, early relapse, and residual disease patients were 27%, 25%, and 52%, respectively, while the event-free survival rates for those groups were 13%, 13%, and 42%, respectively. In a univariate analysis, lactate dehydrogenase level, Ann Arbor stage, poor performance status, high age-adjusted International Prognostic Index score, and age>65years were associated with shorter OS. The use of rituximab and platinum-based chemo during the first salvage treatment was associated with prolonged OS. In a multivariate analysis, age (HR:2.06) and rituximab use (HR:0.54) were associated with OS. Among patients <65years who achieved a CR, autologous stem-cell transplant was associated with higher 2-year OS (90% vs 74%, P=0.10). Patients who were treated with a targeted therapy in the context of a clinical trial after second-line treatment had a higher 2-year OS (34% vs 19%, P=0.06). In conclusion, patients with primary refractory disease or early relapse have very poor outcomes but may benefit from rituximab retreatment during the first salvage treatment.

Clinical characteristics and outcomes of diffuse large B-cell lymphoma in adolescents and young adults

Clinical information regarding non-Hodgkin lymphoma (NHL) in adolescents and young adults (AYA) is lacking. We retrospectively analyzed 1426 consecutively registered patients with newly diagnosed NHL. Of 798 DLBCL patients, 42 (5.3%) were identified as AYA (16-39years). The characteristics of AYA DLBCL patients showed no significant differences compared to older adult DLBCL patients (age ≥ 40years). Progression-free survival (PFS) and overall survival (OS) in AYA were similar to those in patients aged 40-60years. However, in older adult groups, PFS and OS were significantly different according to the age group (40-60, 61-79, and ≥ 80years). In univariate analysis in AYA, performance status, clinical stage, International Prognostic Index (IPI), and age-adjusted IPI significantly affected both PFS and OS. In multivariate analysis, only clinical stage was identified as an independent predictor among AYA. In conclusion, disease characteristics and outcomes of DLBCL in AYA were nearly the same as those in older adults.

ESHAP versus GEMOX in Management of Relapsed or Refractory Lymphoma: A Prospective Randomized Study

Background: There is lack of evidence about the best chemotherapy regimen in treatment of relapsed/refractory Hodgkin'slymphoma (HL) and aggressive non-Hodgkin’s lymphoma (NHL) lymphoma.Aim: To compare GEMOX (gemcitabine, oxaliplatin) with ESHAP (etoposide, methylprednisolone, cytarabine arbinoside,cisplatin) regimes as 2nd line in lymphomas.Methods: This was a prospective randomized study that included relapsed/refractory HL and aggressive NHL patientswho failed 1st line chemotherapy. After assessment for eligibility, patients were randomized to receive GEMOX orESHAP.Results: The study included 41 patients, 21 of them received GEMOX and 20 received ESHAP. The response rate did notdiffer significantly between the GEMOX and ESHAP arms (28.6% vs. 35%, p=0.793) as well as progression free survival(8.7 months vs. 6.6 months, p=0.711). By univariate analysis for the whole group, the response rate differed significantlyaccording to disease status at relapse, time to relapse, lactate dehydrogenase, International Prognostic Index (IPI) andsecondary age-adjusted IPI (2ry aa-IPI). Hematological toxicity was not statistically different between the two treatmentarms. GEMOX was associated with significantly less vomiting of any grade (p=0.013). Acute renal toxicity of any gradewas significantly lower in GEMOX compared to ESHAP (p=0.003). In terms of peripheral neuropathy, GEMOX wasassociated with significantly higher all grades (p=0.0001).Conclusion: The current study results suggest that the response rate and progression free survival of GEMOX and ESHAPare comparable with different toxicity profile.

Third line Treatment in Relapsed/Refractory Hodgkin's Lymphoma and Aggressive non-Hodgkin Lymphoma after 2nd line ESHAP or GEMOX

Background: Treatment after failure of 2nd line chemotherapy in patients with Hodgkin's lymphoma (HL) or aggressive non-Hodgkin’s lymphoma (NHL) is not well studied. Aim: To assess the value of 3rd line treatment in a cohort of HL and aggressive NHL patients. Methods: This was a retrospective study of patients with relapsed/refractory HL or aggressive NHL treated with 3rd line treatment based on physician choice. Response rate as well as overall survival (OS) and factors affecting it were assessed. Results: Fifteen (41%) out of 37 patients who failed 2nd line received 3rd line. The remaining 22 received single-agent palliative chemotherapy or best supportive care only. Third line treatment was IGEV (ifosfamide, gemcitabine, navelbine) in 7 (47%) patients, lenalidomide in 4 (26%), ESHAP (etoposide, methylprednisolone, cytosine arabinoside, cisplatin) in 2 (13%) and GEMOX (gemcitabine, oxaliplatin) in 2 (l3%). Four (27%) patients achieved complete remission (2 with IGEV and 2 with lenalidomide) and 3 of them underwent autologous stem cell transplantation. One (7%) patient achieved partial response and another one (7%) had stable disease. The median OS for the whole group was 4.7 months. For patients who received 3rd line the OS was significantly longer than those who didn’t (13.4 vs. 3.4 months, p=0.001). Among the whole set of patients, performance status, lactate dehydrogenase, tertiary age-adjusted International Prognostic Index, 3rd line treatment, response to 3rd line and transplantation had significant impact on OS.Conclusion: Third line treatment may be feasible in selected HL and aggressive NHL patients who failed 2nd line.

Novel prognostic scoring system for diffuse large B-cell lymphoma.

The objective of the present study was to evaluate the prognostic values of platelet count (PLT) and platelet to lymphocyte ratio (PLR) in diffuse large B-cell lymphoma (DLBCL), creating a novel prognostic scoring system. A total of 309 patients with newly diagnosed DLBCL were retrospectively analyzed. Receiver operating characteristic analysis was used to determine the optimal threshold values for PLT and PLR, which were 250×109/l and 170, respectively. The patients with PLT ≥250×109/l and PLR ≥170 experienced significantly decreased overall survival (OS) (P<0.001) and progression-free survival (PFS) times (P=0.003, P<0.001) In multivariate analysis, PLR was a significant prognostic factor for OS (P<0.001) and PFS (P=0.003) time, whereas PLT was not a risk factor for PFS or OS time. According to the results of Cox regression analysis, a novel prognostic scoring system was created that combined PLR and β2-microglobulin level with International Prognostic Index value or age-adjusted International Prognostic Index value and the patients were divided into three groups: i) Low-risk patients with a PLR <170, International Prognostic Index (IPI) <2 scores or age-adjusted International Prognostic Index (aaIPI)=0 and normal β2m; ii) high-risk patients with a PLR ≥170, IPI ≥4 or aaIPI=3 and high level of β2m; and iii) intermediate-risk patients. The novel score predicted 5-year OS rates of 86.4, 54.1 and 21.1% in the low-, intermediate- and high-risk groups, respectively (P<0.001). This novel prognostic scoring system may aid the evaluation of patient prognosis and guide treatment.

Patients over 40 years old with precursor T-cell lymphoblastic lymphoma have different prognostic factors comparing to the youngers

This study aimed to analyze the clinical characteristics and prognostic factors of patients, divided into over 40-year-old group or not, with precursor T-cell lymphoblastic lymphoma (Pre-T-LBL). Based on the retrospective analysis of the clinical data of 59 patients with Pre-T-LBL during the period from December 2010 to December 2015, albumin level, anemia, pleural or pericardial effusion, protocol, therapy response, mediastinal mass, lactate dehydrogenase (LDH), and international prognostic index (IPI) or age-adjusted international prognostic index (aaIPI) were summarized. For patients aged <40 years, factors correlating with poor progression-free survival (PFS) were pleural or pericardial effusion, regimen, albumin level and therapy response. Pleural or pericardial effusion, aaIPI score, regimen, LDH increased, albumin level, therapy response and mediastinal mass were all related with poor overall survival (OS). In the patients aged ≥40 years, only anemia associated with PFS. However, anemia, involvement of bone marrow and therapeutic response were all related with poor OS. In conclusion, the patients with Pre-T-LBL are characterized by a low incidence and bad prognosis. Different prognostic factors can be discovered for patients over 40-year-old with Pre-T-LBL comparing to the youngers. New prognostic evaluation factors should be explored for patients ≥40 years old.

Comparison of Prognostic Indices in Japanese Patients with Diffuse Large B-cell Lymphoma in the Yonago Area

Several prognostic indices for diffuse large B-cell lymphoma (DLBCL) have been developed. Which index is appropriate for Japanese patients with DLBCL treated in real-world practice is unknown. The prognostic performances of the original international prognostic index (IPI), age-adjusted IPI, National Comprehensive Cancer Network-IPI, elderly IPI and revised IPI were compared using patients with DLBCL treated in a single institute in the Yonago area in Japan. From 2005 through 2015, 182 patients with de novo DLBCL were treated with chemotherapy in Tottori University Hospital; 154 (85%) patients received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine and prednisolone) although full dose was administered in 63 (35%) patients. The median age of the patients was 71 years (range 18 to 91). Three-year overall survival rate was 71.8% (95% CI, 64.1% to 78.2%). All indices significantly discriminate risk groups for overall survival of the patients (P < 0.001). Although no statistical difference of performance was found among these indices, the best scores of model fit/discrimination measures were beaten out by age-adjusted IPI, the simplest and three-factor model. Age-adjusted IPI is still usable in real-world practice while a better predictive model is desired for Japanese patients with DLBCL.

Outcomes for HIV-associated diffuse large B-cell lymphoma in the modern combined antiretroviral therapy era.

Non-Hodgkin's lymphoma (NHL) remains among the most frequent malignancies in persons living with HIV (PLWHIV). Survival among patients with HIV-associated diffuse large B-cell lymphoma (DLBCL), the most frequent NHL subtype, has improved markedly in recent years. We aimed to analyze characteristics and outcomes of DLBCL in HIV-infected patients in the era of modern combined antiretroviral therapy (cART). PLWHIV with lymphoma were prospectively enrolled in the French ANRS-CO16 Lymphovir cohort between 2008 and 2015. We compared the patients treated with R-CHOP) (rituximab, cyclophosphamide, daunorubicin, vin-cristine, prednisolone) with HIV-negative DLBCL patients enrolled simultaneously in the R-CHOP arms of Lymphoma Study Association trials. Among 110 PLWHIV with NHL, 52 (47%) had systemic DLBCL. These 52 cases had frequent extranodal disease (81%), poor performance status (35%) and advanced age-adjusted international prognostic index (aaIPI) (58%), and were mainly treated with R-CHOP (n = 44, 85%). Their median CD4 T-cell count was 233 cells/μl, and 79% of patients were on cART. The 2-year overall and progression-free survival rates were both 75% (95% confidence interval: 64%, 88%). Factors associated with progression or death in univariate analysis were poor performance status [hazard ratio: 3.3 (1.2, 8.9)], more than one extranodal site [hazard ratio: 3.4 (1.1, 10.5)] and an advanced aaIPI [hazard ratio: 3.7 (1.0, 13.1)]. Progression-free survival after R-CHOP therapy did not differ from that of the HIV-negative counterparts (P = 0.11). In the recent cART era, despite frequent high-risk features, the 2-year overall survival of HIV-DLBCL patients reaches 75%. Outcomes after R-CHOP therapy are similar to those of HIV-negative patients with similar aaIPI.

Clinical analysis of B-cell lymphoma treatment with autologous hematopoietic stem cell transplantation

Objective To investigate the clinical efficacy, safety and prognostic factors of autologous hematopoietic stem cell transplantation (auto-HSCT) in treatment of B-cell lymphoma. Methods From March 2001 to December 2014, a total of 50 patients with B-cell lymphoma who underwent auto-HSCT at Tangdu Hospital, the Fourth Military Medical University were selected as the study subjects. Among them, 24 patients were suffering from diffuse large B-cell lymphoma (DLBCL), 2 patients were suffering from follicular lymphoma (FL), 3 patients were suffering from B lymphoblastic lymphoma, 21 patients were suffering from B-cell lymphoma (undifferentiated). According to number of times of receiving auto-HSCT, these 50 patients were divided into two groups: single auto-HSCT group (n=28, only receiving auto-HSCT once) and double autologous hematopoietic stem cell transplantation (DAHSCT) group (n=22, the second auto-HSCT was planned in 2 to 6 months after the first auto-HSCT). Retrospective method was used to collect related clinical data from all patients. The severity of post-transplant adverse events was assessed according to the Common Criteria for Terminology of Incidents, version 4.0 (CTCAE v4.0). The efficacy of auto-HSCT was evaluated according to revised International Working Group (IWG) lymphoma efficacy criteria and the overall response rate of auto-HSCT was calculated. Survival analysis was performed using Kaplan-Meier method. Overall survival (OS) and progression-free survival (PFS) rates were compared between two groups using log-rank test. Cox regression analysis was used to univariate analyze the influencing factors that may influence the OS peroid of B-cell lymphoma patients in this study. According to available research results and clinical experience, multivariate Cox regression analysis was performed on the factors that were statistically significant in the univariate analysis. Results ①The differences of composition ratios of clinical stage and age-adjusted international prognostic index (aaIPI) score in single auto-HSCT group and DAHSCT group were significantly (composition ratio of patients with clinical stage Ⅰ-Ⅱ: 25.0% vs 54.5%, χ2=4.565, P=0.033; Composition ratio of patients with aaIPI 0-2: 35.7% vs 86.4%, χ2=12.974, P 0.05). ④ In single auto-HSCT group, 18 patients achieved complete remission (CR) and 8 patients achieved partial remission (PR), with the total response rate of auto-HSCT of 92.9% (26/28). In DAHSCT group, 20 patients achieved CR and 2 patients achieved PR, with the total response rate of DAHSCT of 100.0% (22/22). The median follow-up time was 54.0 months (24.8-76.3 months) in this study, and OS rate was 68.0%, PFS rate was 52.0%. OS rate and PFS rate were 77.3% and 68.2% in the DAHSCT group, which were both higher than that of 60.7% and 39.3% in the single auto-HSCT group respectively, and the differences were statistically significant (χ2=8.073, 4.250; P=0.004, 0.039). ⑤ The results of univariate Cox regression analysis showed that level of serum lactate dehydrogenase (LDH) and number of times of auto-HSCT were the risk factors influencing OS period in patients with B-cell lymphoma (P=0.033, 0.045). And results of multivariate Cox regression analysis showed that serum LDH levels>245 U/L and single auto-HSCT were independent risk factors for OS period of patients with B-cell lymphoma (HR=0.237, 95%CI: 0.062-0.905, P=0.035; HR=3.063, 95%CI: 0.970-9.675, P=0.047) in this study. Conclusions Auto-HSCT treatment of patients with B-cell lymphoma were with good efficacy, tolerability and safety, which is worth further clinical application. Key words: Lymphoma, B cells; Hematopoietic stem cell transplantation; Transplantation, autologous

Intratumoral FOXP3+ Regulatory T Cells in Diffuse Large B-Cell Lymphoma.

Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma in Egypt and worldwide. Gene expression profiling classifies DLBCL into: germinal center B cell-like (GCB) and non germinal center B cell-like (non-GCB) DLBCL. Hans' algorithm has high concordance with gene expression profiling results. Regulatory T cells (Tregs) represent important modulators for the interaction between lymphoma cells and host microenvironment. FOXP3 is a popular single marker for Tregs. There is little information about the possible role of Tregs in high-grade lymphoma such as DLBCL. This study aims to assess the prognostic impact of FOXP3+ Tregs in DLBCL. The study was carried out on 70 archival cases (61 de novo DLBCL and 9 reactive follicular hyperplasia cases). DLBCL cases were classified into GCB and non-GCB groups using Hans' algorithm. All studied cases are subjected to FOXP3 immunostaining. Density of FOXP3+ Tregs was higher in reactive cases compared with DLBCL (P=0.000). In DLBCL cases, FOXP3 expression was associated with free spleen (P=0.02), early stage (P=0.05), centroblastic variant (P=0.003), and absence of necrosis (P=0.05). In germinal cases, density of FOXP3 was significantly higher in cases with good PS (P=0.02), very good and good revised international prognostic index (P=0.002), and low-risk age-adjusted international prognostic index >60 (P=0.01). Non germinal DLBCL cases with negative FOXP3 were significantly associated with splenic involvement (P=0.005). DLBCL cases with high FOXP3 have longer survival (P=0.03). T cells in the background of DLBCL may play a role in modulation of tumor progression. Their presence is associated with favorable prognostic parameters in DLBCL.

Rituximab-dose-dense chemotherapy with or without high-dose chemotherapy plus autologous stem-cell transplantation in high-risk diffuse large B-cell lymphoma (DLCL04): final results of a multicentre, open-label, randomised, controlled, phase 3 study

The prognosis of young patients with diffuse large B-cell lymphoma at high risk (age-adjusted International Prognostic Index [aa-IPI] score 2 or 3) treated with R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone) is poor. The aim of this study was to investigate the possible benefit of intensification with high-dose chemotherapy and autologous stem-cell transplantation as part of first-line treatment in these patients. We did a multicentre, open-label, randomised, controlled, phase 3 trial with a 2 × 2 factorial design to compare, at two different R-CHOP dose levels, a full course of rituximab-dose-dense chemotherapy (no transplantation group) versus an abbreviated course of rituximab-dose-dense chemotherapy followed by consolidation with R-MAD (rituximab plus high-dose cytarabine plus mitoxantrone plus dexamethasone) and high-dose BEAM chemotherapy (carmustine, etoposide, cytarabine, and melphalan) plus autologous stem-cell transplantation (transplantation group) in young patients (18-65 years) with untreated high-risk diffuse large B-cell lymphoma (aa-IPI score 2-3). At enrolment, patients were stratified according to aa-IPI score and randomly assigned (1:1:1:1) to receive R-CHOP (intravenous rituximab 375 mg/m2, cyclophosphamide 750 mg/m2, doxorubicin 50 mg/m2, and vincristine 1·4 mg/m2 on day 1, plus oral prednisone 100 mg on days 1-5) delivered in a 14-day cycle (R-CHOP-14) for eight cycles; high-dose R-CHOP-14 (R-MegaCHOP-14; R-CHOP-14 except for cyclophosphamide 1200 mg/m2 and doxorubicin 70 mg/m2) for six cycles; R-CHOP-14 for four cycles followed by R-MAD (intravenous rituximab 375 mg/m2 on day 1 or 4 plus intravenous cytarabine 2000 mg/m2 and dexamethasone 4 mg/m2 every 12 h on days 1-3 plus intravenous mitoxantrone 8 mg/m2 on days 1-3) plus BEAM (intravenous carmustine 300 mg/m2 on day -7, intravenous cytarabine 200 mg/m2 twice a day on days -6 to -3, intravenous etoposide 100 mg/m2 twice a day on days -6 to -3, plus intravenous melphalan 140 mg/m2 on day -2) and autologous stem-cell transplantation (day 0); or R-MegaCHOP-14 for four cycles followed by R-MAD plus BEAM and autologous stem-cell transplantation. The primary endpoint was failure-free survival at 2 years in the intention-to-treat population. This study is registered with EudraCT (2005-002181-14; 2007-000275-42) and with ClinicalTrials.gov, number NCT00499018. Between Jan 10, 2006, and Sept 8, 2010, 399 patients were randomly assigned to receive transplantation (n=199) or no transplantation (n=200); 203 patients were assigned to receive R-CHOP-14 and 196 were assigned to receive R-MegaCHOP-14. With a median follow-up of 72 months (IQR 57-88), 2-year failure-free survival was 71% (95% CI 64-77) in the transplantation group versus 62% (95% CI 55-68) in the no transplantation group (hazard ratio [HR] 0·65 [95% CI 0·47-0·91]; stratified log-rank test p=0·012). No difference in 5-year overall survival was observed between these groups (78% [95% CI 71-83] versus 77% [71-83]; HR 0·98 [0·65-1·48]; stratified log-rank test p=0·91). Grade 3 or worse haematological adverse events were reported in 183 (92%) of 199 patients in the transplantation group versus 135 (68%) of 200 patients in the no transplantation group. Grade 3 or worse non-haematological adverse events were reported in 90 (45%) versus 31 (16%); the most common grade 3 or worse non-haematological adverse event was gastrointestinal (49 [25%] vs 19 [10%]). Treatment-related deaths occurred in 13 (3%) patients; eight in the transplantation group and five in the no transplantation group. Abbreviated rituximab-dose-dense chemotherapy plus R-MAD plus BEAM and autologous stem-cell transplantation reduced the risk of treatment failure compared with full course rituximab-dose-dense chemotherapy in young patients with diffuse large B-cell lymphoma at high risk. However, these results might not be clinically meaningful, since this improvement did not reflect an improvement in overall survival. These results do not support further consideration of the use of intensification of R-CHOP as an upfront strategy in patients with diffuse large B-cell lymphoma with poor prognosis. Fondazione Italiana Linfomi.

Favourable outcomes of poor prognosis diffuse large B-cell lymphoma patients treated with dose-dense Rituximab, high-dose Methotrexate and six cycles of CHOP-14 compared to first-line autologous transplantation.

The optimal therapeutic approach for young diffuse large B-cell lymphoma (DLBCL) patients with high-intermediate and high-risk age-adjusted international prognostic index (aaIPI) remains unknown. Hereby we report a 10-year single-centre study of 63 consecutively treated patients. To optimize outcome, two approaches were carried out: Cohort 1 patients received four cycles R-CHOP-21 (rituximab, cyclophosphamide, daunorubicin, vincristine, prednisolone over 21days) followed by first-line high-dose chemotherapy with autologous stem-cell support (HDCT-ASCT), resulting in 2-year progression-free (PFS) and overall survival (OS) of 60·6% and 67·9%. 39·4% of those patients were not transplanted upfront, mainly due to early progressive disease (24·2%). Cohort 2 patients received an early intensified protocol of six cycles of CHOP-14 (cyclophosphamide, daunorubicin, vincristine, prednisolone over 14days) with dose-dense rituximab and high-dose methotrexate resulting in promising overall response- (93·3%) and complete remission (90%) rates and sustained survival (2-year PFS and OS: 93·3%). In an intention-to-treat analysis, 2-year PFS (60·6% vs. 93·3%, hazard ratio [HR] 7·2, P=0·009) and OS (69·7% vs. 93·3%, HR 4·95, P=0·038) differed significantly, in favour of the early intensified protocol (Cohort 2). In a multivariate Cox-regression model, PFS (HR 8·12, 95% confidence interval [CI] 1·83-35·9, P=0·006) and OS (HR 5·86, 95% CI 1·28-26·8, P=0·02) remained superior for Cohort 2 when adjusted for aaIPI3 as the most important prognostic factor. Survival of young poor-prognosis DLBCL patients appears superior after early therapy intensification.

Multicenter Retrospective Analysis of Clinical Characteristics, Treatment Patterns, and Outcomes in Very Elderly Patients with Diffuse Large B-Cell Lymphoma: The Korean Cancer Study Group LY16-01.

PurposeThe treatment strategy for elderly patients older than 80 years with diffuse large B-cell lymphoma (DLBCL) has not been established because of poor treatment tolerability and lack of data.Materials and MethodsThis multicenter retrospective study was conducted to investigate clinical characteristics, treatment patterns and outcomes of patients older than 80 years who were diagnosed with DLBCL at 19 institutions in Korea between 2005 and 2016.ResultsA total of 194 patients were identified (median age, 83.3 years). Of these, 114 patients had an age-adjusted International Prognostic Index (aaIPI) score of 2-3 and 48 had a Charlson index score of 4 or more. R-CHOP was given in 124 cases, R-CVP in 13 cases, other chemotherapy in 17 cases, radiation alone in nine cases, and surgery alone in two cases. Twenty-nine patients did not undergo any treatment. The median number of chemotherapy cycles was three. Only 37 patients completed the planned treatment cycles. The overall response rate from 105 evaluable patientswas 90.5% (complete response, 41.9%). Twentynine patients died due to treatment-related toxicities (TRT). Thirteen patients died due to TRT after the first cycle. Median overall survival was 14.0 months. The main causes of death were disease progression (30.8%) and TRT (27.1%). In multivariate analysis, overall survival was affected by aaIPI, hypoalbuminemia, elevated creatinine, and treatment.ConclusionAge itself should not be a contraindication to treatment. However, since elderly patients show higher rates of TRT due to infection, careful monitoring and dose modification of chemotherapeutic agents is needed.