Risk Stratification for Diffuse Large B-Cell Lymphoma by Integrating Interim Evaluation and International Prognostic Index: A Multicenter Retrospective Study

Abstract

The baseline International Prognostic Index (IPI) is not sufficient for the initial risk stratification of patients with diffuse large B-cell lymphoma (DLBCL) treated with R‐CHOP (rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone). The aims of this study were to evaluate the prognostic relevance of early risk stratification in DLBCL and develop a new stratification system that combines an interim evaluation and IPI. This multicenter retrospective study enrolled 314 newly diagnosed DLBCL patients with baseline and interim evaluations. All patients were treated with R-CHOP or R-CHOP-like regimens as the first-line therapy. Survival differences were evaluated for different risk stratification systems including the IPI, interim evaluation, and the combined system. When stratified by IPI, the high-intermediate and high-risk groups presented overlapping survival curves with no significant differences, and the high-risk group still had >50% of 3-year overall survival (OS). The interim evaluation can also stratify patients into three groups, as 3-year OS and progression-free survival (PFS) rates in patients with stable disease (SD) and progressive disease (PD) were not significantly different. The SD and PD patients had significantly lower 3-year OS and PFS rates than complete remission and partial response patients, but the percentage of these patients was only ~10%. The IPI and interim evaluation combined risk stratification system separated the patients into low-, intermediate-, high-, and very high-risk groups. The 3-year OS rates were 96.4%, 86.7%, 46.4%, and 40%, while the 3-year PFS rates were 87.1%, 71.5%, 42.5%, and 7.2%. The OS comparison between the high-risk group and very high-risk group was marginally significant, and OS and PFS comparisons between any other two groups were significantly different. This combined risk stratification system could be a useful tool for the prognostic prediction of DLBCL patients.

Risk-stratification in diffuse large B-cell lymphoma in the rituximab era

“…Several studies found that interim evaluation results from PET-CT or CT scans are predictors of survival. In the study Shi et al, IPI and interim PET/CT were integrated with the aim of improving the stratification efficacy for patients with DLBCL [27]. They established three groups with different OS and PFS rates.…”

High density of FOXP3 predicts better prognosis in germinal and non‐germinal centre diffuse large B‐cell lymphoma

“…Diffuse large B‐cell lymphoma (DLBCL) is the most common type of non‐Hodgkin lymphoma (NHL) worldwide 1 . In Egypt, it accounts for 49% of adult NHLs, according to the latest registry of the National Cancer Institute, Cairo University 2 .…”

“…In Egypt, it accounts for 49% of adult NHLs, according to the latest registry of the National Cancer Institute, Cairo University 2 . DLBCL comprises a heterogeneous entity resulting from the clonal proliferation of a germinal or postgerminal malignant B cell with different clinical, prognostic immunophenotypic and molecular features 1 . In routine practice, Hans algorithm is the most widely accepted immunohistochemical (IHC)‐based algorithm that depends on CD10, BCL6 and MUM‐1 expression to classify DLBCL according to their cell of origin (COO) into germinal centre B‐cell (GCB) and non‐GCB subtypes using the WHO classification 3…”

“…Although the introduction of Rituximab in treating DLBCL improved the disease outcome, the mortality rate is still high, where about 35% of patients die due to relapsed or refractory disease. Also, the current clinical prognostic indices for DLBCL, including the international prognostic index (IPI), are still insufficient for precise risk stratification and do not reflect the biological features of DLBCL or the surrounding tumour microenvironment cells due to disease heterogeneity 1 . Therefore, a better understanding of different prognostic factors that can predict the response of DLBCL patients to first‐line chemotherapy will facilitate the development of personalized therapeutic strategies and improve the patient's survival.…”

“…Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL) worldwide. 1 In Egypt, it accounts for 49% of adult NHLs, according to the latest registry of the National Cancer Institute, Cairo University. 2 DLBCL comprises a heterogeneous entity resulting from the clonal proliferation of a germinal or postgerminal malignant B cell with different clinical, prognostic immunophenotypic and molecular features.…”