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ESMO E-Learning: Modern Management of DLBCL

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ESMO E-Learning: Modern Management of DLBCL MODERN MANAGEMENT OF DLBCL Ruth Pettengell St George’s University of London NHL OVERVIEW B T NHL ≈ 85% ≈ 15% Main B-cell lymphomas distribution DLBCL: The commonest subtype MALT 9% Follicular 29% Lymphoma Research Foundation. Understanding Non-Hodgkin Lymphoma 2012. Fourth edition; Image By Nephron (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) DLBCL Presentation De novo or after transformation: follicular lymphoma, CLL/SLL1 Percent of New Cases by Age Group: NHL Incidence in Europe SEER 18 2009-2013, All Races, Both Sexes5 2 3.8/100 000/year 30 3 Increases with age 24.3 25 21.5 Median age at diagnosis 64 years 21.0 20 4 Risk factors 15 12.7 Family history 9.4 10 Autoimmune disease New cases(%) 5.7 5 3.7 HIV+ 1.6 0 Hepatitis C Virus+ 1. Raut LS, et al., South Asian J Cancer 2014 2. Sant M, et al., Blood 2010 Age 3. Tilly H, et al., Ann Oncol 2015 4. Morton LM, et al., J Natl Cancer Inst Monogr 2014 5. From the website of the National Cancer Institute (https://www.cancer.gov) 2016 REVISION OF THE WHO CLASSIFICATION DLBCL: Cell of Origin Common somatic mutations: inactivating mutations of TP53, genes in immuno- surveillance (B2M, CD58), alterations in epigenetic regulators (CREBBP/EP300, KMT2D/C [MLL2/3], MEF2B), and oncogenic activation of BCL6. Biomarkers of GCB – CD 10, BCL6, GCET1, LMO2. Frequently histone methyl transferase EZH2, BCL2 translocations, mutations in the cell motility regulator GNA13 Non GCB markers – IRF4/MUM1, FOXP1. Frequently mutations in genes (MYD88, CD79A, CARD11,TNFAIP3) activating the B-cell receptor/Toll-like receptor and NF-kB pathways DLBCL NOS Co expression of MYC and BCL2 (expression >50%) without gene aberrations, considered new prognostic marker (double-expressor lymphoma). Worse outcome than other DLBCL CD30 expression as new antibody-based therapies 1. Swerdlow SH, et al., Blood 2016 127:2375-2390 IMPORTANCE OF CELL-OF-ORIGIN MOLECULAR SUBTYPES GCB Non-GCB + + MUM1 CD10 + – – GCB Bcl-6 – Non-GCB Hans classification 1.0 DLBCL 5-Yr OS, 0.8 subgroup % 0.6 PMBL 64 OS 0.4 GCB DLBCL 59 ABC DLBCL 30 0.2 0 0 2 4 6 8 10 From NEJM 2002, Rosenwald A, et al., The Use of Molecular Profiling to Predict Survival after Chemotherapy for Diffuse Large-B-Cell Lymphoma; 346: 1937-47. Copyright © (2002) Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society; Rosenwald A, et al., J. Exp Med 2003 198,851-862. copyright 2003, with permission from the Rockefeller University Press; Hans CP, et al., Blood 2004;103:275-282 LUGANO CLASSIFICATION Staging1 FDG PET-CT more sensitive than CT for detecting nodal and extra nodal disease in NHL (5 point Deauville score) Modified Ann Arbor classification Routine bone marrow biopsy (BMB) not required for most DLBCL 654 pts –Sens:88.7%, Spec:99.8% 3.1% false negative (<20% BM involvement) 12.5% PET/CT +ve/-ve BMB End of Treatment 1 PET/CT more accurate especially in CRu or PR and extranodal disease 2 Plan for minimum of 3 weeks preferably 6-8 weeks post chemo , 3 months post- radiotherapy3 1. Adams HJA, et al., EJNMMI 2014; 41: 565-574 2. Juweid ME, et al., J Clin Onc 2007;21: 571-8 3. Boellaard R, et al., Eur J Nuc Med Mol Imaging 2010;37:181-200 DLBCL PROGNOSIS Overall Survival according to age and time period Events occur early…. 1989–20071 2005–20102 1.0 1.0 0.8 0.8 0.6 0.6 0.4 0.4 Net Net survival Net survival 15:45 15:45 0.2 45:55 0.2 45:55 55:65 55:65 65:75 65:75 75:++ 75:++ 0 0 0 2 4 6 8 10 0 1 2 3 4 5 Time since diagnosis (years) Time since diagnosis (years) 1. Monnereau A, et al., Survie des personnes atteintes de cancer en France 1989-2007. Lymphomes diffus à grandes cellules. Études à partir des registres des cancers du réseau FRANCIM. 2. Monnereau A, et al., Lymphome diffus à grandes cellules B. Available on invs.santepubliquefrance.fr CD20 MONOCLONAL ANTIBODIES Rituximab Specific anti-CD20 Pan-B cell marker Mature B-cells > 95% B-cell NHL DLBCL: CD20 staining Republished with permission of American Society of Hematology, from The clinical application of monoclonal antibodies in chronic lymphocytic leukemia, Jaglowski SM, et al., Blood 116(19):3705–14, copyright 2010; permission conveyed through Copyright Clearance Center, Inc. PROGNOSTIC SCORES NCCN-IPI1 Score Age, y >40 to ≤60 1 IPI2 Score >60 to ≤75 2 >75 3 Age > 60 y ? LDH, normalised LDH > 1x normal ? >1 to ≤3 1 Stage III-IV 1 >3 2 > 1 extranodal lesion 1 Ann Arbor stage III-IV 1 Performance status ≥2 1 Extranodal disease* 1 IPI Score Performance status ≥2 1 IPI Score Overall survival2 1.00 L (0,1) 100 LI (2,3) 0.75 75 L (0,1) HI (4,5) LI (2) 0.50 50 HI (3) H (>6) Survival (%) Survival 0.25 (%) Patients 25 H (4) NCCN-IPI 0 0 0 1 2 3 4 5 0 2 4 6 8 10 1. Zhou Z, et al., Blood 2014;123:827-842 2. The International Non-Hodgkin's Lymphoma Prognostic Factors Project. N Engl J Med 1993;329:987–99 TREATMENT ALGORITHM FOR DLBCL Aggressive non-Hodgkin Lymphoma First-line treatment First Line Cure First Relapse n=100 n=200 Transplant Eligible n=50 n=50 Transplant Ineligible Second Line Response to salvage No Response to n=25 therapy salvage therapy n=25 Proceed to ASCT Cure Not Cured Relapsed/Refractory n=25 n=50 Relapsed/Refractory n=10 n=15 Third Line ≥ 3rd line salvage ASCT=Autologous Stem cell transplantation n=90 Adapted from: Friedberg JW. Hematology Am Soc Hematol Educ Program. 2011;2011:498–505. LIMITED STAGE DISEASE R-CHOP (3 cycles) plus RT prolonged follow-up PFS OS Stephens DM, et al., Continued Risk of Relapse Independent of Treatment Modality in Limited-Stage Diffuse Large B-Cell Lymphoma: Final and Long-Term Analysis of Southwest Oncology Group Study S8736. J Clin Oncol 2016;25:2997-3004. Reprinted with permission. © 2016, American Society of Clinical Oncology. All rights reserved ESMO CLINICAL PRACTICE GUIDELINES: RECOMMENDED TREATMENT STRATEGIES IN DLBCL First line treatment: R-CHOP (-like) Patients ≤ 60 years IPI low risk (aaIPI = 0) with bulk or IPI intermediate-high risk or IPI high risk (aaIPI = IPI low risk (aaIPI = 0) and no bulk IPI low-intermediate risk (aaIPI = 1) 2, 3) R-CHOP21 × 6–8 or R-CHOP14 × 6 with 8 R R-ACVBP and consolidation Consider more intensive regimens in selected R-CHOP21 × 6 or patients: R-CHOP21 × 6 + IF-RT on bulk R-CHOEP14 × 6 or R-CHOP or R-ACVBP plus ASCT Elderly > 60 years Fit, 60–80 years >80 years without cardiac dysfunction Unfit or frail or >60 years with cardiac dysfunction Doxorubicin substitution with gemcitabine, R-CHOP21 × 6–8 (6 for IPI low risk) etoposide or liposomal doxorubicin or others: Attenuated regimens: or R-miniCHOP21 × 6 R-C(X)OP21 × 6 R-CHOP14 × 6 with 8 R or palliative care Tilly H, et al., Ann Oncol 2015;26 Suppl 5:v116–2 YOUNG PATIENTS (<60 YEARS) EFS PFS OS 0 24 48 72 96 120 0 24 48 72 96 120 0 24 48 72 96 120 Months Median F/U 70 mo, No excess AEs in R group or second malignancies Reprinted from Lancet Oncol 12(11), Pfreundschuh M, et al. CHOP-like chemotherapy with or without rituximab in young patients with good-prognosis diffuse large-B-cell lymphoma: 6-year results of an open-label randomised study of the MabThera International Trial (MInT) Group, 1013–22, copyright 2010 with permission from Elsevier DOSE DENSE CHEMOTHERAPY IN DLBCL R-CHOP14 vs. 21: no difference in outcome No subgroup identifies with better outcome Reprinted with permission from Elsevier. Cunningham D, et al., The Lancet, 2013;381:1817–26 DOSE INTENSIVE CHEMO IN DLBCL Improved outcome in R-ACVBP Arm EFS PFS RFS OS Reprinted from The Lancet, 378(9806), Recher C, et al., Intensified chemotherapy with ACVBP plus rituximab versus standard CHOP plus rituximab for the treatment of diffuse large B-cell lymphoma (LNH03-2B): an open-label randomised phase 3 trial, 1858-1867, Copyright 2011, with permission from Elsevier ONGOING APPROACHES TO INTENSIFICATION CALBG R-CHOP vs. DA-EPOCH-R R-CHOP R-EPOCH G4 neutropenia 90% 56% G4 thrombocytopenia 35% 6% G 3/4 FN 37% 19% G3 neuropathy Motor 8% Motor 1% Sensory 15% Sensory 3% 524 patients, 2005 to 2013 High-intermediate/high IPI (33.6%; 38.2%) Completed per protocol RCHOP 89% and R-EPOCH 83% disease progression on therapy was 2.6% and 1.7% Adverse side effects leading to treatment discontinuation were 1.7% and 5.6% No difference in EFS (HR 1.02 and p=0.89 at a median follow-up of 4.9 years) or OS (HR 1.19 and p=0.40 at median 5.0 years) Wilson W, et al., Blood 2016 128:469 THE RISK OF CNS DISEASE IN PATIENTS WITH AGGRESSIVE B-CELL LYMPHOMA CNS relapse is early (median 5.4 mo from diagnosis, 0.2% isolated CNS relapse1 N=1597 pts, median follow-up 4.2 y; median TT CNS rel 6.7 mo Low risk 0-1 factors; 2 year CNS relapse risk 0.8% Intermediate risk 2-3 factors; 2 year CNS relapse risk 3.9% High risk 4-6 factors; 2 y CNS relapse risk 12% Kidney/Adrenal involvement CNS relapse (2 year CNS risk BCCA 33%; 14% DSHNHL) Risk of CNS relapse according to the CNS IPI2 1.
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