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DLBCLPrognosticIndicesfromPerspectiveofESMOGuidelinesZhitaoYing,M.D.PekingUniversityCancerHospitalMar-18,2017Outcome
of
Patients
with
DLBCL
after
R-CHOP
ChemotherapyCoffier
B,
et
al.
Hematology,
2016:
366-378.TreatmentHistoryofDLBCLClinicalPrognosticFactorsAge>60PS≥2LDH>1xnormalStageIIIorIV>1extranodalsiteIPIPS
≥2LDH>1xnormalStageIIIorIVaa-IPINEJM,
1993,
329(14):
987-94.
Clinical
Factors
are
Still
Prognostic
in
Rituximab
EraPFSOSSehn
LH,
et
al.
Blood,
2007,
109:
1857-1861.IPI
is
Recommended
in
ESMO
GuidelinesTilly
H,
et
al.
Ann
Oncol.
2015,
26
(Suppl
5):
v116-125IPILow-riskDLBCL
Patient
Relapsedafter
R-CHOPCellofOrigin(COO)DeterminestheOutcomeRosenwaldA,etal.NEnglJMed2002;346:1937-1947.Pre-rituximab
eraRituximab
eraPrognosticValueofCOOisIndependentofIPIGCB
(N=115)Type
3
(N=52)ACB
(N=73)P
ValueRisk
Group0.44Low
(0-1)404129Intermediate
(2-3)494351High
(4-5)111519RosenwaldA,etal.NEnglJMed2002;346:1937-1947.Alizadeh
AA,
et
al.
Nature,
2000;
403:
503-511.IPI
0-2IPI
3-5Randomizedphase2open-labelstudyof
R-CHOP±bortezomibinpatientswithuntreatednon-germinalcenterB-cell-likesubtypediffuselargecelllymphoma:
ResultsfromthePYRAMIDtrial(NCT00931918)JPLeonard,KKolibaba,JAReeves,
ATulpule,IWFlinn,TKolevska,
RRobles,CFlowers,RCollins,NJDiBella,SWPapish,PVenugopal,
AHorodner,
ATabatabai,JHajdenberg,GMulligan,RNeuwirth,
KSuryanarayan,D-LEsseltine,SdeVosStudydesignECOGPS,EasternCooperativeOncologyGroupperformancestatus;IHC,immunohistochemistry;IV,intravenous;
PO,oraladministrationArmA(n=95)Bortezomib1.3mg/m2IV,Days1and4R-CHOP?21X6cyclesArmB(n=95)R-CHOP?21X6cyclesNon-GCBSelectionPreviouslyuntreatedDLBCLMeasurablediseaseECOGPS0–2IHCalgorithmAssay/scoringinrealtimeatcentralUSlab*Hansmethod1
(CD10,bcl-6,MUM-1)48–72hourturnaroundRetrospectivemolecularanalysesofRNApatterns,DNAmutationsRANDOMIZE*LocalIHCtestingbycertifiedlocalpathologistswasalsoemployed,confirmedbycentralreview;
?R-CHOPstandarddose(rituximab375mg/m2,cyclophosphamide750mg/m2,doxorubicin
50mg/m2,vincristine1.4mg/m2[max2mg],allIVonDay1,andprednisone100mgPOonDays1–5)
HansCP,etal.Blood2004;103:275–82FPI:Oct2009LPI:July20132-yearPFS:78%R-CHOPvs82%VR-CHOPHR(95%CI):0.73(0.43,1.24);p=0.611Progression-freesurvivalCI,confidenceinterval;HR,hazardratio;
PFS,progression-freesurvival(timefromrandomizationtoinvestigator-assessedprogressionordeath)Patientsatrisk:R-CHOPVR-CHOPPFSprobabilityTimetoevent(months)0.00.10.20.30.40.50.60.70.80.91.00510152025303550556065707540459192727565726166576150513738282757220201000022241513Treatmentgroup:Censoredobservations:R-CHOPVR-CHOPR-CHOPVR-CHOPR-CHOP
(N=91)
25%EventsVR-CHOP
(N=92)
18%Overallsurvival2-yearOS:88%R-CHOPvs93%VR-CHOPHR(95%CI),0.75(0.38,1.45);p=0.763
OS,overallsurvival(timefromrandomizationtodeath)Patientsatrisk:R-CHOPVR-CHOPTimetoevent(months)91928288808575837380646847493538613340301000028332023OSprobability0.00.10.20.30.40.50.60.70.80.91.0Treatmentgroup:Censoredobservations:R-CHOPVR-CHOPR-CHOPVR-CHOPR-CHOP
(N=91)
15%EventsVR-CHOP
(N=92)
12%05101520253035505560657075404514AndrewJDavies1,JoshCaddy2,TomMaishman2,SharonBarrans3,ChristophMamot4,MatthewCare5,ChristopherPocock6,LouiseStanton,2,DebbieHamid2,KeithPugh2,AndrewMcMillan,7,PaulFields8,AntonKruger9,AndrewJack10andPeterW.M.Johnson1AProspectiveRandomisedTrialofTargetedTherapyforDiffuseLargeB-CellLymphoma(DLBCL)BaseduponReal-TimeGeneExpressionProfiling.TheREMoDL-BStudyoftheUKNCRIandSAKKLymphomaGroups1CancerResearchUKCentre,UniversityofSouthampton,Southampton,UnitedKingdom2SouthamptonClinicalTrialsUnit,UniversityofSouthampton,Southampton,UnitedKingdom3StJamesInstituteofOncology,HMDS,Leeds,UnitedKingdom4,CantonalHospitalofAarau,Aarau,Switzerland5UniversityofLeeds,LeedsInstituteofCancerandPathology,Leeds,UnitedKingdom6EastKentHospitals,Canterbury,UnitedKingdom7NottinghamCityHospital,Nottingham,UnitedKingdom8DepartmentofHaematology,Guy'sandStThomas'HospitalsNHSTrust,London,UnitedKingdom9RoyalCornwallHospital,Truro,UnitedKingdom10HMDS,LeedsCancerCentre,LeedsTeachingHospitalsNHSTrust,Leeds,UnitedKingdomREMoDL-BREMoDL-Bstudy(UK)
RandomizedevaluationofmolecularguidedtherapyinDLBCLwithBortezomibAllpatientsinitiallyrandomized,designedtocloseforGCBsubjectsifevidenceoffutilityUpto940subjects,minimum260ABCsubtype(April2011–2020)ClinicalTIdentifier:NCT01324596DLBCLdiagnosis&subtypingR-CHOPx1cycleRR-CHOPSixcyclesoftreatment(3weekspercycle)RB-CHOPcycles2-6oftreatment(3weekspercycle)BxGEPNonrandom.ABCGCBUnclass.Responserate(%):MolecularprofileandarmPRCR/CR(u)90.2%87.7%88.0%87.5%90.5%96.3%81.8%R-CHOP-Ibrutinib
for
Patients
with
B-NHLYounes
A,
et
al.
LancetOncol2014;15:1019–1026.Outcomes
of
DLBCL
Patients:
R2-CHOP
vs.
R-CHOP
(Phase
II
study)Nowakowski
GS,
et
al.
J
Clin
Oncol,
2015,
33(3):
251-257.
OngoingClinicalTrialsEvaluatingNewStrategiesinNon-GCBDLBCLPHOENIXIHCROBUSTThe
distinction
between
GCB-like
subtype
and
ABC-like
subtype,studiedbyGEPandsuggestedbyIHCdonotinfluencetreatmentchoicesatthemoment.
TillyH,etal.AnnOncol,2012,23;(Suppl7):vii78-82.TheABC
subtype
has
been
shown
to
have
a
worse
prognosis
when
compared
with
GCB
in
patients
treated
by
R-CHOP.At
present
time,
pending
results
of
large
comparative
studies,none
of
these
agents
are
appropriate
for
routine
therapy
in
practice.DA-EPOCHR-CHOP-BortezomibR2-CHOPR-CHOP-Ibrutinib
Tilly
H,
et
al.
Ann
Oncol,2015,
26
(Suppl
5):
v116-125.MYC基因重排能夠預(yù)測(cè)DLBCL預(yù)后11/14
Bcl2+11/14
Bcl2+K;apper
W,
et
al.
Leukemia,
2008(22):
2226-2229Savage
KJ,
et
al.
Blood,
2009,
114(17):
3533-3537.
8/12
Bcl2+R
eraPre-Rera8/12
Bcl2+PoorOutcomeofDHL(MYC+/BCL2+)DHLDLBCLBLSnuderl
M,
et
al.
Am
J
Surg
Patho,2010,
34(3):
327-340.DHL:
the
MDACCExperienceOki
Y,
et
al.
BrJHaematol.2014;166(6):891-901.R-EPOCH
is
Associated
with
a
better
PFS
(SystemicReviewandMeta-analysis)Howlett
C,et
al.BrJHaematol.2015;170(4):504-514.IHC
=
FISH?Johnson
NA,
et
al.
J
Clin
Oncol,
2012:
30(28):
3452-3459DHITOtherMYC+/BCL2+NoMYC+/BCL2+CutoffMYC
IHCCutoffBCL2
IHCPrognosisMYCPrognosisBCL2Green,JCO
201213518%≥40%≥70%nonoJohnson
N,
JCO
201218629%≥40%≥50%noyesHorn
H,
Blood
201314128%≥40%≥1%yesyesHu
S,
Blood
201346634%≥40%≥70%nonoValera,
Hematologica201312027%≥10%≥50%yesyesPerry
AM,
bjh,
201431127%>50%>30%yesyesAlthoughR-CHOPgivespooroutcomes
fordouble-hitlymphomas,onlypreliminaryresultshavesuggested
betterresultswithmoreintensiveregimens,andclinical
trialsarerequiredinthissubtype.
Tilly
H,
et
al.
Ann
Oncol,2015,
26
(Suppl
5):
v116-125.Definition
of
HGBL
in
2016
WHO
ClassificationSwerdlow
SH,
et
al.
Blood.2016,
127(20):
2375-2390OutcomesDifferwithDifferentDiseaseLocationsIELSG-INTERNATIONALEXTRANODALLYMPHOMASTUDY
GROUPNeedtoFocusonDifferentPathologySubtypesSwerdlow
SH,
et
al.
Blood.2016,
127(20):
2375-2390Recommended
Treatment
Strategies
for
DLBCL
in
ESMO
GuidelinesTilly
H,
et
al.
Ann
Oncol.
2015,
26
(Suppl
5):
v116-125HaiounC,
et
al.
Blood.2005;106(4):1376-81.DupuisJ,
et
al.
AnnOncol2009;20:503-507.InterimPETisaPowerfulTooltoPr
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