Bone marrow biopsy superiority over PET/CT in predicting progression‐free survival in a homogeneously‐treated cohort of diffuse large B‐cell lymphoma

Abstract

Several studies have reported uneven results when evaluating the prognostic value of bone marrow biopsy (BMB) and PET/CT as part of the staging of diffuse large B‐cell lymphoma (DLBCL). The heterogeneity of the inclusion criteria and not taking into account selection and collinearity biases in the analysis models might explain part of these discrepancies. To address this issue we have carried a retrospective multicenter study including 268 DLBCL patients with a BMB and a PET/CT available at diagnosis where we estimated both the prognosis impact and the diagnostic accuracy of each technique. Only patients treated with R‐CHOP/21 as first line (n = 203) were included in the survival analysis. With a median follow‐up of 25 months the estimated 3‐year progression‐free survival (PFS) and overall survival (OS) were 76.3% and 82.7% respectively. In a multivariate analysis designed to avoid a collinearity bias with IPI categories, BMB‐BMI [bone marrow involvement](+) (HR: 3.6) and ECOG PS > 1 (HR: 2.9) were independently associated with a shorter PFS and three factors, age >60 years old (HR: 2.4), ECOG PS >1 (HR: 2.4), and abnormally elevated B2‐microglobulin levels (HR: 2.2) were independently associated with a shorter OS. In our DLBCL cohort, treated with a uniform first‐line chemotherapy regimen, BMI by BMB complemented performance status in predicting those patients with a higher risk for relapse or progression. In this cohort BMI by PET/CT could not independently predict a shorter PFS and/or OS.

Prognostic Value of Bone Marrow FDG Uptake Pattern of PET/CT in Newly Diagnosed Diffuse Large B-cell Lymphoma

“…To sum up, the focal pattern of BM is of better prognostic value than BMB. Unlike Chen-Liang 's and Khan's results, we didn't obtain the result that BMB was independently predictive for PFS and OS 14 , 19 . We found the BMB+ rate in our study and previous studies differed in a considerable disparity, ranging from 6.0% to16.4% 2 , 24 .…”

“…The finding of dPET+ of BM is not rare in DLBCL. In some studies, this kind of BM pattern was interpreted negative for BMI 2 , while some other researchers considered it as positive 11 , 19 , 20 . The disagreement on the interpretation made it difficult to accurately assess the value of dPET+ in DLBCL.…”

“…The prognostic value of BMI based on FDG PET/CT is still not demonstrated clearly. Some studies indicated the excellent prognostic value of PET-BMI in DLBCL patients 2 , 11 , 13 , 22 , while some studies drew the opposite conclusion 14 , 19 , 20 . In their studies, the diffuse BM pattern was interpreted differently, thus more or less leading to different conclusions.…”

The Role of Integrated Positron Emission Tomography/Computed Tomography (PET/CT) and Bone Marrow Examination in Staging Large B-Cell Lymphoma

“…Other studies confirm this prognostic impact 11,12 although for those patients who are stage IV by criteria other than BMI it seems that PET/CT-defined BM involvement loses its prognostic impact while BMB-defined BM involvement still predicts a worse outcome. 13,14 In this study, diffuse BM change on PET/CT was not deemed to indicate BM involvement, as per the predetermined methodology. None of the patients with a diffuse increase in BM uptake of FDG had a positive BMB.…”

Bone marrow infiltration by flow cytometry at diffuse large B‐cell lymphoma NOS diagnosis implies worse prognosis without considering bone marrow histology

“…Recent reported recommendations about staging and response assessment in lymphomas (Cheson et al, 2014) indicate that morphologic examination of the BM trephine biopsy (BMB) in patients with DLBCL is only needed when BM infiltration is negative by positron emission tomography (PET) and the identification of occult discordant histology is clinically important. Nevertheless, recent publications have reported that BMB offer different and complementary clinical information in DLBCL patients (Adams & Kwee, 2015;Adams & Kwee, 2017;Avigdor, 2013;Chen-Liang et al, 2017).…”