Diffuse large B-cell lymphoma in very elderly patients: Towards best tailored treatment – A systematic review

Tavares, A.; Moreira, Ilídia

doi:10.1016/j.critrevonc.2021.103294

Cited by 10 publications

(11 citation statements)

References 53 publications

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“…Although the initial management of DLBCL in older adults (aged ≥ 60 years) still remains centered on the R-CHOP-21, an appreciable portion of cases will not be candidates for this regimen due to very old age, poor performance status, or due to severe and limiting comorbidities [3,4,18,27]. Therefore, the primary treatment of DLBCL in old and very old adults is challenging, and to determine the better up-front therapeutic modality, we must weigh the biological aggressiveness of the neoplasm, its high curative potential, and the geriatric vulnerability presented by this population [27].…”

Section: Discussionmentioning

confidence: 99%

“…The overall mortality rate (OMR) during all follow-up was 52.4% (97), with disease progression as the main cause of death (56; 57.7%). The early mortality rate (EMR), characterized as the percentage of deaths during the first 100 days after the DLBCL diagnosis, was 9.7% (18), occurring mainly due to infectious complications (10; 55.6%).…”

Section: Clinical Epidemiological Laboratorial and Histopathological ...mentioning

confidence: 99%

“…on D1, and prednisone 40 mg/sqm P.O. on days 1 to 5), R-GEMOX (rituximab, gemcitabine, and oxaliplatin), R-CEOP (rituximab, cyclophosphamide, etoposide, vincristine, and prednisone), R-COMP (rituximab, cyclophosphamide, non-pegylated liposomal doxorubicin, vinblastine, and prednisone), R-GCVP (rituximab, gemcitabine, cyclophosphamide, vincristine, and prednisone), R-CEPP (rituximab, cyclophosphamide, etoposide, procarbazine, and prednisone), and BR (bendamustine plus rituximab) [12,18,19]. Although potentially curable, such attenuated immunochemotherapeutic regimens offer decreased responses and poorer outcomes when compared to the conventional R-CHOP-21.…”

Section: Introductionmentioning

confidence: 99%

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Predictors of Survival, Treatment Modalities, and Clinical Outcomes of Diffuse Large B-Cell Lymphoma in Patients Older Than 70 Years Still an Unmet Medical Need in 2024 Based on Real-World Evidence

de Pádua Covas Lage,

De Vita,

de Oliveira Alves

et al. 2024

Cancers

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Background: Diffuse large B-cell lymphoma (DLBCL) especially affects the older population. Old (≥60 years) and very old age (≥80 years) DLBCL patients often present high-risk molecular alterations, lower tolerability to conventional immunochemotherapy, and poor clinical outcomes. In this scenario, attenuated therapeutic strategies, such as the R-MiniCHOP and R-MiniCHOP of the elderly regimens, have emerged for this particularly fragile population. However, the responses, clinical outcomes, and toxicities of these regimens currently remain poorly understood, mainly because these individuals are not usually included in controlled clinical trials. Methods: This retrospective, observational, and single-center real-world study included 185 DLBCL, NOS patients older than 70 years treated at the largest oncology center in Latin America from 2009 to 2020. We aimed to assess the outcomes, determine survival predictors, and compare responses and toxicities between three different primary therapeutic strategies, including the conventional R-CHOP regimen and the attenuated R-MiniCHOP and R-MiniCHOP of the elderly protocols. Results: The median age at diagnosis was 75 years (70–97 years), and 58.9% were female. Comorbidities were prevalent, including 19.5% with immobility, 28.1% with malnutrition, and 24.8% with polypharmacy. Advanced clinical stage was observed in 72.4%, 48.6% had bulky disease ≥7 cm, 63.2% had B-symptoms, and 67.0% presented intermediate–high/high-risk IPI. With a median follow-up of 6.3 years, the estimated 5-year OS and PFS were 50.2% and 44.6%, respectively. The R-MiniCHOP of the elderly regimen had a lower ORR (p = 0.040); however, patients in this group had higher rates of unfavorable clinical and laboratory findings, including hypoalbuminemia (p = 0.001), IPI ≥ 3 (p = 0.013), and NCCN-IPI ≥ 3 (p = 0.002). Although associated with higher rates of severe neutropenia (p = 0.003), the R-CHOP regimen promoted increased OS (p = 0.003) and PFS (p = 0.005) in comparison to the attenuated protocols. Additionally, age ≥ 75 years, high levels of LDH, B-symptoms, advanced clinical stage (III/IV), neutrophilia, and low lymphocyte/monocyte ratio were identified as poor prognostic factors in this cohort. Conclusions: In this large and real-life Latin American cohort, we demonstrated that patients with DLBCL, NOS older than 70 years still do not have satisfactory clinical outcomes in 2024, with half of cases not reaching 5 years of life expectancy after diagnosis. Although the conventional R-CHOP offers response and survival advantages over attenuated regimens, its myelotoxicity is not negligible. Therefore, the outcomes reported and the prognostic factors here identified may assist clinicians in the appropriate selection of therapeutic strategies adapted to the risk for old and very old DLBCL patients.

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Section: Discussionmentioning

confidence: 99%

Section: Clinical Epidemiological Laboratorial and Histopathological ...mentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Predictors of Survival, Treatment Modalities, and Clinical Outcomes of Diffuse Large B-Cell Lymphoma in Patients Older Than 70 Years Still an Unmet Medical Need in 2024 Based on Real-World Evidence

de Pádua Covas Lage,

De Vita,

de Oliveira Alves

et al. 2024

Cancers

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“…It is estimated that approximately 30% of people with DLBCL are at least 75 years of age, yet therapeutic trials for DLBCL rarely include octogenarians [ 28 ]. The few studies that do include Merli et al, Olivieri et al, and Spina et al, which focus on dependence in geriatric criteria [ 29 , 30 , 31 ].…”

Section: Discussionmentioning

confidence: 99%

Prescription of Blood Lymphocyte Immunophenotyping in the Diagnosis of Lymphoid Neoplasms in Older Adults

Vovelle¹,

Row

Larosa³

et al. 2022

JCM

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Lymphoid neoplasms are a heterogeneous group of lymphoid neoplastic diseases with multiple presentations, and varying prognoses. They are especially frequent in older patients (OPs) and the atypism of this frail elderly population can make the diagnostic process even more difficult. Blood lymphocyte immunophenotyping (BLI) is essential in rapid noninvasive diagnosis orientation and guides complementary investigations. To our knowledge, BLI prescription has never been evaluated in OPs. We hypothesized that, when there is a suspicion of lymphoid neoplasm in the geriatric population, a BLI is performed in view of various clinical or biological abnormalities. This study aimed to: (1) describe the characteristics of hospitalized OPs having undergone BLI for suspected lymphoid neoplasm, (2) identify the causes leading to BLI prescription, and (3) identify the most profitable criteria for BLI prescription. This was a descriptive retrospective study on 151 OPs aged ≥75 years who underwent BLI over a 2-year period. Regarding BLI prescriptions, eight had lymphocytosis, constituting the “lymphocytosis group” (LG+), while the 143 others had BLI prescribed for reasons other than lymphocytosis (LG−), mainly general weakness and anemia. In the LG−, we compared OPs with positive and negative BLI results. The criteria found to be profitable for BLI prescription were lymphadenopathy, splenomegaly, lymphocytosis, and thrombocytopenia. BLI identified circulating lymphoid neoplasms (positive BLI) in 21/151 OPs, mainly marginal zone lymphoma and chronic lymphocytic leukemia. In polymorbid OPs, as per our study population, the diagnostic and therapeutic complexity explained in part the sole use of indirect and minimally invasive diagnostic techniques such as BLI.

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“…As seen in the references above, the majority of data come from patients with more frequent aggressive lymphomas—i.e., diffuse large B-cell lymphoma (DLBCL), commonly treated with the CHOP-R regimen [ 27 ]. Currently, we are witnessing a positive trend in successful treatment of older patients with aggressive lymphoma, as shown by a meta-analysis conducted by Tavares et al [ 28 ]. In this particular analysis, however, only 3 out of 38 studies involving very elderly patients (age ≥ 80) with DLBCL focused on cGA.…”

Section: Geriatric Approach To Aggressive Lymphomasmentioning

confidence: 99%

Clinical Dilemmas in the Treatment of Elderly Patients Suffering from Hodgkin Lymphoma: A Review

et al. 2022

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Elderly patients make up a significant number of cases of newly diagnosed Hodgkin lymphoma. However, unlike in young patients, the outcomes of elderly patients are poor, and they are under-represented in phase III trials. Prior to treatment initiation, geriatric assessment should ideally be performed to address the patient’s fitness and decide whether to pursue a curative or palliative approach. The ABVD regimen is poorly tolerated in unfit patients, with high treatment-related mortality. Alternative chemotherapy approaches have been explored, with mixed results obtained concerning their feasibility and toxicity in phase II trials. The introduction of brentuximab vedotin-based regimens led to a paradigm shift in first- and further-line treatment of elderly Hodgkin lymphoma patients, providing adequate disease control within a broader patient population. As far as checkpoint inhibitors are concerned, we are only just beginning to understand the role in the treatment of this population. In relapsed/refractory settings there are few options, ranging from autologous stem cell transplantation in selected patients to pembrolizumab, but unfortunately, palliative care is the most common modality. Importantly, published studies are frequently burdened with numerous biases (such as low numbers of patients, selection bias and lack of geriatric assessment), leading to low level of evidence. Furthermore, there are few ongoing studies on this topic. Thus, elderly Hodgkin lymphoma patients are hard to treat and represent an unmet need in hematologic oncology. In conclusion, treatment needs to be personalized and tailored on a case-by-case basis. In this article, we outline treatment options for elderly Hodgkin lymphoma patients.

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Diffuse large B-cell lymphoma in very elderly patients: Towards best tailored treatment – A systematic review

Cited by 10 publications

References 53 publications

Predictors of Survival, Treatment Modalities, and Clinical Outcomes of Diffuse Large B-Cell Lymphoma in Patients Older Than 70 Years Still an Unmet Medical Need in 2024 Based on Real-World Evidence

Predictors of Survival, Treatment Modalities, and Clinical Outcomes of Diffuse Large B-Cell Lymphoma in Patients Older Than 70 Years Still an Unmet Medical Need in 2024 Based on Real-World Evidence

Prescription of Blood Lymphocyte Immunophenotyping in the Diagnosis of Lymphoid Neoplasms in Older Adults

Clinical Dilemmas in the Treatment of Elderly Patients Suffering from Hodgkin Lymphoma: A Review

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