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Author: This article is the author's permission Chunlan Qiugui NMT Medical publish, please do not reprint without authorization.
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of B-cell non-Hodgkin's lymphoma (B-NHL) and is a type of aggressive lymphoma.
The overall prognosis of DLBCL patients who have failed the first-line standard immunochemotherapy regimen (R-CHOP: rituximab, cyclophosphamide, vincristine, doxorubicin, prednisone) is poor, especially those first-line or subsequent Intractable patients during treatment.
Therefore, it is particularly important to improve the cure rate of newly diagnosed DLBCL.
Adequate evaluation of newly diagnosed patients in clinical work helps clinical decision-making, thereby improving the overall prognosis of DLBCL patients.
This article summarizes the factors that need to be clarified before DLBCL treatment and the methods of efficacy evaluation for the reference of the majority of colleagues.
The staging of DLBCL At present, the staging standard of DLBCL is Lugano's modified Ann Arbor staging system in 2014 [1], see Table 1 for details.
Although the lymphoma staging system has been modified by Lugano, there are still some unresolved problems, such as mediastinal mass involving the pericardium, lungs, pleura, and even the sternum, chest wall, or accompanied by pericardial or pleural effusion, it is still considered local Invasion rather than stage IV; whether the serosal effusion or serous cavity effusion is extranodal involvement is controversial.
In addition, for the judgment of central nervous system (CNS) involvement, it is necessary to perform imaging examinations such as CT, MRI, and cerebrospinal fluid examination to assist the diagnosis based on clinical symptoms.
Due to its high sensitivity, PET/CT has replaced CT in the staging of DLBCL patients in recent years.
If the patient's PET/CT examination reveals that the bone marrow is not involved, then routine bone marrow aspiration biopsy is not required.
Table 1 Ann Arbor staging system Remarks: Symptom B: fever of unknown origin (above 38°C); weight loss (weight loss of more than 10% within 6 months); night sweats.
Extranodal organs: organs and tissues except lymph nodes, spleen, thymus, tonsil ring, appendix and Peyer lymph nodes.
Extranodal lesions are classified as stage IV and include invasion of bone marrow, lung, bone, or liver.
The prognostic factors of DLBCL The International Prognostic Index (IPI) is still the current stratification system used to predict the prognosis of DLBCL patients.
It is also the main clinical tool for stratifying DLBCL patients in clinical trials.
IPI has been proved to still have the value of judging the prognosis of DLBCL in the current era of immunochemotherapy.
In addition, the National Comprehensive Cancer Network IPI (NCCN-IPI) has better stratified patients with high-risk DLBCL [2] (Table 2).
However, these prognostic systems that integrate DLBCL clinical indicators cannot be used to distinguish the biological heterogeneity of DLBCL.
Studies have confirmed that many biological factors are related to the prognosis of DLBCL [3], but they have not been integrated into a validated prognostic system.
In addition, the total metabolic tumor volume (TMV), the parameter of PET/CT examination at the time of diagnosis, may also affect the patient's prognosis.
Bone marrow involvement (present in 15%-20% of patients) also indicates a poor prognosis.
Table 2 Commonly used prognostic stratification system of DLBCL Remarks: IPI: International Prognostic Index; PFS: Progression-Free Survival; OS: Overall Survival; LDH: Lactate Dehydrogenase; ULN: Upper Limit of Normal; ECOG Score: Eastern Tumor Cooperation Group Score ; CNS: Central Nervous System.
Efficacy evaluation of DLBCL At present, PET/CT examination has been widely used in DLBCL patients.
It is recommended to use PET/CT for better staging before DLBCL treatment, and use PET/CT for more accurate assessment of treatment response in the middle of treatment and after treatment. And according to the PET/CT Deauville five-point scale for efficacy evaluation [4], with the mediastinum and liver blood pool SUV as the reference point, a score of 1 or 2 indicates complete metabolic remission (CMR), 3 is also possible Represents CMR.
With the widespread application of PET-CT in lymphoma, in 2007, Professor Cheson proposed a modified Chenson efficacy evaluation standard; in 2014, the 11th International Lymphoma Conference determined the revised Lugano efficacy evaluation standard for lymphoma[4] .
At present, domestic and foreign guidelines recommend the above criteria for the evaluation of the efficacy of DLBCL patients, as shown in Table 3.
Table 3 Remarks on DLBCL Efficacy Evaluation Criteria: Regarding the selection of measurable dominant lesions when using CT for efficacy evaluation, a maximum of 6 lymph nodes or extranodal lesions with the largest diameter can be selected, and the longest transverse diameter of each lesion (LDi ) And the shortest path perpendicular to LDi (SDi); lymph nodes are best from different areas of the body.
If mediastinal and retroperitoneal lymph nodes are enlarged, these lesions should be included; extranodal lesions include solid organs (such as liver, spleen, kidney) , Lungs, etc.
), gastrointestinal tract, skin or marked parts that can be palpated.
In addition, the PET/CT assessment results of DLBCL patients after 2 to 4 cycles of treatment may affect the patient's prognosis.
However, the results of related studies have failed to show that guiding follow-up treatment based on only mid-term PET/CT results can change the treatment outcome.
Therefore, it is not recommended to guide the follow-up treatment of DLBCL based on the results of mid-term PET/CT evaluation outside of clinical trials.
After the end of treatment, patients should undergo clinical monitoring every 3 months for 2 years, and then every 6 to 12 months.
The life expectancy of patients who remain event-free for 2 years from the date of diagnosis is almost similar to that of the age-matched general population.
It is worth noting that clinicians should monitor patients for long-term complications after treatment, including advanced infections, autoimmune diseases, secondary tumors, and cardiovascular events.
Reference 1.
Cheson BD, Fisher RI, Barrington SF, et al.
Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification.
J Clin Oncol 2014;32:3059-68.
2.
Ruppert AS, Dixon JG, Salles G, et al.
International prognostic indices in diffuse large B-cell lymphoma: a comparison of IPI, R-IPI, and NCCN-IPI.
Blood 2020;135:2041-8.
3.
Laurie H.
Sehn, and Gilles Salles.
Diffuse Large B-Cell Lymphoma.
N Engl J Med 2021;384:842-58.
4.
Barrington SF, Mikhaeel NG, Kostakoglu L, et al.
Role of imaging in the staging and response assessment of lymphoma:consensus of the International Conference on Malignant Lymphomas Imaging Working Group.
J Clin Oncolo 2014;32:3048-58.
Stamp "read the original text", we make progress together
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of B-cell non-Hodgkin's lymphoma (B-NHL) and is a type of aggressive lymphoma.
The overall prognosis of DLBCL patients who have failed the first-line standard immunochemotherapy regimen (R-CHOP: rituximab, cyclophosphamide, vincristine, doxorubicin, prednisone) is poor, especially those first-line or subsequent Intractable patients during treatment.
Therefore, it is particularly important to improve the cure rate of newly diagnosed DLBCL.
Adequate evaluation of newly diagnosed patients in clinical work helps clinical decision-making, thereby improving the overall prognosis of DLBCL patients.
This article summarizes the factors that need to be clarified before DLBCL treatment and the methods of efficacy evaluation for the reference of the majority of colleagues.
The staging of DLBCL At present, the staging standard of DLBCL is Lugano's modified Ann Arbor staging system in 2014 [1], see Table 1 for details.
Although the lymphoma staging system has been modified by Lugano, there are still some unresolved problems, such as mediastinal mass involving the pericardium, lungs, pleura, and even the sternum, chest wall, or accompanied by pericardial or pleural effusion, it is still considered local Invasion rather than stage IV; whether the serosal effusion or serous cavity effusion is extranodal involvement is controversial.
In addition, for the judgment of central nervous system (CNS) involvement, it is necessary to perform imaging examinations such as CT, MRI, and cerebrospinal fluid examination to assist the diagnosis based on clinical symptoms.
Due to its high sensitivity, PET/CT has replaced CT in the staging of DLBCL patients in recent years.
If the patient's PET/CT examination reveals that the bone marrow is not involved, then routine bone marrow aspiration biopsy is not required.
Table 1 Ann Arbor staging system Remarks: Symptom B: fever of unknown origin (above 38°C); weight loss (weight loss of more than 10% within 6 months); night sweats.
Extranodal organs: organs and tissues except lymph nodes, spleen, thymus, tonsil ring, appendix and Peyer lymph nodes.
Extranodal lesions are classified as stage IV and include invasion of bone marrow, lung, bone, or liver.
The prognostic factors of DLBCL The International Prognostic Index (IPI) is still the current stratification system used to predict the prognosis of DLBCL patients.
It is also the main clinical tool for stratifying DLBCL patients in clinical trials.
IPI has been proved to still have the value of judging the prognosis of DLBCL in the current era of immunochemotherapy.
In addition, the National Comprehensive Cancer Network IPI (NCCN-IPI) has better stratified patients with high-risk DLBCL [2] (Table 2).
However, these prognostic systems that integrate DLBCL clinical indicators cannot be used to distinguish the biological heterogeneity of DLBCL.
Studies have confirmed that many biological factors are related to the prognosis of DLBCL [3], but they have not been integrated into a validated prognostic system.
In addition, the total metabolic tumor volume (TMV), the parameter of PET/CT examination at the time of diagnosis, may also affect the patient's prognosis.
Bone marrow involvement (present in 15%-20% of patients) also indicates a poor prognosis.
Table 2 Commonly used prognostic stratification system of DLBCL Remarks: IPI: International Prognostic Index; PFS: Progression-Free Survival; OS: Overall Survival; LDH: Lactate Dehydrogenase; ULN: Upper Limit of Normal; ECOG Score: Eastern Tumor Cooperation Group Score ; CNS: Central Nervous System.
Efficacy evaluation of DLBCL At present, PET/CT examination has been widely used in DLBCL patients.
It is recommended to use PET/CT for better staging before DLBCL treatment, and use PET/CT for more accurate assessment of treatment response in the middle of treatment and after treatment. And according to the PET/CT Deauville five-point scale for efficacy evaluation [4], with the mediastinum and liver blood pool SUV as the reference point, a score of 1 or 2 indicates complete metabolic remission (CMR), 3 is also possible Represents CMR.
With the widespread application of PET-CT in lymphoma, in 2007, Professor Cheson proposed a modified Chenson efficacy evaluation standard; in 2014, the 11th International Lymphoma Conference determined the revised Lugano efficacy evaluation standard for lymphoma[4] .
At present, domestic and foreign guidelines recommend the above criteria for the evaluation of the efficacy of DLBCL patients, as shown in Table 3.
Table 3 Remarks on DLBCL Efficacy Evaluation Criteria: Regarding the selection of measurable dominant lesions when using CT for efficacy evaluation, a maximum of 6 lymph nodes or extranodal lesions with the largest diameter can be selected, and the longest transverse diameter of each lesion (LDi ) And the shortest path perpendicular to LDi (SDi); lymph nodes are best from different areas of the body.
If mediastinal and retroperitoneal lymph nodes are enlarged, these lesions should be included; extranodal lesions include solid organs (such as liver, spleen, kidney) , Lungs, etc.
), gastrointestinal tract, skin or marked parts that can be palpated.
In addition, the PET/CT assessment results of DLBCL patients after 2 to 4 cycles of treatment may affect the patient's prognosis.
However, the results of related studies have failed to show that guiding follow-up treatment based on only mid-term PET/CT results can change the treatment outcome.
Therefore, it is not recommended to guide the follow-up treatment of DLBCL based on the results of mid-term PET/CT evaluation outside of clinical trials.
After the end of treatment, patients should undergo clinical monitoring every 3 months for 2 years, and then every 6 to 12 months.
The life expectancy of patients who remain event-free for 2 years from the date of diagnosis is almost similar to that of the age-matched general population.
It is worth noting that clinicians should monitor patients for long-term complications after treatment, including advanced infections, autoimmune diseases, secondary tumors, and cardiovascular events.
Reference 1.
Cheson BD, Fisher RI, Barrington SF, et al.
Recommendations for initial evaluation, staging, and response assessment of Hodgkin and non-Hodgkin lymphoma: the Lugano classification.
J Clin Oncol 2014;32:3059-68.
2.
Ruppert AS, Dixon JG, Salles G, et al.
International prognostic indices in diffuse large B-cell lymphoma: a comparison of IPI, R-IPI, and NCCN-IPI.
Blood 2020;135:2041-8.
3.
Laurie H.
Sehn, and Gilles Salles.
Diffuse Large B-Cell Lymphoma.
N Engl J Med 2021;384:842-58.
4.
Barrington SF, Mikhaeel NG, Kostakoglu L, et al.
Role of imaging in the staging and response assessment of lymphoma:consensus of the International Conference on Malignant Lymphomas Imaging Working Group.
J Clin Oncolo 2014;32:3048-58.
Stamp "read the original text", we make progress together
