Search

Objectives Gastric mucosa-associated lymphoid tissue (MALT) lymphoma is historically associated with Helicobacter pylori (HP) infections in more than 80% of patients. However, the incidence of HP-negative MALT lymphoma has been increasing. The clinicopathologic features have not been well studied, and optimal management strategies remain unclear. Methods The pathology database was searched for primary gastric MALT lymphomas diagnosed from 2000 to 2017. The clinical data and the slides were reviewed. The cases were divided for analysis into those with a background of chronic gastritis with HP, chronic gastritis without HP, and without either a background of chronic gastritis or HP. Results Of 70 gastric MALT lymphoma cases identified, 26 (37% of total) had chronic gastritis and were positive for HP histologically (n = 23) or were HP positive by additional laboratory testing (n = 3). The remaining 44 (63% of total) cases were HP negative by histology. Within the HP-negative cases, 5 (11% of HP-negative cases) showed histologic gastritis while 39 (89% of HP-negative cases) did not have sufficient evidence of gastritis through review of slides (n = 18) or based on available pathology reports (n = 21). The HP-negative cases without gastritis had higher propensities to show a mass lesion on endoscopy compared with HP-positive cases (37.5% vs 11.1%, P =.02) at the initial diagnosis. The immunophenotype and rate of positive B-cell gene rearrangement were not significantly different between the 2 groups. While all HP-positive patients received antibiotics for HP eradication, treatment in the HP-negative group varied among antibiotics, radiation, rituximab, or chemotherapy. Among HP-negative patients with available follow-up, 13 (39%) showed disease recurrence, similar to the recurrence rate in HP-positive patients; however, no individual from either group has died of the disease thus far. Conclusions The incidence of HP-negative MALT lymphoma is increasing, and in our practice, it is currently more common than HP-associated MALT lymphomas. The pathophysiology of HP-negative MALT lymphoma without chronic gastritis remains unclear. Follow-up data in our study suggest that the prognosis of these cases is excellent despite varied management modalities. [ABSTRACT FROM AUTHOR]

Most patients with diffuse large B‐cell lymphoma (DLBCL) are diagnosed at age 60 years or older. Challenges to effective therapy among older individuals include unfavorable biologic features of DLBCL, geriatric vulnerabilities, suboptimal treatment selection, and toxicities of cytotoxic chemotherapy. Wider application of geriatric assessments may help identify fit older patients who benefit from standard immunochemotherapy without unnecessary dose reductions. Conversely, attenuated regimens may provide a better balance of risk and benefit for selected unfit or frail patients. Supportive care with the use of corticosteroid‐based prephase, prophylactic growth factors, and early institution of supportive and palliative care can help maximize treatment tolerance. Several novel or emerging therapies have demonstrated favorable toxicity profiles, thus facilitating effective treatment for elderly patients. In the relapsed or refractory setting, patients who are not candidates for stem cell transplantation can benefit from newly approved options including polatuzumab vedotin‐based combinations or tafasitamab plus lenalidomide, which may have higher efficacy and/or lower toxicity than historical chemotherapy regimens. Chimeric antigen receptor T‐cell therapy has been successfully applied to older patients outside of clinical trials. In the first‐line setting, emerging immunotherapy options (bispecific antibodies) and targeted therapies (anti‐CD20 antibodies combined with lenalidomide and/or B‐cell receptor inhibitors) may provide chemotherapy‐free approaches for DLBCL. Enrolling older patients in clinical trials will be paramount to fully examine potential efficacy and toxicity of these strategies. In this review, we discuss recent advances in fitness stratification and therapy that have expanded curative options for older patients, as well as future opportunities to improve outcomes in this population. Implications for Practice: Management of diffuse large B‐cell lymphoma in older patients poses challenges due to aggressive disease biology and geriatric vulnerability. Although R‐CHOP remains standard first‐line treatment, geriatric assessment may help evaluate patients' fitness for immunochemotherapy. Corticosteroid prephase, prophylactic growth factors, and early palliative care can improve tolerance of treatment. Novel salvage options (polatuzumab vedotin‐based combinations, tafasitamab plus lenalidomide) or chimeric antigen receptor T‐cell therapy should be considered in the relapsed or refractory setting for patients ineligible for stem cell transplantation. Emerging immunotherapies (bispecific antibodies) and targeted therapies provide potential first‐line chemotherapy‐free approaches, which need to be rigorously assessed in clinical trials that involve geriatric patients. Diffuse large B‐cell lymphoma (DLBCL) is an aggressive but potentially curable cancer that mainly affects older individuals. This review presents recent advances in fitness stratification and therapy that have expanded curative options for older patients with DLBCL and future opportunities to improve outcomes in this population. [ABSTRACT FROM AUTHOR]

Background: Although classical Hodgkin lymphoma (cHL) is highly curable, 20%–30% of patients will not be cured with conventional treatments. The programmed death‐1 (PD‐1) inhibitors (PD‐1i) nivolumab and pembrolizumab have been Food and Drug Administration‐approved for relapsed/refractory (R/R) cHL. There is limited data on the real‐world experience with PD‐1i in cHL and it is unknown whether fewer selected patients treated with PD‐1i derive benefits similar to those observed in published trials. Materials and Methods: We performed a multicenter, retrospective analysis of R/R cHL patients treated with PD‐1i in the nontrial setting. The primary objective was to describe progression‐free survival (PFS) and overall survival (OS) in this population. Secondary objectives were to characterize response rates, toxicities, discontinuation patterns, and post‐PD‐1i therapies. Results: The study included 53 patients from nine U.S. centers. Overall response rate (ORR), complete response (CR), and partial response (PR) to PD‐1i were 68%, 45%, and 23%, respectively. Twelve‐month OS and PFS were 89% and 75%, respectively; median PFS was 29 months. Ninety‐six percent of patients with CR continue to respond at a median follow‐up of 20 months. Toxicities were similar to those previously described. Seventy percent of patients treated with systemic therapy after PD‐1i demonstrated objective responses. Conclusion: To our knowledge, this analysis is the first describing real‐world experience with PD‐1i in cHL patients in the U.S. Here, we demonstrate similar response rates compared to prior studies. The toxicity profile of PD‐1i was similar to that seen in previous studies; we further describe toxicity patterns in those with prior autoimmune disease or allogeneic transplant. Post‐PD‐1i systemic therapies appear active. These results support the effectiveness and tolerability of PD‐1i therapy in R/R cHL in a real‐world setting. Implications for Practice: Two PD‐1 inhibitors have recently been approved for patients with relapsed/refractory classical Hodgkin lymphoma based on results from nonrandomized clinical trials. However, to date, there have been no studies evaluating the effectiveness and toxicity profile of these drugs in the real‐world setting in the U.S. The present study demonstrates that patients treated in a real‐world context experience similar rates of overall effectiveness compared with published clinical trials. Patients who discontinue PD‐1 inhibitors may experience clinical responses to subsequent treatment with systemic chemotherapy or targeted therapy. This study provides clinicians with further insight into the effectiveness and tolerability of PD‐1 inhibitors and suggests that when patients progress while on these drugs, conventional systemic chemotherapy may be an effective treatment option. Until now, no studies have evaluated the effectiveness of PD‐1 inhibitors in classical Hodgkin lymphoma in a real‐world context (outside the context of study protocols). This article reports on clinical response to PD‐1 inhibitors, progression‐free and overall survival, and the prevalence and management of immune‐related adverse events in a population of patients with relapsed or refractory Hodgkin lymphoma treated with PD‐1 inhibitors. [ABSTRACT FROM AUTHOR]

Physician ownership of imaging equipment has been shown to be associated with greater use of low-value imaging. However, it is unclear whether ownership also influences utilization of appropriate imaging. We conducted a cohort study of older adults diagnosed with three non-Hodgkin lymphomas with distinct guideline recommendations concerning the use of positron emission tomography (PET) during staging (recommended, not recommended, or equivocal). We found patients who were treated by oncologists with PET ownership were more likely to receive a staging PET regardless of lymphoma subtype. However, the difference in utilization by ownership status was smallest (6%, 95% confidence interval = 2% to 11%, P =.01) in the setting of diffuse large B cell lymphoma, where consensus guidelines recommend routine use of PET. Overall, removing financial incentives related to imaging self-referral may reduce utilization during cancer care, with the potential for greatest impact on imaging of equivocal or low clinical utility. [ABSTRACT FROM AUTHOR]