What are the outcomes for B-cell lymphoma patients who receive salvage treatment for cancer that does not respond to R-CHOP chemotherapy?

This study compared the outcomes of different salvage treatments in patients with aggressive B-cell non-Hodgkin lymphoma with PET-positive disease (remaining cancer cells) after R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy. This study concluded that B-cell NHL patients with PET-positive disease after R-CHOP can be treated with radiotherapy.

For patients with aggressive B-cell non-Hodgkin’s lymphoma (NHL), R-CHOP chemotherapy is the current standard of first-line treatment. To evaluate the response of these patients to treatment, FDG-PET scanning is used. Compared to older imaging methods such as CT scanning, FDG-PET scanning more accurately visualizes cancer and predicts relapse. Important decisions to proceed with salvage treatment in these patients are based on this scanning.

After first-line R-CHOP chemotherapy, 12 – 40% of these patients tend to have a poor prognosis due to refractory (does not respond to treatment) disease. After receiving salvage therapy, about 50% of patients are long-term survivors. However, little data is available for the outcomes of these patients post-salvage therapy.

This study involved 26 patients with diffuse large B-cell lymphoma (DLBCL) or grade 3 follicular lymphoma (FLG3). 81% of patients had stage 3-4 disease. 92% of patients had bulky disease (large tumors 10 centimeters or more). 89% of patients had at least six cycles of R-CHOP chemotherapy, after which all patients had remaining cancer.

Salvage treatments included high-dose radiotherapy (RT) or high-dose chemotherapy followed by autologous stem cell transplant (ASCT). 65% of patients received high-dose RT and 15% received ASCT. 20% of patients received non-radical cancer management. This included observation, palliative chemotherapy or RT, or supportive care. The average follow-up period was 31 months.

For all patients, the progression-free survival (PFS; time from treatment before disease progression) rate at 3 years was 41% after salvage therapy. The overall survival (OS; time from treatment until death from any cause) rate at 3 years was 52%.

For each salvage treatment, the 3-year PFS rates were 51% (RT), 25% (ASCT), and 20% (non-radical). 3-year OS rates were 65% (RT), 25% (ASCT), and 40% (non-radical). Only the differences in PFS were statistically significant.

Overall, 58% of patients experienced progressive or recurrent disease despite salvage treatment. 47% of the RT patients relapsed. 75% of the ASCT patients relapsed. 80% of the non-radical treatment patients relapsed. 40% of these patients received a second salvage treatment, including RT (13%), ASCT (20%), and chemotherapy only (6.7%). Of those who received ASCT, 86% succumbed to their disease by the end of the study.

This study concluded that B-cell NHL patients with PET-positive disease after R-CHOP can be treated with radiotherapy.

This study was retrospective, meaning it looked back in time to analyze patient records. The sample size of this study was also quite small. Two patients were also excluded from the analysis, further shrinking the sample size. Salvage treatments were also specifically chosen for each patient, instead of being randomly assigned as in randomized clinical trials. Therefore, any conclusions comparing the salvage treatments are limited. Larger studies investigating different salvage treatments are needed to confirm these results.

If you have refractory aggressive B-cell non-Hodgkin’s lymphoma, talk to your care team about the potential benefits of salvage radiotherapy.