From the Journals

Upfront chemotherapy yields excellent survival in patients with MZLs



For patients with advanced or recurrent marginal zone lymphomas (MZL) typically treated with radiotherapy, antibiotics, single-agent therapy, or observation, upfront chemotherapy was associated with high rates of both failure-free and overall survival at 10 years.

A retrospective analysis of data on 44 patients with either extranodal MZL (MALT), splenic MZL (SMZL), or nodal MZL (NMZL) treated with either the standard of care (for early-stage MALT) or with chemotherapy plus rituximab (for patients with advanced MALT, SMZL, or NMZL) showed a projected 10-year failure-free survival rate of 80%, and an overall survival rate of 100%, reported José L. Ortega, MD, of the University of Puerto Rico in San Juan, and his colleagues (Clin Lymphoma Myeloma Leuk. 2017 Sep 23. pii: S2152-2650[17]30632-8. doi: 10.1016/j.clml.2017.09.014).

“Although the watch and wait modality is still the most-used strategy for patients with advanced MZLs, with chemotherapy traditionally reserved for relapsed or advanced symptomatic disease, our data suggest that upfront chemotherapy is very effective for patients with advanced MALT, SMZL, and NMZL. However, it was not possible to definitely exclude that a less-aggressive approach such as single-agent rituximab could yield similar results,” the investigators wrote.

The standard of care for patients with localized MALT has traditionally been either antibiotic therapy for gastric MALT, or radiotherapy when antibiotics are not feasible. There is no standard of care, however, for either SMZL or NMZL, which are typically managed with either observation or single-agent rituximab, the investigators stated.

To see whether upfront chemotherapy with either FND-R (fludarabine, mitoxantrone, dexamethasone, and rituximab) or CHOP-R (cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab) could improve outcomes in patients with advanced or recurrent MZLs, the investigators conducted a retrospective study of outcomes for 44 patients treated at their institution.

Group 1 comprised 22 patients with early-stage MALT treated with either radiotherapy or antibiotics, with or without surgery. Group 2 comprised 9 patients with advanced MALT, 9 with SMZL, and 4 with NMZL. Patients in this group underwent upfront chemotherapy with either FND-R (14 patients) or CHOP-R (8 patients). In addition, 16 patients in group 2 received maintenance rituximab.

All patients in each group had complete remissions. Two patients in group 1 had relapses (one at 70 months and one at 75 months) of stage I MALT that had previously been treated with radiotherapy. Both patients underwent salvage FND-R, and remained disease free at 27 and 39 months after relapse. There were no relapses in group 2.

The investigators deemed long-term toxicities to be “acceptable,” with most adverse effects in group 2 being hematologic in origin, including grade 3 or 4 neutropenia in 70%, thrombocytopenia in 22%, and anemia in 17%. Nonhematologic adverse events were mostly grade 1 or 2. There were no second malignancies reported at the most recent follow-up.

The investigators noted that the high complete remission rate and durable remissions with FND-R suggest that it has excellent activity against MZL, and that the long failure-free survival suggests the possibility of cure. They acknowledged, however, that their impressions were based on retrospective data and a small sample size, and that larger clinical trials are needed to confirm their results.

The investigators reported having no conflicts of interest.

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