scholarly journals Impact of HIV Status on Treatment Choice and Outcomes of Primary Central Nervous System Lymphoma in a Minority Enriched Population: Experience from a Safety Net Hospital

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 14-15
Author(s):  
Jude Khatib ◽  
Hsiao Ching Li ◽  
Radhika Kainthla ◽  
Chul Ahn ◽  
Navid Sadeghi
Keyword(s):  
Overall Survival ◽  
Clinical Characteristics ◽  
Central Nervous System Lymphoma ◽  
Safety Net ◽  
Treatment Patterns ◽  
Line Treatment ◽  
First Line ◽  
Hiv Patients ◽  
Safety Net Hospital ◽  
Progression Of Disease

Background Primary central nervous system lymphoma (PCNSL) is a rare and aggressive form of non-Hodgkin lymphoma. High-dose methotrexate is the cornerstone of treatment for PCNSL, often in combination with other agents. Outcomes are poor with an estimated 5-year overall survival (OS) of 30-40%. Outcomes in AIDS-related PCNSL have been historically inferior to immunocompetent individuals, although recent data suggests some improvement with anti-retroviral therapy. We sought to evaluate clinical characteristics, treatment patterns, and outcomes of patients with PCNSL at our institution. Methods A total of 30 patients were diagnosed and treated for PCNSL at Parkland Health and Hospital System (Dallas, TX) between 2010 and 2019. Parkland is a safety net hospital for Dallas County and is affiliated with the University of Texas Southwestern Medical Center. Electronic records were reviewed and data on demographics, clinical characteristics, treatment patterns, and outcomes were extracted. Descriptive statistics and survival data, comparing HIV(-) and HIV(+) patients, are presented. Results Median age at diagnosis was 51 years (range 24-78). Two thirds of patients were male and 40% (12 patients) were HIV(+). HIV(+) patients were younger compared to HIV(-) with a median age of 40 vs 57 years. Seventy three percent of patients belonged to minority groups (40% Hispanic; 33% Black). First line treatment consisted of chemotherapy in 18 (60%), chemotherapy and radiation in 4 (13%), and radiation alone in 8 (27%) patients; the latter was primarily used in HIV(+) patients (58%; 7/12). The most common chemotherapy regimen was CALGB 50202.HIV(+) patients were also started on anti-retroviral therapy. Fifty percent of the patients had a complete response (CR) to first line therapy. Five patients with a partial response converted to a CR with additional treatment for a final CR rate of 67%. CR rate was higher in HIV(+) patients. Five patients (17%), all HIV(-), experienced progression of disease while on 1st line treatment. Patients with progression of disease on treatment had poor response to salvage therapy and short survival (median OS 49 days). The majority of the patients were not eligible for autologous stem cell transplant (A-SCT) due to financial constraints or comorbid conditions. Only one patient underwent consolidation A-SCT, after achieving a second CR. After a median follow up of 51 months, median OS was not reached. Three-year OS was 74% for the entire cohort. HIV(+) patients had a longer 3-yr OS compared to HIV(-) patients (91% vs 61%), this difference was statistically significant (p=0.034). Conclusion We report the outcome of PCNSL in a minority enriched population treated at a safety net hospital. Compared to prospective clinical trials, HIV(-) patients in our cohort had a lower than expected CR rate, although survival rates were comparable. In addition, we observed higher response rates and better overall survival in HIV(+) patients, including in those who were treated with combination of antiretroviral agents and radiation. Disclosures No relevant conflicts of interest to declare.

scholarly journals Primary Central Nervous System Lymphoma: A Real-World Comparison of Therapy Access and Outcomes by Hospital Setting

2022 ◽  
Author(s):  
Akshat Patel ◽  
Omer Ali ◽  
Radhika Kainthla ◽  
Syed M Rizvi ◽  
Farrukh T Awan ◽  
...  
Keyword(s):  
Public Safety ◽  
Care Delivery ◽  
Primary Cns Lymphoma ◽  
Hospital Setting ◽  
Central Nervous System Lymphoma ◽  
Safety Net ◽  
Treatment Patterns ◽  
Cancer Center ◽  
Survival Difference ◽  
Safety Net Hospital

Abstract Background This study analyzes sociodemographic barriers for primary CNS lymphoma (PCNSL) treatment and outcomes at a public safety-net hospital versus a private tertiary academic institution. We hypothesized that these barriers would lead to access disparities and poorer outcomes in the safety-net population. Methods We reviewed records of PCNSL patients from 2007-2020 (n = 95) at a public safety-net hospital (n = 33) and a private academic center (n = 62) staffed by the same university. Demographics, treatment patterns, and outcomes were analyzed. Results Patients at the safety-net hospital were significantly younger, more commonly Black or Hispanic, and had a higher prevalence of HIV/AIDS. They were significantly less likely to receive induction chemotherapy (67% vs 86%, p = 0.003) or consolidation autologous stem cell transplantation (0% vs. 44%, p = 0.001), but received more whole-brain radiation therapy (35% vs 15%, p = 0.001). Younger age and receiving any consolidation therapy were associated with improved progression-free (PFS, p = 0.001) and overall survival (OS, p = 0.001). Hospital location had no statistical impact on PFS (p = 0.725) or OS (p = 0.226) on an age-adjusted analysis. Conclusions Our study shows significant differences in treatment patterns for PCNSL between a public safety-net hospital and an academic cancer center. A significant survival difference was not demonstrated, which is likely multifactorial, but likely was positively impacted by the shared multidisciplinary care delivery between the institutions. As personalized therapies for PCNSL are being developed, equitable access including clinical trials should be advocated for resource-limited settings.

Retrospective Analysis of 41 Consecutive Patients with Non Gastrointestinal (GI) Extranodal Marginal Zone B-Cell Lymphoma (EMZL): Correlation of Clinical Characteristics and Outcome with Disease Localization.

Blood ◽  
2005 ◽  
Vol 106 (11) ◽  
pp. 4785-4785
Author(s):  
Christina Kalpadakis ◽  
Marina P. Siakantaris ◽  
Marie-Christine Kyrtsonis ◽  
Theodoros P. Vassilakopoulos ◽  
Tatiana Tzenou ◽  
...  
Keyword(s):  
Overall Survival ◽  
Clinical Characteristics ◽  
Marginal Zone ◽  
Advanced Stage ◽  
Line Treatment ◽  
First Line ◽  
Extranodal Site ◽  
Stage Disease ◽  
First Line Treatment

Abstract Extranodal marginal zone B-cell lymphomas of mucosa associated lymphoid tissue (MALT) are indolent lymphomas with specific clinical and pathologic features. MALT lymphomas can arise from any extranodal site. Non-gastrointestinal (non-GI) MALT lymphomas are rarer (<1% of NHL) and have been described in various sites (salivary glands, orbit, lung, skin etc). We retrospectively studied 41 patients with an initial diagnosis of EMZL according to the REAL/WHO classification criteria and presenting with a clinically dominant non-GI site of localization in order to evaluate the clinical characteristics of patients and to correlate disease localization with clinical behaviour, treatment and patient outcome. The studied population included 20 men and 21 women with a median age of 50 years (23–87). The most commonly affected sites were skin (13,32%), salivary glands (11%), followed by lung (7%), orbit (5%), oral cavity non salivary (4%), upper airway (1%) and thyroid (1%). The majority of patients (69%) presented in stage I. Advanced stage disease was due to bone marrow (12%) or/and lymph node involvement (12%), while in 4 patients there was more than one extranodal site involved. Autoimmune disorders were noticed in 7 patients, while monoclonal gamopathy in 5 (12%). Two patients presented B-symptoms (both with BALT ). Patiens with extranodal skin lymphoma (SALT) received treatment with interferon-α (54%), Mabthera iv or intralesionally (31%) or resection alone with a 100% CR rate. With a median follow up of 42 months no disease related death was noticed. Among 11 patients with salivary gland EMZL 5 had stage IV disease at presentation (45%). First line treatment was chlorombucil +/− Mabthera with a 90% CR rate. With a median follow up of 80 months two relapses in another MALT site (stomach) and one disease related death due to disease transformation were noticed. Patients with BALT lymphomas presented some specific clinical characteristics: There was a long time interval between onset of symptoms and diagnosis, B-symptoms were presented in 2 of 7 patients while most of them had symptoms from the respiratory system (cough, dyspnea, expectoration). 3 patients had advanced stage disease. First line treatment was chlorambucil +/− Mabthera +/− surgical excision with response rates of 70%. With a median follow up of 51 months two disease related death were noticed (one due to disease transformation). 4 of 5 patients with orbital MALT lymphoma received chlorambucil while one patient received radiotherapy alone. With a median follow up of 52 months one relapse to another extranodal site was noticed and no disease related death. In conclusion our data confirms the indolent behaviour of MALT lymphomas with a 5- and 10-year overall survival 82±8% and 65±13% respectively. The 5-year overall survival was 90% or more for each non-lung presentation vs 70% for BALT NHL. The optimal management of MALT lymphomas with regard to surgery, chemotherapy, immunotherapy and radiation therapy alone or in combination as well as abstention from therapy is not well defined. Additionally MALT lymphomas of various anatomic sites seem to present a clinical heterogeneity that may reflect heterogeneity at a molecular level.

Population Based Analysis of Outcomes of Primary Central Nervous System Lymphoma (PCNSL) Suggests a Treatment Strategy Including Intensive Chemotherapy with Autologous Stem Cell Transplantation Provides a Survival Advantage for Patients <65 Years of Age

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 2520-2520 ◽  
Author(s):  
Joanna Graczyk ◽  
Sunita Ghosh ◽  
Neil Chua ◽  
Douglas A. Stewart ◽  
Carolyn J. Owen
Keyword(s):  
Overall Survival ◽  
Central Nervous System Lymphoma ◽  
Median Number ◽  
High Dose ◽  
Primary Therapy ◽  
Line Treatment ◽  
First Line ◽  
First Remission ◽  
Number Of Cycles ◽  
First Line Treatment

Abstract Background: Primary central nervous system lymphoma (PCNL) is rare, associated with poor outcomes, and lacks widely accepted management guidelines. Prior to 2011, one Alberta tertiary cancer centre consolidated high dose methotrexate (HDM)-based induction with whole brain radiation therapy (WBRT), while the other utilized high dose cytarabine (HDAC) and then high dose therapy (HDT) with thiotepa, busulfan, cyclophosphamide and autologous stem cell transplant (ASCT), especially for patients <65 years of age. Since November 2011, both tertiary Alberta centres followed the same protocol incorporating high dose thiotepa and busulfan (without cyclophosphamide) and ASCT, but avoided WBRT. Methods: A retrospective analysis was conducted on all consecutive Alberta patients diagnosed with human immunodeficiency virus (HIV) negative PCNSL from 01/98-12/13 to evaluate patient characteristics and outcomes of treatment approaches used during this period. Results: Characteristics of the identified 107 PCNSL patients include: median age 61 years (33-86), 37% aged 65 years or older, 34% ECOG 3-4 performance status, 61% deep brain involvement, 22% elevated LDH, 9% immune suppressed. Overall, 60% of patients received HDM-based therapy, 29% received HDT and ASCT as part of primary therapy and 35% received WBRT as part of primary therapy (Figure 1). Of patients receiving HDM-based therapy, the median number of cycles of MTX was 4 with 45% of these patients receiving a dose of HDM ≥ 4g/m2. Where given, the median number of cycles of HDAC ≥ 2g/m2 was 2. The median follow up for surviving patients is 60.7 months (4.4 – 190.5 months). For all patients, 5 year overall survival (OS) was significantly improved with the use of HDT-ASCT (57.8% overall, 52.6% in first remission (PR1) and 66.7% at relapse) compared with HDM +/- WBRT (36.7%) or WBRT alone (15.5%) (p < 0.001) (Figure 2). Similarly, in all patients 5 year event free survival (EFS) was significantly improved with the use of HDT-ASCT in first remission (49.9%), compared with HDM-based therapy (29.9%) or WBRT alone (15.6%) (p<0.001). This was most notable in patients age < 65 years (N=67), where HDT-ASCT demonstrated improved 5 year OS (63.6% overall, 60.4% in PR1, 66.7% at relapse) compared with HDM-based therapy (34.5%) or WBRT alone (20.8%) (p<0.001) and in which HDT-ASCT in first remission showed superior 5 year EFS (57.5%) over combination HDM-based therapy (30.5%) and isolated WBRT (20.8%) (p<0.001). However, none of the 3 patients treated with HDT-ASCT over age 65 years achieved 5 year OS. This compares poorly with the 5 year OS rates of 60% for HDM-based therapy or 11.8% for WBRT alone in patients age ≥ 65 years (p 0.006). Factors independently associated with improved OS in multivariate analysis were: Age < 65y, ECOG 0-2, HDM, WBRT, HDT-ASCT. Of these factors, age <65 and HDT-ASCT were the only factors predictive of improved EFS. Thus far, 14 patients have been treated using the uniform Alberta treatment approach that was established in November 2011. These 14 patients achieved a 2 year EFS rate of 64.6% compared to the 45.1% 2 year EFS seen in the 93 historical patients treated in Alberta from 1998-2011. Of patients receiving HDT-ASCT in first remission, treatment related grade 3-4 toxicities were seen in 5 patients (16%) and treatment related mortality was 9.7% (3 infections) with all deaths occurring prior to 2011. The use of WBRT in combination with HDM and/or HDT-ASCT resulted in marked increases in neurotoxicity compared to treatments that avoided WBRT (OR 3.8, p 0.0093). Conclusion: HDT-ASCT is an effective first remission consolidation treatment for PCNSL and could be considered for all fit patients age < 65 years. Patients age ≥ 65 years with PCNSL should be offered HDM-based therapy without HDT-ASCT. WBRT also confers an OS advantage relative to palliation, but is associated with a significant increased risk of neurotoxicity with implications for impaired quality of life. Figure 1 First-line treatment received by patients with PCNSL diagnosed in Alberta from 1998-2013 Figure 1. First-line treatment received by patients with PCNSL diagnosed in Alberta from 1998-2013 Figure 2 Overall survival of all PCNSL patients diagnosed 1998-2013 in Alberta Figure 2. Overall survival of all PCNSL patients diagnosed 1998-2013 in Alberta Disclosures No relevant conflicts of interest to declare.

scholarly journals Primary Central Nervous System Lymphoma: A Real-World Comparison of Therapy Access and Outcomes by Hospital Setting

2021 ◽  
Author(s):  
Akshat Maneesh Patel ◽  
Omer Ali ◽  
Radhika Kainthla ◽  
Syed M. Rizvi ◽  
Farrukh T. Awan ◽  
...  
Keyword(s):  
Central Nervous System ◽  
Nervous System ◽  
Public Safety ◽  
Central Nervous System Lymphoma ◽  
Safety Net ◽  
Treatment Patterns ◽  
Survival Outcomes ◽  
Academic Center ◽  
Safety Net Hospital ◽  
To Receive

Abstract Purpose: Primary central nervous system lymphoma (PCNSL) is an aggressive disease with many tools for management that may be subject to resource barriers. This study compares the treatment patterns and survival outcomes among PCNSL patients treated at a safety-net hospital versus a tertiary academic institution.Methods:We retrospectively reviewed records of PCNSL patients from 2007-2020 (n = 95) at a public safety-net hospital (n = 33) and a private academic center (n = 62) staffed by the same university. Demographics, treatment patterns, and outcomes were analyzed.Results:Compared to the tertiary academic center, patients at the safety-net hospital were significantly younger, more commonly Black or Hispanic, and had a higher proportion of presenting patients with HIV. The safety-net hospital cohort was significantly less likely to receive induction chemotherapy (67% vs 86%, p = 0.003) than those at the academic center. Safety-net hospital patients were significantly less likely to receive autologous stem cell transplant (ASCT) consolidation (0% vs. 44%, p = 0.001) and had higher rates of consolidative WBRT (35% vs 15%, p = 0.001). Younger age and receiving consolidation were associated with improved progression-free survival (PFS, p = 0.001) and overall survival (OS, p = 0.001). Hospital location had no statistical effect on PFS (p = 0.725) or OS (p = 0.226) on age-adjusted analysis. Conclusions:Our study showed significant treatment differences between a public safety-net hospital and an academic cancer center reflecting access disparities. Despite variable treatment patterns, survival outcomes were not different. Further research is needed to determine optimal treatments for an orphan disease like PCNSL and it will be essential to advocate for equitable access in resource-limited settings.

scholarly journals Impact of insurance status on overall survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC)

2020 ◽  
Vol 5 (3) ◽  
Author(s):  
Ravi J. Chokshi ◽  
Jin K. Kim ◽  
Jimmy Patel ◽  
Joseph B. Oliver ◽  
Omar Mahmoud
Keyword(s):  
Overall Survival ◽  
Neoadjuvant Chemotherapy ◽  
Abdominal Wall ◽  
Intraperitoneal Chemotherapy ◽  
Hyperthermic Intraperitoneal Chemotherapy ◽  
Safety Net ◽  
Insurance Status ◽  
Gynecologic Malignancies ◽  
Safety Net Hospital ◽  
The Impact

AbstractObjectivesThe impact of insurance status on oncological outcome in patients undergoing cytoreduction and hyperthermic intraperitoneal chemotherapy (CRS-HIPEC) is poorly understood.MethodsRetrospective study on 31 patients having undergone 36 CRS-HIPEC at a single institution (safety-net hospital) between 2012 and 2018. Patients were categorized as insured or underinsured. Demographics and perioperative events were compared. Primary outcome was overall survival (OS).ResultsA total of 20 patients were underinsured and 11 were insured. There were less gynecologic malignancies in the underinsured (p=0.02). On univariate analysis, factors linked to poor survival included gastrointestinal (p=0.01) and gynecologic malignancies (p=0.046), treatment with neoadjuvant chemotherapy (p=0.03), CC1 (p=0.02), abdominal wall resection (p=0.01) and Clavien–Dindo 3-4 (p=0.01). Treatment with neoadjuvant chemotherapy and abdominal wall resections, but not insurance status, were independently associated with OS (p=0.01, p=0.02 respectively). However, at the end of follow-up, six patients were alive in the insured group vs. zero in the underinsured group.ConclusionsIn this small, exploratory study, there was no statistical difference in OS between insured and underinsured patients after CRS-HIPEC. However, long-term survivors were observed only in the insured group.

scholarly journals Comparison of dose-dense vs. 3-weekly paclitaxel and carboplatin in the first-line treatment of ovarian cancer in a propensity score-matched cohort

BMC Cancer ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Rafaela Pirolli ◽  
Viviane Teixeira Loiola de Alencar ◽  
Felipe Leonardo Estati ◽  
Adriana Regina Gonçalves Ribeiro ◽  
Daniella Yumi Tsuji Honda ◽  
...  
Keyword(s):  
Ovarian Cancer ◽  
Overall Survival ◽  
Propensity Score ◽  
Ovarian Carcinoma ◽  
Matched Cohort ◽  
Line Treatment ◽  
First Line ◽  
Western Population ◽  
Dose Dense ◽  
First Line Treatment

Abstract Background Benefit of carboplatin and dose-dense weekly paclitaxel (ddCT) in first line treatment of ovarian cancer patients has been different in Western and Asian studies. In the present study we compare progression-free survival (PFS) of ddCT to three-weekly carboplatin and paclitaxel (CT) in first-line treatment of ovarian carcinoma in a single institution in a Western population. Materials and methods We conducted a retrospective review of medical records from patients with ovarian carcinoma treated in a tertiary cancer center from 2007 to 2018. All patients treated with ddCT or CT in the first-line setting were included. Patients who received first-line bevacizumab were not included. PFS and overall survival (OS) were compared in a propensity score-matched cohort to address selection bias. Patients were matched according to age, ECOG performance status, CA 125, FIGO stage, residual disease, and histological subtype, in a 1:2 ratio. Results Five hundred eighty-eight patients were eligible for propensity score matching, the final cohort consisted of 69 patients treated with ddCT and 138 CT group. Baseline characteristics were well-balanced. After a median follow-up of 65.1 months, median PFS was 29.3 vs 20.0 months, favouring ddCT treatment (p = 0.035). In the multivariate cox regression ddCT showed a 18% lower risk of progression (HR 0.82, 95% CI 0.68–0.99, p = 0.04). Overall survival data is immature, but suggested better outcomes for ddCT (not reached versus 78.8 months; p = 0.07). Conclusion Our retrospective study has shown superior PFS of ddCT over CT regimen in first-line treatment of ovarian carcinoma in a Western population not treated with bevacizumab.

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