Фолликулярная лимфома (ФЛ) – это опухоль, развивающаяся из В-клеток герминального центра, характеризующаяся рецидивирующим и ремиттирующим течением; возможна трансформация в диффузную В-крупноклеточную лимфому (ДВККЛ). При генерализованном поражении и прогрессировании ФЛ наиболее часто применяются режимы терапии R-CHOP и R-B. Выбор схемы терапии в зависимости от различных цитологических, клинических и лабораторных характеристик пациентов остается предметом дискуссий. Цель исследования – анализ клинических, лабораторных и морфологических характеристик пациентов с ФЛ, получивших полихимиотерапию (ПХТ) по схемам R-B и R-CHOP; определение критериев выбора индукционной терапии. Материалы и методы. В исследование включено 203 пациента с ФЛ за период с 2000 по 2018 г. Курсы R-B проводились в пяти клиниках г. Москвы и четырех региональных клиниках России (в Кирове, Туле, Смоленске и Хабаровске). Терапию по схеме R-B на момент данного анализа получили 77 больных. Курсы R-CHOP проведены в НМИЦ гематологии Минздрава России. Лечение по схеме R-CHOP начато 126 пациентам, 14 из которых в дальнейшем получили высокодозную химиотерапию (ВХТ) (R-DHAP в составе: ритуксимаб, дексаметазон, цисплатин, цитарабин) без трансплантации аутологичных стволовых клеток крови (аутоТСКК), 21 пациент получил ВХТ с аутоТСКК; 89 больных получили лечение курсами R-CHOP и поддерживающей терапией ритуксимабом (двое больных, у которых заболевание прогрессировало, кроме терапии R-CHOP, получили лечение по программе mNHL-BFM-90). Эффективность различных схем терапии оценивается в данной работе в первую очередь по общей выживаемости. Результаты и обсуждение. R-B. Терапию по схеме R-B получили 77 больных. Полная ремиссия заболевания достигнута у 47 (61%) пациентов (у трех из них в дальнейшем развился рецидив заболевания), частичная ремиссия – у 15 (19%) пациентов, в 13 случаях (17%) зафиксировано прогрессирование опухоли. Цитологический тип опухоли 1–2 имели 70 пациентов, цитологический тип 3А – 6 пациентов. У 6/13 (46%) больных с прогрессированием заболевания диагностирован цитологический тип 3А ФЛ. Медиана наблюдения (на момент анализа) – 34 мес. R-CHOP. ВХТ с R-CHOP (6–8 курсов) и поддерживающую терапию ритуксимабом получили 89 пациентов с ФЛ. У 39 (44%) больных достигнута и сохранялась ремиссия заболевания, у 50 (56%) – развился рецидив. 50 пациентов имели 1–2-й цитологический тип, 39 – 3-й цитологический тип. У 18 из 50 рецидивировавших пациентов (т. е. у 36%) диагностирован цитологический тип 3А. Медиана наблюдения – 93 мес. R-CHOP+ВХТ с аутоТСКК. В связи с недостаточным противоопухолевым ответом 21 пациенту после курсов R-CHOP лечение продолжена ВХТ, а также выполнена аутоТСКК. В 18 случаях из 21 (86%) достигнута и сохраняется полная ремиссия заболевания, в 3 случаях (14%) развился рецидив. 16 пациентов имели 1–2-й цитологический тип опухоли, 5 (рецидивировавших) пациента имели 3-й цитологический тип. Медиана наблюдения – 81 мес. R-CHOP + ВХТ без аутоТСКК. 14 пациентам в качестве индукционной терапии начата ПХТ по программе R-CHOP, однако потом (в связи с недостаточным противоопухолевым ответом) лечение продолжено высокодозной терапии (аутоТСКК этим пациентам по ряду причин не выполнялась). 10 больных имели 2-й цитологический тип, 4 больных – 3-й цитологический тип. 11 (79%) пациентов находятся в настоящее время в ремиссии заболевания, у 3 (21%) – случился рецидив. Медиана наблюдения – 80 мес. 7-летняя общая выживаемость больных ФЛ на терапии R-B составила 89% (95% ДИ 75–99), на R-CHOP – 85% (95% ДИ 73–90), на R-CHOP+ВХТ с аутоТСКК – 87% (95% ДИ 57–100), на R-CHOP+ВХТ без аутоТСКК – 82%. Бессобытийная 7-летняя выживаемость больных ФЛ на терапии R-B составила 70% (95% ДИ 75–99), на R-CHOP – 44% (95% ДИ 73–90), на R-CHOP+ВХТ с аутоТСКК – 74% (95% ДИ 57–100), на R-CHOP + ВХТ без аутоТСКК – 80%. Заключение. Цитологический тип опухоли и характер опухолевого роста не имеют взаимооднозначного соответствия: при цитологических типах 3А и 3А+3В встречаются как нодулярный и нодулярно-диффузный, так и диффузный типы роста опухоли. Следовательно, при выборе индукционного режима терапии в первую очередь нужно руководствоваться цитологическим типом ФЛ. Режим R-B наиболее эффективен при 1-м и 2-м цитологических типах ФЛ. Предиктором резистентности к терапии R-B является высокий (>35%) индекс пролиферативной активности (Ki67). Химиорезистентность опухоли ассоциируется также с отсутствием интерфолликулярной Т-клеточной реакции в опухолевой ткани. Предиктором плохого ответа на терапию является наличие крупных опухолевых конгломератов (bulky), которые (у большинства больных) ассоциируются с индексом FLIPI со значениями от 3 до 5. Пациентам, имеющим в дебюте заболевания фактор bulky, высокий (>35%) индекс Ki67 и индекс FLIPI от 3 до 5 в качестве терапии первой линии предпочтительнее выбрать режим R-CHOP, а при отсутствии (после 4–6 курсов) полной или частичной ремиссии продолжить лечение ВХТ.
Follicular lymphoma (FL) is a tumor that develops from the B cells of the germinal center; characterized by recurrent and remitting course of the disease, the transformation of a tumor into diffuse large B-cell lymphoma (DLBCL) is possible. In generalized lesions and progression of FL, the most commonly used courses are R-CHOP and R-B. The choice of therapy for different cytological types, clinical and laboratory parameters remains disputable. Aim. To analyze the clinical, laboratory, morphological parameters of patients with FL, who got R-B and R-CHOP therapy; determine the criteria for selecting induction therapy. Materials and methods. The study included 203 patients with FL from 2000 to 2018. R-CHOP treatment was initiated in 126 patients, 14 of whom later received high-dose therapy (HDT) (R-DHAP: rituximab, dexamethasone, cisplatin, cytarabine) without autologous stem cell transplantation (autoSCT), 21 – HDT with autoSCT; treatment of 89 patients was limited to courses of R-CHOP and maintenance therapy with rituximab, two patients (in whom the disease progressed, despite R-CHOP therapy) were assigned the mNHL-BFM-90 program. The efficacy of treatment on various treatment regimens was evaluated primarily by overall survival. Results and discussion. R-B. 77 patients received R-B therapy. Complete remission of the disease was achieved in 47/77 (61%) patients (3 of them later developed a relapse of the disease), partial remission was achieved in 15/77 (19%) patients, in 13/77 (17%) cases progression was recorded tumors. 70 patients had 1–2 cytological type of tumor, 6 patients – 3A cytological type. In cases of progression, 3 of 13 patients (46%) were diagnosed with 3A cytological type FL. Median observation (at the time of analysis) – 34 months. R-CHOP. 89 patients with FL received high-dose therapy with R-CHOP (6–8 courses) and maintenance therapy with rituximab. In 39 (44%) patients, the disease remained in remission, and in 50 (56%), a relapse of the disease developed. 50 patients had 1–2 cytological types, 39 – 3 cytological types. In cases of recurrence of FL, a 3A cytologic type (36%) was diagnosed in 18/50 patients. Median observation – 93 months. R-CHOP + HDT and autoSCT. 21 patients after the R-CHOP courses continued (due to insufficient antitumor response) high-dose chemotherapy (HDT) and auto-SCT were performed. In 18/21 (86%) cases, complete remission of the disease was achieved and maintained, in 3 (14%) cases relapse developed. 16 patients had 1–2 cytological types, 5 – 3 cytological types. Median observation – 81 months. R-CHOP + HDT without autoSCT. 14 patients started therapy under the R-CHOP program as induction therapy, but then (due to insufficient antitumor response), the treatment was continued according to the HDT without autoSCT. 11 (79%) patients are currently in remission of the disease, in 3 (21%) – there was a relapse. 10 patients had 2 cytological types of PL, 4 – 3 cytological types. 11 (79%) patients are currently in remission of the disease, in 3 (21%) – there was a relapse. Median observation – 80 months. 7-year OS of patients with FL on RB therapy was 89% (95% CI 75–99), on R-CHOP therapy – 85% (95% CI 73–90), on R-CHOP + HDT and autoSCT – 87% (95% CI 57–100), on R-CHOP + HDT without autoSCT – 82%. 7-year PFS of FL patients on RB therapy was 70% (95% CI 75–99), on R-CHOP therapy – 44% (95% CI 73–90), on R-CHOP + HDT and autoSCT – 74% (95% CI 57–100), on R-CHOP + HDT without autoSCT – 80%. Conclusion. The R-B is most effective in FL 1 and 2 cytological types. The cytological type does not correspond to the type of tumor growth: at 3A and 3A + 3B cytological types, nodular / nodular-diffuse and diffuse types of growth are found. When choosing an induction course, one should look at the cytological type of FL. A high proliferative activity index (according to Ki67) is a predictor of resistance to R-B therapy. The absence of an interfollicular T-cell reaction in tumor tissue FL is associated with tumor chemoresistance. The presence of the bulky factor is associated (in most patients) with the FLIPI index with values from 3 to 5, and is a predictor of a poor response to therapy. Patients with bulky, high (more than 35%) Ki67 index and FLIPI from 3 to 5 in the debut of the disease as the first line therapy, it is preferable to choose the R-CHOP mode, and in the absence of (after 4–6 courses) to complete or partial remission to continue conducting the HDT.
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1. Swerdlow SH, Swerdlow S, Campo E, Harris N, et al. WHO classification of tumours of haematopoietic and lymphoid tissues. Revised 4th ed. World Health Organization, 2017; Vol. 2.
2. Anastasia A, Rossi G. Novel Drugs in Follicular Lymphoma. Mediterr J Hematol Infect Dis. 2016;8(1):e2016061. doi: 10.4084/MJHID.2016.061
3. Cheah CY, Fowler NH. Novel agents for relapsed and refractory follicular lymphoma. Best Pract Res Clin Haematol. 2018;31(1):41-8. doi: 10.1016/j.beha.2017.11.003
4. Dreyling M, Ghielmini M, Rule S, Salles G, Vitolo U, Ladetto M; ESMO Guidelines Committee. Newly diagnosed and relapsed follicular lymphoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol. 2016;27(Suppl 5):v83-90. doi: 10.1093/annonc/mdx020
5. [Poddubnaya IV, Savchenko VG, eds. Rossiiskie klinicheskie rekomendatsii po diagnostike i lecheniyu limfoproliferativnykh zabolevanii [Russian clinical guidelines for the diagnosis and treatment of lymphoproliferative diseases]. Moscow, 2018 (In Russ.)].
6. NCCN 2018-2019 oncology case manager and medical director program: diagnosis and management of hematologic malignancies. Version 2.2018. 2018 Jan 19.
7. Mondello P, Steiner N, Willenbacher W, Wasle I, Zaja F, Zambello R, et al. Bendamustine plus rituximab versus R-CHOP as first-line treatment for patients with indolent non-Hodgkin’s lymphoma: evidence from a multicenter, retrospective study. Ann Hematol. 2016;95(7):1107-14. doi: 10.1007/s00277-016-2668-0. Epub 2016 Apr 22.
8. Luminari S, Goldaniga M, Cesaretti M, Orsucci L, Tucci A, Pulsoni A, et al. A phase II study of bendamustine in combination with rituximab as initial treatment for patients with indolent non-follicular non-Hodgkin lymphoma. Leuk Lymphoma. 2016;57(4):880-7. doi: 10.3109/10428194.2015.1091934. Epub 2016 Feb 8.
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