II.SPECIAL PART
2.1 Objectives
The objectives of our study are to highlight the treatment with the best percentage of complete remission and long survival. We also intended to investigate whether age, gender and treatment response influence the rate of survival.
2.2 Material and methods
This is a retrospective study on 58 patients with Non-Hodgkin Lymphoma developed in the Hematology Department at the Municipal Emergency Hospital Timisoara in 2017.
Inclusion criteria:
• Non-Hodking Lymphoma (both B and T-type)
• Patients under treatment with CHOP, R-CHOP,
• Age over 18 years old
Exclusion criteria:
• Other types of lymphoma
The diagnosis of Non-Hodking lymphoma was determined by histopathological exam obtained from biopsy, which was examined in Pathological Anatomy Laboratory of the Municipal Emergency Hospital of Timișoara. The histological type was identified according to WHO classification (World Health Organization), and staging was performed following the Ann-Arbor staging criteria.
In order to establish with certainty the suspected malignancy diagnosis, the immunohistochemical technique was used. The expression of Ki-67 was studied for the proliferative profile analysis, thus diminishing the cases with less intense proliferation (under 30%) than those with a increased tumor growth rate (over 60%)
Since these patients were periodically admitted for treatment, as well as for specialist control, they could be constantly monitored during these years. Patient evaluation was performed both clinically and paraclinically, obtaining information such as:
• Age, gender, environment
• Stage of disease, localization, bone marrow implication
• Hemoglobin, Ki 76 and LDH levels
• Type of treatment, response to treatment, complication
• ECOG performance
We defined ECOG performance as in table below:
0 Fully active, able to carry on all pre-disease performance without restriction
1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work
2 Ambulatory and capable of all self-care but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited self-care, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any self-care. Totally confined to bed or chair
5 Dead
Table 1 ECOG performance
Data analysis was performed using SPSS v.24.0 (Statistical Package for the Social Sciences, Chicago, IL, USA). Continuous variables were presented as a mean and standard deviation (SD). We performed descriptive and inferential statistics analysis to summarize the characteristics of the study population. In order to examine the strength of a linear relationship between two values we used the Spearman's rank-order correlation. To evaluate the distribution of ordinal data we apply the chi-squared test (χ2).
A ”p” value of less than 0.05 was considered to indicate a statistically significant difference. The study was done in accordance with the Ethics Committee regulations, which implied that patients were requested to sign a written consent.
V. RESULTS
V.1. General caracteristics study
From the 58 patients included in the study, 27 patients were female (47%) and 31 were male (47%), with a female:male rapport 1:1,15.
Figure 1 Gender distribution
The average age (mean±SD) was 58,91±15,86 with the lower limit at 26, and the upper limit at 89 years old. For the female group, the average age (mean±SD) was 61,15±14,09 and for male group the average age (mean±SD) was 56,97±17,12 years old.
We could not find any significant statistical difference between the age of the two gender groups, p=0.321 (t student test) .
Figure 2 Populational piramid
As shown in the chart above, we wish to highlight that in this study, most of the subjects were registered within the age group of 45-65 years old, both in women and men.
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According to the figure below (Fig. 3), it is highlighted that the general sign of the disease were present in most patients from our study, recording a percentage of 64%.
Figure 3 General sign distribution
V.2. Laboratory results study
Some hematological parameters were also monitored. As respects the laboratory results regarding the count of PLT in the patients, it can be notice from the figure below (Fig. 4) that the most results falls within the normal range of PLT (>150.000/µL), recording a high percentage of 79% (46 cases).
Figure 4 Distribution of PLT
As respects the other parameters of the investigated cell blood count test: hemoglobin (Hb) level and white blood cell (WBC), it can be seen from the figure below (Fig. 5) that the most patients recording a percentage of 47% (27 cases) Hb level which corresponds to the interval 10-13 g/dL. According to reference range of some medical laboratories, regardless of gender, this range corresponds to normal values of hemoglobin level.
Figure 5 Distribution of hemoglobin levels
From figure below (Fig. 6) regarding the count of WBC, it is highlighted that the number of the WBC in the range 3.000-10.000/µL recording a high percentage of 78% (45 cases).
Figure 6 Distribution of WBC
As respects the lymphocyte distribution in the investigated patients, B-type lymphoma predominance was recorded, accounting 83% (48 cases) compared to T-type lymphoma, which recorded a percentage of 17% (10 cases) (Fig. 7).
Figure 7 Distribution of B and T cell
The Ki67 is an important molecular marker in the diagnosis of cancer, so its presence is a prognosis factor. The highest frequency for Ki67 was noted at the level 30-60%, registering a percentage of 38% (22 cases) according to the figure below (Fig.8). The smallest frequency was noted to the patients who presented a big proportion of Ki67 29% (17 cases), and the patients who had a proportion of Ki67 less than 30% recorded a percentage of 33% (19 cases).
Figure 8 Ki76 distribution
V.3. Stage of disease study
Regarding the stage of the disease in patients, it was noted that the IV B stage recorded predominant frequency 31% (18 cases). It is worth noting that II B, III B and IV A stages have the same frequency in patients 15.5% (9 cases), and the I A stage has the lowest percentage 3.4% (2 cases) (Fig. 9).
Figure 9 Distribution of the stage of disease
As respects the gender distribution on disease stage, from figure below (Fig. 10) it can be notice that the most men and females were included in IV B stage of the disease, while the fewest man and females were included in the first stage I A. The other stages include different proportions of gender distribution as shown in Fig. 10.
Figure 10 Gender and stage of disease distribution
Regarding the treatment distribution on disease stage, from figure 11 it is noted that R-CHOP treatment is more predominant than CHOP treatment in most stages of disease, six out of seven stages. The high distribution of R-CHOP treatment was recorded at III B disease stage, while the high distribution of CHOP treatment was recorded at IV B stage.
Figure 11 Distribution of treatment and stage
Figure 12 Stage of disease by age distribution
In the figure above (Fig. 12) we see the distribution of stage of disease by age, with prediminant age group of 50-70 years old.
5.3. Treatment and response study
The table below shows that the most frequently used treatment in the investigated patients was represented by R-CHOP which recorded a predominant percentage of 60.3% (35 cases), followed by other PCT with 27.6% (16 cases).
Table 2 Type of treatment applied in this study
Treatment
Type Frequency
CHOP 7 (12.1 %)
R-CHOP 35 (60.3 %)
Other PCT 16 (27.6 %)
Following treatment, most of the patients obtained full remission 38% of the cases studied (22 patients). It is also noteworthy a high frequency of progressive disease in 36% of the cases (21 patients) (Fig. 13).
Figure 13 Distribution of the response to treatment
Figure 14 Response to the treatment type
From figure above ( Fig. 14) it is noted that most patients from this study, who had as R-CHOP treatment, recorded a favorable response to the treatment, and they were fully recovered
The Spearman correlation between the type of treatment applied and response to treatment shows a positive correlation for R-CHOP treatment (r=0.588), comparative to others type of treatment used in this study, which didn’t have a favorable response
Correlations (Output SPSS)
Response R-CHOP
Spearman's rho Response Correlation Coefficient 1.000 .588**
Sig. (2-tailed) . .000
N 58 58
R-CHOP Correlation Coefficient .588** 1.000
Sig. (2-tailed) .000 .
N 58 58
Also, it is noted that the R-CHOP treatment recorded a high frequency of treatment response, 54% in patients from our study. The response was favorable and the patients had a complete remission (Fig. 15).
Figure 15 Treatment response to R-CHOP treatment
As respects the response to CHOP treatment, compared to R-CHOP treatment, from figure below (Fig. 16) it can be notice that this treatment didn’t have a favorable response regarding the recovering of patients. The high frequency of CHOP treatment response was recorded in patients with progressive disease 57%.
Figure 16 Treatment response to CHOP treatment
As can be seen in the figure below (Fig. 17), the high frequency of complications that occurred, was highlighted in CHOP treatment group. In R-CHOP treatment group, the frequency of complications is lower.
Figure 17 Complication rates depending on treatment
Figure 15Figure 16Figure 17
5.4. ECOG performance study
According to the graph below (fig. 18), it can be observed that male and female patients recorded similar values of the ECOG scale score. Thus, most females was noted at the level of score 2, registering a percentage of 22.41% (13 cases), while in the male patients there was a 24.13% (14 cases). It was found that 0 is the lowest score for female 1.72% (1 case). The Chi square test between gender and ECOG Performance status score shows no statistical significance (p=0.551).
Figure 18 Distribution of ECOG by gender
The Chi square test between ECOG Performance status score and patients response to treatment shows statistical significance (p<0.05). Based on the results we can see that patients who have complete and partial remission records lower scores of the ECOG Performance scale.
ECOG Performance status * Response Crosstabulation (Output SPSS)
Response Total
Progressive disease Complete remission Partial remission
ECOG Performance status 0 0 1 0 1
1
0 8 1 9
2
4 13 10 27
3
11 0 4 15
4 6 0 0 6
Total 21 22 15 58
Figure 19 ECOG performance for different response to treatment
5.5. Survival study
The survival curve was represented by Kaplan-Meier Survival Estimates, which represents the time of survival after the applied treatment (Fig. 20).
The time of survival (mean±SD) after CHOP treatment type was 13,00±8.98 months, while the time of survival (mean±SD) after R-CHOP treatment was 22.97±7.71 months.
Figure 20 Survival depending of treatment
Anova test shows statistical significance in survival between groups after their treatment (p=0.007). The patients with R-CHOP treatment survived longer than the patients with CHOP treatment.
The time of survival (mean±SD), independent of response to the treatment type, was 19,05±9,66 months, with a lower limit of 1 and the upper limit at 37 months. (Fig.21)
Figure 21 Time of survival
The gender distribution of patients in our study was approximately equal. In addition, from the figure below (Fig. 22), it can be seen that the chances of survival of males and females within this study was almost equal. The mean(±SD) value of time of survival for male subjects was 19,23±9,62 months and for females was 18,85±9,89 months.
Figure 22 The survival of females and males (output SPSS)
The Student Test shows no significant difference on mean value of time of survival from gender point of view (p=0.812).
When correlating the hemoglobin level of patients with the survival rates, the highest survival mean(±SD) was 23,59±7,65 months and corresponds to the group with normal hemoglobin level. In the figure below (Fig.23) it is represented the time of survival of patients correlates with hemoglobin levels.
Figure 23 Time of survival from Hb level point of view (output SPSS)
Anova test shows statistical significance in survival between hemoglobin level groups (p<0.0001). The patients with normal values of Hb level survived longer than the rest of the group, wich were with abnormal Hb levels.
When we studied the correlation between the disease subtype and patient survival, we could not find a significant difference. As respects the distribution of B and T type lymphoma in time of survival of patients, there is no significance differences p=0.127 (T Student Test).
The bone marrow infiltration had no impact on time of survival of patients, as can be seen from the figure below. (Fig. 24)
Figure 24 Time of survival from bone marrow infiltration levell point of view (output SPSS)
Anova test shows no statistical significance in time of survival correlated with bone marrow infiltration levels (p=0.732). It is noted that the patients with a 20-40% of bone marrow infiltration survived as much as those who had a high infiltration, >60%. However, it can be noted that the patients with the lowest proportion of infiltration have survived the most.
Also the presence of Ki97 is relevant in correlation with the time of survival of patients. As seen in the figure below, you can ovserve that the patients with a big proportion of Ki67 have survived less than others. (Fig. 25)
Figure 25 Time of survival from Ki 67 level point of view (output SPSS)
In addition, the ANOVA Test shows statistical significance in time of survival between patients, who presented different proportion of Ki67 level (p<0.05). The greatest chance of survival was recorded in patients with a percentage of Ki67 comprised between 30-60%, while those who recorded a percentage of Ki67 bigger than 60% survived less than 30 months.
The graphic below (Fig.26) shows the importance of treatment success in time of survival of patients after their treatment. The patients which obtained complete remission after treatment survived the most.
Figure 26 Time of survival from response point of view (output SPSS)
ANOVA Test shows statistical significance in time of survival between patient groups after teatment (p<0.001). The mean(±SD) survival time of patients presented the lowest level of 11,52±9,50 months, while the upper level of 23,77±7,37 months, a big statistical difference.
Analysing relationship between age and survival time we found a weak negative correlation (r= -0.290; p=0.027), showing that a younger age of pacients result in a longer survival time. (Fig. 27)
Figure 27 Correlation between age and survival
*** A younger age and a good response to treatment are positive prognostic factors to survival time.
*** Gender its a independent factor to survival time.
2.4 Discussion
This study analyze the efficacy and safety of rituximab in combination with CHOP chemotherapy with that of CHOP chemotherapy alone in elderly patients with NHL. We found higher response rates and improved event free survival among patients treated with the combination of rituximab and CHOP.
Compared with our results, Hidemann et al had higher results in their study where 205 patients were treated with CHOP alone, and 223 patients were treated with R-CHOP. Overall response rates were 96% with R-CHOP and 90% with CHOP alone compare with the results from our study (R-CHOP 54% and CHOP 29%).Also, the rate of relapse or progression after successful initial therapy was lower in R-CHOP–treated patients, resulting a longer duration of response, a significantly longer rate of survival was observed for R-CHOP–treated patients (22).
Perez et al didn’t find differences between R-CHOP and CHOP treatment in their study on 181 patients in advanced stages where median age was 57.8 years. Addition of rituximab to CHOP regimens did not improve the treatment response (23).
Coiffier study developed in 86 centers in France, Belgium, and Switzerland. A total of 400 patients were enrolled between July 1998 and March 2000, and 398 patients (201 in the R-CHOP group and 199 in the CHOP group) received at least one dose of protocol-specified treatment. The median age of the patients was 69 years. Event-free survival was significantly longer for patients treated with CHOP plus rituximab than for those treated with CHOP alone (25) .
.III Conclusions
The results of the current study show that the addition of rituximab to frontline therapy with CHOP leads to a significantly better outcome for patients with symptomatic, advanced-stage compared with those receiving CHOP alone, and a younger age , a good response to treatment are positive prognostic factors to survival time.Gender its a independent factor to survival time.
In a disease in which a curative tratment is not yet available, the achievement of long periods without symptomatic disease is of great benefit to patients and is an essential goal of therapeutic measures aimed at a good quality of life. These goals can be achieved by R-CHOP in most patients without an increase of clinically relevant adverse effects.
The data from the study show that rituximab has a beneficial effect in patients with advanced-stage.
Therefore, the question is no longer whether rituximab should be applied with first-line therapy for advanced-stage but how it should be applied. Although further studies are needed to address this question in important detail, it may be speculated that these different ways of application might not be used alternatively but rather complementarily and that they might be appropriate for different patient populations as defined by age, performance status, IPI, or the recently introduced IPI and other clinical or biologic risk factors.
In this context, R-CHOP may be the preferred treatment option in patients with advanced-stage symptomatic disease in whom longer remission rate and long-lasting remission are the primary objective of therapy.
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