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T-Cell Lymphoma Differential Diagnosis and CD30 Treatment

Insights From: Neha Mehta-Shah, MD, Washington University School of Medicine in St. Louis
Published: Monday, Jan 28, 2019



Transcript: 

Neha Mehta-Shah, MD: Patients who are suspected to have T-cell lymphoma should always undergo a core needle biopsy to make the diagnosis. We’ve learned that excisional biopsies might be even better but are not always practically done for safety reasons or patient-preference reasons. And we’ve also learned that among peripheral T-cell lymphomas, the diagnosis made at a community center is often changed up to 25% of the time at an academic center. And most of those changes are within different subtypes of T-cell lymphoma, but expert review at an academic center is very important for reclassification, especially in the era when therapy may be different for different subtypes of lymphoma or eligibility for clinical trials might be different based on the histological subtype.

Otherwise, most patients present with other symptoms similar to those of other types of aggressive lymphomas. It’s not often with B symptoms like fevers, chills, or night sweats. Often with lymph nodes that are larger than normal, that sometimes the patient brings to notice, and patients can present with bone marrow involvement relatively commonly, so we always check for bone marrow traditionally. To stage patients, we usually use a PET/CT [positron emission tomography/computed tomography] scan because that’s been better to look at extranodal sites of peripheral T-cell lymphoma.

Historically, patients with the systemic peripheral T-cell lymphomas—that means excluding the cutaneous T-cell lymphomas—have been treated with systemic chemotherapy for curative intent. And if you look back at data from the International Peripheral T-cell Lymphoma Project or from the Swedish National Patient Register, as well as many other older registries, you can see that most patients end up succumbing to their disease. So the 5-year survival is often quoted as about 20%. Sorry, the 5-year survival is usually quoted at about 30% or so, with the 5-year progression-free survival being about 20% or so.

That means that although some of our patients are cured of this disease, they’re a subset of the patients, and many of our patients will relapse from their initial therapy. And this means that we have to do better with initial therapy. And so there have been efforts to add medicines to a CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone] backbone, which tends to be the most commonly given treatment for this disease, to augment the rate of cure. Some efforts have been made to follow CHOP-like therapy with a stem cell transplant from your own cells or an autologous stem cell transplant. And we think that that improves the rate of cure by some fraction, often quoted in the order of 1 in 5 patients if you just look at phase II studies that were not randomized.

Other efforts to improve on CHOP have been to add etoposide to CHOP, and we think that that improves the complete remission rate from this disease, which is a meaningful outcome. And more recently, there has been a large international randomized study to look at adding CD30 to a CHOP-like backbone to see whether this would improve outcomes in peripheral T-cell lymphoma.

Transcript Edited for Clarity
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Transcript: 

Neha Mehta-Shah, MD: Patients who are suspected to have T-cell lymphoma should always undergo a core needle biopsy to make the diagnosis. We’ve learned that excisional biopsies might be even better but are not always practically done for safety reasons or patient-preference reasons. And we’ve also learned that among peripheral T-cell lymphomas, the diagnosis made at a community center is often changed up to 25% of the time at an academic center. And most of those changes are within different subtypes of T-cell lymphoma, but expert review at an academic center is very important for reclassification, especially in the era when therapy may be different for different subtypes of lymphoma or eligibility for clinical trials might be different based on the histological subtype.

Otherwise, most patients present with other symptoms similar to those of other types of aggressive lymphomas. It’s not often with B symptoms like fevers, chills, or night sweats. Often with lymph nodes that are larger than normal, that sometimes the patient brings to notice, and patients can present with bone marrow involvement relatively commonly, so we always check for bone marrow traditionally. To stage patients, we usually use a PET/CT [positron emission tomography/computed tomography] scan because that’s been better to look at extranodal sites of peripheral T-cell lymphoma.

Historically, patients with the systemic peripheral T-cell lymphomas—that means excluding the cutaneous T-cell lymphomas—have been treated with systemic chemotherapy for curative intent. And if you look back at data from the International Peripheral T-cell Lymphoma Project or from the Swedish National Patient Register, as well as many other older registries, you can see that most patients end up succumbing to their disease. So the 5-year survival is often quoted as about 20%. Sorry, the 5-year survival is usually quoted at about 30% or so, with the 5-year progression-free survival being about 20% or so.

That means that although some of our patients are cured of this disease, they’re a subset of the patients, and many of our patients will relapse from their initial therapy. And this means that we have to do better with initial therapy. And so there have been efforts to add medicines to a CHOP [cyclophosphamide, doxorubicin, vincristine, and prednisone] backbone, which tends to be the most commonly given treatment for this disease, to augment the rate of cure. Some efforts have been made to follow CHOP-like therapy with a stem cell transplant from your own cells or an autologous stem cell transplant. And we think that that improves the rate of cure by some fraction, often quoted in the order of 1 in 5 patients if you just look at phase II studies that were not randomized.

Other efforts to improve on CHOP have been to add etoposide to CHOP, and we think that that improves the complete remission rate from this disease, which is a meaningful outcome. And more recently, there has been a large international randomized study to look at adding CD30 to a CHOP-like backbone to see whether this would improve outcomes in peripheral T-cell lymphoma.

Transcript Edited for Clarity
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