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 Treatment Outcomes

As you go through treatment, and read more about lymphoma you will hear a lot about the results of your treatment, or clinical trial results. Click on any of the terms below to go to their definition.

Cure: 
Where there are no signs of the disease reappearing, doctors may cautiously begin using the word cure. The ability to cure NHL depends on the type of lymphoma. Many high-grade lymphomas can be cured. Low-grade NHLs tend to reappear, even after long-term remission. The usual standard for aggressive lymphomas is that you must be in complete remission 5 years or more before they will consider calling you cured.

Complete remission: 
This term is used when all signs of the disease have disappeared after treatment. Patients are especially fond of calling this NED (No Evidence of Disease). Although this does not mean that the disease is completely gone, the symptoms have disappeared and the lymphoma cannot be detected using current tests. If this response is maintained for a long period, it is called a durable remission. The longer a patient is in remission the better the prognosis or outcome. However, as with other cancers, the disease could still possibly return and long-term follow-up is necessary.

Molecular Remission
Sometimes (often in a clinical trial setting) advanced testing techniques are used to detect minute quantities of lymphoma. Some of these tests can detect just a single lymphoma cell in a sample of 10,000 cells or more. Some of the techniques used for such sensitive testing are Polymerace Chain Reaction, Flow Cytometry and DNA Microarray.

Partial remission:
This term is used if the NHL is treated and the tumour shrinks to less than one-half of its original size. 

Improvement:
This term is used if the tumour shrinks following therapy but is still more than one-half of its original size. 

Stable disease:
The disease does not get better or worse following therapy.

Refractory
A cancer that is resistant to treatment. 

Prognosis
What is the likely outcome of the disease. Every patient wants to know their prognosis. It is just natural to want to know, even though doctors can only tell you statistically what is likely. They cannot tell you what will happen to you. Yet in the quest to better define the prognosis there exists the "IPI" below.  Use it with caution. It is designed to help define who is "at risk" of relapsing not who is going to die tomorrow morning.

The International Prognostic Index for aggressive NHL
An international index for aggressive NHL (diffuse large cell lymphoma) identifies 5 significant risk factors prognostic of overall survival. For each positive risk factor there is a greater risk of relapse. This index can also be applied to the indolent forms of Lymphoma but with a smaller degree of accuracy.

  • Age (<60 years of age versus >60 years of age),

  • Serum lactate dehydrogenase-LDH (normal versus elevated),

  • Performance status (0 or 1 versus 2-4), (see definition below)

  • Stage (I or II versus III or IV),

  • Extranodal site involvement (0 or 1 versus 2-4).

In the pre-Rituximab era patients with 2 or more risk factors have less than a 50% chance of relapse-free and overall survival at 5 years. However the proposed revised IPI indicates since the inclusing of Rituxaimab with CHOP there are three distinct prognostic risk groups.

0 risk factors, very good - 90% progression free survival @ 5 years

1-2 risk factors, good - 80% progression free survival @ 5 years

3-5 risk factors, poor - 50% progression free survival @ 5 years

The International Prognostic Index for Follicular NHL
This one has been proposed by an international cooperative group in 2004, and it pertains to follicular lymphoma, and perhaps to other low grade types as well. 

Click here to read the abstract from the Journal Blood about this new index.

  • Age (< 60 years of age versus >60 years of age)

  • Ann Arbor Stage III or IV

  • Haemoglobin level < 120 g/L

  • Elevated LDH

  • Greater than 4 nodal sites

Note OS means Overall Survival

Risk Group Number of Factors % 5 year OS % 10 year OS
Low 0-1 90.6 70.7
Intermediate 2 77.6 50.9
High 3 or higher 52.5 35.5

Mantle Cell Lymphoma International Prognostic Index

The MIPI identifies four risk factors for overall survival. For each factor your get points from zero up to 3. The maximum score is 11

Points Age years) ECOG PS LDH (ULN) WBC, 10^9/L
0 < 50 0-1 <0.67 <6.700
1 50-59 - 0.67-0.99 6.700-9.999
2 60-69 2-4 1.0-1.49 10.000-14.999
3 ≥ 70 - ≥1.5 ≥15.00

ECOG PS = Eastern Cooperative Oncology Group performance status
LDHULN = lactic acid dehydrogenase institutional upper limit of normal
WBC = white blood cell count from the complete blood count

  • Low risk (0-3 points)
  • Intermediate risk (4-5 points)
  • High risk (6-11 points)

When the MIPI was applied to the 455 cases:
44% were low risk (median OS, not reached)
35% intermediate risk (median OS, 51 months)
21% high risk (median OS, 29 months).

Source: Bloodjournal article "Vol 111, No. 2, pp.558-565"

Prognostic Index for peripheral T-cell lymphoma unspecified
This index identifies 4 significant risk factors for overall survival.
Read the published paper here

  • Age > 60, relative risk 1.732

  • Performance status >=2, relative risk 1.719

  • Elevated LDH, relative risk 1.905

  • Bone marrow involvement, relative risk 1.454

0 adverse factors 5 year survival 62.3%, 10 year survival 54.9%

1 adverse factor, 5 year survival 52.9%, 10 year survival 38.8%

2 adverse risk factors, 5 year survival 32.9%, 10 year survival 18%

3 or 4 adverse risk factors, 5 year survival 18.3%, 10 year survival 12.6%

Performance status
Performance status in the aggressive IPI is defined as

Grade Description
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 selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours
3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours
4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair
5 Dead

So if you are 2-4 on this scale then you get one point on the IPI scale. If you are 0-1 on the Performance scale you get zero on the IPI. As you can see the goal is to have a low IPI score.

You may also hear of the Karnofsky score. It is a similar scoring system used to evaluate a patients overall performance. However it goes into more detail in an effort to more accurately evaluate a patient for general medical purposes. It is not used when calculating the IPI score above.

Click here to read the Karnofsky performace scale

 

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