Epidemiology and Treatment Outcomes of Diffuse Large B-Cell Lymphoma in Elderly Indian Patients: A Retrospective Study from South India

Introduction: Diffuse large B-cell lymphoma (DLBCL) is the most common type of non-Hodgkin lymphoma (NHL) affecting the elderly population, constituting a significant proportion of lymphoma cases in this demographic. With India's aging population on the rise, it is crucial to understand the clinical presentation and management outcomes of DLBCL in this group. This study investigates the epidemiology, clinical features, and treatment outcomes of elderly patients with DLBCL treated at a tertiary care oncology center in South India over an eight-year period.

Materials and Methods: This retrospective study reviewed medical records of 102 patients aged 60 years and older, diagnosed with DLBCL at MIOT International Hospital, Chennai, India, from January 2015 to January 2023. Demographic data, clinical staging based on Ann Arbor staging modified by Cotswold's criteria, and International Prognostic Index (IPI) scores were analyzed. Statistical analysis was performed using SPSS software, with survival rates calculated using the Kaplan-Meier method.

Results: The mean age of the patients was 67 years (±4.5), with a male-to-female ratio of 1.5:1. B symptoms were observed in 47 patients (46.08%). The majority (50.98%) were diagnosed at stage I/II, while 30.39% were at stage III, and the rest at stage IV. Extranodal involvement was noted in 32 patients (31.37%), with axillary nodes being the most common site. The distribution of IPI scores was as follows: low risk (41.18%), Low intermediate risk (33.33%), high-intermediate risk (19.61%), and high risk (5.88%).

Treatment and Outcomes: Of the 102 patients, 73 (71.57%) received treatment with combinations of rituximab, cyclophosphamide, vincristine, and prednisolone (R-CVP) or rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone (R-CHOP), or similar dose-adjusted regimens. The overall response rate (ORR) was 56.86%, with 58 patients showing a response to treatment.Few patients had Bendamustine + Rituximab based therapy and few had only palliative care.Interim PET-CT was done in 90% cases. The overall survival (OS) ranged from 2 to 123 months, with a median OS of 9.5 months. Univariate analysis revealed that bulky disease (P = 0.02) and high IPI scores (P ≤ 0.05) were significantly associated with poorer survival outcomes.

Discussion: The study highlights the prevalence of DLBCL among the elderly, with a peak incidence in the seventh decade of life. Despite presenting primarily in early stages with low IPI scores, the prognosis remains guarded, especially for those with bulky disease and high IPI scores. The addition of rituximab to chemotherapy regimens has improved survival rates, but the prognosis for elderly patients is still influenced by comorbidities and disease characteristics.Dose adjustment were needed in a good number of patients.

Recent advancements in treatment options, such as the inclusion of polatuzumab in 2024, may improve overall survival rates. However, this study's small cohort size underscores the need for detailed analyses in larger cohorts to validate these findings. While other drugs like lenalidomide and BTK inhibitors were trialed, they did not prove particularly useful in this scenario. Notably, seven patients underwent BEAM autografts, reflecting the ongoing exploration of varied therapeutic approaches.

The recent availability of Indian CAR T-cell therapy offers a promising future direction and may significantly impact treatment outcomes in the coming years. Future studies should incorporate genetic and molecular profiling to better understand the disease's behavior and response to treatment in the elderly.

Conclusion: DLBCL in the elderly presents unique challenges, with a significant proportion presenting with advanced-stage disease and comorbid conditions that impact treatment outcomes. The incorporation of rituximab into treatment regimens has shown positive effects on survival. However, ongoing research and tailored therapeutic approaches, including new treatments like polatuzumab and CAR T-cell therapy, are necessary to improve outcomes for this vulnerable population.

No relevant conflicts of interest to declare.