Case Control Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World Journal of Hepatology. Feb 27, 2020; 12(2): 34-45
Published online Feb 27, 2020. doi: 10.4254/wjh.v12.i2.34
Clinical characteristics and treatment outcomes in patients with liver cirrhosis and lymphoma
José A González-Regueiro, Astrid Ruiz-Margáin, Mariana Cruz-Contreras, Ana M Montaña-Duclaud, Andrea Cavazos-Gómez, Roberta Demichelis-Gómez, Ricardo U Macías-Rodríguez
José A González-Regueiro, Astrid Ruiz-Margáin, Mariana Cruz-Contreras, Ana M Montaña-Duclaud, Andrea Cavazos-Gómez, Ricardo U Macías-Rodríguez, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
Roberta Demichelis-Gómez, Department of Hematology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City 14080, Mexico
Author contributions: González-Regueiro JA and Ruiz-Margáin A contributed equally to this article; González-Regueiro JA, Demichelis-Gómez R, Ruiz-Margáin A and Macías-Rodríguez RU contributed to study conception and design; González-Regueiro JA, Cruz-Contreras M, Montaña-Duclaud AM and Cavazos-Gómez A contributed to acquisition of clinical data from medical records; Ruiz-Margáin A and Macías-Rodríguez RU performed the analysis of data and contributed with critical revisions for the content of the manuscript; González-Regueiro JA, Cruz-Contreras M, Montaña-Duclaud AM, Cavazos-Gómez A, Demichelis-Gómez R, Ruiz-Margáin A and Macías-Rodríguez RU contributed to interpretation of data and writing the final version of the article to be published.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of the Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (INCMNSZ) (Ref. No. “2914”).
Informed consent statement: Given the retrospective design of this study, patients were not required to provide informed consent as the data was obtained from medical records after the completion of treatment.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
STROBE statement: The guidelines of the STROBE statement have been adopted.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Ricardo U Macías-Rodríguez, MD, MSc, PhD, Assistant Professor, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, Belisario Domínguez Sección XVI, Tlalpan, Mexico City 14080, Mexico. ricardomacro@yahoo.com.mx
Received: September 10, 2019
Peer-review started: September 10, 2019
First decision: September 26, 2019
Revised: November 21, 2019
Accepted: December 19, 2019
Article in press: December 19, 2019
Published online: February 27, 2020
Processing time: 169 Days and 15.2 Hours
ARTICLE HIGHLIGHTS
Research background

A significant number of patients with liver cirrhosis concomitantly develop some type of solid or hematological cancer, including lymphoma. Treatment of patients with lymphoma and cirrhosis is challenging for physicians due to the clinical characteristics related to cirrhosis and lack of scientific evidence, limiting the use of chemotherapy. Currently, experts recommend only offering oncological treatment to patients with compensated cirrhosis and the best supportive care to those in a decompensated state.

Research motivation

The treatment of lymphomas in patients with cirrhosis is a difficult task, and even the involvement of a multidisciplinary team may still not be enough, considering the lack of published literature about clinical outcomes, the narrow therapeutic index of the drugs and the safety issues that are typical in these patients. A study that evaluates treatment with chemotherapy in patients with cirrhosis and lymphoma is necessary to address this knowledge gap.

Research objectives

To evaluate the clinical characteristics and treatment outcomes (type of chemotherapy regimen, response rate and complications derived from it, and survival) in patients with cirrhosis and lymphoma treated with chemotherapy to generate scientific evidence in this regard.

Research methods

This was a case-control study conducted at a tertiary care center in Mexico. Data was recorded from medical files from 2000 through 2018, and from 8658 possible candidates with cirrhosis and/or lymphoma, only 23 cases had both diseases concomitantly; 10 patients with cirrhosis and lymphoma (cases) met the selection criteria and were included, and 20 patients with lymphoma (controls) were included and matched according to age, sex, and date of diagnosis, type and clinical stage of lymphoma. All patients received treatment with chemotherapy. For statistical analysis, descriptive statistics, Shapiro-Wilk test, Mann-Whitney U test, chi-square test and Fisher's exact test were used. Survival was evaluated using Kaplan-Meier curves and the log-rank test.

Research results

There were differences in biochemical variables inherent to liver disease and portal hypertension in patients with cirrhosis. The most frequent etiology of cirrhosis was hepatitis C virus (50%); 80% were decompensated, the median Child-Turcotte-Pugh score was 7.5 (6.75-9.25), and mean Model for End-stage Liver Disease was 11.5 ± 4.50. Regarding lymphomas, non-Hodgkin's were the most common (90%), and diffuse large B cell subtype was the most frequent, with a higher International Prognostic Index in the cases (3 vs 2, P = 0.049). The chemotherapy regimens had to be adjusted more frequently in the case group (50% vs 5%, P = 0.009). The complications derived from chemotherapy were similar between both groups (80% vs 90%, P = 0.407); however, non-hematological toxicities were more common in the case group (30% vs 0%, P = 0.030). There was no difference in the response to treatment between groups. Survival was higher in the control group (56 wk vs 30 wk, P = 0.269), although it did not show statistical significance. This study included mainly decompensated patients with cirrhosis and lymphoma with acceptable treatment outcomes.

Research conclusions

The clinical characteristics of patients with lymphoma and cirrhosis are similar to those with lymphoma, except for some changes inherent to cirrhosis. It may be possible to administer chemotherapy in selected cirrhotic patients, regardless of their severity, obtaining satisfactory clinical outcomes.

Research perspectives

We propose that lymphoma treatment can be provided in patients with cirrhosis at any clinical state without neglecting their safety, although more prospective clinical trials are needed to generate stronger recommendations and better establish safety margins.