Published online Feb 27, 2020. doi: 10.4254/wjh.v12.i2.34
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
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.
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.
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.
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.
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.
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.
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.