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    International Prognostic Index for Diffuse Large B-cell Lymphoma (IPI and R-IPI)

    Predicts overall and progression-free survival in DLBCL based on risk factors.
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    INSTRUCTIONS

    Note: IPI results are included for historical comparisons only. Use in CD20+ DLBCL patients. Do not use in patients with HIV, secondary malignancies, low grade lymphoproliferative disorders, or comorbidities precluding curative therapy attempt.

    When to Use
    Pearls/Pitfalls
    Why Use

    Use in CD20+ DLBCL patients. Do not use in patients with HIV, secondary malignancies, low grade lymphoproliferative disorders, or comorbidities precluding curative therapy attempt.

    • The International Prognostic Index for Diffuse Large B-cell Lymphoma (IPI and R-IPI) estimates 4-year progression-free survival and 4-year overall survival for patients with diffuse large B-cell non-Hodgkin’s lymphoma (DLBCL).
    • The R-IPI provides greater discrimination amongst DLBCL patients with differing survival based on easily obtained factors.
    • Does not identify any risk group with 4-year survival <50%; hence, other molecular or genetic markers are being researched to help select the worst-outcome patients for alternative treatment/clinical trials.

    Using the same criteria as the older International Prognostic Index (IPI), the revised IPI (R-IPI) discriminates among three different prognostic groups (versus two by IPI), providing more clinical relevance.

    ≤60 years
    0
    >60 years
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1
    No
    0
    Yes
    +1

    Result:

    Please fill out required fields.

    Next Steps
    Evidence
    Creator Insights

    Management

    Patients with poor prognosis should be strongly considered for clinical trial enrollment and tertiary center referral for investigational therapy.

    Critical Actions

    Correct staging and selecting correct performance status are the most potentially difficult factors.

    Formula

    Addition of the selected points:

     

    0 points

    1 point

    Age

    ≤60

    >60 years

    Ann Arbor stage*

    Stage I or II (localized disease)

    Stage III or IV (advanced disease)

    ECOG performance status

    0 or 1

    ≥2

    Serum LDH

    ≤1× normal

    >1× normal

    Extranodal sites

    ≤1

    >1

    *Ann Arbor stages: 

    I

    Involvement of a single lymph node region or lymphoid structure (e.g. spleen, thymus, Waldeyer’s ring)

    II

    Involvement of two or more lymph node regions on the same side of the diaphragm

    III

    Involvement of lymph regions or structures on both sides of the diaphragm

    IV

    Involvement of extranodal site(s) beyond that designated E (see below)

    For all stages

    A

    No symptoms

    B

    Fever (38ºC), drenching sweats, weight loss (10% body weight over 6 months)

    For stages I to III

    E

    Involvement of a single, extranodal site contiguous or proximal to known nodal site

     

    Facts & Figures

    Interpretation:

     

    Risk group

    4-year overall survival, %

    4-year progression-free survival, %

    R-IPI

    0

    Very good

    94

    94

    1–2

    Good

    79

    80

    3–5

    Poor

    55

    53

    IPI

    0–1

    Low

    82

    85

    2

    Low-intermediate

    81

    80

    3

    High-intermediate

    49

    57

    4–5

    High

    59

    51

    Note: IPI is listed for historical comparison only.

    Evidence Appraisal

    The R-IPI evolved from a retrospective study of 365 patients at least 16 years of age with newly diagnosed DLBCL treated in British Columbia with R-CHOP prior to 2005. There was central pathology review in 95% of cases. Patients were followed for 7–64 months after 6–8 cycles of R-CHOP. Progression-free survival (PFS) and overall survival (OS) outcomes were calculated using conventional IPI for comparison. Risk factors were then redistributed to create a more meaningful stratification grouping.

    The utility of the R-IPI has been validated in the following studies:

    • El-Galaly et al 2015:
      • Authors also looked at impact of PET staging, not routinely used during IPI/R-IPI development, for prognosis, and concluded R-IPI showed high accuracy in PET era as well.
    • Olszewski et al 2015:
      • The R-IPI validated via cancer registry data of 19,511 patients (of 119,942 patient pool). Noted that the IPI and R-IPI account for only 16% of survival variation, suggesting molecular markers be evaluated and incorporated into future prognostic indexes.
    • Bari et al 2010:
      • Retrospective study of 831 patients from two Italian registries. Confirmed IPI less useful in rituximab era, and validated use of R-IPI, noting still did poorly in worst prognosis patients.

    The original and validation articles address the lack of recognition of the poorest prognosis patients, and this is an area of active research.

    Literature

    Validation

    Research PaperEl-galaly TC, Villa D, Alzahrani M, et al. Outcome prediction by extranodal involvement, IPI, R-IPI, and NCCN-IPI in the PET/CT and rituximab era: A Danish-Canadian study of 443 patients with diffuse-large B-cell lymphoma. Am J Hematol. 2015;90(11):1041-6.Research PaperOlszewski AJ, Winer ES, Castillo JJ. Validation of clinical prognostic indices for diffuse large B-cell lymphoma in the National Cancer Data Base. Cancer Causes Control. 2015;26(8):1163-72.Research PaperBari A, Marcheselli L, Sacchi S, et al. Prognostic models for diffuse large B-cell lymphoma in the rituximab era: a never-ending story. Ann Oncol. 2010;21(7):1486-91.Research PaperBlay J, Gomez F, Sebban C, et al. The International Prognostic Index correlates to survival in patients with aggressive lymphoma in relapse: analysis of the PARMA trial. Parma Group. Blood. 1998;92(10):3562-8.Research PaperFanin R, Silvestri F, Geromin A, et al. Autologous stem cell transplantation for aggressive non-Hodgkin's lymphomas in first complete or partial remission: a retrospective analysis of the outcome of 52 patients according to the age-adjusted International Prognostic Index. Bone Marrow Transplant. 1998;21(3):263-71.Research PaperFoussard C, Desablens B, Sensebe L, et al. Is the International Prognostic Index for aggressive lymphomas useful for low-grade lymphoma patients? Applicability to stage III-IV patients. The GOELAMS Group, France. Ann Oncol. 1997;8 Suppl 1:49-52.Research PaperHermans J, Krol AD, Van groningen K, et al. International Prognostic Index for aggressive non-Hodgkin's lymphoma is valid for all malignancy grades. Blood. 1995;86(4):1460-3.
    Dr. Laurie H. Sehn

    About the Creator

    Laurie H. Sehn, MD, is a medical oncologist at the British Columbia Cancer Agency and a clinical associate professor at the University of British Columbia. She is on the Board of Directors and is the director of research fellowships for the Lymphoma Foundation Canada (LFC). Dr. Sehn is an active researcher studying aspects of lymphoid cancers.

    To view Dr. Laurie H. Sehn's publications, visit PubMed

    Content Contributors
    About the Creator
    Dr. Laurie H. Sehn
    Content Contributors