Dose-intensive chemoimmunotherapy may be more effective than standard chemoimmunotherapy as frontline treatment for primary mediastinal B-cell lymphoma (PMBCL), a meta-analysis suggests.

Researchers found that dose-intensive chemoimmunotherapy prolonged overall survival (OS) and progression-free survival (PFS) while reducing the use of radiation. These findings were published in Haematologica.

The researchers reviewed data from 4068 patients with PMBCL enrolled in 11 prospective and 41 retrospective studies. The patients were divided into a dose-intensive chemoimmunotherapy cohort (n=2517) and a standard chemoimmunotherapy cohort (n=1551). The median follow-up was 56 months for both cohorts.

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In the standard cohort, 456 patients received CHOP-21 (cyclophosphamide, doxorubicin, vincristine, and prednisone over 21 days), and 1095 patients received rituximab plus CHOP-21 (R-CHOP-21).

In the dose-intensive cohort, the most common regimen (n=670) was da-EPOCH-R (dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, and rituximab). The second most common regimens (n=458) were VACOP-B or MACOP-B (etoposide or methotrexate plus doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin), with or without rituximab.


The pooled OS rate was 88% with dose-intensive chemoimmunotherapy and 80% with standard chemoimmunotherapy (P <.01). The pooled PFS rate was 83% and 72%, respectively (P <.01).

Patients in the standard chemoimmunotherapy cohort were more likely than those in the dose-intensive cohort to receive consolidative mediastinal radiotherapy — 55% and 22%, respectively (P <.01).

When the researchers compared rituximab-based regimens, they found a 91% OS rate with rituximab-based dose-intensive chemoimmunotherapy and an 86% OS rate with R-CHOP-21 (P =.03).

The researchers also compared da-EPOCH-R to R-CHOP-21 and found no significant differences in OS and PFS but a significant difference in radiation use. The OS rate was 90% with da-EPOCH-R and 86% with R-CHOP-21. The PFS rate was 83% and 77%, respectively. The proportion of patients who received radiation was 13% and 57%, respectively (P <.01).   

Based on these results, the researchers hypothesized that the intensity of the chemotherapy backbone is “vital” to achieving the best outcome. The researchers also theorized that the lower radiation exposure in the dose-intensive cohort could reduce the risk of secondary malignancy and ischemic heart disease. However, the follow-up period was too short to evaluate these outcomes.

“Our findings — as we await prospective randomized data — suggest that dose-intensive CIT [chemoimmunotherapy] alone should be the preferred approach in the management of patients with newly diagnosed PMBCL,” the researchers wrote.

Disclosures: Some study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of disclosures.


Cook MR, Williams LS, Dorris CS, et al. Improved survival for dose-intensive chemotherapy in primary mediastinal B-cell lymphoma: A systematic review and meta-analysis of 4068 patients. Haematologica. Published online August 31, 2023. doi:10.3324/haematol.2023.283446