Prognostic Indices and NLR in DLBCL at a Comprehensive Cancer Center in Colombia
Authors: Lombana Milton , Gonzalez Guido , Avila Juan Carlos , Cancelado Jacome Sergio Andres 
Published: December 2024

Background
In pts with DLBCL, the use of the IPI is correlated with OS in Colombian population. NCCN-IPI prognostic index is associated with favorable OS with better prognostic performance than IPI and R-IPI. The use of neutrophil to lymphocyte ratio (NLR) has been validated as a prognostic marker in Latin American population.There are no studies in Colombia that validate if the joint use of these prognostic factors improves the prediction of PFS and OS outcomes.
Methods
We identified pts with adequate clinical information managed at the Comprehensive Cancer Center of the Clínica de Occidente in Cali, Colombia, with diagnosis of DLBCL between the years January 2014 to december 2023. Our primary objective was to determine the prognosis impact of risk scores and other clinical relevant variables in outcomes OS and PFS. We performed Kaplan Meier, and cox regression for survival analysis in STATA 16.
Results
We identified 314 pts with DLBCL, of whom 176 had complete information and were evaluated for survival analysis.
Median age was 65y (20-99), 52% were female, 35% live in rural areas or non-capital cities, 74% had mixed health insurance (private + subsidized by state), PS ECOG was 0-1 in 74%. Subtype cell of origin (by Hans algorithm) was GCB in 53%, stage III/IV 62%. Most frequent extranodal involvement was bone marrow (18%), gastrointestinal (11%), pleuropulmonary (3%), breast (3%), CNS (2%), and others (5%). PET/CT was used in 68% of pts. It was obtained complete response in 84%, partial response 7%, stable disease 1% and progressive disease in 8% of evaluated pts.
NLR 4 (OR 3.26, 95% CI 1.05-10.71, P=0.019) and extranodal involvement (OR 3.52, 95% CI 0.93-19.69, P=0.04) were associated with an increased risk of non-complete response.
Median PFS was 45months and 5y PFS 47% for the entire cohort. Hypertension (HR 1.64, P=0.03), diabetes (HR 2.19, P=0.04), other malignant neoplasms (HR 1.51, P=0.00), and renal disease (HR 5.3, P=0.02) were significantly associated with increased risk of progression.
In the prognostic indices, both IPI Score (HR 1.73 95% CI 1.37-2.17, P=0.0001), R-IPI (HR 2.12 95% CI 1.40-3.20, P=0.002) and NCCN-IPI (HR 2.19 95% CI 1.62-2.96, P=0.0001) impacted the PFS significantly, with no major differences between them by ROC analysis (IPI AUC 0.70; R-IPI AUC 0.67; NCCN-IPI AUC 0.71).
The NLR 6 (HR 1.42, P=0.15), and ABC subtype (HR 1.48, P=0.10) were associated with an increased risk of relapse, not statistically significant.
5y PFS was 36% in ABC vs 57% in GCB. By NCCN-IPI was 92% in low, 64% Low-Intermediate, 34% High-Intermediate and 20% in High .
Median OS was not reached and 5y OS was 55%. Hypertension (HR 1.94 P=0.01), diabetes (HR 2.74, P=0.01), other malignant neoplasms (HR 5.76, P=0.01), and renal disease (HR 6.1, P=0.01) were significantly associated with increased risk of death.
IPI Score (HR 1.96 95% CI 1.53-2.48, P=0.0001), R-IPI (HR 2.62 95% CI 1.70-4.04, P=0.001) and NCCN-IPI (HR 2.45 95% CI 1.81-3.32, P=0.0001) impacted OS significantly, without major differences between them by ROC analysis (IPI AUC 0.72, R-IPI AUC 0.68, NCCN-IPI AUC 0.74).
NLR 6 was associated with an increased risk of death (HR 1.69, 95% CI 1.04-2.73, P=0.037). ACB subtype (HR 1.24, P=0.37) was associated with an increased risk of death, but not statistically significant.
In the multivariate analysis only renal disease, diabetes and prognostic score indices (NCCN-IPI or IPI or R-IPI) were significantly associated with increased risk of death.
By risk score indices 5y OS was 92% in low, 73% Low-Intermediate, 39% High-Intermediate and 25% in High NCCN-IPI.
5y OS and 5y PFS were 100% in pts with NCCN-IPI low and NLR &lt;6 or NCCN-IPI and GCB subtype, but PFS was only 66% in NCCN-IPI low with ABC subtype or 50% with NCCN-IPI low and NLR 6.
Conclusions
In this cohort of pts, the use of NCCN-IPI combined with NLR or molecular subtype identified a population with a very good prognosis (5y 100% OS and PFS) managed with rituximab-based chemotherapy regimens. These data need to be validated in additional independent and larger cohorts, and they could be used to make therapeutic decisions that avoid the need to escalate treatments in this subgroup of pts, but with the consideration of upgrade to more efficacy therapeutic protocols in those patients who do not meet these criteria. Especially considering that the relapse management options in our country are limited (Non availability of bi-conjugated antibodies or cell therapies with CART-Cells).