Impact of etoposide and ASCT on survival among patients aged < 65 years with stage II to IV PTCL: a population-based cohort study

Patients <65 years with peripheral T-cell lymphoma are treated with cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP). While the addition of etoposide and consolidation with autologous stem cell transplantation (ASCT) are preferred in some countries, randomized trials are lacking. This nationwide population-based study assessed the impact of etoposide and ASCT on overall survival (OS) among patients aged 18-64 years with stage II-IV anaplastic large T-cell lymphoma (ALCL), angioimmunoblastic T-cell lymphoma (AITL) and peripheral T-cell lymphoma not otherwise specified (PTCL-NOS), diagnosed between 1989-2018, utilizing the Netherlands Cancer Registry. Patients were categorized into two calendar periods, which represent the pre- and post-era of etoposide and ASCT implementation, respectively. A total of 1,427 patients were identified (35% ALCL, 21% AITL and 44% PTCL-NOS). OS increased from 39% in 1989-2009 to 49% in 2009-2018 (p<0·01). The 5-year OS was superior for patients treated with CHOEP, as compared to patients with CHOP (64% and 44%, respectively; p<0·01). When adjusted for subtype, IPI-score, and ASCT, the risk of mortality was similar between the two groups, except for ALK+ ALCL patients for whom risk of mortality was 6.3 times higher when treated with CHOP as compared to CHOEP. Patients consolidated with ASCT demonstrated a superior 5-year OS of 81% as compared to 39% for patients not receiving an ASCT (p<0·01), regardless of whether a complete remission was achieved. In patients <65 years with advanced stage ALK- ALCL, AITL and PTCL, the use of ASCT consolidation, but not the addition of etoposide, was associated with improved OS.