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Body mass index as a prognostic factor in Asian patients treated with chemoimmunotherapy for diffuse large B cell lymphoma, not otherwise specified

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Abstract

Obesity was recently reported to confer a survival advantage in diffuse large B cell lymphoma (DLBCL) among Western populations. Given ethnic differences, previous studies recommended a revision of the WHO classification of obesity for Asians. We investigated the prognostic impact of body mass index (BMI) using modified WHO criteria in a retrospective cohort of 562 Korean patients with DLBCL. Patients were categorized into five groups according to BMI: 26 (4.6 %) as underweight (<18.5 kg/m2), 230 (40.9 %) as normal weight (18.5–22.9 kg/m2), 129 (23.0 %) as overweight (23.0–24.9 kg/m2), 160 (28.5 %) as obese (25.0–29.9 kg/m2), and 17 (3.0 %) as severely obese (≥30 kg/m2). As BMI increased, the relative hazard ratio (HR) decreased sharply, reaching the lowest value in the overweight group, and then rose again in the obese and severely obese. On univariate analysis, both overall survival (OS) and progression-free survival (PFS) were best in the overweight group, followed by normal > obese > severely obese > underweight groups. Multivariate analysis showed a significantly shorter survival in the underweight (OS: HR 2.90, 95 % confidence interval (CI) 1.35–6.19, P = 0.006; PFS: HR 3.08, 95 % CI 1.55–6.09, P = 0.001) and severely obese groups (OS: HR 2.93, 95 % CI 1.08–7.95, P = 0.035; PFS: HR 2.59, 95 % CI 1.06–6.36, P = 0.038). We show that being underweight or, contrary to findings in Western patients, being severely obese has a deleterious prognostic impact in DLBCL in Koreans. Revising the BMI criterion that defines obesity according to the patient’s ethnic differences could therefore better delineate DLBCL risk groups in Asian patients.

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Acknowledgments

This study was partly supported by a grant (2015-090) from Asan Institute for Life Sciences, Seoul, Korea.

Conflict of interest

The authors declare no conflict of interest.

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Authors and Affiliations

  1. Department of Pathology, University of Ulsan College of Medicine, Asan Medical Center, 88, Olympic-ro 43-gil, Seoul, 138-736, Korea

    Hee Sang Hwang & Jooryung Huh

  2. Department of Oncology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea

    Dok Hyun Yoon & Cheolwon Suh

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  1. Hee Sang Hwang
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Correspondence to Jooryung Huh.

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Online resource 1

The restricted cubic spline plots according to the (a) height and (b) weight. The horizontal dotted line in the restricted cubic spline plots indicates the baseline hazard ratio (=1), and the vertical dotted line indicates the cutoff values between BMI groups. The gray-filled area indicates the 95 % confidence interval. P model indicates the P-value of the Cox regression model calculated by likelihood ratio test. (GIF 57 kb)

High resolution image (TIFF 4867 kb)

Online resource 2

Plots of Martingale residuals with smoothing curves of the Cox models applying various BMI cutoff criteria. (a) The residual plot of the ‘null’ Cox model, which did not contain the BMI category as the predictive variable. The smoothing curve exhibits a descent-ascent pattern, similar to that seen in the restricted cubic spline plot shown in Fig. 1a. (b) The residual plot of the Cox model applying the five-tiered BMI category (underweight, <18.5 kg/m2; normal weight, 18.5–22.9 kg/m2; overweight, 23.0–24.9 kg/m2; obesity, 25.0–29.9 kg/m2; and severe obesity, ≥30.0 kg/m2) as predictive variables. In contrast to the pattern shown in (a), the smoothing curve remains close to the baseline (dotted line), meaning that this model may predict the effect of BMI with a smaller chance of over- and/or underprediction. (c and d) The residual plots of Cox models applying the dichotomized BMI classifications (cutoff values, 20 kg/m2 or 25 kg/m2) show smoothing curves floating above the baseline at both extremes, meaning that these models would underpredict the effect of BMI. Abbreviations: BMI, body mass index. (GIF 141 kb)

High resolution image (TIFF 10947 kb)

Online resource 3

The Kaplan-Meier survival curve according to the (a, b, e and f) height and (c, d, g and h) weight quartile groups. The whole patients were separated into two sexual groups and individually analyzed. Note the plot (d) and (h) showing that the weight quartile 3 group was likely to show better prognosis than the other groups in female patients. However, this pattern did not displayed in male patients. (GIF 84 kb)

High resolution image (TIFF 2804 kb)

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Hwang, H.S., Yoon, D.H., Suh, C. et al. Body mass index as a prognostic factor in Asian patients treated with chemoimmunotherapy for diffuse large B cell lymphoma, not otherwise specified. Ann Hematol 94, 1655–1665 (2015). https://doi.org/10.1007/s00277-015-2438-4

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