Peripheral T-cell lymphoma in older patients: a narrative review of initial and subsequent treatments and clinical outcomes

Background and Objective: The mature T-cell and NK-cell neoplasms (MTNKNs), a group which encompasses the peripheral T-cell lymphomas (PTCLs), are a rare and heterogeneous group of mature lymphoid neoplasms characterized in most cases by their aggressive nature and poor prognoses. Given the aggressive nature and advanced age at which these diseases present, a more comprehensive understanding of treatment approaches and outcomes in older patients is urgently needed. The aim of this review is to summarize important considerations when treating older patients and provide a comprehensive overview of the current evidence and highlight gaps in knowledge and opportunities for future research. Initial and subsequent treatment options will be reviewed along with treatment outcomes, with a particular focus on treatment efficacy and treatment-related adverse events (AEs) in patients >60 years old. Methods: We surveyed the five highest ranked biomedical databases (Wiley, EMBASE, PubMed/MEDLINE, Cochrane Library, Clinical Key) for original research articles published after January 1, 1990 pertaining to the topic of interest. We independently analyzed and interpreted the data from each article by strictly following pre-determined eligibility criteria. Studies in patients 60 years or older were emphasized where available, as well as studies where a significant proportion of patients were in this age category. Key Content and Findings: We present a narrative review of historical and contemporary studies examining the approach to treatment-naïve and relapsed/refractory (R/R) MTNKN in older patients with primarily the most common nodal subtypes of MTNKN, including PTCL, not otherwise specified (PTCL-NOS), systemic anaplastic large T-cell lymphoma (ALCL), angioimmunoblastic T-cell lymphoma (AITL), and PTCL with T-follicular helper phenotype (TFh-PTCL). Conclusions: Careful identification of older patients who are fit to receive intensive therapies is a critical first step in optimizing outcomes. Geriatric assessment (GA) tools can aid in selecting patients suited for such an approach. Initial therapy with anthracycline-based regimens, incorporating subtype-specific targeted agents where possible [e.g., brentuximab vedotin (Bv)], followed by consideration of hematopoietic stem cell transplantation (HSCT) in highly selected individuals continues to offer the best chance at durable remission. For patients not fit for such an approach, treatment with emerging novel agents should be prioritized. Otherwise, palliative approaches with gemcitabine or bendamustine-based regimens or oral metronomic regimens can provide clinical benefit for selected patients.