International Prognostic Index
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
The International Prognostic Index (IPI) is a clinical tool developed by oncologists to aid in predicting the prognosis of patients with aggressive non-Hodgkin's lymphoma. Prior to 1993, when the IPI was developed, the primary consideration in assessing prognosis was the Ann Arbor stage alone, but this was increasingly found to be an inadequate means of predicting survival outcomes, and so other factors were studied.
A retrospective analysis was performed on 2031 patients with aggressive non-Hodgkin's lymphoma, of all ages, treated with a doxorubicin-based chemotherapy regimen such as CHOP between 1982 and 1987.[1] Several patient characteristics were analyzed to determine whether they were associated with differences in survival, and the factors that emerged as significant were, in addition to the Ann Arbor stage: age, elevated serum lactate dehydrogenase (LDH), performance status, and number of extranodal sites of disease.
International Prognostic Index
One point is assigned for each of the following risk factors:
- Age greater than 60 years
- Stage III or IV disease
- Elevated serum LDH
- ECOG/Zubrod performance status of 2, 3, or 4
- More than 1 extranodal site
The sum of the points allotted correlates with the following risk groups:
- Low risk (0-1 points) - 5-year survival of 73%
- Low-intermediate risk (2 points) - 5-year survival of 51%
- High-intermediate risk (3 points) - 5-year survival of 43%
- High risk (4-5 points) - 5-year survival of 26%
Although the IPI has shown itself to be a useful clinical tool, widely used by oncologists and a mainstay of risk stratification in clinical trials for lymphoma, it should be kept in mind that it was developed prior to the use of rituximab, which is now included with anthracycline-based combination chemotherapy as of the standard of care in B-cell lymphomas (the majority of non-Hodgkin's lymphomas). Rituximab has dramatically improved the outcomes of lymphoma patients, and its effect on the prognostic value of the IPI is uncertain.
Follicular Lymphoma International Prognostic Index (FLIPI)
Given the success of the IPI for intermediate grade lymphomas, an effort was undertaken to develop a similar prognostic index for the most common low-grade lymphoma, follicular lymphoma. The prognostic factors that emerged from this were: age, stage, number of lymph node areas involved, serum hemoglobin level, and serum LDH.[2]
One point is assigned for each of the following adverse prognostic factors:
- Age greater than 60 years
- Stage III or IV disease
- Greater than 4 lymph node groups involved
- Serum hemoglobin less than 12 g/dL
- Elevated serum LDH
The sum of the points allotted correlates with the following risk groups:
- Low risk (0-1 points) - 5 and 10-year survivals of 91% and 71%, respectively
- Intermediate risk (2 points) - 5 and 10-year survivals of 78% and 51%, respectively
- High risk (3-5 points) - 5 and 10-year survivals of 53% and 36%, respectively