1
|
Carranza J, Fatobene G, Otuyama LJ, Dos Santos JG, Cordeiro AC, Mariano L, Rocha V. Early Toxicity and Efficacy of Four Different Conditioning Regimens for Autologous Hematopoietic Cell Transplantation in Patients With Lymphoma: Impact of Drug Shortages in a Resource-Constrained Country. Transplant Cell Ther 2024:S2666-6367(24)00555-4. [PMID: 39097096 DOI: 10.1016/j.jtct.2024.07.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 06/22/2024] [Accepted: 07/28/2024] [Indexed: 08/05/2024]
Abstract
High-dose therapy followed by autologous hematopoietic cell transplant (AHCT) remains a viable consolidation strategy for a subset of patients with relapsed or refractory (R/R) lymphomas. BEAM (carmustine, etoposide, cytarabine, and melphalan) is widely recognized as the predominant conditioning regimen due to its satisfactory efficacy and tolerability. Nevertheless, shortages of carmustine and melphalan have compelled clinicians to explore alternative conditioning regimens. The aim of this study was to compare the toxicity and transplant outcomes following BEAM, CBV (carmustine, etoposide, cyclophosphamide), BuMel (busulfan, melphalan), and BendaEAM (bendamustine, etoposide, cytarabine, melphalan). We retrospectively analyzed data from 213 patients (CBV 65, BuMel 42, BEAM 68, BendaEAM 38) with R/R lymphomas undergoing AHCT between 2014 and 2020. Multivariate models were employed to evaluate toxicity and transplant outcomes based on conditioning type. Among grade III to IV toxicities, oral mucositis was more frequently observed with BuMel (45%) and BendaEAM (24%) compared to BEAM (15%) and CVB (6%, P ≤ .001). Diarrhea was more common with BendaEAM (42%) and less frequent with BuMel (7%, P = .01). Acute kidney injury was only found after BendaEAM (11%). Febrile neutropenia and infectious complications were more frequent following BendaEAM. Frequencies of other treatment-related toxicities did not significantly differ according to conditioning type. BendaEAM (odds ratio [OR] 3.07, P = .014) and BuMel (OR 4.27, P = .002) were independently associated with higher grade III to IV toxicity up to D+100. However, there were no significant differences in relapse/progression, nonrelapse mortality, progression-free survival, or overall survival among the four regimens. BuMel and BendaEAM were associated with a higher rate of grade III to IV toxicity. Carmustine-based regimens appeared to be less toxic and safer; however, there were no significant differences in transplant outcomes. The utilization of alternative preparative regimens due to drug shortages may potentially lead to increased toxicity after AHCT for lymphoma.
Collapse
Affiliation(s)
- Jhonny Carranza
- Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Servicio de Hematología y Hemoterapía, Hospital Vozandes, Quito, Ecuador
| | - Giancarlo Fatobene
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Vila Nova Star-Rede D'Or, São Paulo, Brazil.
| | - Leonardo Jun Otuyama
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Joaquim Gasparini Dos Santos
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Ana Costa Cordeiro
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hematology Departament AC Camargo Cancer Center, São Paulo, Brazil
| | - Livia Mariano
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Centro Paulista de Oncologia-Oncoclínicas, São Paulo, Brazil
| | - Vanderson Rocha
- Laboratório de Investigação Médica (LIM) 31, Universidade de São Paulo, São Paulo, Brazil; Serviço de Hematologia, Hemoterapia e Terapia Celular, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil; Hospital Vila Nova Star-Rede D'Or, São Paulo, Brazil; Department of Hematology, Churchill Hospital Oxford, Oxford University Hospitals, Oxford, UK
| |
Collapse
|
2
|
Wang R, Shangguan X, Zhu Z, Cong D, Bai Y, Zhang W. BeEAM vs. BEAM: evaluating conditioning regimens for autologous stem cell transplantation in patients with relapsed or refractory DLBCL. Ann Hematol 2024; 103:2455-2462. [PMID: 38809456 DOI: 10.1007/s00277-024-05813-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2024] [Accepted: 05/22/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE To evaluate whether BeEAM is an alternative to BEAM for autologous stem cell transplantation (ASCT) in patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL). METHODS Data of 60 patients with relapsed or refractory DLBCL who underwent ASCT from January 2018 to June 2023 in our center, including 30 patients in the BeEAM group and 30 patients in the BEAM group, were retrospectively analyzed. The time to hematopoietic reconstitution, treatment-related adverse events, number of hospitalization days, hospitalization cost, and survival benefit were compared between the two groups. RESULTS The clinical characteristics of the patients did not significantly differ between the two groups. The median number of reinfused CD34 + cells was 5.06 × 106/kg and 5.17 × 106/kg in the BeEAM and BEAM groups, respectively, which did not significantly different (p = 0.8829). In the BeEAM and BEAM groups, the median time to neutrophil implantation was 10.2 and 10.27 days, respectively (p = 0.8253), and the median time to platelet implantation was 13.23 and 12.87 days, respectively (p = 0.7671). In the BeEAM and BEAM groups, the median hospitalization duration was 30.37 and 30.57 days, respectively (p = 0.9060), and the median hospitalization cost was RMB 83,425 and RMB 96,235, respectively (p = 0.0560). The hospitalization cost was lower in the BeEAM group. The most common hematologic adverse events were grade ≥ 3 neutropenia and thrombocytopenia, whose incidences were similar in the two groups. The most common non-hematologic adverse events were ≤ grade 2 and the incidences of these events did not significantly differ between the two groups. Median overall survival was not reached in either group, with predicted 5-year overall survival of 72.5% and 60% in the BeEAM and BEAM groups, respectively (p = 0.5872). Five-year progression-free survival was 25% and 20% in the BeEAM and BEAM groups, respectively (p = 0.6804). CONCLUSION As a conditioning regimen for relapsed or refractory DLBCL, BeEAM has a desirable safety profile and is well tolerated, and its hematopoietic reconstitution time, number of hospitalization days, and survival benefit are not inferior to those of BEAM. BeEAM has a lower hospitalization cost and is an alternative to BEAM.
Collapse
Affiliation(s)
- Ruiqi Wang
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Xinghe Shangguan
- Department of Hematology, The First Affiliated Hospital of Dalian Medical University, 222 Zhongshan Road, Dalian, 116021, China
| | - Zhenxing Zhu
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Dan Cong
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Yuansong Bai
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China
| | - Wenlong Zhang
- Department of Hematology and Oncology, China-Japan Union Hospital of Jilin University, Changchun, 130033, China.
| |
Collapse
|
3
|
Keil F, Müller AM, Berghold A, Riedl R, Buxhofer-Ausch V, Schuster J, Vorburger C, Böhm A, Panny M, Nösslinger T, Greil R, Samaras P, Bencker C, Rütti M, Pabst T. BendaEAM versus BEAM as conditioning regimen for ASCT in patients with relapsed lymphoma (BEB): a multicentre, randomised, phase 2 trial. EClinicalMedicine 2023; 66:102318. [PMID: 38024477 PMCID: PMC10679477 DOI: 10.1016/j.eclinm.2023.102318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 10/23/2023] [Accepted: 10/31/2023] [Indexed: 12/01/2023] Open
Abstract
Background Replacement of carmustine (BCNU) in the BEAM regimen (BCNU, etoposide, cytarabine, melphalan) with bendamustine (BendaEAM) before autologous stem cell transplantation (ASCT) is feasible in lymphoma. However, randomised trials are lacking. Here, we present the first trial addressing this topic. Methods This multicentre, randomised, phase 2 study (BEB-trial) conducted at four haematological centres in Austria and Switzerland compares BEAM with BendaEAM in patients with relapsed lymphoma. Both regimens were administered intravenously before ASCT, in BEAM according to the standard protocol (300 mg/m2 BCNU on day -6), in BendaEAM, BCNU was replaced by 200 mg/m2 bendamustine given on days -7 and -6. Eligible patients were aged 18-75 years and had mantle cell lymphoma, diffuse large B-cell lymphoma, or follicular lymphoma in first or second remission or chemosensitive relapse. The primary endpoint of the study was to evaluate whether replacement of BCNU by bendamustine reduces lung toxicity, defined as a decrease of the diffusion capacity of the lung for carbon monoxide by at least 20% at three months after ASCT. Data analyses were performed on an intention-to-treat basis. This study is registered with ClinicalTrials.gov, number NCT02278796, and is complete. Findings Between April 20, 2015, and November 28, 2018, 108 patients were enrolled; of whom 53 were randomly assigned to receive BendaEAM (36 male, 17 female) and 55 to receive BEAM (39 male, 16 female). All patients engrafted rapidly. Lung toxicity did not differ between groups (BendaEAM: n = 8, 19.5%; BEAM: n = 11, 25.6%; risk difference = -6.1%: 95% confidence interval: -23.9% to 11.7%). Acute toxicities of at least grade 3 were comparable in both groups (BendaEAM: 35.8%, BEAM: 30.9%). Overall survival (BendaEAM: 92.5%, BEAM: 89.1%) and complete remission (BendaEAM: 76.7%, BEAM: 74.3%) after 1 year (median follow-up: 369 days) were similar. No difference in quality of life was observed. Interpretation Results were similar for both regimens in terms of survival and response rates. A phase 3 non-inferiority study is required to investigate whether BendaEAM can be considered as an alternative to BEAM. Funding Mundipharma.
Collapse
Affiliation(s)
- Felix Keil
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Antonia M.S. Müller
- Department of Transfusion Medicine and Cell Therapy, Medical University of Vienna, Vienna, Austria
- Department of Medical Oncology and Haematology, University Hospital Zurich, Zurich, Switzerland
| | - Andrea Berghold
- Institute for Medical Informatics, Statistics, and Documentation, Medical University Graz, Graz, Austria
| | - Regina Riedl
- Institute for Medical Informatics, Statistics, and Documentation, Medical University Graz, Graz, Austria
| | - Veronika Buxhofer-Ausch
- Department of Internal Medicine I with Haematology, Stem Cell Transplantation, Haemostaseology and Medical Oncology, Ordensklinikum Linz Elisabethinen, Linz, Austria
- Medical Faculty, Johannes Kepler University Linz, Linz, Austria
| | - Judith Schuster
- Austrian Group Medical Tumor Therapy (AGMT), Salzburg, Austria
| | - Corinne Vorburger
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Alexandra Böhm
- Haematological Health Care Centre of the ÖGK Mariahilf, Vienna, Austria
| | - Michael Panny
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Thomas Nösslinger
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Richard Greil
- Austrian Group Medical Tumor Therapy (AGMT), Salzburg, Austria
- Cancer Cluster Salzburg (CCS), Salzburg, Austria
- III Medical Department with Haematology and Medical Oncology, Haemostaseology, Rheumatology and Infectious Diseases, Oncologic Centre, Paracelsus Medical University, Salzburg, Austria
- Salzburg Cancer Research Institute with Laboratory of Immunological and Molecular Cancer Research and Centre for Clinical Cancer and Immunology Trials (CCCIT), Salzburg, Austria
| | - Panagiotis Samaras
- Clinic for Haematology and Oncology Hirslanden Zurich, Zurich, Switzerland
| | - Celine Bencker
- 3rd Medical Department for Haematology and Oncology, Hanusch Hospital, Vienna, Austria
| | - Markus Rütti
- Department of Medical Oncology and Haematology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, Bern University Hospital, Bern, Switzerland
| |
Collapse
|
4
|
Plante MÉ, Feng X, Boudreault JS. Single-center retrospective study assessing the efficacy and safety of BeEAM (bendamustine, etoposide, cytarabine, melphalan) as conditioning regimen for autologous hematopoietic stem cell transplantation. Leuk Lymphoma 2023; 64:1234-1242. [PMID: 37154396 DOI: 10.1080/10428194.2023.2203790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 03/01/2023] [Accepted: 04/09/2023] [Indexed: 05/10/2023]
Abstract
One of the most widely accepted conditioning regimens for hematopoietic stem cell transplantation (HSCT) is BEAM (carmustine, etoposide, cytarabine, melphalan). However, a recent increase in the cost of carmustine has limited its use bringing our institution to replace carmustine with bendamustine. This observational retrospective single-center study aims to report the efficacy and safety of the BeEAM regimen. 55 patients with diffuse large B-cell lymphoma (47%), Hodgkin lymphoma (25%), mantle cell lymphoma (25%), or follicular lymphoma (2%) were included. Progression-free survival (PFS) at 24 months was 75% and overall survival (OS) was 83%. Treatment-related mortality was 4%. The most common adverse effects were febrile neutropenia (98%), mucositis (72%) and colitis (60%). Our study demonstrated excellent efficacy of the BeEAM regimen. However, the toxicity profile of BeEAM significantly varies from one study to another, and guidelines suggesting optimal dose of bendamustine and supportive care are currently lacking.
Collapse
Affiliation(s)
- Marie-Élaine Plante
- Division of Hematology and Oncology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Canada
| | - Xue Feng
- Division of Hematology and Oncology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Canada
| | - Jean-Samuel Boudreault
- Division of Hematology and Oncology, Hôpital du Sacré-Coeur de Montréal, Université de Montréal, Montreal, Canada
| |
Collapse
|
5
|
Brooks TR, Jagadeesh D. Conditioning regimens: balancing efficacy and toxicity. Leuk Lymphoma 2023; 64:1223-1224. [PMID: 37501586 DOI: 10.1080/10428194.2023.2239970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 07/17/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Taylor R Brooks
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
| | - Deepa Jagadeesh
- Department of Hematology and Medical Oncology, Cleveland Clinic Taussig Cancer Center, Cleveland, OH, USA
| |
Collapse
|
6
|
Wu R, Ma L. BeEAM (Bendamustine, Etoposide, Cytarabine, Melphalan) Versus BEAM (Carmustine, Etoposide, Cytarabine, Melphalan) as Conditioning Regimen Before Autologous Haematopoietic Cell Transplantation: A Systematic Review and Meta-Analysis. Cell Transplant 2023; 32:9636897231179364. [PMID: 37350429 PMCID: PMC10291416 DOI: 10.1177/09636897231179364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 05/03/2023] [Accepted: 05/16/2023] [Indexed: 06/24/2023] Open
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a standard of care for selected patients with refractory/relapsed Hodgkin's lymphoma (HL) or non-Hodgkin's lymphoma (NHL), and it is also used as first-line clinical consolidation option for some aggressive NHL subtypes. Conditioning regimen prior to ASCT is one of the essential factors related with clinical outcomes post transplant. The conditioning regimen of carmustine, etoposide, cytarabine, and melphalan (BEAM) traditionally is considered the standard of care for patients with lymphoma who are eligible for transplantation. Replacement of carmustine with bendamustine (BeEAM) was described as an alternative conditioning regimen in the autograft setting for patients with lymphoma. Several studies have reported inconsistent clinical outcomes comparing BeEAM and BEAM. Therefore, in the lack of well-designed prospective comparative studies, the comparison of BeEAM versus BEAM is based on retrospective trials. To compare the clinical outcomes between BeEAM and BEAM, we performed a meta-analysis of 10 studies which compared the outcomes between BeEAM and BEAM in patients autografted for lymphoma disease (HL or NHL). We searched article titles and compared transplantation with BeEAM versus BEAM in MEDLINE (PubMed), Cochrane library, and EMBASE database. Here, we report the results of nine main endpoints in our meta-analysis comparing BeEAM and BEAM, including neutrophil engraftment (NE), platelet engraftment (PE), overall survival (OS), progression free survival (PFS), non-relapse mortality (NRM), relapse rate (RR), grade 3 mucositis, renal toxicity, and cardiotoxicity. We discovered that the BeEAM regimen was associated with a slightly better PFS [pooled odds ratio (OR) of 0.70, 95% confidence interval (CI), 0.52-0.94, P = 0.02], lower RR (0.49, 95% CI, 0.31-0.76, P = 0.002), higher mucositis (3.43, 95% CI, 2.29-5.16, P = 0.001), renal toxicity (4.49, 95% CI, 2.68-7.51, P = 0.001), and cardiotoxicity (1.88, 95% CI, 1.03-3.40, P = 0.03). We also discovered that the two groups had equivalent NE (pooled WMD -0.64, 95% CI, -1.46 to 0.18, P = 0.13), PE (pooled WMD -0.3, 95% CI, -1.68 to 2.28, P = 0.77), OS (0.73, 95% CI, 0.52-1.01, P = 0.07), and NRM (1.51, 95% CI, 0.76-2.98, P = 0.24). The results of this meta-analysis show that the BeEAM regimen is a viable alternative to BEAM. More prospective comparisons between BeEAM and BEAM are required.
Collapse
Affiliation(s)
- Ran Wu
- Department of Radiation Oncology, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Liyuan Ma
- Department of Hematology, Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| |
Collapse
|
7
|
Lachance S, Bourguignon A, Boisjoly JA, Bouchard P, Ahmad I, Bambace N, Bernard L, Cohen S, Delisle JS, Fleury I, Kiss T, Mollica L, Roy DC, Sauvageau G, Veilleux O, Zehr J, Chagnon M, Roy J. Impact of Implementing a Bendamustine-Based Conditioning Regimen on Outcomes of Autologous Stem Cell Transplantation in Lymphoma while Novel Cellular Therapies Emerge. Transplant Cell Ther 2023; 29:34.e1-34.e7. [PMID: 36243319 DOI: 10.1016/j.jtct.2022.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Revised: 09/28/2022] [Accepted: 10/05/2022] [Indexed: 11/07/2022]
Abstract
With the advent of new cellular and targeted therapies, treatment options for relapsed and refractory (r/R) lymphomas have multiplied, and the optimal approach offering the best outcomes remains a matter of passionate debate. High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is still considered a treatment option for patients with chemosensitive lymphoma when cure is the expected goal. The myeloablative conditioning regimen preceding the stem cell infusion is considered the effective component of this approach. Carmustine (BCNU)-based preparative regimens, such as BEAM and BEAC, are considered the standard of care and have shown efficacy and low nonrelapse mortality (NRM). Comparative studies between conditioning regimens have failed to identify a better option. After a BCNU drug shortage in Canada followed by a steep increase in price, we elected to substitute BCNU for bendamustine (benda) in the preparative regimen. The purpose of this substitution was to improve response while preserving safety and controlling costs. From May 2015 to May 2018, a total of 131 consecutive lymphoma patients received benda-EAM conditioning. These patients were compared with 96 consecutive patients who received BCNU-based conditioning from January 2012 to May 2015. Apart from conditioning, supportive care measures were the same in the 2 groups. Patients receiving benda were older (55.7 years versus 51.1 years; P = .002). The development of grade ≥3 mucositis was more frequent with benda conditioning (39.5% versus 7.8%; P < .001) leading to a greater requirement for parenteral nutrition (48.9% versus 21.9%; P < .001). A transient creatinine increase >1.5 times the upper limit of normal (15.3% versus 4.2%; P < .008) and intensive care unit admission (6.9% versus 1.1%; P < .029) were more frequent with benda; however, there were no between-group differences in cardiac, pulmonary, or liver toxicity and NRM. With a median follow-up of 48 months for the benda group and 60 months for the BCNU group, benda was associated with significantly better progression-free survival (71% versus 61%; P = .040; hazard ratio [HR], 1.6; 95% confidence interval [CI], 1.0 to 2.7) and overall survival (86% vs 71%; P = .0066; HR, 2.6; 95% CI, 1.3 to 5.4) compared with BCNU-based conditioning regimens. While novel therapies emerge, our study demonstrates that benda-EAM is safe and effective and should be considered a valid alternative to BCNU conditioning to improve outcomes of patients with chemosensitive r/R lymphomas undergoing ASCT.
Collapse
Affiliation(s)
- Sylvie Lachance
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada.
| | - Alex Bourguignon
- Division of Hematology and Oncology, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Josie-Anne Boisjoly
- Division of Hematology and Oncology, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Philippe Bouchard
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Imran Ahmad
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Nadia Bambace
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Léa Bernard
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Sandra Cohen
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Jean-Sébastien Delisle
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Isabelle Fleury
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Thomas Kiss
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Luigina Mollica
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Denis-Claude Roy
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Guy Sauvageau
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Olivier Veilleux
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Justine Zehr
- Department of Medicine and Biostatistics, Université de Montréal, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Miguel Chagnon
- Department of Medicine and Biostatistics, Université de Montréal, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| | - Jean Roy
- Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular Therapy, Hôpital Maisonneuve-Rosemont, Montreal, Quebec, Canada; Hopital Maisonneuve-Rosemont, Division of Hematology, Oncology, Hematopoietic Cell Transplant and Cellular therapy, Université de Montréal, Montreal, Quebec, Canada
| |
Collapse
|
8
|
Xiong YY, Wang J, Wang L, Chen JB, Liu L, Tang XQ, Wang X, Zhang HB. Comparison of CEAC, BEAM and IEAC conditioning regimens followed by autologous stem cell transplantation in peripheral T-cell lymphoma patients. Sci Rep 2022; 12:14369. [PMID: 35999255 PMCID: PMC9399089 DOI: 10.1038/s41598-022-18540-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 08/16/2022] [Indexed: 11/09/2022] Open
Abstract
Autologous stem cell transplantation (ASCT) is an important treatment for peripheral T-cell lymphoma (PTCL) patients both during front and salvage therapy. In order to explore the appropriate conditioning regiments and seek ways to improve the efficacy and safety of PTCL, we retrospectively compared the outcomes of 52 PTCL patients treated with CEAC (lomustine, etoposide, cytarabine and cyclophosphamide; n = 28), BEAM (carmustine, etoposide, cytarabine and melphalan; n = 14) and IEAC (idarubicin, etoposide, cytarabine and cyclophosphamide; n = 10) regimens followed by ASCT at our center between 2012 and 2021. Although the time of neutrophil engraftment in CEAC group was earlier than that in IEAC group (P = 0.042) and platelet infusion in BEAM group was significantly more than CEAC group (P = 0.042), there were no significant difference in platelet engraftment, hematopoietic engraftment and red blood cells infusion among the 3 groups. The transplantation related mortality rate (TRM) and the early overall response rate (ORR) was 3.8% and 85.7% respectively. The 5-year OS and PFS was 62.8% (95% CI: 54.8-70.8%) and 61.0% (95% CI: 53.1-68.9%) respectively. There was no significant difference in TRM, ORR and survival among the 3 groups. Univariate and multivariate analysis showed that high PIT score (the T cell lymphoma prognostic index, > 1) and failure to reach complete response (non-CR) at 3 months after ASCT were common risk factors for OS (P = 0.036 and 0.007) and PFS (P = 0.021 and 0.012). In conclusion, CEAC and IEAC regimen can be used as alternative conditioning regiments for ASCT in PTCL patients, and their efficacy and safety are comparable to BEAM regiment. Patients with high PIT score and non-CR early after ASCT had worse outcomes.
Collapse
Affiliation(s)
- Yi-Ying Xiong
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jing Wang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Li Wang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Jian-Bin Chen
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Lin Liu
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xiao-Qiong Tang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Xin Wang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Hong-Bin Zhang
- Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
| |
Collapse
|
9
|
BeEAM High-Dose Chemotherapy with Polatuzumab (Pola-BeEAM) before ASCT in Patients with DLBCL—A Pilot Study. J Clin Med 2022; 11:jcm11133748. [PMID: 35807041 PMCID: PMC9267272 DOI: 10.3390/jcm11133748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/15/2022] [Accepted: 06/24/2022] [Indexed: 01/27/2023] Open
Abstract
(1) Introduction: BEAM is a high-dose chemotherapy (HDCT) frequently administered before autologous stem cell transplantation (ASCT) in diffuse large B-cell lymphoma (DLBCL). Bendamustine replacing BCNU (BeEAM) is similarly effective at lower toxicities. However, relapse remains the major cause of death in DLBCL. (2) Methods: This is a 12-patient pilot study of the BeEAM preparative regimen with additional polatuzumab vedotin (PV, targeting CD79b) aiming to establish feasibility and to reduce toxicity without increasing the early progression rate. PV was given once at the standard dose of 1.8 mg/kg at day −6 together with BeEAM-HDCT (days −7 to −1) before ASCT. (3) Results: 8/12 patients (67%) received PV with BeEAM as a consolidation of first-line treatment, and 4/12 patients (33%) received PV with BeEAM after relapse treatment. All patients experienced complete engraftment (neutrophils: median 11 days; platelets: 13 days). Gastrointestinal toxicities occurred in 7/12 patients (58%, grade 3). All patients developed neutropenic infections with at least one identified pathogen (bacterial: 10/12 patients; viral: 2/12; and fungal: 1/12). The complete remission rate by PET-CT 100 days post-ASCT was 92%, with one mortality due to early progression. Eleven out of twelve patients (92%) were alive without progression after a median follow-up of 15 months. (4) Conclusions: Our study with 12 patients suggests that combining PV with BeEAM HDCT is feasible and safe, but the limited cohort prevents definite conclusions regarding efficacy. Larger cohorts must be evaluated.
Collapse
|
10
|
Costes-Tertrais D, Hueso T, Gastinne T, Thieblemont C, Oberic L, Bouabdallah K, Garciaz S, Tchernonog E, Dartigeas C, Ribrag V, Fogarty P, Casasnovas RO, Houot R, Delette C, Malak S, Fornecker LM, Gressin R, Damaj G, Le Gouill S. Bendamustine-EAM versus R-BEAM after high-dose cytarabine-based induction in newly diagnosed patients with mantle cell lymphoma, a LYSA retrospective study. Bone Marrow Transplant 2022; 57:627-632. [PMID: 35149851 DOI: 10.1038/s41409-022-01596-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/18/2022] [Accepted: 01/19/2022] [Indexed: 11/09/2022]
Abstract
Cytarabine-based immuno-chemotherapy followed by autologous stem cell transplantation (ASCT) consolidation is standard of care for fit patients with Mantle Cell Lymphoma (MCL). BEAM (Carmustine, Etoposide, Aracytine, Melphalan) is among the most frequently used conditioning regimen. Studies comparing BEAM with Bendamustine-EAM (BeEAM) have suggested that patients treated with BeEAM have a better progression-free survival (PFS). We performed a cross-study analysis to better evaluate BeEAM. Thirty-five patients from a retrospective study who received R-DHAP/BeEAM were compared to 245 patients from the LyMa trial (NCT00921414) who all received R-DHAP followed by R-BEAM. PFS and Overall Survival (OS) were estimated using Kaplan-Meier methods. At 2 years there was no difference between R-BEAM and BeEAM in either PFS (84.9% versus 87.9%; p = 0.95) or OS (91.8% versus 94.2%; p = 0.30). Analyses were repeated on a propensity score to reduce biases. Each patient from the BeEAM cohort (n = 30) was matched to three patients from the R-BEAM cohort (n = 90) for age, sex, MIPI score, pre-transplant status disease and rituximab maintenance (RM). PFS and OS at 2 years remained similar between R-BEAM and BeEAM with more renal toxicity in BeEAM group. MCL patients who received R-DHAP induction before ASCT have similar outcome after R-BEAM or BeEAM conditioning regimen.
Collapse
Affiliation(s)
- Domitille Costes-Tertrais
- Department of Hematology, CHU de Nantes, University Hospital of Nantes, Nantes, France.,School of Medicine, Nantes University, Nantes, France
| | - Thomas Hueso
- Department of Hematology, APHP-Avicenne Hospital, Paris, France.,Sorbonne University Paris Nord, Bobigny, France
| | - Thomas Gastinne
- Department of Hematology, CHU de Nantes, University Hospital of Nantes, Nantes, France
| | - Catherine Thieblemont
- Department of Hemato-oncology, APHP-Saint-Louis Hospital, Paris, France.,Diderot Sorbonne Paris-Cité University, Paris, France.,Descartes University, Paris, France
| | - Lucie Oberic
- Department of Clinical Hematology, Toulouse Oncopole, Toulouse, France
| | - Krimo Bouabdallah
- Department of Clinical Hematology, Bordeaux University Hospital, Bordeaux, France
| | - Sylvain Garciaz
- Department of Clinical Hematology, Paoli Calmettes Institute, Marseille, France
| | - Emmanuelle Tchernonog
- Department of Clinical Hematology, Montpellier University Hospital, Montpellier, France
| | - Caroline Dartigeas
- Department of Clinical Hematology, Tours University Hospital, Tours, France
| | | | | | - René-Olivier Casasnovas
- Department of Clinical Hematology, François Mitterrand University Hospital, Dijon, France.,Inserm UMR 1231, Dijon, France
| | - Roch Houot
- Department of Clinical Hematology, Rennes University Hospital, F-35033, Rennes, France.,MICMAC-Inserm UMR 1236, Rennes University, F-35000, Rennes, France
| | - Caroline Delette
- Department of Clinical Hematology, Amiens University Hospital, Amiens, France
| | - Sandra Malak
- Department of Clinical Hematology, Curie Institute, René Huguenin Hospital, Saint-Cloud, France
| | | | - Remy Gressin
- Department of Clinical Hematology, Grenoble University Hospital, Grenoble, France
| | - Gandhi Damaj
- Department of Clinical Hematology, Caen University Hospital, F-14000, Caen, France.,School of Medicine, Normandy University, F-14000, Caen, France
| | - Steven Le Gouill
- Department of Hematology, CHU de Nantes, University Hospital of Nantes, Nantes, France. .,Now at Curie Insitute, Paris, France.
| |
Collapse
|
11
|
[Safety and the short-term efficacy of bendamustine in the conditioning regimen for autologous stem cell transplantation in patients with lymphoma]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:63-65. [PMID: 35231995 PMCID: PMC8980672 DOI: 10.3760/cma.j.issn.0253-2727.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
|
12
|
Desjardins A, Le-Nguyen V, Turgeon-Mallette L, Vo C, Boudreault JS, Rioux JP, Feng X, Veilleux A. Bendamustine-induced nephrogenic diabetes insipidus - A case report. J Oncol Pharm Pract 2021; 28:205-210. [PMID: 33990157 PMCID: PMC8685724 DOI: 10.1177/10781552211013878] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION In patients with relapsed or refractory lymphoma, high-dose chemoimmunotherapy with subsequent autologous hematopoietic cell transplantation (HCT) is a standard of care. Bendamustine, an alkylating agent, is used in the BeEAM (bendamustine, etoposide, cytarabine, melphalan) protocol for conditioning therapy before autologous HCT in patients with relapsed or refractory lymphoma who are eligible for transplant. There is no consensus regarding an optimal salvage regimen and the approach varies according to toxicity. CASE REPORT We present a case of partial nephrogenic diabetes insipidus after receiving bendamustine, as part of the BeEAM protocol.Management and outcome: The patient was managed with parenteral fluid administration and intranasal desmopressin before the condition resolved on its own. DISCUSSION We summarize published reports of bendamustine-induced diabetes insipidus.
Collapse
Affiliation(s)
| | | | | | - Chloé Vo
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada
| | - Jean-Samuel Boudreault
- Division of Hematology and Oncology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Jean-Philippe Rioux
- Division of Nephrology, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Xue Feng
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Amélie Veilleux
- Department of Pharmacy, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| |
Collapse
|
13
|
Stokes J, Molina MS, Hoffman EA, Simpson RJ, Katsanis E. Immunomodulatory Effects of Bendamustine in Hematopoietic Cell Transplantation. Cancers (Basel) 2021; 13:1702. [PMID: 33916711 PMCID: PMC8038415 DOI: 10.3390/cancers13071702] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 03/25/2021] [Accepted: 04/01/2021] [Indexed: 12/22/2022] Open
Abstract
Bendamustine (BEN) is a unique alkylating agent with efficacy against a broad range of hematological malignancies, although investigations have only recently started to delve into its immunomodulatory effects. These immunomodulatory properties of BEN in the context of hematopoietic cell transplantation (HCT) are reviewed here. Pre- and post-transplant use of BEN in multiple murine models have consistently resulted in reduced GvHD and enhanced GvL, with significant changes to key immunological cell populations, including T-cells, myeloid derived suppressor cells (MDSCs), and dendritic cells (DCs). Further, in vitro studies find that BEN enhances the suppressive function of MDSCs, skews DCs toward cDC1s, enhances Flt3 expression on DCs, increases B-cell production of IL-10, inhibits STAT3 activation, and suppresses proliferation of T- and B-cells. Overall, BEN has a broad range of immunomodulatory effects that, as they are further elucidated, may be exploited to improve clinical outcomes. As such, clinical trials are currently underway investigating new potential applications of BEN in the setting of allogeneic HCT.
Collapse
Affiliation(s)
- Jessica Stokes
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Megan S. Molina
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
| | - Emely A. Hoffman
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
| | - Richard J. Simpson
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- Department of Nutritional Sciences, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
| | - Emmanuel Katsanis
- Department of Pediatrics, University of Arizona, Tucson, AZ 85721, USA; (J.S.); (M.S.M.); (E.A.H.); (R.J.S.)
- Department of Immunobiology, University of Arizona, Tucson, AZ 85721, USA
- The University of Arizona Cancer Center, Tucson, AZ 85721, USA
- Department of Medicine, University of Arizona, Tucson, AZ 85721, USA
- Department of Pathology, University of Arizona, Tucson, AZ 85721, USA
| |
Collapse
|
14
|
Ghesquières H, Dalban C, Nicolas-Virelizier E, Jardin F, Le Bras F, Le Gouill S, Casasnovas O, Vizoso S, Hernandez C, Metzger S, Pérol D, Cartron G. BeEAM (bendamustine, etoposide, cytarabine, melphalan) prior to autologous stem cell transplant for chemosensitive relapses in patients with follicular lymphoma: a prospective multicentre phase II study in Lymphoma Study Association centres †. Br J Haematol 2021; 192:e94-e98. [PMID: 33421031 DOI: 10.1111/bjh.17279] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 11/24/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Hervé Ghesquières
- Department of Hematology, Centre Léon Bérard, Université Claude Bernard Lyon 1, Lyon, France.,Department of Hematology, Hôpital Lyon Sud, Université Claude Bernard Lyon 1, Pierre Bénite, France
| | - Cécile Dalban
- Department of Clinical Research and Innovation, Centre Léon Bérard, Lyon, France
| | | | - Fabrice Jardin
- Centre Henri Becquerel, Inserm U1245, Université de Rouen, IRIB, Rouen, France
| | - Fabien Le Bras
- Department of Hematology, CHU Henri Mondor, Creteil, France
| | - Steven Le Gouill
- Service d'Hématologie clinique du CHU de Nantes, INSERM CRCINA Nantes-Angers, NeXT Université de Nantes, Nantes, France
| | - Olivier Casasnovas
- Department of Hematology, CHU Dijon Bourgogne and INSERM 1231, Dijon, France
| | - Séraphine Vizoso
- Department of Clinical Research and Innovation, Centre Léon Bérard, Lyon, France
| | - Caroline Hernandez
- Department of Clinical Research and Innovation, Centre Léon Bérard, Lyon, France
| | - Séverine Metzger
- Department of Clinical Research and Innovation, Centre Léon Bérard, Lyon, France
| | - David Pérol
- Department of Clinical Research and Innovation, Centre Léon Bérard, Lyon, France
| | - Guillaume Cartron
- Department of Hematology, CHU Montpellier, UMR 5535, Université de Montpellier, Montpellier, France
| |
Collapse
|
15
|
熊 艺, 陈 建, 刘 林, 罗 小, 唐 晓, 王 欣, 肖 青, 张 红, 王 利. [IEAC versus CEAC high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation for lymphoma: analysis of efficacy and safety in 106 cases]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:1760-1767. [PMID: 33380399 PMCID: PMC7835682 DOI: 10.12122/j.issn.1673-4254.2020.12.10] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Indexed: 11/24/2022]
Abstract
ObjectiveTo evaluate the efficacy and safety of IEAC (idarubici, etoposide, cytosine arabinoside, and cyclophosphamide) and CEAC (lomustine, etoposide, cytosine arabinoside, and cyclophosphamide) high-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT) in the treatment of lymphoma.MethodWe retrospectively analyzed the data of 106 lymphoma patients undergoing ASCT from 2013 to 2018 using IEAC (n=43) or CEAC (n=63) regimens. The time of hematopoietic reconstruction, adverse events and the patients' survival outcomes in the two groups were compared to evaluate the efficacy and safety of the two regimens. Univariate and multivariate analyses were performed to identify the factors potentially affecting the patients' survival.ResultsIn the total of 106 patients, successful hematopoietic reconstruction was achieved in 104 patients and treatment-related deaths occurred in 2 patients. No significant differences were observed in the time to hematopoietic recovery, adverse events or survival outcomes between the patients receiving IEAC and CEAC regimens. In the 104 patients with successful hematopoietic reconstruction who were followed for a median of 27.4 months (range 4.3 to 74.3 months), the 5-year progress-free survival (PFS) and overall survival (OS) rates were 72.9% and 81.9%, respectively. The main adverse events (beyond grade 2 based on CTCAE v5.0) included infection, oral mucositis, nausea and vomiting, liver damage, cardiotoxicity, hypokalemia, and diarrhea. No significant difference was found in the survival outcomes or adverse events between the 2 regimens. T cell lymphoma and failure to achieve complete remission (CR) before ASCT were the risk factors of PFS (P=0.015 and P=0.007, respectively) and OS (P=0.038 and 0.031, respectively). The patients who achieved CR 3 months after the transplantation had higher rates of PFS (P=0.007) and OS (P=0.003).ConclusionIEAC and CEAC regimens prior to by ASCT are both safe and effective in the treatment of lymphoma and can be used as alternative conditioning regimens for lymphoma patients undergoing ASCT.
Collapse
Affiliation(s)
- 艺颖 熊
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 建斌 陈
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 林 刘
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 小华 罗
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 晓琼 唐
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 欣 王
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 青 肖
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 红宾 张
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - 利 王
- />重庆医科大学附属第一医院血液内科,重庆 400016Department of Hematology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| |
Collapse
|
16
|
AlJohani NI, Nasani M, Ahmed HE, Ur Rehman J, Nawaz A, Alzahrani Z, Albeirouti B. Dose-adjusted bendamustine as a replacement for carmustine in autologous stem cell transplant conditioning for patients with relapsed lymphoma: A retrospective single-center study. Hematol Oncol Stem Cell Ther 2020; 14:327-335. [PMID: 33306964 DOI: 10.1016/j.hemonc.2020.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 11/02/2020] [Accepted: 11/09/2020] [Indexed: 12/01/2022] Open
Abstract
BEAM conditioning regimen (carmustine [BCNU], etoposide, cytarabine, and melphalan) has been widely used for autologous stem cell transplantation in patients with relapsed or refractory lymphoma. However, BCNU-associated toxicities have prompted research to explore other options. This study aimed to assess the feasibility of bendamustine as an alternative to BCNU. We compared 71 patients who received either bendamustine (Benda-EAM group) or BCNU (BEAM group) conditioning. Considering previous reports of increased cardiotoxicity, nephrotoxicity, and mucositis, we adopted a lower bendamustine dose of 160 mg/m2/day administered for 2 days. There was no increase in nephrotoxicity and cardiotoxicity. Further, positive results were also obtained for neutrophil and platelet engraftment, appearing earlier in patients treated with Benda-EAM (10 vs. 14 days and 16 vs. 27 days, respectively). However, caution is warranted because an increased frequency of Grade 3 mucositis was observed in the Benda-EAM group (82.4% vs. 48%). This was accompanied by an increased need for parenteral nutrition. Despite the lower dose of bendamustine, the overall and progression-free survival rates were comparable between the Benda-EAM and BEAM groups. In conclusion, a lower dose of bendamustine may be an attractive alternative to BCNU as a tolerable treatment modality for patients with relapsed/refractory lymphoma.
Collapse
Affiliation(s)
- Naif I AlJohani
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Momen Nasani
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia.
| | - Hosam E Ahmed
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Jalil Ur Rehman
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Azhar Nawaz
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Zayed Alzahrani
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Bassim Albeirouti
- Adult Hematology and Bone Marrow Transplant Section, Oncology Department, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| |
Collapse
|
17
|
Glover A, Fox CP, McMillan A, Beech A, Martinez-Calle N, Griffiths C, Richardson F, Russell N, Bishton MJ. A comparison of bendamustine-EAM versus BEAM conditioning for autogolous stem cell transplant in lymphoma. Leuk Lymphoma 2020; 61:3529-3531. [PMID: 32897170 DOI: 10.1080/10428194.2020.1811863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Alexander Glover
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Christopher P Fox
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Andrew McMillan
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Amy Beech
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | | | - Catherine Griffiths
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Faith Richardson
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Nigel Russell
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Mark J Bishton
- Centre for Clinical Haematology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| |
Collapse
|
18
|
Kim DY, Chung JS, Jo JC, Cho SH, Shin HJ. Phase II study of safety and efficacy of BEB (bendamustine, etoposide, and busulfan) conditioning regimen for autologous stem cell transplantation in non-Hodgkin lymphoma. Ann Hematol 2020; 99:819-828. [PMID: 32025840 DOI: 10.1007/s00277-020-03942-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 01/26/2020] [Indexed: 11/29/2022]
Abstract
Autologous stem cell transplant (ASCT) is an effective treatment for non-Hodgkin lymphoma (NHL). However, recent supply issues and toxicity of carmustine have necessitated a new conditioning regimen. We conducted a multicenter, phase II study of BEB (busulfan, etoposide, and bendamustine) conditioning regimen for ASCT in patients with NHL. Thirty-one patients were enrolled and underwent ASCT with the BEB conditioning regimen. The most common subtype was diffuse large B-cell lymphoma (n = 23, 74.2%). Nine patients (29.0%) had a history of relapse, and 18 patients (58.1%) received more than 2 lines of chemotherapy before ASCT. A median number of 6.05 × 106/kg CD34 cells were infused, and all patients engrafted after a median period of 11 days. Thirteen patients (41.9%) experienced neutropenic fever, and 16 patients (51.6%) had grade 3 or 4 toxicities during ASCT. No one had a documented infection, veno-occlusive disease, or treatment-related death. Three-month complete remission rate was 81.8%. Median follow-up period of 15 months showed 6 patients (19.4%) relapsed or progressed and 3 patients died. The estimated 2-year progression-free survival and overall survival rate were 73.0% and 89.8%, respectively. Our results show that BEB conditioning regimens for ASCT are feasible with tolerable toxicity in patients with NHL.
Collapse
Affiliation(s)
- Do Young Kim
- Division of Hematology-Oncology, Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea
| | - Joo-Seop Chung
- Division of Hematology-Oncology, Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea
| | - Jae-Cheol Jo
- Division of Hematology-Oncology, Department of Internal Medicine, Ulsan University Hospital, Ulsan, South Korea
| | - Su-Hee Cho
- Division of Hematology-Oncology, Departments of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, South Korea
| | - Ho-Jin Shin
- Division of Hematology-Oncology, Department of Internal Medicine, Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, South Korea.
| |
Collapse
|
19
|
Bendamustine-EAM versus BEAM regimen in patients with mantle cell lymphoma undergoing autologous stem cell transplantation in the frontline setting: a multicenter retrospective study from Lymphoma Study Association (LYSA) centers. Bone Marrow Transplant 2020; 55:1076-1084. [PMID: 31953532 DOI: 10.1038/s41409-020-0783-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 12/29/2019] [Accepted: 01/03/2020] [Indexed: 11/08/2022]
Abstract
The combination of carmustine, etoposide, cytarabine, and melphalan (BEAM) as conditioning regimen prior to autologous stem-cell transplantation (ASCT) remains the standard of care for patients with mantle cell lymphoma (MCL) who are eligible for transplantation. The replacement of carmustine with bendamustine (BeEAM) was described as a promising alternative in non-Hodgkin lymphoma. The aim of this retrospective study was to compare the BeEAM with the BEAM regimen in MCL patients in the frontline setting. Sixty and 108 patients were included in the BeEAM and the BEAM groups, respectively. At 3 years, progression-free survival (PFS) was significantly higher in the BeEAM than in the BEAM group (84% [73-96] vs. 63% [51-79], p = 0.03). The overall survival was not statistically different between the two groups (p = 0.2). In multivariable analysis, BeEAM regimen remained associated with higher PFS (HR = 0.377, 95% CI, 0.146-0.970; p = 0.043). Subgroup analyses in patients treated with prior rituximab-aracytine induction alone showed that BeEAM improved the PFS compared with BEAM regimen (p = 0.04). Despite the high rate of acute renal failure KDIGO III (32%), treatment-related mortality was not increased with the BeEAM regimen. A prospective randomized trial will be necessary to confirm the beneficial effect of the BeEAM regimen in MCL patients undergoing ASCT.
Collapse
|
20
|
Dahi PB, Lazarus HM, Sauter CS, Giralt SA. Strategies to improve outcomes of autologous hematopoietic cell transplant in lymphoma. Bone Marrow Transplant 2019; 54:943-960. [PMID: 30390059 PMCID: PMC9062884 DOI: 10.1038/s41409-018-0378-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/05/2018] [Accepted: 09/30/2018] [Indexed: 11/08/2022]
Abstract
High-dose chemotherapy and autologous hematopoietic cell transplantation (HDT-AHCT) remains an effective therapy in lymphoma. Over the past several decades, HDT with BEAM (carmustine, etoposide, cytarabine, and melphalan) and CBV (cyclophosphamide, carmustine, and etoposide) have been the most frequently used preparatory regimens for AHCT in Hodgkin (HL) and non-Hodgkin lymphoma (NHL). This article reviews alternative combination conditioning regimens, as well as novel transplant strategies that have been developed, to reduce transplant-related toxicity while maintaining or improving efficacy. These data demonstrate that incorporation of maintenance therapy posttransplant might be the best way to improve outcomes.
Collapse
Affiliation(s)
- Parastoo B Dahi
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
- Weill Cornell Medical College, New York, NY, USA.
| | - Hillard M Lazarus
- Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - Craig S Sauter
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| | - Sergio A Giralt
- Adult Bone Marrow Transplant Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Weill Cornell Medical College, New York, NY, USA
| |
Collapse
|
21
|
Visani G, Loscocco F, Bagaloni I, Ruzzo A, Fuligni F, Graziano F, Magnani M, Isidori A. XRCC1 399GG genotype predicts significantly longer overall survival in resistant lymphoma patients treated with Benda-EAM and ASCT. Bone Marrow Transplant 2019; 55:818-820. [PMID: 31231123 DOI: 10.1038/s41409-019-0572-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/15/2019] [Accepted: 03/28/2019] [Indexed: 11/09/2022]
Affiliation(s)
- Giuseppe Visani
- Hematology and Stem Cell Transplant Center, Marche Nord Hospital, Pesaro, Italy.
| | - Federica Loscocco
- Hematology and Stem Cell Transplant Center, Marche Nord Hospital, Pesaro, Italy
| | - Irene Bagaloni
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Annamaria Ruzzo
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Fabio Fuligni
- Genetics and Genome Biology, Paediatric Laboratory Medicine (PLM), The Hospital for Sick Children, Toronto, Canada
| | | | - Mauro Magnani
- Department of Biomolecular Sciences, University of Urbino "Carlo Bo", Urbino, Italy
| | - Alessandro Isidori
- Hematology and Stem Cell Transplant Center, Marche Nord Hospital, Pesaro, Italy
| |
Collapse
|
22
|
Jaimovich G, Ostriz MBR, Castro M, Riera L, Foncuberta C, Longoni H, Cia A, Duarte P, Vitriu A, Lastiri F, Gale RP. CBeV (cyclophosphamide, bendamustine and etoposide) pre-autotransplant conditioning in persons with lymphoma. Bone Marrow Transplant 2019; 55:265-267. [DOI: 10.1038/s41409-019-0528-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 02/26/2019] [Accepted: 03/13/2019] [Indexed: 11/09/2022]
|
23
|
Chantepie S, Yakoub‐Agha I, Damaj G. Be ever cautious until the truth is proven. Am J Hematol 2019; 94:E106. [PMID: 30663789 DOI: 10.1002/ajh.25410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 11/07/2022]
Affiliation(s)
| | | | - Gandhi Damaj
- Hematology Institute University Hospital Caen France
| |
Collapse
|
24
|
Isidori A, Loscocco F, Guiducci B, Visani G. Benda-EAM prior to ASCT and renal toxicity: Much ado about nothing. Am J Hematol 2019; 94:E104-E105. [PMID: 30663798 DOI: 10.1002/ajh.25413] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/16/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Alessandro Isidori
- Hematology and Hematopoietic Stem Cell Transplant Center AORMN Pesaro Italy
| | - Federica Loscocco
- Hematology and Hematopoietic Stem Cell Transplant Center AORMN Pesaro Italy
| | - Barbara Guiducci
- Hematology and Hematopoietic Stem Cell Transplant Center AORMN Pesaro Italy
| | - Giuseppe Visani
- Hematology and Hematopoietic Stem Cell Transplant Center AORMN Pesaro Italy
| |
Collapse
|
25
|
High incidence of reversible renal toxicity of dose-intensified bendamustine-based high-dose chemotherapy in lymphoma and myeloma patients. Bone Marrow Transplant 2019; 54:1923-1925. [PMID: 30890768 DOI: 10.1038/s41409-019-0508-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 12/23/2022]
|
26
|
Lucijanic M, Prka Z, Jaksic O, Mitrovic Z, Vrkljan A, Pejsa V. Bendamustine-based conditioning prior to autologous stem cell transplantation is associated with high rate of febrile neutropenia and higher mortality. Am J Hematol 2019; 94:E42-E43. [PMID: 30394567 DOI: 10.1002/ajh.25340] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 10/31/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Marko Lucijanic
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
| | - Zeljko Prka
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
| | - Ozren Jaksic
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
- School of Medicine; University of Zagreb; Zagreb Croatia
| | - Zdravko Mitrovic
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
- School of Medicine; University of Zagreb; Zagreb Croatia
| | - Anamarija Vrkljan
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
| | - Vlatko Pejsa
- Department of Hematology; University Hospital Dubrava; Zagreb Croatia
- School of Medicine; University of Zagreb; Zagreb Croatia
| |
Collapse
|
27
|
High-dose Benda-EAM versus BEAM in patients with relapsed/refractory classical Hodgkin lymphoma undergoing autologous stem cell transplantation. Bone Marrow Transplant 2018; 54:481-484. [DOI: 10.1038/s41409-018-0328-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Revised: 07/20/2018] [Accepted: 08/14/2018] [Indexed: 11/08/2022]
|