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Samaniego F, Hagemeister F, Romaguera JE, Fanale MA, Pro B, McLaughlin P, Rodriguez MA, Neelapu SS, Fayad L, Younes A, Feng L, Berkova Z, Khashab T, Sehgal L, Vega-Vasquez F, Kwak LW. Pentostatin, cyclophosphamide and rituximab for previously untreated advanced stage, low-grade B-cell lymphomas. Br J Haematol 2015; 169:814-23. [PMID: 25828695 PMCID: PMC5278955 DOI: 10.1111/bjh.13367] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 01/20/2015] [Indexed: 11/26/2022]
Abstract
We conducted a prospective phase II trial of pentostatin, cyclophosphamide and rituximab as initial therapy for patients with previously untreated advanced stage low-grade or indolent B-cell lymphomas (iNHLs). Of 83 evaluable patients, 91·6% attained an overall response and 86·8% a complete or unconfirmed complete response. The 3-year progression-free survival (PFS) and overall survival rates were 73% and 93%, respectively. The 3-year PFS rate was significantly different for different diagnoses (P = 0·01): 83% [95% confidence interval (CI): 0·72, 0·96] for follicular lymphomas, 73% (95% CI: 0·54, 1·0) for marginal zone lymphomas and 61% (95% CI: 0·46, 0·81) for small lymphocytic lymphomas. The most common adverse events were haematological. Of 509 cycles of chemotherapy administered, grade 3 or 4 neutropenia was reported in 68 cycles (13% of cycles administered) and most frequently occurred during cycles 4-6. This is the first report demonstrating the effectiveness of pentostatin, cyclophosphamide and rituximab in patients with previously untreated iNHLs, including those over 60 years of age.
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Affiliation(s)
- Felipe Samaniego
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Fredrick Hagemeister
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jorge E. Romaguera
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Michelle A. Fanale
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Barbara Pro
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter McLaughlin
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - M. Alma Rodriguez
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sattva S. Neelapu
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Luis Fayad
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anas Younes
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lei Feng
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Zuzana Berkova
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Tamer Khashab
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lalit Sehgal
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francisco Vega-Vasquez
- Department of Hematopathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Larry W. Kwak
- Department of Lymphoma and Myeloma, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Zinzani PL, Pellegrini C, Broccoli A, Gandolfi L, Stefoni V, Casadei B, Maglie R, Argnani L, Pileri S. Fludarabine-Mitoxantrone-Rituximab regimen in untreated indolent non-follicular non-Hodgkin's lymphoma: experience on 143 patients. Hematol Oncol 2014; 33:141-6. [DOI: 10.1002/hon.2151] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 06/04/2014] [Indexed: 11/05/2022]
Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Cinzia Pellegrini
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Alessandro Broccoli
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Letizia Gandolfi
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Vittorio Stefoni
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Beatrice Casadei
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Roberto Maglie
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Lisa Argnani
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
| | - Stefano Pileri
- Institute of Hematology ‘L. e A. Seràgnoli’; University of Bologna; Bologna Italy
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3
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Zinzani PL, Pellegrini C, Gandolfi L, Casadei B, Derenzini E, Broccoli A, Quirini F, Argnani L, Pileri S, Celli M, Fanti S, Poletti V, Stefoni V, Baccarani M. Extranodal marginal zone B-cell lymphoma of the lung: experience with fludarabine and mitoxantrone-containing regimens. Hematol Oncol 2012; 31:183-8. [DOI: 10.1002/hon.2039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2012] [Revised: 10/08/2012] [Accepted: 11/07/2012] [Indexed: 11/09/2022]
Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Cinzia Pellegrini
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Letizia Gandolfi
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Beatrice Casadei
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Enrico Derenzini
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Alessandro Broccoli
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Federica Quirini
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Lisa Argnani
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Stefano Pileri
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Monica Celli
- Department of Nuclear Medicine; University of Bologna; Bologna Italy
| | - Stefano Fanti
- Department of Nuclear Medicine; University of Bologna; Bologna Italy
| | | | - Vittorio Stefoni
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
| | - Michele Baccarani
- Institute of Hematology “L. e A. Seràgnoli”; University of Bologna; Bologna Italy
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4
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Abstract
Indolent lymphoma comprises a unique and challenging subset of non-Hodgkin lymphoma (NHL). While definitions of indolence will vary, the most common indolent NHL subtypes include follicular lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma. Patients with indolent NHL (iNHL) excluding those with rare localized presentations are often met with an incurable but highly treatable NHL. In the rituximab era, response rates are approaching 90% with rituximab plus chemotherapy and time to next treatment are beginning to be measured in years. As a result of a prolonged natural history, we are encountering a gridlock of novel regimens and agents that appropriately fill peer-reviewed journals. In this review, we tackle a spectrum of topics in the management of indolent lymphoma including the initial approach to the newly diagnosed patient, approaches to first cytotoxic chemotherapy, maintenance and consolidation techniques, as well as highlight promising treatments on the horizon in iNHL. Clinicians continue to face tough choices in the management of iNHL. Through well-thought out clinical trials and peer-reviewed vetting of data we will continue to determine how to best manage the clinical continuum that is iNHL.
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Affiliation(s)
- Matthew Lunning
- Memorial Sloan-Kettering Cancer Center, 1275 York Ave, New York, NY, 10065, Phone: 212-639-3127, Fax: 646-422-2164
| | - Julie M. Vose
- Internal Medicine, University of Nebraska Medical Center, 987680 NE Med Center, Omaha, NE, 68198 Phone: 402-559-3848, Fax: 402-559-6520
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5
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Ahn JS, Yang DH, Jung SH, Bae SY, Tran HTT, Park HC, Kim HN, Kim YK, Kim HJ, Lee JJ. Fludarabine-containing chemotherapy for patients with previously untreated low-grade non-Hodgkin's lymphoma. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:180-5. [PMID: 22065973 PMCID: PMC3208201 DOI: 10.5045/kjh.2011.46.3.180] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Revised: 08/17/2011] [Accepted: 08/23/2011] [Indexed: 11/17/2022]
Abstract
BACKGROUND The clinical efficacy and safety of fludarabine combination chemotherapy was investigated for the treatment of previously untreated patients with low-grade (NHL). METHODS Twenty-five patients who were newly diagnosed as low-grade NHL were treated with fludarabine combination chemotherapy. Fludarabine combination regimens consisted of fludarabine, mitoxantrone and dexamethasone or fludarabine, cyclophosphamide and mitoxantrone with or without rituximab and repeated every 4 weeks. RESULTS The median age was 60 years (range, 35-77 years), with 13 of 25 patients (52%) ≥60 years of age. Seven of 25 patients (28%) with an intermediate risk follicular lymphoma international prognostic index (FLIPI) and 9 of 25 patients (36%) with a high risk FLIPI were enrolled in this study. The delivered median number of chemotherapy was six (range, 2-9 cycles). The overall response rate with fludarabine-based treatment was 88%, including 52% complete remission and 36% partial remission. During the median follow-up of 19 months, the estimated 2-year event-free survival was 63±10% (95% CI, 43-83) and the 2-year overall survival was 78±9% (95% CI, 60-96). Fludarabine combination chemotherapy was frequently associated with grade 3 or 4 neutropenia in 84% patients. However, neutropenic infection was observed in only one (4%) patient. Four patients (16%) showed grade 3 or more non-hematologic toxicities, such as acute coronary syndrome, intracranial hemorrhage, anaphylaxis and gastric cancer. CONCLUSION Fludarabine-combination treatment was a highly active regimen with well toleration in untreated low-grade NHL.
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Affiliation(s)
- Jae-Sook Ahn
- Department of Hematology-Oncology, Chonnam National University Hwasun Hospital, Hwasun, Korea
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Park E. Low-grade lymphoma: Beyond fludarabine-single therapy. THE KOREAN JOURNAL OF HEMATOLOGY 2011; 46:145-7. [PMID: 22065965 PMCID: PMC3208193 DOI: 10.5045/kjh.2011.46.3.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Eunkyung Park
- Division of Hematology and Oncology, Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
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7
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Salar A, Domingo-Domenech E, Estany C, Canales MA, Gallardo F, Servitje O, Fraile G, Montalbán C. Combination therapy with rituximab and intravenous or oral fludarabine in the first-line, systemic treatment of patients with extranodal marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue type. Cancer 2009; 115:5210-7. [PMID: 19672998 DOI: 10.1002/cncr.24605] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Currently, there are no consensus guidelines regarding the best therapeutic option for patients with extranodal marginal zone lymphomas of the mucosa-associated lymphoid tissue (MALT) type. METHODS Patients with systemically untreated or de novo extranodal MALT lymphoma received rituximab 375 mg/m(2) intravenously on Day 1 and fludarabine 25 mg/m(2) intravenously on Days 1 through 5 (Days 1-3 in patients aged >70 years) every 4 weeks, for 4 to 6 cycles. After the first cycle, oral fludarabine could be given orally at 40 mg/m(2) on the same schedule. After 3 cycles, a workup was done. Patients who achieved a complete remission (CR) received an additional cycle, and patients who achieved a partial remission (PR) received a total of 6 cycles. RESULTS Twenty-two patients were studied, including 12 patients with gastric lymphoma and 10 patients with extragastric MALT lymphoma. Six patients (27%) had stage IV disease. In total, 101 cycles were administered (median, 4 cycles per patients). After the third cycle, 13 patients (62%) achieved a CR, and 8 patients (38%) achieved a PR. Primary extragastric disease was an adverse factor to achieve CR after 3 cycles of chemotherapy (hazard ratio, 23.3; 95% confidence interval, 2.0-273.3). At the end of treatment, the overall response rate was 100%, and 90% of patients achieved a CR. The progression-free survival rate at 2 years in patients with gastric and extragastric MALT lymphoma was 100% and 89%, respectively. Toxicities were mild and mainly were hematologic. CONCLUSIONS Combination therapy with rituximab and fludarabine is a very active treatment with favorable safety profile as first-line systemic treatment for patients with extranodal MALT lymphoma.
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Affiliation(s)
- Antonio Salar
- Department of Clinical Hematology, Hospital Universitari del Mar, Barcelona, Spain.
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8
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Bordonaro R, Petralia G, Restuccia N, Todaro AM, Serraino D, Giuffrida D, Cordio S, Giannitto-Giorgio C, Salice P, Ursino M, Novello G, Marletta F, Manusia M. Fludarabine, Mitoxantrone and Dexamethasone as Front-line Therapy in Elderly Patients Affected by Newly-diagnosed, Low-grade Non-Hodgkin's Lymphomas with Unfavorable Prognostic Factors: Results of a Phase II Study. Leuk Lymphoma 2009; 45:93-100. [PMID: 15061203 DOI: 10.1080/1042819031000139765] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
About one-third of the cases of non-Hodgkin's lymphomas occur in patients aged 60 years or more. Nevertheless, there are very few data in the literature regarding the optimal therapeutic approach for both aggressive and indolent histologies. Fludarabine-based combination regimens are an effective choice for younger patients affected by low-grade non-Hodgkin's lymphomas, but there is a lack of information about their tolerability and efficacy in older patients. We performed a phase II study to test the efficacy and safety of the combination of Fludarabine, Mitoxantrone and Dexamethasone (FND) in newly-diagnosed, chemo-naive elderly patients affected by low-grade non-Hodgkin's lymphomas with unfavorable prognostic factors. From March 1999 to March 2002, 18 patients were enrolled into the study. All the patients were evaluated for toxicity and response. Neutropenia and thrombocytopenia have been registered as the main toxicities. Thirteen (72%) patients experienced a complete response and 4 (22%) a partial response: the overall response rate was 94%. At a median follow-up of 19 months, the median time for progression-free-survival and the median survival time were not reached yet. The 2-years projected progression-free-survival and overall-survival are 52% and 67% respectively. When administered as first-line treatment to a population of elderly patients affected by high-risk, low-grade non-Hodgkin's lymphomas, FND showed a high efficacy and a good toxicity profile. Our data compare favorably to those reported for the same schedule administered both as first- or second-line therapy in younger patients.
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9
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Zinzani PL, Pulsoni A, Gentilini P, Visani G, Perrotti A, Molinari AL, Guardigni L, Tani M, Villivà N, Stefoni V, Alinari L, Martelli M, Bonifazi F, Pileri S, Tura S, Baccarani M. Effectiveness of Fludarabine, Idarubicin and Cyclophosphamide (FLUIC) Combination Regimen for Young Patients with Untreated Non-Follicular Low-Grade Non-Hodgkin's Lymphoma. Leuk Lymphoma 2009; 45:1815-9. [PMID: 15223641 DOI: 10.1080/1042819042000219502] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
In the last years, fludarabine (FLU) alone or in combination with other drugs has been reported to be effective in the treatment of previously untreated low-grade non-Hodgkin's lymphomas (LG-NHL). We report on the therapeutic efficacy and toxicity of a combination of FLU, idarubicin and cyclophosphamide (FLUIC regimen) in untreated non-follicular LG-NHL. We administered a three-drug combination of FLU (25 mg/m2 i.v. on days 1 to 3), idarubicin (14 mg/m2 i.v. on day 1) and cyclophosphamide (200 mg/m2 i.v. on days 1 to 3) to treat 41 young, previously untreated patients with non-follicular LG-NHL. Chemotherapy was repeated every 4 weeks for a total of 6 cycles. Among 41 patients, 24 (59%) were diagnosed with small lymphocytic, 10 (24%) with immnocytoma, and 7 (17%) with marginal zone subtypes. Nineteen (46%) patients achieved complete response (CR) and 21 (51%) partial response, while the remaining 1 (3%) showed no benefit from the treatment. With respect to histology, we observed CR rates of 38% for the small lymphocytic subtype, 40% for the immunocytoma subtype, and 86% for the marginal zone subtype. Estimated 42-month overall survival and relapse-free survival rates were 64% and 100%, respectively. Hematologic grade 3-4 toxicity was seen in 9 (22%) patients; no opportunistic infection or death was associated with administration of the FLUIC regimen. These preliminary data suggest that FLUIC is a very active, well-tolerated regimen for young, untreated patients with advanced non-follicular LG-NHL.
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Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology "Seràgnoli", University of Bologna, Bologna, Italy.
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Economopoulos T, Psyrri A, Fountzilas G, Tsatalas C, Anagnostopoulos A, Papageorgiou S, Xiros N, Dimopoulos MA. Phase II study of low-grade non-Hodgkin lymphomas with fludarabine and mitoxantrone followed by rituximab consolidation: promising results in marginal zone lymphoma. Leuk Lymphoma 2008; 49:68-74. [PMID: 18203014 DOI: 10.1080/10428190701784714] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The majority of patients with indolent lymphomas relapse due to minimal residual disease (MRD). In the present study, we sought to determine whether by using rituximab consolidation, for eradication of MRD, following induction chemotherapy with fludarabine and mitoxantrone (FN) combination could improve the outcome of indolent lymphomas. Patients with indolent lymphoma received fludarabine 25 mg/m2 Day 1-3 and mitoxantrone 10 mg/m2 on Day 1 every 28 days. Patients who attained a response (complete response, CR or partial response, PR) received four weekly doses of Rituximab 375 mg/m2 1 month and 3 months after completion of treatment. Forty-five patients were entered into this Phase II trial. The median follow-up time was 39 months. The median number of delivered cycles was 6. Fifty-three percent of patients attained a CR and 38% a PR for an overall response rate of 91%. One patient had stable disease, one had progression of the disease, whereas 2 were non-evaluable. After a median follow-up of 39 months, 32 of 46 patients (74%) are alive and disease-free. Grade III and IV toxicities included leucopenia (37%), neutropenia (28%), thrombocytopenia (7%), anemia (4%), and diarrhea (2%). Grade V toxicities included septic death in one patient and death due to hepatitis B reactivation 6 months after the last Rituximab dose in another patient. FN followed by R consolidation is a well-tolerated and active regimen in the treatment of patients with indolent lymphomas. Further follow-up is required to determine if these remissions are maintained.
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11
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Zinzani PL, Tani M, Fanti S, Stefoni V, Musuraca G, Vitolo U, Perrotti A, Fina M, Derenzini E, Baccarani M. A phase 2 trial of fludarabine and mitoxantrone chemotherapy followed by yttrium-90 ibritumomab tiuxetan for patients with previously untreated, indolent, nonfollicular, non-Hodgkin lymphoma. Cancer 2008; 112:856-62. [PMID: 18189293 DOI: 10.1002/cncr.23236] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND A prospective, single-arm, open-label, nonrandomized Phase 2 study of combined fludarabine and mitoxantrone (FM) plus radioimmunotherapy was conducted to evaluate efficacy and safety in patients with untreated, indolent, nonfollicular non-Hodgkin lymphoma (NHL). METHODS Between February 2005 and June 2006, at their institute, the authors treated 26 eligible patients with previously untreated, indolent, nonfollicular NHL (10 marginal zone lymphomas, 8 lymphoplasmacytic lymphomas, and 8 small lymphocytic lymphomas) using a novel regimen that consisted of 6 cycles of FM chemotherapy followed 6 to 10 weeks later by yttrium-90 (90Y) ibritumomab tiuxetan. RESULTS After FM chemotherapy, the overall response rate was 80.5% and included a 50% complete remission (CR) rate (13 patients) and a 30.5% partial remission (PR) rate (8 patients). Of the 20 patients (13 with CR and 7 with PR) who were evaluable (at least a PR with normal platelet counts and bone marrow infiltration <25%) for subsequent 90Y ibritumomab tiuxetan, 100% obtained a CR at the end of the entire treatment regimen. At a median follow-up of 20 months, the estimated 3-year progression-free survival rate was 89.5%, and the estimated 3-year overall survival rate was 100%. The 90Y ibritumomab tiuxetan toxicity included grade >or=3 hematologic toxicity in 16 of 20 patients; the most common grade >or=3 toxicities were neutropenia (11 patients) and thrombocytopenia (16 patients) (adverse events were graded according to the World Health Organization criteria for toxicity). Transfusions of erythrocytes and/or platelets were given to 5 patients. CONCLUSIONS The current study established the feasibility, tolerability, and efficacy of the FM plus 90Y ibritumomab tiuxetan regimen for the treatment of patients with untreated, indolent, nonfollicular NHL.
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Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology L&A Seragnoli, University of Bologna, Bologna, Italy.
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12
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Zhao X, Wu J, Muthusamy N, Byrd JC, Lee RJ. Liposomal Coencapsulated Fludarabine and Mitoxantrone for Lymphoproliferative Disorder Treatment**Xiaobin Zhao and Jianmei Wu contributed equally to this study. J Pharm Sci 2008; 97:1508-18. [PMID: 17722102 DOI: 10.1002/jps.21046] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Fludarabine (FLU)-based combination therapies are commonly used to treat low-grade lymphoma and chronic lymphocytic leukemia (CLL) patients. In vitro and clinical studies have indicated advantages when FLU and mitoxantrone (MTO) are applied in combination. To further enhance this effect, these two agents were coencapsulated in liposomes. FLU was passively encapsulated during liposome formation, and MTO was loaded with a transmembrane pH gradient. Entrapment efficiency, particle size, stability, and drug release kinetics were characterized. In vitro cytotoxicity study was carried out in two representative B-cell lines: Wac3CD5 and Raji. Synergism as measured by combination index (CI) was observed in cells treated with liposomes coencapsulating FLU and MTO. Annexin V/propidium iodide (PI) analysis further confirmed that coencapsulated FLU and MTO improved the percentage of apoptosis among primary CLL cells. These data suggest that adopting liposomes containing coencapsulated drug combinations constitutes a potential strategy to promote drug synergism and may have utility in the treatment of leukemia and lymphoma.
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Affiliation(s)
- Xiaobin Zhao
- Division of Pharmaceutics, College of Pharmacy, The Ohio State University, Columbus, Ohio 43210, USA
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Abstract
Indolent lymphomas are a group of lymphoid malignancies with differing patterns of behavior and responses to treatment. The progress in treating patients with hairy cell leukemia (HCL) using nucleoside analogues can be used as a model for other indolent B-lymphoproliferative disorders, such as follicular lymphoma. Recent advancements in therapeutic options available for these patients include combination therapy with agents that have differing mechanisms of action and non-overlapping toxicity. It has been shown that patients who are candidates for aggressive therapy might receive benefit, including disease-free survival and overall survival, from combination purine analogue therapy. Using these more aggressive therapeutic approaches earlier in the disease course and as maintenance therapy may further enhance outcomes. With the advent of these new therapies along with the molecular evaluation of these regimens, we may be nearing the time where the goal for more advanced indolent lymphoma will be to achieve a cure.
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Affiliation(s)
- Nicholas Di Bella
- Rocky Mountain Cancer Centers, Aurora, CO 80012, and Department of Leukemia, University of Texas, Houston, USA.
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Abstract
Non-Hodgkin's lymphoma (NHL) is not a single disease, but a group of closely related B- and T-cell cancers of the lymphatic system. The incidence of NHL is rising, particularly in the countries of the industrialized world. The increased incidence is poorly understood, but several risk factors have been postulated to be associated with NHL, including: exposure to chemicals, viral infections, organ transplantation and blood transfusion, family history, and lifestyle factors. Precise staging of NHL is a prerequisite for the selection of a suitable therapeutic regimen and influences the likelihood of its success. Staging of lymphoma is traditionally conducted using tumor biopsy, imaging (X-ray, computerized tomography [CT], magnetic resonance imaging, lymphangiogram, gallium scan using 67 Ga citrate single photon emission CT [ 67 Ga-SPECT], or positron emission tomography), blood tests, bone marrow examination, and examination of cerebrospinal fluid. CT is the most commonly used imaging technique, but several studies indicate that other techniques, such as 67 Ga-SPECT, are more sensitive and better predictors of response. Low- and high-grade lymphomas differ markedly in prognosis and response to treatment. The management of NHL has been characterized by the increasing recognition that distinct subgroups of NHL respond differently to various therapeutic approaches. In follicular lymphoma (FL), a successful approach has been to combine fludarabine with mitoxantrone (FM), resulting in an overall response rate of 89% (67% complete remission). In an ongoing phase III trial in patients with untreated, advanced, low-grade follicular lymphoma, FM was compared with CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) with or without rituximab. Patients previously treated with FM achieved a significantly better complete remission rate (67% v 38%; P = .0013) and a better molecular remission (36% v 20%; P = .049) than patients previously treated with CHOP. Following rituximab treatment, 88% of patients who had received FM achieved clinical and molecular remission compared with 70% who had received CHOP. Strategies using various chemotherapy combinations, including innovative agents such as 90 Y-ibritumomab tiuxetan, show promise in the treatment of NHL, particularly indolent NHL, and hopefully will lead to an improvement in prognosis.
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Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology, "L. e A. Seràgnoli", University of Bologna, Italy.
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Di Bella N, Reynolds C, Faragher D, Muscato J, Boehm KA, Asmar L. An open-label pilot study of pentostatin, mitoxantrone, and rituximab in patients with previously untreated, Stage III or IV, low-grade non-Hodgkin lymphoma. Cancer 2005; 103:978-84. [PMID: 15672388 DOI: 10.1002/cncr.20820] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND In a previous study, the authors demonstrated that the combination of pentostatin (P) and rituximab (R) was well tolerated and was active in patients with low-grade non-Hodgkin lymphoma (NHL). In the current study, mitoxantrone (M) was added to P + R to evaluate the toxicity and efficacy of this three-drug combination (PMR). METHODS Twenty-four previously untreated patients with histologically proven, Stage III or IV, low-grade NHL were registered between April and September, 2002. Patients received P (4 mg/m2), M (10 mg/m2), and R (375 mg/m2) every 28 days (M on Day 1; P and R on Days 1 and 8; in Cycle 1, R was given on Day 8 only). Eighty-three percent of patients had Stage IV disease, the median patient age was 62 years (range, 4-81 years), and the performance status was 0-2. RESULTS Responses included 9 patients who achieved complete remission (CR) (38%), 3 patients with unconfirmed CR (CRu) (12%), 8 patients who achieved partial remission (33%), and 4 patients who achieved stable disease (17%); the overall response rate (CR + CRu + PR) was 83%. PMR appeared to result in comparable activity in all histologies. The median response duration was 10.0 months (range, 3.5-15.1 months). Patients received a median of 5 cycles (range, 1-10 cycles). Eighteen patients (75%) required dose reduction or delay due to toxicity, mainly neutropenia (the administration of growth factors was not permitted). Three patients died (two patients died of disease progression, and one patient died from unrelated cardiopulmonary arrest). Grade > or = 3 drug-related toxicities included neutropenia (67%), leukopenia and febrile neutropenia (17% each), and sepsis (8%), and 38% of neutropenic episodes occurred in Cycles 1 and 2. CONCLUSIONS In this study, PMR was active and well-tolerated in patients with low-grade NHL, and the combination is deserving of further study.
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16
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Tsimberidou AM, Younes A, Romaguera J, Hagemeister FB, Rodriguez MA, Feng L, Ayala A, Smith TL, Cabanillas F, McLaughlin P. Immunosuppression and infectious complications in patients with stage IV indolent lymphoma treated with a fludarabine, mitoxantrone, and dexamethasone regimen. Cancer 2005; 104:345-53. [PMID: 15948158 DOI: 10.1002/cncr.21151] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Myelosuppression and immunosuppression occur with purine analogs. The objective of the current study was to investigate the effects of combined fludarabine, mitoxantrone, and dexamethasone (FND) followed by interferon/dexamethasone on myelosuppression (absolute neutrophil counts), immunosuppression (CD4 and CD8 counts), and infectious complications in patients with previously untreated, Stage IV indolent lymphoma. METHODS Seventy-three patients were treated. All patients received Pneumocystis carinii pneumonia (PCP) prophylaxis. CD4 and CD8 counts, serum immunoglobulin (Ig) levels, and neutrophil counts were correlated with infectious complications. RESULTS The median follow-up was 6.1 years. Sixty of 73 patients had CD4, CD8, or Ig measurements. The median baseline CD4 count was 764/microL. This CD4 level decreased to 238/microL at 1 year and to 264/microL at 2 years; and it rose to 431/microL by 3 years and to 650/microL at 4 years. CD8 counts did not change significantly. The median baseline serum IgG level was 989 mg/d, decreased to 536 mg/dL at 1 year and to 693 mg/dL at 2 years, and it rose to 949 mg/dL at 3 years and to 1080 mg/dL at 4 years. Fourteen patients (19%) developed Grade 3-4 infections, the majority during FND therapy with neutropenia and/or accompanied by CD4 counts < 200/microL. CD4, CD8, and neutrophil counts did not differ between patients who developed Grade 3-4 infections, Grade 1-2 infections, or no infections. CONCLUSIONS Most infections with FND occurred during FND, in the setting of neutropenia, often with concurrent low CD4 counts. The overall safety profile for FND was good. However, patients should be monitored for opportunistic infections, and prophylactic antibiotics are recommended, particularly against PCP.
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Yung L, Cunningham D, Hancock B, Smith P, Maclennan K, Linch D, McMillan A. Fludarabine, adriamycin and dexamethasone (FAD) in newly diagnosed advanced follicular lymphoma: a phase II study by the British National Lymphoma Investigation (BNLI). Br J Cancer 2004; 91:695-8. [PMID: 15280929 PMCID: PMC2364798 DOI: 10.1038/sj.bjc.6602031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The optimal first-line treatment for symptomatic patients with advanced stage follicular lymphoma remains unclear. Fludarabine-based combination regimens have been extensively used in relapsed disease and merit consideration as first-line therapy. We here report the results of a phase II study of FAD (fludarabine, adriamycin, dexamethasone) regimen in 30 patients with advanced stage follicular lymphoma requiring treatment. The response rate was in excess of 90% with 39% achieving a complete remission. The major toxicity was myelosuppression, but only 3% of cycles were associated with grade IV leucopenia. The high response rate has not translated into major improvements in failure-free survival and consideration must be given to alternative treatment modalities to consolidate the high rate of initial responses.
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Affiliation(s)
- L Yung
- Department of Haematology, University College London, UK.
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18
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Zinzani PL, Pulsoni A, Perrotti A, Soverini S, Zaja F, De Renzo A, Storti S, Lauta VM, Guardigni L, Gentilini P, Tucci A, Molinari AL, Gobbi M, Falini B, Fattori PP, Ciccone F, Alinari L, Martelli M, Pileri S, Tura S, Baccarani M. Fludarabine Plus Mitoxantrone With and Without Rituximab Versus CHOP With and Without Rituximab As Front-Line Treatment for Patients With Follicular Lymphoma. J Clin Oncol 2004; 22:2654-61. [PMID: 15159414 DOI: 10.1200/jco.2004.07.170] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Promising new therapeutic options for follicular lymphoma (FL) include fludarabine plus mitoxantrone (FM) and the mouse/human anti-CD20 antibody, rituximab. We performed a randomized comparative trial of FM with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) front-line chemotherapy with and without sequential rituximab. Patients and Methods All previously untreated CD20+ FL patients presenting in 15 Italian cooperative institutions from October 1999 were randomly allocated to FM or CHOP. Following clinical or molecular restaging, patients in complete remission (CR) with bcl-2/IgH negativity (CR−) received no further treatment; those in CR with bcl-2/IgH positivity (CR+) received rituximab, as did those in partial remission (PR) with bcl-2/IgH negativity (PR−) or positivity (PR+); nonresponders (NR subgroup) were off study. Results After chemotherapy, the FM arm achieved higher rates of CR (68% [49 of 72 patients] v 42% [29 of 68 patients]; P = .003) and CR− (39% [28 of 72 patients] v 13 of 68 patients [19%]; P = .001). Rituximab elicited CR− in 55 of 95 treated patients (58%). The final CR− rate was higher in the FM arm (71% [51 of 72 patients] v 51% [35 of 68 patients]; P = .01). However, with a median follow-up of 19 months (range, 9 to 37 months), no statistically significant difference was found among the various study arms in terms of both progression-free (PFS) and overall survival (OS). Conclusion These results indicate that FM is superior to CHOP for front-line treatment of FL and that rituximab is an effective sequential treatment option. However, they also confirm that this superiority is unlikely to translate into either better PFS or OS.
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Affiliation(s)
- Pier Luigi Zinzani
- Institute of Hematology and Medical Oncology L. e A. Seràgnoli, University of Bologna, Italy.
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19
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Tsimberidou AM, Keating MJ, Giles FJ, Wierda WG, Ferrajoli A, Lerner S, Beran M, Andreeff M, Kantarjian HM, O'Brien S. Fludarabine and mitoxantrone for patients with chronic lymphocytic leukemia. Cancer 2004; 100:2583-91. [PMID: 15197800 DOI: 10.1002/cncr.20264] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The objective of the current study was to assess the efficacy of combination therapy with fludarabine and mitoxantrone in patients with B-cell chronic lymphocytic leukemia (CLL). METHODS Eighty-eight patients were treated with fludarabine 30 mg/m(2) intravenously daily for 3 days and mitoxantrone 10 mg/m(2) on Day 1 (FN). Patients were divided into four groups based on expected response to single-agent fludarabine. These four groups included previously untreated patients, patients who previously were treated with alkylating agents, patients who were successfully treated with alkylating agents and fludarabine but who developed recurrent disease, and patients whose disease was refractory to fludarabine with or without alkylating agents. RESULTS The overall response rate was 66%. The response rates were 83% in previously untreated patients, 87% in patients previously treated with alkylating agents, 50% in patients whose disease was not refractory to fludarabine at the start of therapy, and 25% in patients whose disease was refractory to fludarabine. The complete remission (CR) rate was 20% for previously untreated patients, which was not significantly different from the CR rate for a group of historical control patients who were treated with single-agent fludarabine. The median follow-up was 8 years for surviving patients. The median progression free survival was 24 months for all patients and 34 months for previously untreated patients. The median overall survival was 40 months, and the median survival of previously untreated patients was 88 months. The most common toxicities were myelosuppression and infection. Eleven patients (12.5%) developed a second malignancy after a median of 62 months. CONCLUSIONS The FN regimen did not have a significant advantage over fludarabine alone in the treatment of patients with CLL.
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Affiliation(s)
- Apostolia M Tsimberidou
- Department of Leukemia, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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20
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Zinzani PL, Stefoni V, Musuraca G, Tani M, Alinari L, Gabriele A, Marchi E, Pileri S, Baccarani M. Fludarabine-containing chemotherapy as frontline treatment of nongastrointestinal mucosa-associated lymphoid tissue lymphoma. Cancer 2004; 100:2190-4. [PMID: 15139063 DOI: 10.1002/cncr.20237] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Mucosa-associated lymphoid tissue (MALT) lymphoma is a specific clinicopathologic entity with gastric and nongastrointestinal site involvement. The authors reported the clinical outcome of patients with Stage IE nongastrointestinal MALT lymphoma treated with a frontline fludarabine-containing regimen or with a regimen containing cyclophosphamide, vincristine, and prednisone (CVP). METHODS Between 1998 and 2001, 31 patients with Stage IE disease were referred to the Seràgnoli Institute of Hematology and Medical Oncology at the University of Bologna (Bologna, Italy). Presenting sites included periorbital soft tissue (n = 8), lung (n = 5), skin (n = 5), salivary glands (n = 5), lacrimal glands (n = 5), and thyroid (n = 3). Twenty patients were treated with fludarabine and mitoxantrone (FM), and 11 were treated with the CVP regimen. The median follow-up was 3 years. RESULTS All patients achieved complete responses (CR). Four patients, all treated with CVP, experienced disease recurrence and then achieved a second CR after FM salvage treatment. No tumor recurrence was observed in patients with thyroid, lacrimal gland, or pulmonary lymphoma. The projected 5-year overall survival and disease-free survival rates were 100% and 85%, respectively. CONCLUSIONS The fludarabine-containing FM regimen provided a relatively effective frontline (or salvage) treatment option for patients with nongastrointestinal Stage IE MALT lymphoma and probably was superior to CVP in terms of efficacy.
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Affiliation(s)
- Pier Luigi Zinzani
- Seràgnoli Institute of Hematology and Medical Oncology, University of Bologna, Bologna, Italy.
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21
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Bordonaro R, Fratino L, Serraino D. Treatment of Non-Hodgkin's Lymphomas in Elderly Patients. ACTA ACUST UNITED AC 2004; 5:37-44. [PMID: 15245606 DOI: 10.3816/clm.2004.n.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The roles of evolving treatment strategies for non-Hodgkin's lymphomas (NHL) in elderly patients are still not well defined and their effects on the overall epidemiology of the disease are still not clear. Three questions arise when discussing the management of NHL in elderly patients. First, should older patients be treated with the same regimens usually administered to younger patients? Second, are health outcomes of elderly patients similar to those usually observed in young patients, particularly response rate and overall survival? Third, which strategies should be adopted to improve overall health outcomes? Periodic review of the literature and updated data on the management of NHL in elderly patients may provide an answer to all these queries. In essence, older patients must be treated with the same intensive approaches that are usually reserved for younger patients. The results reported in randomized controlled clinical trials are consistent with the capability of older patients to exhibit overall response rate, event-free survival, and overall survival similar to those observed in their younger counterparts. Combining chemotherapy and monoclonal antibodies seems to be the main optional strategy for better outcomes in elderly patients. In contrast, knowledge concerning the management of indolent lymphomas in elderly patients is still lacking, and available clinical data are limited in this setting, especially in patients with poor prognostic factors who may need an immediate therapeutic intervention.
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22
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Ma SY, Au WY, Chim CS, Lie AKW, Lam CCK, Tse E, Leung AYH, Liang R, Kwong YL. Fludarabine, mitoxantrone and dexamethasone in the treatment of indolent B- and T-cell lymphoid malignancies in Chinese patients. Br J Haematol 2004; 124:754-61. [PMID: 15009063 DOI: 10.1111/j.1365-2141.2004.04852.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The treatment results of indolent lymphoid malignancies in Chinese are poorly reported. The efficacy of FND (fludarabine 25 mg/m2/d, x3; mitoxantrone 10 mg/m2/d, x1; dexamethasone 20 mg/d, x5; monthly cycles, x6) in 95 Chinese patients with indolent B-cell malignancies (at diagnosis: 55, relapse/refractory disease: 40) and nine Chinese patients with T-cell large granular lymphocyte leukaemia (T-LGL leukaemia) (at diagnosis: two, refractory disease: seven) was evaluated. For B-cell malignancies, the complete response (CR), partial response (PR) and overall response (OR) rates were 50.5%, 18% and 68.5% respectively. Better results were obtained for primary versus relapse/refractory disease (CR: 60% vs. 37.5%, P = 0.03; OR: 84% vs. 47.5%, P < 0.001; median progression-free survival (PFS): 44 months vs. 22 months; 2-year PFS: 66% vs. 47%, P = 0.039; overall survival (OS): not reached vs. 32%; 2-year OS: 92% vs. 58%, P < 0.001). Responsive patients (CR/PR) had a better median PFS (44 months vs. 5 months, P < 0.001) and OS (67 months vs. 13 months, P < 0.001) than unresponsive patients. For T-LGL leukaemia, the CR and molecular-remission rates were 56% and 67% (median follow-up: 23 months). FND is an active regimen for the treatment of indolent B- and T-cell malignancies in Chinese patients, with results comparable with Western patients with similar indolent lymphomas.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antibodies, Monoclonal/administration & dosage
- Antibodies, Monoclonal, Murine-Derived
- Antineoplastic Combined Chemotherapy Protocols/administration & dosage
- Antineoplastic Combined Chemotherapy Protocols/adverse effects
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Asian People
- Dexamethasone/administration & dosage
- Dexamethasone/adverse effects
- Disease-Free Survival
- Female
- Humans
- Leukemia, Prolymphocytic, T-Cell/drug therapy
- Leukemia, Prolymphocytic, T-Cell/ethnology
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/ethnology
- Lymphoma, Non-Hodgkin/drug therapy
- Lymphoma, Non-Hodgkin/ethnology
- Male
- Middle Aged
- Mitoxantrone/administration & dosage
- Mitoxantrone/adverse effects
- Prospective Studies
- Rituximab
- Survival Analysis
- Treatment Outcome
- Vidarabine/administration & dosage
- Vidarabine/adverse effects
- Vidarabine/analogs & derivatives
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Affiliation(s)
- Shing Y Ma
- Department of Medicine, Queen Mary Hospital, Hong Kong, China
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23
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Velasquez WS, Lew D, Grogan TM, Spiridonidis CH, Balcerzak SP, Dakhil SR, Miller TP, Lanier KS, Chapman RA, Fisher RI. Combination of fludarabine and mitoxantrone in untreated stages III and IV low-grade lymphoma: S9501. J Clin Oncol 2003; 21:1996-2003. [PMID: 12743154 DOI: 10.1200/jco.2003.09.047] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To determine the efficacy of combination fludarabine and mitoxantrone (FN) in untreated stages III and IV low-grade lymphoma. The major end point was to estimate progression-free survival (PFS) in all eligible patients. PATIENTS AND METHODS Seventy-eight eligible patients were registered. Chemotherapy courses were administered every 4 weeks with mitoxantrone 10 mg/m2 on day 1 and fludarabine 25 mg/m2 on days 1, 2, and 3 for a total of six to eight cycles. Pneumocystis carinii prophylaxis was required. RESULTS Seventy-three patients (94%) attained an objective response. Complete remission was demonstrated in 34 patients (44%) and partial remission was demonstrated in 39 patients (50%). With a median follow-up time of 5.5 years, the median PFS was 32 months, with a 4-year PFS rate of 38%. Median survival has not been reached and 88% of all patients are alive at 4 years. The application of the International Prognostic Index and serologic staging showed significant differences in PFS in all risk groups, whereas overall survival was markedly worse for the highest-risk group in either prognostic model. Three prior Southwest Oncology Group trials using a regimen of cyclophosphamide, doxorubicin, vincristine, and prednisone or a combination of prednisone, vincristine, methotrexate, cytarabine, cyclophosphamide, etoposide, nitrogen mustard, vincristine, procarbazine, and prednisone in similar patient populations demonstrated comparable clinical outcome, although the 4-year survival for FN was better. FN was well tolerated, but mild to severe reversible myelosuppression was noted. Other complications were rare. CONCLUSION FN is an effective, safe chemotherapy combination for patients with advanced-stage, low-grade lymphoma. Clinical outcomes were comparable to prior published data using anthracycline-based regimens.
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Abstract
Indolent non-Hodgkin's lymphoma is the commonest form of lymphoma in the USA and Europe, with a long natural history with multiple responses and relapses. Indolent lymphomas include follicular lymphomas (the more frequent subtype), immunocytoma, and small lymphocytic lymphomas according to the Revised European-American Lymphoma classification. The tendency has been to use simple oral medication until patients have more advanced aggressive disease but new agents such as the purine analogues have led to re-evaluation of this approach. The newer purine analogues -- fludarabine, 2-chlorodeoxyadenosine (cladribine) and deoxycoformycin (pentostatin) -- are a group of potently lymphotoxic antimetabolite molecules. Their activity in the indolent non-Hodgkin's lymphomas, in particular in the follicular subtype, may be due to their unique ability as antimetabolites to inhibit resting as well as dividing cells. Within the last decade they have moved from salvage therapy to front-line studies. Further insight into the mechanism of action of the purine analogues will to lead to further advances in this group of diseases.
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Affiliation(s)
- Pier Luigi Zinzani
- Institute of Haematology and Medical Oncology L. e A. Seràgnoli, University of Bologna, Bologna, Italy
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25
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Rummel MJ, Chow KU, Karakas T, Jäger E, Mezger J, von Grünhagen U, Schalk KP, Burkhard O, Hansmann ML, Ritzel H, Bergmann L, Hoelzer D, Mitrou PS. Reduced-dose cladribine (2-CdA) plus mitoxantrone is effective in the treatment of mantle-cell and low-grade non-Hodgkin's lymphoma. Eur J Cancer 2002; 38:1739-46. [PMID: 12175690 DOI: 10.1016/s0959-8049(02)00143-0] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cladribine (2-chlorodeoxyadenosine) (2-CdA) has been shown to be effective in mantle-cell (MCL) and low-grade lymphomas (lgNHL). The aim of this multicentre study was to evaluate the rate and duration of remissions and to examine the toxicity of the combination of reduced-dose 2-CdA and mitoxantrone (CdM) in MCL and lgNHL as first-line therapy or for patients in their relapse. A total of 285 courses, median of five courses per patient, were administered to 62 evaluable patients (42 previously untreated, 20 relapsed) with 5 mg/m(2) 2-CdA per day given as an intermittent 2-h infusion over 3 consecutive days combined with 8 mg/m(2) mitoxantrone on days 1 and 2 for the untreated patients or 12 mg/m(2) mitoxantrone on day 1 for patients in their first relapse for a maximum of six cycles every four weeks. 32 follicular, 18 MCL, 9 lymphoplasmacytoid, 2 marginal zone and 1 unclassified low-grade B-cell lymphoma were involved in the study. 56 of the 62 patients responded to CdM resulting in an overall response rate of 90% (95% confidence interval (CI), 80-96%) with a complete remission (CR) rate of 44% (95% CI, 31-57%) and a median duration of remission of 25 months (range 6-42+). The overall survival rate at 48 months was 80%. For 42 previously untreated patients, the overall response rate was 88% (95% CI, 74-96%) with a CR rate of 38% (95% CI, 24-54%), whereas the response rate for the group of 20 previously treated patients was similar with a 95% overall response (95% CI, 75-100%) and a CR rate of 55% (95% CI, 32-77%). In MCL, CdM showed a high activity, achieving a response rate of 100% (95% CI, 81-100%) with a CR rate of 44% and a median duration of remission of 24 months (range 6-35+). Myelosuppression was the major toxicity with 23% grade 3 granulocytopenia and 50% grade 4. Thrombocytopenia was less commonly observed, with only 8% grades 3 and 4. These results demonstrate that the combination of reduced-dose 2-CdA and mitoxantrone is a highly active regimen in the treatment of low-grade lymphomas, and in particular of MCL.
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Affiliation(s)
- M J Rummel
- Department of Internal Medicine, Hematology/Oncology, University Hospital, Theodor-Stern-Kai 7, 60590, Frankfurt/Main, Germany
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26
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Wilder DD, Ogden JL, Jain VK. Efficacy of fludarabine/mitoxantrone/dexamethasone alternating with CHOP in bulky follicular non-Hodgkin's lymphoma. CLINICAL LYMPHOMA 2002; 2:229-37. [PMID: 11970762 DOI: 10.3816/clm.2002.n.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This phase II study investigated the efficacy of alternating fludarabine/mitoxantrone/ dexamethasone (FMD) with cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) chemotherapy for patients with high tumor burden, follicular non-Hodgkin's lymphoma. Maintenance interferon was given in a nonrandomized fashion, and a retrospective analysis of its impact was performed. A total of 87 patients were included (44 females and 43 males). The median age of patients was 56 years (range, 25-86 years). All patients had high tumor burden as defined by the Groupe d'Etude des Lymphomes Folliculaires (GELF) criteria. Eighty-four percent of patients (73/87) had stage III/IV disease and 99% of patients (86/87) had good performance status. The majority of patients had not been previously treated, with only 3 patients receiving prior oral alkylators or cyclophosphamide/vincristine/prednisone (COP). A total of 637 cycles of FMD/CHOP were administered and were well tolerated during this trial, the majority on an outpatient basis. The overall response rate was 95% (79 complete response/ unconfirmed complete response/partial response) in the 83 evaluable patients. Event-free survival (EFS) was 28.7 months, with time to progression (TTP) at 29 months and time to treatment failure at 41 months. Overall survival was not reached. Patients had similar EFS and TTP as patients in the French GELF trial with a shorter duration of chemotherapy. Patients with a lower International Prognostic Index (IPI) score had better EFS when compared to those with a higher IPI score (median EFS not reached versus 22.6 months). Serum beta2-microglobulin levels were not a significant predictive factor. An informal analysis of interferon maintenance therapy suggests that patients who tolerated the immune modifier did better than those who did not. Alternating FMD/CHOP is a feasible and effective therapeutic option for patients with high tumor burden, low-grade non-Hodgkin's lymphoma. While this regimen may not offer dramatic benefit over FMD alone, it is beneficial in those patients for whom a prompt treatment response is needed.
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Affiliation(s)
- Diane D Wilder
- Baylor-Charles A. Sammons Cancer Center, Baylor University Medical Center, Dallas, TX 75246, USA
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27
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Dimopoulos MA, Fountzilas G, Papageorgiou E, Kiamouris C, Mantzios G, Anagnostopoulos A, Nicolaides C, Economopoulos T. Primary treatment of low-grade non-Hodgkin's lymphoma with the combination of fludarabine and mitoxantrone: a phase II study of the Hellenic Cooperative Oncology Group. Leuk Lymphoma 2002; 43:111-4. [PMID: 11908713 DOI: 10.1080/10428190210177] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The treatment of patients with recurrent low-grade lymphoma with the combination of fludarabine, mitoxantrone and dexamethasone has been associated with significant activity but has also caused frequent infectious complications. We designed a phase II study for previously untreated patients with the combination of fludarabine and mitoxantrone but without steroids. Our aim was to assess the activity of this combination as primary treatment for low-grade lymphoma and to avoid the additional immunosuppression induced by dexamethasone. Twenty seven patients with low-grade lymphoma received fludarabine 25 mg/m2/day i.v. on days 1-3 and mitoxantrone 10 mg/m2 i.v. on day 1. The treatment was repeated every 28 days for a maximum of six cycles. Twenty patients (74%) achieved an objective response including 12 (44%) complete and 8 (30%) partial responses. The main toxicity was grade III or IV neutropenia, which occurred in 40% of patients but there were no severe opportunistic infections. The median time to progression for all patients was 32 months. With a median follow-up of 33.4 months, six patients have died and the probability of survival at 3 years is 75%. We conclude that the fludarabine and mitoxantrone regimen is safe and effective for newly diagnosed patients with low-grade lymphoma who require treatment. Prospective randomized trials are needed in order to assess the impact of this treatment on patients' survival.
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Affiliation(s)
- Meletios A Dimopoulos
- Department of Clinical Therapeutics, University of Athens School of Medicine, Greece.
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28
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Seymour JF, Grigg AP, Szer J, Fox RM. Fludarabine and mitoxantrone: effective and well-tolerated salvage therapy in relapsed indolent lymphoproliferative disorders. Ann Oncol 2001; 12:1455-60. [PMID: 11762819 DOI: 10.1023/a:1012551809100] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Prior studies of the combination of fludarabine, mitoxantrone and dexamethasone have yielded high response rates but are associated with a significant risk of opportunistic infections, predominantly Pneumocystis Carinii pneumonia (PCP) requiring routine prophylaxis. PATIENTS AND METHODS We evaluated the combination of fludarabine (25 mg/m2/day x 3) and mitoxantrone (10 mg/m2 x 1) without corticosteroids or PCP prophylaxis in 29 patients with relapsed or refractory indolent lymphoproliferative disorders; median age 56 years, 62% refractory to preceding chemotherapy. RESULTS A median of four cycles was administered without cumulative myelosuppression. Neutropenia <0.5 x 10(9/)l was seen in 16% of cycles. Infections complicated 10.4% of cycles. with impaired performance status (> or = ECOG 2) and increased age ( > 56 years) significant risk factors (P < or = 0.01). No cases of PCP were encountered. The response rate was 90%, median remission duration 11.9 months and the median survival 57 months. Peripheral blood progenitor cell mobilization was attempted in 11 patients and yielded > or = 2 x 10(6) CD34+ cells/kg in only 5 cases (45%). CONCLUSIONS High response rates can be attained with fludarabine and mitoxantrone in combination without corticosteroids, and routine PCP prophylaxis can safely be omitted. Peripheral blood progenitor collections are problematic in these heavily pretreated patients.
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Affiliation(s)
- J F Seymour
- Department of Haematology, The Peter MacCallum Cancer Institute, East Melbourne, Victoria, Australia.
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