Experience with salvage regimens at M.D. Anderson Hospital

[High-dose ifosfamide and etoposide regimen as salvage and mobilization therapy for patients with lymphoma]

BACKGROUND AND OBJECTIVE

Several groups have used salvage chemotherapy in relapsed or refractory lymphomas to mobilize peripheral blood stem cells. The objective of this study was to evaluate the antilymphomatous efficacy, the ability of mobilization and the toxicity of a regimen containing high-dose ifosfamide, etoposide, methylprednisolone (IFOVM) and granulocyte colony-stimulating factor (G-CSF).

PATIENTS AND METHOD

Twenty-four patients with relapsed or refractory lymphoma received IFOVM and G-CSF. The median age was 45 years and 13 were males. The histologyc subtypes of lymphoma were: diffuse large B cell (DLBCL) (n = 15), Hodgkin (n = 2), Burkitt (n = 2), mantle cell (n = 2), anaplastic (n = 1), peripheral T-cell (n = 1) and follicular (n = 1).

RESULTS

Two patients died of sepsis within the pancytopenia period. In 17 (77%) of the remaining patients more than 1.5 x 10(6) CD34+ cells/kg (median: 7.7 x 10(6) CD34+ cells/kg) were collected. The median time to peripheral blood stem cells harvest was 17 (range: 13-24) days and 4 patients required 2 procedures of apheresis. Sixteen patients (67%) developed neutropenic fever. The median time to achieve granulocyte cell count > 1 x 10(9)/l and platelet count > 20 x 10(9)/l was 15 and 16 days, respectively. The only factor predicting successful mobilization was the diagnosis of DLBCL (p = 0.04). Ten patients underwent peripheral blood stem cells transplantation.

CONCLUSIONS

The regimen IFOVM and G-CSF allows an effective peripheral blood stem cells mobilization in patients with lymphoma, particularly in those with DLBCL, but it is associated with significant toxicity.

ESHAP salvage therapy for refractory and relapsed non-Hodgkin's lymphoma: a single center experience

BACKGROUND

The ESHAP chemotherapy regimen, that is, the combination of the etoposide, methylprednisolone, high-dose cytarabine and cisplatin, has been shown to be active against relapsing or refractory non-Hodgkin's lymphoma (NHL) in previous therapeutic trials. We attempted to determine whether ESHAP therapy would be effective and well-tolerated in Korean patients.

METHODS

Twenty two patients with refractory or relapsed NHLs (all aggressive types) were enrolled in this study. We retrospectively evaluated the treatment response, the survival rate and the time to progression.

RESULTS

Six patients (27.3%) attained complete remission and eight patients (36.4%) attained partial remission. The overall response rate was 63.6%. The median survival duration was 15.5 months (95% confidence interval; 10.7 to 20.3 months), and the median duration of the time to progression was 8.3 months (95% confidence interval; 0.3 to 16.3 months). Myelosuppression was the major toxicity, but severe neutropenia or thrombocytopenia was rare, and renal toxicity was also infrequent.

CONCLUSIONS

ESHAP regimen is effective in Korean patients suffering with relapsed or refractory NHLs, but a more effective salvage modality is needed because of the short duration of remission and the insignificant impact on long-term survival.

Fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone plus rituximab and granulocyte-macrophage-colony stimulating factor (GM-CSF) alternating with methotrexate and cytarabine plus rituximab and GM-CSF in patients with Richter syndrome or fludarabine-refractory chronic lymphocytic leukemia

BACKGROUND

Therapy for patients with Richter syndrome (RS) or fludarabine-refractory chronic lymphocytic leukemia (CLL) is unsatisfactory. A Phase II study was conducted to evaluate an alternating combination cytotoxic regimen given with rituximab and granulocyte-macrophage-colony stimulating factor (GM-CSF) in these patients.

METHODS

Fludarabine-refractory CLL was defined as failure to respond to most recent prior fludarabine-containing regimen. Patients received up to six cycles of fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone (hyper-CVXD) plus rituximab and GM-CSF alternating with methotrexate and cytarabine plus rituximab and GM-CSF. Response, toxicity, and survival data were compared with data from prior therapy with hyper-CVXD alone in this patient group.

RESULTS

Forty-nine patients with RS (n = 30 patients) or refractory CLL (n = 19 patients) were treated on study. Nine patients (18%) achieved a complete remission, and 11 patients achieved a partial remission (22%), for an overall objective response (OR) rate of 41%. With a median follow-up of 7.5 months and a maximum follow-up of 15.2 months, the 12-month failure free survival (FFS) rate was 27%, and the overall survival (OS) rate was 39%. Nine patients (18%) died during the first cycle of therapy, and two patients (4%) died during the second cycle. There were no significant differences between the rates of OR, OS, and FFS in the current study and those obtained with hyper-CVXD alone on a prior study.

CONCLUSIONS

The study regimen had activity and significant toxicity in patients with RS or fludarabine-refractory CLL. It was not clearly better compared with hyper-CVXD alone in this patient population.

Phase II study of fludarabine, cytarabine (Ara-C), cyclophosphamide, cisplatin and GM-CSF (FACPGM) in patients with Richter's syndrome or refractory lymphoproliferative disorders

A phase II study was conducted to evaluate the safety and efficacy of fludarabine, cytarabine (ara-C), cyclophosphamide, cisplatin and GM-CSF (FACPGM) treatment in patients with Richter's syndrome (RS), refractory prolymphocytic leukemia (PLL) or refractory non-Hodgkin's lymphoma (NHL). Twenty-two patients with RS, refractory PLL, or refractory NHL were entered into this trial between March 1997 and February 2001. Median age was 62 years (42-74); 77% were over 60 years of age. Histologic diagnosis was large cell NHL transformation in 15 patients with CLL, immunoblastic transformation of CLL in one, refractory PLL in three, and refractory NHL in three patients. Treatment consisted of fludarabine 30mg/m2 (days 1-3), ara-C 0.5g/m2 (days 3-4), cyclophosphamide 250 mg/m2 (days 2-4), cisplatin 15 mg/m2 IV CI (days 1-4) with GM-CSF 250 microg/m2 from day 5 to recovery of neutrophils and antibiotic prophylaxis. Patients with response were to receive a maximum of six cycles of therapy. Eighteen patients were evaluable for response; one patient achieved a complete remission (5%), 12 stable disease/no response (67%) and five patients had progressive disease (28%). The median survival was 2.2 months (range, 1-19); the median failure-free survival was 1.5 months (range, 0.5-18.6). Grade III/IV toxicities were as follows: anemia in 62% of cycles; leucopoenia in 66%; granulocytopenia in 90%; thrombocytopenia in 83%; hyperbilirubinemia in 14%; hyperuricemia in 17%; hyponatremia in 17%; hypokalemia in 14%; hypophosphatemia in 10%; hypoalbulinemia in 14%; hypocalcemia in 7%; and hypercalcemia in 3%. One (3%) patient developed cardiac failure. Forty-one percent of the cycles were complicated with fever, 34% with non-neutropenic fever, and 55% cycles with infections (fungal 31%; bacterial 57%; HSV 6%; VZV 6%). FACPGM had very limited activity and significant toxicity in a cohort of patients with heavily pretreated refractory lymphoproliferative disorders.

The management of adult aggressive non-Hodgkin's lymphomas

Aggressive non-Hodgkin's lymphona include diffuse large B-cell lymphoma, anaplastic large cell lymphona, and different peripheral T-cell lymphomas. An international prognostic index has been developed including age, serum LDH, performance status, and extranodal involvement. For localized aggressive lymphoma, the preferred treatment is 3-4 CHOP and radiation therapy, with a cure rate of 70-80%. For disseminated aggressive lymphoma, current regimens have a cure rate of less than 40%. Innovative strategies, including dose escalation, autologus stem cell support, new drugs, and immunotherapy are being explored to improve these results.

Effects of 4-hydroperoxy ifosfamide in combination with other anticancer agents on human cancer cell lines

Ifosfamide is one of the currently available anticancer agents with a broad spectrum of clinical activity against a variety of tumors. To investigate its optimal combinations, we studied the effect of 4-hydroperoxy ifosfamide (the active form of ifosfamide) in combination with other anticancer agents against two human cancer cell lines, MG-63 (an osteosarcoma cell line) and MOLT-3 cells (a T-cell leukemia cell line). The cells were incubated for 4 days and 3 days, respectively, in the presence of 4-hydroperoxy ifosfamide and the other agent. Cell growth inhibition was determined by MTT assay. The effects of these drug combinations at the concentration producing 50% inhibition (IC50) were analyzed by the isobologram method. 4-Hydroperoxy ifosfamide showed additive effects with bleomycin, cisplatin, cytarabine, doxorubicin, etoposide, 5-fluorouracil, and mitomycin C, while it showed a protective effect with methotrexate in both cell lines. 4-Hydroperoxy ifosfamide showed an additive effect with vincristine in the MG-63 cell line, while it showed a sub-additive effect in the MOLT-3 cell line. No anticancer agents tested showed a supra-additive effect with 4-hydroperoxy ifosfamide. These data suggest that ifosfamide is advantageous for simultaneous administration with a majority of the anticancer agents we studied. Methotrexate is an inappropriate drug for simultaneous administration with ifosfamide.

Intensive chemotherapy with hematopoietic cell transplantation after ESHAP therapy for relapsed or refractory non-Hodgkin's lymphoma. Results of a single-centre study of 65 patients

This study was designed to assess the results of protracted courses of ESHAP (etoposide, cytarabine, cisplatin, methylprednisolone) therapy followed by intensive chemotherapy and hematopoietic cell transplantation (IC+HCT) for relapsed or refractory non-Hodgkin's lymphoma (NHL). Treatment consisted of 3 cycles of ESHAP; responsive patients (pts) then received 3 more cycles, and IC+HCT was used for pts in maintained partial (PR) or complete (CR) remission after the sixth ESHAP. Sixty-five pts entered the study. At enrollment, 27 pts had bone marrow (BM) and/or central nervous system (CNS) lymphomatous infiltration. Disease status was primary refractory lymphoma in 41 pts (63 %), and relapse in 24 pts (37 %). Results showed that two pts were not evaluable for the therapeutic response because of early treatment-related death. Thirty-nine (62 %) pts entered PR or CR after 3 cycles of ESHAP. Eleven pts subsequently had disease progression. Twenty-eight pts were in persistent CR or PR after 6 cycles of ESHAP. Refractory pts did not show a different response rate to relapsing pts (chi2= 1.73). Five pts were excluded from IC+HCT because of an inadequate graft or treatment-related toxicity. Twenty-three (35 %) pts completed the procedure. Five pts (22 %) relapsed after IC+HCT. The overall survival rate of the 39 responsive pts is 45 % at 60 months, with a median survival time of 30 months. Median survival among the 35 pts in whom second-line chemotherapy failed is 7.1 months, with a 4-year survival rate of 3 %. Despite the poor prognostic features of this group, 45% of pts responding to the first 3 cycles of chemotherapy are in prolonged remission, suggesting that rather than to transplant after just 2 cycles of salvage therapy, pursuing second-line chemotherapy may better discriminate between patients more likely to benefit from a subsequent transplant.

Combination salvage chemotherapy with MIZE (ifosfamide-mesna, idarubicin and etoposide) for relapsing or refractory lymphoma

In this study, 54 patients with relapsed or refractory non-Hodgkin's lymphoma (NHL) were treated in a phase II, multicentric trial with ifosfamide-mesna 1500 mg/m2 IV days 1-3, idarubicin 12 mg/m2 IV day 1 and etoposide 100 mg/m2 IV day 1-3 (MIZE). Overall response was 72%; complete response (CR) and partial response (PR) were 46% and 26% respectively. In Stage I-II pts CR was 59% and in Stage III-IV pts CR was 40.5%. Patients who relapsed from an initial CR had a 64% CR rate when treated with MIZE, in contrast to refractory disease's patients who only had 19% CR (p = 0.004). The group of pts that had an objective response (CR + PR) to front line therapy had a 2 year survival rate of 55% compared with none for refractory disease (p = 0.029) after salvage therapy. Median survival for the entire group was 17.5 months. Better survival was seen in pts who were asymptomatic with low levels of LDH, previous CR, non high-grade histology, and limited disease stage at relapse. Toxicity was mainly hematologic: 91.5% had neutropenia, (56.5% grade III-IV), and 9.5% died from infectious complications. Other clinical toxicities including cardiac toxicity were negligible. MIZE chemotherapy was effective in patients with relapsed and refractory lymphoma and showed limited clinical and cardiac toxicity. Myelosupression was the most frequent single toxicity.

Multiple cycles of aggressive chemotherapy prior to autologous peripheral stem cell transplantation for lymphoma

BACKGROUND

Based on in vitro evidence of synergy between certain chemotherapeutic agents and of improved efficacy of cytotoxics administered as continuous infusions we devised a novel chemotherapy regimen for use in patients with lymphoma.

AIMS

To assess the efficacy and tolerability of this regimen alone and in combination with autologous stem cell transplantation (ASCT) in patients with relapsed or refractory lymphoma.

METHODS

The regimen consisted of cytosine arabinoside and etoposide given as five day continuous infusions, bolus doses of methotrexate and cyclophosphamide and four days of oral dexamethasone (MADEC), together with prophylactic G-CSF. Fifty-one patients aged 17 to 65 years (median 43) were treated; 34 had intermediate or high grade non-Hodgkin's lymphoma and 17 had Hodgkin's disease. Patients with responsive disease received a second cycle.

RESULTS

Eleven patients (22%) achieved a complete response and 19 patients (38%) achieved a partial response, eight of whom were gallium negative. Previous chemosensitivity was highly predictive for response; minimal response was seen in patients with primary refractory disease. The probability of survival and event-free survival at 40 months for the entire group is 46% (+/- 8% SEM) and 26 +/- 8% respectively. Thirty-one patients proceeded to ASCT; the probability of survival of the transplanted group is 65 +/- 11% at 40 months. The regimen caused significant myelosuppression. The majority of cycles were complicated by febrile neutropenia and the requirement for platelet and red cell transfusions. Non-haematological toxicity was predominantly mucositis and was generally mild.

CONCLUSIONS

MADEC is a highly active regimen in patients with relapsed lymphoma. Patients responding to MADEC who proceed to ASCT have a good chance of achieving a durable remission.

Prolonged daily administration of oral etoposide in lymphoma following prior therapy with adriamycin, an ifosfamide-containing salvage combination, and intravenous etoposide

Prolonged daily administration of oral etoposide has been reported to be active in refractory lymphoma. The purpose of this phase II trial was to confirm the activity of this schedule of etoposide in a selected group of heavily pretreated patients with non-Hodgkin's lymphoma (NHL) or Hodgkin's disease (HD). A total of 26 patients (20 with NHL and 6 with HD) were entered in the trial; all had previously been treated with an Adriamycin-based chemotherapy, an ifosfamide-containing salvage combination, and i.v. etoposide. Etoposide was given in a fixed oral daily dose of 100 mg over 3 weeks; the weekly dose (500-700 mg) was selected such that the average daily dose was approximately 50 mg/m2. Cycles were repeated on day 29. An objective response was seen in 16 patients (62%; 95% confidence interval, 42%-80%), with a complete response (CR) being observed in 3 cases (12%) and a partial response (PR), in 13 (50%). The median duration of PRs was 3 months. CRs lasted for 15 months in one patient and continue at 12+ and 20+ months in the remaining two patients. The overall actuarial survival for the entire group was 40% at 2 years; the median survival time was 12 months. The main toxicity was myelosuppression; WHO grade 3 or 4 leukopenia and thrombocytopenia developed in 31% and 12% of the patients, respectively. There was no drug-related death. We conclude that oral etoposide is an effective and tolerable palliative treatment for heavily pretreated lymphoma patients.

E-SHAP: an effective treatment in selected patients with relapsed non-Hodgkin's lymphoma

BACKGROUND

The optimal treatment of relapsed or refractory non-Hodgkin's lymphoma is unknown. The reported encouraging results of a salvage regimen, E-SHAP (etoposide 40 mg/m2/day x 4, methyl prednisolone 500 mg daily x 4, cytosine arabinoside 2 gm/m2 one dose and cisplatinum 25 mg/m2/day x 4), at the M.D. Anderson Hospital in Texas, which resulted in a 65% response rate, could not be reproduced in the United Kingdom (0% response).

PATIENTS AND METHODS

Twenty-six patients with relapsed (n = 16) or refractory (n = 10) non-Hodgkin's lymphoma were treated at our Centre by a modified E-SHAP regimen (cytosine arabinoside 1 gm/m2 one dose). The treatment was intended as remission induction before BMT (n = 16), as salvage by itself (n = 5) and for palliation of symptoms (n = 5).

RESULTS

The overall response rate was 72% (CR = 7 and PR = 11). A comparison of Kaplan-Meier curves showed a statistically significant improvement in median relapse-free survival in patients who had previously achieved CR (p = 0.0012), no bulky disease (P = 0.0006) and no B-symptoms (P = 0.0004). The toxicity was acceptable: 8 instances of febrile neutropenia, 2 of reversible renal impairment and 2 symptomatic electrolyte abnormalities. No fatal toxicities were encountered. The median time to treatment failure was 191 days and median overall survival was 190 days.

CONCLUSIONS

E-SHAP is an active combination chemotherapy when used as a salvage regimen or for remission induction before bone marrow transplantation in selected patients with relapsed non-Hodgkin's lymphoma. Patients who previously achieved CR, with low tumour burden and no B-symptoms are the best candidates for this treatment. It has a limited palliative effect.

Salvage therapy for non-Hodgkin's lymphoma with a combination of dexamethasone, etoposide, ifosfamide, and cisplatin

A total of 30 consecutive patients with refractory or relapsing non-Hodgkin's lymphoma (NHL) were treated with a combination of dexamethasone, etoposide (VP-16), ifosfamide, and cisplatin (DVIP). In all, 9 subjects (30%) showed a partial response and 10 (33%) achieved a complete response (CR) lasting from 2.5 to 24+ months. Aggressive histology, no prior therapy with VP-16, a CR to previous chemotherapy, and a treatment-free interval of greater than 6 months prior to the present study were associated with the high CR rate. DVIP caused pronounced myelosuppression (median granulocyte nadir and median platelet nadir, 380/mm3 and 73.000/mm3, respectively), but no drug-related death occurred. We conclude that DVIP is an effective salvage combination, especially in aggressive NHL, that produces acceptable toxicity.