A phase I-II study of rituximab, ifosfamide, mitoxantrone and etoposide (R-IME) for B cell non-Hodgkin's lymphoma prior to and after high-dose chemotherapy and autologous stem cell transplantation (HDC-ASCT)

Cumulative mitoxantrone-induced haematological and hepatic adverse effects in a subchronic in vivo study

Mitoxantrone (MTX) is an antineoplastic agent that can induce hepato- and haematotoxicity. This work aimed to investigate the occurrence of cumulative early and late MTX-induced hepatic and haematological disturbances in an vivo model. A control group and two groups treated with three cycles of 2.5 mg/kg MTX at days 0, 10 and 20 were formed. One of the treated groups suffered euthanasia on day 22 (MTX22) to evaluate early MTX toxic effects, while the other suffered euthanasia on day 48 (MTX48), to allow the evaluation of MTX late effects. An early immunosuppression with a drop in the IgG levels was observed, causing a slight decrease in the plasma total protein content. The early bone marrow depression was followed by signs of recovery in MTX48. The genotoxic potential of MTX was demonstrated by the presence of several micronuclei in MTX22 leucocytes. Increases in plasma iron and cholesterol levels in the MTX22 rats were observed, while in both groups increases in the unconjugated bilirubin, C4 complement, and decreases in the triglycerides, alanine aminotransferase, alkaline phosphatase and transferrin were found in plasma samples. On MTX 48, the liver histology showed more hepatotoxic signs, the hepatic levels of reduced and oxidized glutathione were increased, and ATP hepatic levels were decreased. However, the hepatic total protein levels were decreased only in the livers of MTX22 group. Results demonstrated the MTX genotoxic effects, haemato- and direct hepatotoxicity. While the haematological toxicity is ameliorated with time, the same was not observed in the hepatic injury.

The role of rituximab in autologous and allogeneic hematopoietic stem cell transplantation for non-Hodgkin's lymphoma

The addition of rituximab to chemotherapy has substantially changed the treatment strategies for patients with B-cell lymphomas. Rituximab, combined with standard chemotherapy regimens, shows consistently improved results compared with chemotherapy alone and has been extensively employed in both newly diagnosed and relapsed patients with B-cell lymphoma. Because of its low toxicity profile and its potent antilymphoma activity mediated through direct apoptotic and indirect effector mechanisms, rituximab also has been actively incorporated into stem cell transplantation (SCT) protocols to attain a state of minimal disease, provide a safe and effective method for in vivo purging prior to autologous SCT, and promote graft-versus-lymphoma effects in allogeneic SCT. This review compiles the still immature but rapidly growing data on this combined modality.

Immunoglobulin G Fc receptor FcgammaRIIIa 158 V/F polymorphism correlates with rituximab-induced neutropenia after autologous transplantation in patients with non-Hodgkin's lymphoma

PURPOSE

Rituximab has been given after autologous hematopoietic cell transplantation for recurrent or refractory B-cell lymphoma with the goal of eradicating minimal residual disease. Our previous report showed that administration of two courses of rituximab after transplantation is feasible, with encouraging clinical outcomes after a short follow-up. However, neutropenia after the first or second post-transplantation rituximab treatment occurred in 52% of patients. We previously reported that polymorphisms of two immunoglobulin G Fc receptors predict rituximab response, presumably because of their role in antibody-dependent cellular cytotoxicity. In the current report, we determine whether FcgammaR polymorphisms are correlated with clinical outcomes in 33 patients with B-cell non-Hodgkin's lymphoma who received post-transplantation rituximab.

PATIENTS AND METHODS

Genomic DNA was used for FcgammaRIIIa V/F or the FcgammaRIIa H/R genotyping. The FcgammaR polymorphisms were then correlated with the incidence of rituximab-induced neutropenia, event-free survival (EFS), and overall survival (OS).

RESULTS

The FcgammaRIIIa 158 V allele dose was correlated with a higher incidence of rituximab-induced neutropenia. The odds of neutropenia after the first or second post-transplantation rituximab increased three-fold with each V allele (robust z = 2.08, P = .038). The FcgammaRIIa polymorphism had no impact on rituximab-induced neutropenia. We did not observe a correlation of either FcgammaRIIIa or FcgammaRIIa polymorphism with EFS or OS.

CONCLUSION

The high affinity FcgammaRIIIa 158 V allele is associated with rituximab-induced neutropenia after autologous transplantation. This is a potential tool to identify a high-risk population for developing neutropenia after antibody therapy.

Ifosfamide, Epirubicin and Etoposide (IEV) Regimen as Salvage and Mobilization Therapy for Refractory or Early Relapsing Patients with Aggressive Non-Hodgkin's Lymphoma

The prognosis of early relapsing or refractory aggressive non-Hodgkin's lymphoma (NHL) is still poor. Effective salvage therapy should be able to induce high response rate as well as to mobilize hematopoietic precursors. A combination of ifosfamide, epirubicin and etoposide (IEV) was given to 28 patients with refractory or relapsing high grade NHL (4 lymphoblastic lymphoma and 24 large cell lymphoma). All patients were evaluated for response. After 2 courses of IEV, the overall and complete response rate were 64% and 39%, respectively. All patients were controlled for mobilization of peripheral blood stem cells, which was successful in 26 out of 28 (93%). Overall, 25 out of 26 patients proceeded to autologous stem cell transplantation (ASCT). Toxicity was mild, with no occurrence of severe persisting extra-hematologic side-effects. Following the entire therapeutic program, including IEV and ASCT, median progression free survival has not yet been reached and 21 patients are alive (18 in continuous complete remission) after a median follow-up of 18 months. Our results demonstrate that treatment with IEV regimen is effective in refractory or relapsing aggressive NHL, resulting in a high percentage of successful stem cell mobilization and feasibility of ASCT.

Feasibility and Efficacy of High-Dose Melphalan, Cyclophosphamide, Etoposide, and Dexamethasone (LEED) Chemotherapy with or without Rituximab Followed by Autologous Stem Cell Transplantation for Aggressive and Relapsed Non-Hodgkin's Lymphoma

To investigate the feasibility and efficacy of high-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT) for patients with newly diagnosed aggressive and relapsed non-Hodgkin's lymphoma (NHL), we administered LEED, a drug-only HDCT regimen consisting of melphalan, cyclophosphamide, etoposide, and dexamethasone, followed by ASCT in this single-institution trial. Furthermore, rituximab was added to the LEED regimen (R-LEED) for patients with CD20+ NHL. Twenty-six patients in the LEED group and 24 patients in the R-LEED group were enrolled and assessed for this study. All patients achieved complete engraftment after ASCT. As for the nonhematologic toxicities, infection toxicities of grades 3 and 4 were observed in 9 patients (34.6%) of the LEED group and 12 patients (50%) of the R-LEED group. Four patients (15.4%) in the LEED group and 5 (20.8%) in the R-LEED group developed grade 3 toxicity in the elevation of aspartate aminotransferase/alanine aminotransferase levels. Other grade 4 toxicities were rare in both groups. With a median follow-up time from the date of ASCT of 30 months in the LEED group and 18 months in the R-LEED group, the overall survival rates were 66.5% and 78.2%, respectively. These results suggested that LEED, as well as R-LEED, was a safe and feasible high-dose regimen for aggressive and relapsed NHL.

Delayed-onset grade 4 neutropenia associated with rituximab therapy in a patient with lymphoma: case report and literature review

A 53-year-old man developed delayed-onset neutropenia 6 weeks after completing first-line therapy with rituximab, cyclophosphamide, mitoxantrone, vincristine, and prednisone for high-grade B-cell lymphoma. Bone marrow biopsy demonstrated hypercellular marrow with normal maturation. He also developed interstitial pneumonitis, an adverse event associated with rituximab use. Infiltrates of T cells were found in the patient's lungs. For the next 6 months, the patient required subcutaneous granulocyte colony-stimulating factor 300 mug twice/week to maintain a granulocyte count above 1000 cells/mm3. He also received oral antibiotics for mouth sores and thrush. Based on the existing evidence, monitoring blood counts for as long as 8 weeks after rituximab therapy may be advisable, although the literature reports that neutropenia can develop up to 1 year after treatment. The development of a registry and uniform testing may help uncover the cause of this delayed-onset neutropenia.

B-cell purging in autologous stem-cell transplantation for non-Hodgkin lymphoma

Autologous stem-cell transplantation is a common therapy for B-cell non-Hodgkin lymphoma. However, a concern with the procedure is the potential of malignant cells to reinfuse with the stem-cell graft. Thus attempts have been made to purge, or eliminate, malignant cells from the graft. The oldest, and most well studied, method for prevention of reinfusion is in vitro use of antibodies against B cells that bind or lyse malignant B cells and healthy cells, while leaving T cells and stem cells to be reinfused. In the past 5 years, investigators have used rituximab, an antibody against CD20, to purge malignant cells in vivo without any manipulation in vitro. Both conventional and new techniques have shown promise, but their exact role remains to be defined. We analysed data on the purging of B cells by use of antibodies in the setting of autologous transplantation, with emphasis on the emerging technique of in vivo purging.