Pilot study of an outpatient-based approach for advanced lymphoma using vinorelbine, gemcitabine and filgrastim

Gemcitabine and Vinorelbine (GemVin) Regimen

The complexity of cancer chemotherapy requires pharmacists be familiar with the complicated regimens and highly toxic agents used. This column reviews various issues related to preparation, dispensing, and administration of antineoplastic therapy, and the agents, both commercially available and investigational, used to treat malignant diseases. Questions or suggestions for topics should be addressed to Dominic A. Solimando, Jr, President, Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203, e-mail: OncRxSvc@comcast.net; or J. Aubrey Waddell, Professor, University of Tennessee College of Pharmacy; Oncology Pharmacist, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804, e-mail: waddfour@charter.net.

Update on salvage options in relapsed/refractory hodgkin lymphoma after autotransplant

Despite a high clinical success, relapse in Hodgkin lymphoma occurs in 10–30% of cases and 5–10% patients are nonresponsive to initial chemotherapy. The standard management of these patients includes high-dose chemotherapy followed by autologous stem cell transplant. However, 50% of patients ultimately relapse after autotransplant which poses a big challenge. Allogeneic stem cell transplantation offers the only chance of cure in these patients. For patients who are not candidates for allogeneic stem cell transplantation, achieving cure with other possible options is highly unlikely, and thus the treatment plan becomes noncurative. Various novel agents have shown promising results but the duration of response is short lived. A standard approach to deliver the most effective treatment for these patients is still lacking. This review focuses on the treatment options currently available for relapsed and refractory disease after autotransplant.

The Outcome of HyperCVAD Combined with Alemtuzumab for the Treatment of Aggressive T-Cell and NK-Cell Neoplasms

We report our experience in using six cycles of hyperCVAD in combination with alemtuzumab for the treatment of aggressive T-cell and NK/T-cell neoplasms. Seven females and six males with the median age of 41 (range 18-60) diagnosed with T-cell acute lymphoblastic lymphoma and peripheral T-cell and NK/T-cell neoplasms (n(PTCL) = 6, n(T-cell ALL) = 3, n(NK/T-cell neoplasms) = 4) from 2006 to 2008 were treated with alemtuzumab-hyperCVAD regimen. A total of nine patients (69%) responded to the regimen, with seven achieved complete remission and two achieved partial remission. The median progression free survival and overall survival duration among the responders with complete remission were 12.9 and 24.9 months respectively. The incidence of relapse among the responders was 44% and the overall survival rate was 23%. Only four (31%) patients completed the six cycles of alemtuzumab-hyperCVAD. Others were stopped earlier due to progressive disease (n = 2), cytomegalovirus (CMV) reactivation and/or disease (n = 3), death not due to disease (n = 2), and patient's refusal to continue alemtuzumab (n = 2). The incidence of death not due to disease, CMV reactivation and recurrent CMV reactivation were 50, 50 and 17%, respectively. This study shows that alemtuzumab in combination with hyperCVAD regimen is a feasible regimen but with high toxicity. The toxicity might be reduced with the incorporation of filgrastim and use of valganciclovir as CMV prophylaxis.

Assessment of gemcitabine, cisplatin and methylprednisolone (GEM-P) combination treatment for non-Hodgkin T cell lymphoma

T cell lymphoma is rare with few dedicated studies and no consensus regarding optimal treatment. We undertook a retrospective hospital review to assess the efficacy of gemcitabine, cisplatin and methylprednisolone (GEM-P) combination therapy. Twenty-nine patients were followed up for a median duration of 28 months. Twenty-three patients received standard GEM-P. Due to hearing impairment, 3 patients had cisplatin substituted with carboplatin and 1 with oxaliplatin. In 2 cases, rituximab was added to GEM-P in view of the presence of EBV + B cell clones. Overall response rate (RR) [complete response (CR) + partial response (PR)] was 73 % (95 % CI range 54-86 %). 11/29 (38 %) achieved CR and 10/29 (35 %) had PR. In first-line treatment, 4/10 patients achieved CR and 4/10 had PR relating to a RR of 80 %. CR was seen in 4/9 (45 %), 2/8 (25) and 1/2 (50 %) patients treated in the second, third and fifth-sixth line respectively. Thus, GEM-P was found to be effective as first-line or salvage therapy in T cell lymphoma.

Evolving Therapy of Peripheral T-cell Lymphoma: 2010 and beyond

The peripheral T-cell lymphomas are a rare, heterogeneous group of non-Hodgkin's lymphomas which have an aggressive clinical course. Treatment approaches have traditionally been similar to those of diffuse large B-cell lymphomas, but outcomes have been inferior. Novel approaches involving agents and pathways developed from a better understanding of the biology of the diseases have led to therapeutic advances. The introduction of new agents, including antifolates, immunoconjugates, histone deacetylase inhibitors, monoclonal antibodies, nucleoside analogs, proteasome inhibitors, and signaling inhibitors have improved outcomes for patients with relapsed and refractory disease and are being incorporated into strategies for first-line therapy. Stem cell transplantation remains a potentially curative option for a subset of patients.

The Role of Allogeneic Stem Cell Transplantation in Relapsed/Refractory Hodgkin's Lymphoma Patients

Despite the favorable prognosis of most patients with Hodgkin's Lymphoma (HL), 15-20% of patients remain refractory to chemoradiotherapy, and 20-40% experience relapses following autologous stem cell transplantation (SCT) being used as salvage approach in this situation. Long-term survival of only 20% was reported for patients who failed this option. As some authors suggested the presence of a graft versus HL effect, allogeneic SCT was introduced as a further option. Myeloablative strategies were reported to be able to achieve cure in some younger patients, but high nonrelapse mortality remains a problem. Reduced intensity conditioning, in turn, was found to be associated with high posttransplant relapse rates. As there is currently no standard in the management of HL patients who failed autologous SCT, we here review the literature on allogeneic stem cell transplantation in HL patients with a special focus on the outcomes and risk factors being reported in the largest studies.

Novel therapies in peripheral T-cell lymphomas

Peripheral T-cell lymphomas (PTCLs) are a rare and heterogeneous group of disorders associated with a very poor prognosis. Historically, treatment protocols have been largely based on regimens used to treat aggressive B-cell lymphomas; unfortunately, the efficacy of these regimens has been suboptimal, with most patients experiencing relapse after initial therapy. An improved understanding of the molecular biology, pathogenesis, and progression of these disorders has led to the development of a variety of novel targeted agents that may improve outcomes in patients with PTCLs. The purpose of this review is to focus on these novel agents and the various treatment approaches that are currently being evaluated in PTCLs.

Effects of recombinant human granulocyte colony-stimulating factor (filgrastim) on ECG parameters in neutropenic patients: a single-centre, prospective study

BACKGROUND AND OBJECTIVE

Human granulocyte colony-stimulating factor (G-CSF) is a haematopoietic hormone that promotes the growth, proliferation, differentiation and maturation of neutrophil precursors. Filgrastim is a recombinant human G-CSF. Myocardial infarction, atrial fibrillation and arrhythmia have been reported in several patients with malignancy receiving filgrastim, but a causal relationship with the drug has not been established. The purpose of this study was to investigate the changes in ECG parameters in neutropenic patients during treatment with filgrastim.

METHODS

This was a single-centre, prospective study carried out in a hospital emergency room. Patients with neutropenia and malignancy who were required to receive filgrastim were eligible for the study. After a reference ECG had been obtained, filgrastim was administered to all patients at a dose of 5 microg/kg/day subcutaneously for 2 days. Follow-up ECGs were then obtained at 12-hourly intervals. Continuous telemetric monitoring was conducted throughout hospitalization.

RESULTS

Serial ECG parameters were compared in 102 patients. There were no statistically significant differences between baseline and follow-up ECG measurements of rhythm, P-wave duration, PR interval, QRS-wave duration, corrected QT (QTc) interval, ECG axis, premature supraventricular events, ventricular arrhythmia, R-wave progression, right bundle branch block or left bundle branch block. There was a significant reduction in mean heart rate in subsequent ECGs compared with baseline (p < 0.05).

CONCLUSION

This study did not demonstrate any ECG changes other than a significant reduction in mean heart rate in this selected population of neutropenic patients given 2 days' treatment with subcutaneous 5 microg/kg/day of filgrastim.

Phase II study of weekly gemcitabine and vinorelbine for children with recurrent or refractory Hodgkin's disease: a children's oncology group report

PURPOSE

The Children's Oncology Group conducted this phase II study to assess the efficacy and toxicity of gemcitabine and vinorelbine (GV) in pediatric patients with heavily pretreated relapsed/refractory Hodgkin's disease. Both agents have significant single-agent response rates in this setting.

METHODS

GV was given on days 1 and 8 of each 21-day treatment cycle: vinorelbine 25 mg/m(2)/dose administered via intravenous (IV) push before gemcitabine 1,000 mg/m(2)/dose IV over 100 minutes. Any patients who demonstrated a measurable response (complete response [CR], very good partial response [VGPR], or partial response [PR]) were considered to have experienced a response to GV. Response was evaluated after every two cycles. A two-stage minimax rule was used to test the null hypothesis that the response rate is

RESULTS

Thirty eligible patients with a median age of 17.7 years (range, 10.7 to 29.4 years) were enrolled. All patients had received at least two prior chemotherapy regimens, and 17 patients had undergone prior autologous stem-cell transplantation. Hematologic toxicity was predominant in all treatment cycles. Nonhematologic grade 3 to 4 toxicity, including elevated hepatic enzymes and hyperbilirubinemia, was less common. Pericardial and pleural effusions developed in one patient after cycles 4 and 5 of GV, consistent with gemcitabine-induced radiation recall. There were no toxic deaths. Measurable responses were seen in 19 (76%) of 25 assessable patients (95% exact binomial CI, 55% to 91%), including six CRs, 11 VGPRs, and two PRs.

CONCLUSION

GV is an effective and well-tolerated reinduction regimen for children with relapsed or refractory Hodgkin's disease.

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Key Words Collapse

MESH Headings

• Adolescent
• Adult
• Antineoplastic Combined Chemotherapy Protocols/administration & dosage
• Antineoplastic Combined Chemotherapy Protocols/adverse effects
• Child
• Deoxycytidine/administration & dosage
• Deoxycytidine/adverse effects
• Deoxycytidine/analogs & derivatives
• Disease-Free Survival
• Drug Administration Schedule
• Hodgkin Disease/drug therapy
• Humans
• Neoplasm Recurrence, Local/drug therapy
• Treatment Outcome
• Vinblastine/administration & dosage
• Vinblastine/adverse effects
• Vinblastine/analogs & derivatives
• Vinorelbine
• Young Adult
• Gemcitabine

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Grants

• U10 CA098543 NCI NIH HHS
• CA98543 NCI NIH HHS

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Affiliation(s)

Peter D Cole Children's Oncology Group, Arcadia, CA, USA.
Cindy L Schwartz
Richard A Drachtman
Pedro A de Alarcon
Lu Chen
Tanya M Trippett

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Novel therapies in peripheral T-cell lymphomas

Peripheral T-cell lymphomas (PTCLs) are a rare and heterogeneous group of disorders associated with a very poor prognosis. Historically, treatment protocols have been largely based on regimens used to treat aggressive B-cell lymphomas; unfortunately, the efficacy of these regimens has been suboptimal, with most patients experiencing relapse after initial therapy. An improved understanding of the molecular biology, pathogenesis, and progression of these disorders has led to the development of a variety of novel targeted agents that may improve outcomes in patients with PTCLs. The purpose of this review is to focus on these novel agents and the various treatment approaches that are currently being evaluated in PTCLs.

Novel Therapies and Role of Transplant in the Treatment of Peripheral T-Cell Lymphomas

Peripheral T-cell lymphomas (PTCL) are an uncommon, heterogeneous group of non-Hodgkin lymphomas that carry a much poorer prognosis than their more common B-cell counterparts. The most commonly used treatment is CHOP or its variations. However, while the results with CHOP are inadequate, there is little compelling data to suggest a preferred alternate strategy. Many of these alternate strategies have been assembled from retrospective data, small case series, subset analyses, phase II studies and individual experience. The greatest experience with alternative treatments has been with the use of high-dose therapy as consolidation. These approaches are promising, but most of the studies are retrospective and include patients with diverse prognoses, making interpretation difficult. Preliminary results of prospective trials in PTCL are only recently being reported. Perhaps more exciting have been the increasing numbers of new therapies being studied for patients with PTCL. The activities of new drugs are being described in studies specifically for PTCL, and attempts at novel combinations are beginning.

Management of Hodgkin lymphoma in relapse after autologous stem cell transplant

Recurrence of Hodgkin lymphoma (HL) occurs in about 50% of patients after autologous stem cell transplantation (ASCT), usually within the first year, and represents a significant therapeutic challenge. The natural history of recurrent HL in this setting may range from a rapidly progressive to a more indolent course. Patients in this setting are often young, without comorbidities and able to tolerate additional therapies: expectations are often still high. The approach to treatment depends on clinical variables (time to relapse, perceived sensitivity to additional cytotoxic therapy, disease stage), prior history of radiation therapy, the availability of an HLA-identical donor, and the availability of new agents via clinical trials. Although very few of these patients can be cured, results from reported series, albeit often small and sometimes with relatively short follow-up, document that excellent disease control can be achieved with radiation, single or multiagent chemotherapy, and reduced-intensity allogeneic transplantation. The results of these approaches will be reviewed, and a treatment algorithm incorporating the use of standard or investigational agents or approaches will be discussed.