MOPPEBVCAD Chemotherapy with Limited and Conditioned Radiotherapy in Advanced Hodgkin's Lymphoma: 10-Year Results, Late Toxicity, and Second Tumors

Efficacy and safety of front-line treatments for advanced Hodgkin lymphoma: a systematic literature review

OBJECTIVE

To assess evidence on the safety and efficacy of ABVD (doxorubicin [Adriamycin®], bleomycin, vinblastine, and dacarbazine), BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone), and A+AVD (brentuximab vedotin, with doxorubicin, vinblastine, and dacarbazine) for advanced-stage Hodgkin lymphoma (HL).

METHODS

A systematic literature review (SLR) was conducted on 29 July 2016 (updated 26 July 2018) to identify randomized controlled trials (RCTs) and non-RCTs assessing the treatment of newly-diagnosed advanced-stage HL with ABVD and BEACOPP (and their variants), and A+AVD.

RESULTS

The SLR identified 62 RCTs and 42 non-RCTs. Five-year overall survival rates for ABVD and BEACOPP were 60-97% and 84-99%, and 5-year progression-free survival rates were 58-81% and 83-96%, respectively. Both regimens were associated with tolerability issues and side effects. Discontinuation or dose reduction of bleomycin resulted in fewer adverse events, without significantly affecting efficacy. A head-to-head trial demonstrated improved efficacy for A+AVD vs ABVD, with an acceptable tolerability profile. No data from head-to-head trials comparing A+AVD with BEACOPP were available, and an indirect treatment comparison was not feasible.

CONCLUSION

New therapies, such as A+AVD, maintain the efficacy observed with current treatments, and may provide a more tolerable treatment option for patients with advanced-stage HL.

Persistent genomic instability in peripheral blood lymphocytes from Hodgkin lymphoma survivors

Advances in cancer treatment have led to an increase in patient survival. However, exposure to genotoxic chemotherapeutic agents and ionizing radiation may induce persistent genetic damage in cancer survivors. In this study, we detected genomic instability in chromosomes of peripheral blood lymphocytes from Hodgkin lymphoma patients, 2-17 years after MOPP (nitrogen mustard, Oncovin, procarbazine, and prednisone) chemotherapy with or without radiotherapy. Samples were obtained from 11 healthy individuals, 5 pretreatment patients, and 20 posttreatment patients. Cytogenetic analysis with GTG banding was performed on 1,000 lymphocyte metaphases per donor to identify genomic instability, including numerical and structural chromosomal aberrations, at a resolution of 10 Mb across the entire genome. Our results showed that anticancer treatment did not induce significant differences in the frequency of aneuploidy among the three study groups. However, 1 of the 11 healthy individuals, and 13 of the 20 posttreatment patients had a high frequency of chromosomal breaks and gross chromosomal rearrangements. The types of aberrations observed were random and complex, consistent with persistent genomic instability that was induced by cancer treatment. Clonal expansion of cells with chromosomal lesions was observed in one posttreatment patient only. These findings show that anticancer treatments induce persistent genomic instability, but not aneuploidy. Chemotherapy may affect genes with a role in DNA damage surveillance or repair, which in turn allows the accumulation of nontargeted structural chromosomal damage in future generations of cells. This genomic instability may facilitate the development of second malignancies in Hodgkin lymphoma survivors.

Reappraisal of the use of procarbazine in the treatment of lymphomas and brain tumors

Procarbazine HCl is a 'nonclassical' oral alkylating anticancer agent that was first synthesized in the late 1950s. It has been used in the treatment of many cancers, but its main use is in the treatment of Hodgkin's lymphoma and brain tumors and, to a lesser extent, Non-Hodgkin's lymphoma and primary central nervous system lymphoma. Procarbazine is a prodrug that undergoes metabolic transformation into active intermediates that are thought to inhibit DNA, RNA, and protein synthesis. Early use of procarbazine in combination with mechlorethamine, vincristine, and prednisone (MOPP) was effective in the treatment of advanced Hodgkin's lymphoma, but late toxic effects such as secondary cancer and infertility led to its replacement by other regimens. However, its recent reintroduction in the dose-intensified BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) regimen has yielded very promising findings. Procarbazine alone, or more commonly combined in the PCV (procarbazine, lomustine [CCNU], and vincristine) regimen, is also effective in treating gliomas comprising astrocytomas, glioblastomas, and oligodendrogliomas. The most common side effects of procarbazine are gastrointestinal disturbances, myelosuppression, and central nervous system effects. In conclusion, the use of procarbazine in combination with other drugs means that it remains a major anticancer drug in the management of Hodgkin's lymphoma and gliomas.

The early- and intermediate-term toxicity to primitive hematopoietic progenitor cells of three chemotherapy regimens for advanced hodgkin lymphoma

BACKGROUND

The early stem cell reservoir can be impaired by a few cycles of chemotherapy, and this impairment might persist after normalization of peripheral cytopenias. We directly evaluated the damage caused to marrow progenitor cells by 3 currently used chemotherapy regimens for advanced Hodgkin lymphoma.

PATIENTS AND METHODS

Bone marrow samples from 37 patients randomly treated according to either the ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine), COPPEBVCAD (cyclophosphamide/vincristine/procarbazine/prednisone/epirubicin/bleomycin/vinblastine/lomustine/melphalan/ vindesine), or BEACOPP (bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone) schedule were taken a few days before the start of chemotherapy and 30 days and 6 months after its completion. Samples were cryopreserved, thawed in a single session, and cultured for 5 weeks to detect long-term culture-initiating cells (LTC-IC).

RESULTS

On the basis of the numbers of LTC-IC detected and of their relative variations, the ABVD regimen was associated with the least early reduction and the best late recovery of LTC-IC. COPPEBVCAD produced the greatest early damage, but recovery was nearly complete by 6 months. BEACOPP caused intermediate early toxicity that persisted at 6 months.

CONCLUSION

The different late toxicity exerted on marrow progenitors by these chemotherapy regimens should be carefully weighed in relation to both the expected early response rate and subsequent possibility of rescue in the case of first treatment failure.

Search algorithms as a framework for the optimization of drug combinations

Combination therapies are often needed for effective clinical outcomes in the management of complex diseases, but presently they are generally based on empirical clinical experience. Here we suggest a novel application of search algorithms -- originally developed for digital communication -- modified to optimize combinations of therapeutic interventions. In biological experiments measuring the restoration of the decline with age in heart function and exercise capacity in Drosophila melanogaster, we found that search algorithms correctly identified optimal combinations of four drugs using only one-third of the tests performed in a fully factorial search. In experiments identifying combinations of three doses of up to six drugs for selective killing of human cancer cells, search algorithms resulted in a highly significant enrichment of selective combinations compared with random searches. In simulations using a network model of cell death, we found that the search algorithms identified the optimal combinations of 6-9 interventions in 80-90% of tests, compared with 15-30% for an equivalent random search. These findings suggest that modified search algorithms from information theory have the potential to enhance the discovery of novel therapeutic drug combinations. This report also helps to frame a biomedical problem that will benefit from an interdisciplinary effort and suggests a general strategy for its solution.

Fine-needle aspiration cytology in the follow-up of Hodgkin lymphoma

Hodgkin lymphoma (HL) is characterized by long survival and risk of relapse and second neoplasm. The aim of this study is to evaluate the possibility of improving the accuracy of fine-needle cytology (FNC) in HL follow-up using Power Doppler ultrasound (US) assistance and immediate microscopic evaluation (ICE). The study was performed in two consecutive groups of 200 FNC in HL patients. In the first group FNC of palpable lymph-nodes or extra lymph-nodal masses were performed without US assistance except for impalpable and/or deep located masses (nonassisted group); In the second group, all the FNC were performed under Power Doppler US assistance with ICE and immediately repeated in inadequate cases (assisted group). Cytological diagnoses were controlled by histology (61) or clinical follow-up (69); sensitivity and specificity were calculated in the two groups and to evaluate the effect of Power Doppler alone, adequate cases were compared with the total number of FNC in each of the two groups.FNC identified 90 negative cases, 3 false negatives, 70 HL relapse, 16 inadequate and 14 suspicious; second neoplasia were diagnosed in 12 cases and all histologically confirmed. Sensitivity and specificity were 64 and 84% in the nonassisted group and 86 and 94% in the assisted group and there were significant differences between the number of adequate cases v.s. the total number of FNC in each of the two groups. Sensitivity and specificity in assisted FNC are higher than in nonassisted ones. The main advantage of assisted FNC in the follow-up of HL is to produce accurate diagnoses avoiding invasive biopsies.