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Campbell BA, Brown R, Lambertini A, Hofman MS, Bressel M, Seymour JF, Wirth A, MacManus M, Dickinson M. Are dynamic or fixed FDG-PET measures of disease of greater prognostic value in patients with relapsed/refractory diffuse large B-cell lymphoma undergoing autologous haematopoietic stem cell transplantation? Br J Haematol 2023; 201:502-509. [PMID: 37015002 DOI: 10.1111/bjh.18644] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 12/02/2022] [Accepted: 12/29/2022] [Indexed: 04/06/2023]
Abstract
Positron emission tomography (PET) response assessment using the Deauville score has prognostic utility in relapsed/refractory (R/R) diffuse large B-cell lymphoma (DLBCL) undergoing autologous stem-cell transplantation (ASCT). Improved predictive methods are required to identify patients with poor outcomes who may be better considered for other salvage options. We investigated the prognostic value of mean tumour volume (MTV) and maximum standardised uptake value (SUVmax) at pre-salvage and pre-ASCT time-points, and the quantitative changes between scans (∆MTV and ∆SUVmax). One hundred and twenty-five patients with R/R DLBCL underwent salvage immunochemotherapy and ASCT: 80 patients had pre-salvage PET and 90 had pre-ASCT PET available. With a median follow-up of 5.6 years, 5-year progression-free survival (PFS) and overall survival (OS) were 52% and 65%, respectively. For patients with PET-positive residual disease after salvage therapy, pre-ASCT MTV was a significant negative prognosticator for PFS (HR 1.19 per 100 ml, p < 0.001) and OS (HR 1.78 per 100 ml, p < 0.001). Similarly, pre-ASCT SUVmax was negatively associated with PFS (HR 1.08, p < 0.001) and OS (HR 1.08, p < 0.001). Notably, pre-salvage MTV and SUVmax and ∆MTV and ∆SUVmax were not associated with PFS or OS. In conclusion, pre-ASCT MTV and SUVmax appear to be of greater predictive value than the degree of response. Potential application may exist for PET-directed management of R/R DLBCL patients.
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Affiliation(s)
- Belinda A Campbell
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Clinical Pathology, The University of Melbourne, Victoria, Australia
| | - Rachel Brown
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Victoria, Australia
| | | | - Michael S Hofman
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Cancer Imaging, Peter MacCallum Cancer Centre, Victoria, Australia
| | - Mathias Bressel
- Centre for Biostatistics and Clinical Trials, Peter MacCallum Cancer Centre, Victoria, Australia
| | - John F Seymour
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Victoria, Australia
| | - Andrew Wirth
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Michael MacManus
- Department of Radiation Oncology, Peter MacCallum Cancer Centre, Victoria, Australia
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
| | - Michael Dickinson
- Sir Peter MacCallum Department of Oncology, The University of Melbourne, Victoria, Australia
- Department of Haematology, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Victoria, Australia
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Snider JT, McMorrow D, Song X, Diakun D, Wade SW, Cheng P. Burden of Illness and Treatment Patterns in Second-line Large B-cell Lymphoma. Clin Ther 2022; 44:521-538. [PMID: 35241295 DOI: 10.1016/j.clinthera.2022.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/23/2021] [Accepted: 02/05/2022] [Indexed: 12/01/2022]
Abstract
PURPOSE This study examined real-world treatment patterns with curative intent, adverse events, and health care resource utilization and costs in patients with relapsed or refractory large B-cell lymphoma (LBCL) to understand the unmet medical need in the United States. METHODS Adult patients with ≥2 LBCL diagnoses between January 1, 2012, and March 31, 2019, were identified (index date was the date of the earliest LBCL diagnosis) from MarketScan® Commercial and Medicare Supplemental Databases. Patients had ≥1 claim for any LBCL treatment, ≥6 months of data before (baseline) and ≥12 months of data after (follow-up period) the index date, and no baseline LBCL diagnosis. Treatment patterns, adverse events, and all-cause and LBCL-related health care resource utilization and costs were examined. All patients had received first-line therapy of cyclophosphamide, doxorubicin, vincristine, and prednisone with or without rituximab; etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin hydrochloride with or without rituximab; or regimens with anthracycline and second-line therapy with stem cell transplant (SCT)-intended intensive therapy or platinum-based chemotherapy. Patients who received an SCT-intended second-line regimen or received an SCT regardless of second-line regimen were considered SCT eligible. FINDINGS A total of 188 patients met the criteria of eligibility for SCT. Among the 119 patients who received a second-line regimen intended for SCT, only 22.7% received an SCT. Patients eligible for SCT started first-line therapy within 1 month of their LBCL index date, and the mean duration of first-line therapy was 4.1 months. The mean gap in therapy between first- and second-line therapy was 6.6 months, and the mean duration of second-line therapy was 3.0 months. During the second-line therapy treatment window (mean duration with SCT, 12.4 months; mean duration without SCT, 4.8 months), the most common regimens for patients eligible for SCT were ifosfamide, carboplatin, and etoposide with or without rituximab and gemcitabine and oxaliplatin with or without rituximab; the top 4 most common treatment-related adverse events were febrile neutropenia (56.4%), anemia (49.5%), thrombocytopenia (42.6%), and nausea and vomiting (36.2%), which were similar regardless of receipt of SCT; mean (SD) per-patient-per-month all-cause costs were $46,174 ($49,057) for patients with SCT and $45,780 ($52,813) for patients without SCT. IMPLICATIONS Treatment patterns among patients with relapsed or refractory LBCL eligible for SCT were highly varied. Only 22.7% of patients who received an SCT-preparative regimen ultimately received SCT, which highlights the magnitude of unmet needs in this population. The occurrence of treatment-related adverse events was similar regardless of SCT status. Per-patient-per-month all-cause costs were also similar with upfront SCT costs averaged during a longer follow-up.
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Affiliation(s)
| | | | - Xue Song
- IBM Watson Health, Cambridge, Massachusetts
| | | | - Sally W Wade
- Wade Outcomes Research and Consulting, Salt Lake City, Utah
| | - Paul Cheng
- Kite, A Gilead Company, Santa Monica, California
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The Use of Etoposide, Ara-Cytarabine, and Melphalan (EAM) Conditioning Chemotherapy in Autologous Stem Cell Transplantation (ASCT) for a Patient with Relapsed Hodgkin's Lymphoma. Case Rep Hematol 2021; 2021:9632427. [PMID: 34777885 PMCID: PMC8580659 DOI: 10.1155/2021/9632427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 10/15/2021] [Indexed: 11/24/2022] Open
Abstract
Up to 20–40% of patients with Hodgkin's lymphoma will eventually relapse after treatment, among which early relapse confers a poor outcome. With salvage chemotherapy followed by autologous stem cell transplantation (ASCT), the long-term remission rate is 30%. We report our experience of using a modified-BEAM conditioning regimen without BCNU consisting of etoposide, cytarabine, and melphalan (EAM) in a patient with relapsed Hodgkin's lymphoma. Before transplantation, the patient achieved second complete remission (CR2) using brentuximab vedotin and ESHAP (BR-ESHAP) chemotherapy. The ASCT went well without significant complications. This case demonstrated the considerable efficacy of EAM protocol as a conditioning regimen in terms of sufficient ablative capabilities, and the patient showed a successful hematopoietic engraftment. Although durability of the disease-free survival needs further observation, it had nearly 18 months of complete remission and the patient was in good performance status at the time of writing this manuscript.
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BEAM or BUCYVP16-conditioning regimen for autologous stem-cell transplantation in non-Hodgkin’s lymphomas. Bone Marrow Transplant 2019; 54:1553-1561. [DOI: 10.1038/s41409-019-0463-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 11/09/2022]
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Kameoka Y, Akagi T, Murai K, Noji H, Kato Y, Sasaki O, Ito S, Ishizawa K, Ishida Y, Ichinohasama R, Harigae H, Takahashi N. Safety and efficacy of high-dose ranimustine (MCNU) containing regimen followed by autologous stem cell transplantation for diffuse large B-cell lymphoma. Int J Hematol 2018; 108:510-515. [DOI: 10.1007/s12185-018-2508-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 07/04/2018] [Accepted: 07/11/2018] [Indexed: 10/28/2022]
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Advantages of non-cryopreserved autologous hematopoietic stem cell transplantation against a cryopreserved strategy. Bone Marrow Transplant 2018; 53:960-966. [DOI: 10.1038/s41409-018-0117-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 01/15/2018] [Accepted: 01/20/2018] [Indexed: 11/08/2022]
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Vardhana SA, Sauter CS, Matasar MJ, Zelenetz AD, Galasso N, Woo KM, Zhang Z, Moskowitz CH. Outcomes of primary refractory diffuse large B-cell lymphoma (DLBCL) treated with salvage chemotherapy and intention to transplant in the rituximab era. Br J Haematol 2017; 176:591-599. [PMID: 27982423 PMCID: PMC5556376 DOI: 10.1111/bjh.14453] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Accepted: 09/12/2016] [Indexed: 12/15/2022]
Abstract
Rituximab-containing salvage chemotherapy followed by high-dose therapy and autologous stem cell transplant (ASCT) in chemosensitive patients remains the standard of care for patients with relapsed and refractory diffuse large B-cell lymphoma (DLBCL). However, its role in those patients achieving less than a complete response to first-line therapy (primary refractory disease) in the rituximab era is not well defined. We reviewed the outcomes of 82 transplant-eligible patients with primary refractory DLBCL who underwent salvage therapy with the intent of administering high-dose therapy and ASCT to patients achieving chemosensitive remission. The estimated 3-year overall and progression-free survival for all patients was 38% and 29%, respectively, and 65% and 60% respectively for patients proceeding to stem cell transplant. Long-term remission was achieved in 45% of patients achieving a partial response (PR) to initial induction therapy and <20% of patients with stable or progression of disease following initial therapy. These results suggest that salvage chemotherapy with the intent of subsequent high-dose therapy and ASCT remains a feasible strategy in certain patients with primary refractory DLBCL, particularly for those achieving a PR to frontline therapy. The primary barrier to curative therapy in patients with primary refractory disease is resistance to salvage therapy, and future studies should be aimed towards increasing the response rate in this population.
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Affiliation(s)
- Santosha A. Vardhana
- Deparment of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig S. Sauter
- Deparment of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Matthew J. Matasar
- Deparment of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrew D. Zelenetz
- Deparment of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Natasha Galasso
- Department of Epidemiology and Biostatistics, Sloan Kettering Cancer Center, New York, NY, USA
| | - Kaitlin M. Woo
- Department of Epidemiology and Biostatistics, Sloan Kettering Cancer Center, New York, NY, USA
| | - Zhigang Zhang
- Department of Epidemiology and Biostatistics, Sloan Kettering Cancer Center, New York, NY, USA
| | - Craig H. Moskowitz
- Deparment of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Esbah O, Tekgündüz E, Şirinoğlu Demiriz I, Civriz Bozdağ S, Kaya A, Tetik A, Kayıkçı Ö, Durgun G, Kocubaba Ş, Altuntaş F. Finding the Optimal Conditioning Regimen for Relapsed/Refractory Lymphoma Patients Undergoing Autologous Hematopoietic Cell Transplantation: A Retrospective Comparison of BEAM and High-Dose ICE. Turk J Haematol 2016; 33:209-15. [PMID: 26377357 PMCID: PMC5111466 DOI: 10.4274/tjh.2014.0214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 01/19/2015] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE High-dose chemotherapy followed by autologous hematopoietic stem cell transplantation (AHCT) is a well-defined treatment modality for relapsed/refractory non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL). Although there are several options in terms of conditioning regimens before AHCT, no one treatment is accepted as a standard of care. This study aimed to compare different conditioning regimens for the treatment of NHL and HL.
MATERIALS AND METHODS Medical records of 62 patients who had undergone AHCT following BEAM (BCNU, etoposide, cytarabine, and melphalan) and high-dose ICE (hICE; ifosfamide, carboplatin, and etoposide) conditioning regimens were analyzed retrospectively and compared in terms of efficacy and adverse effects.
RESULTS The study included a total of 29 and 33 patients diagnosed with relapsed/refractory NHL and HL, respectively. Patients received BEAM (n=37) or hICE (n=25) regimens for conditioning. One-year overall survival was 73±6% in all patients. One-year overall survival was 71±8% and 74±9% in the BEAM and hICE groups, respectively (p=0.86). The incidences of nausea/vomiting (grade ≥2) (84% vs. 44.7%; p=0.04) and mucositis (grade ≥2) (13% vs. 3%; p=0.002) were higher in the hICE group compared to the BEAM group. In addition, we witnessed significantly more hepatotoxicity of grade ≥2 (40% vs. 2.7%; p<0.005) and nephrotoxicity of grade ≥2 (48% vs. 2.7%; p<0.005) among patients who received hICE. Significantly more patients (n=4; 25%) in the hICE group experienced veno-occlusive disease (VOD) compared to the BEAM arm, where no patients developed VOD (p=0.01). CONCLUSION There was no difference in terms of overall survival between the BEAM and hICE groups. We observed significantly more adverse effects among patients treated with hICE. The BEAM regimen seems to be superior to hICE in terms of toxicity profile with comparable efficacy in patients with relapsed/refractory NHL and HL.
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Affiliation(s)
| | | | - Itır Şirinoğlu Demiriz
- Ankara Oncology Hospital, Hematology and Stem Cell Transplantation Unit, Ankara, Turkey, Phone : +90 0532 296 89 98, E-mail:
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9
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FDG-PET for the early treatment monitoring, for final response and follow-up evaluation in lymphoma. Clin Transl Imaging 2015. [DOI: 10.1007/s40336-015-0134-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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10
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El-Galaly TC, Hutchings M. Imaging of non-Hodgkin lymphomas: diagnosis and response-adapted strategies. Cancer Treat Res 2015; 165:125-46. [PMID: 25655608 DOI: 10.1007/978-3-319-13150-4_5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023]
Abstract
Optimal lymphoma management requires accurate pretreatment staging and reliable assessment of response, both during and after therapy. Positron emission tomography with computerized tomography (PET/CT) combines functional and anatomical imaging and provides the most sensitive and accurate methods for lymphoma imaging. New guidelines for lymphoma imaging and recently revised criteria for lymphoma staging and response assessment recommend PET/CT staging, treatment monitoring, and response evaluation in all FDG-avid lymphomas, while CT remains the method of choice for non-FDG-avid histologies. Since interim PET imaging has high prognostic value in lymphoma, a number of trials investigate PET-based, response-adapted therapy for non-Hodgkin lymphomas (NHL). PET response is the main determinant of response according to the new response criteria, but PET/CT has little or no role in routine surveillance imaging, the value which is itself questionable. This review presents from a clinical point of view the evidence for the use of imaging and primarily PET/CT in NHL before, during, and after therapy. The reader is given an overview of the current PET-based interventional NHL trials and an insight into possible future developments in the field, including new PET tracers.
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Bode U, Zimmermann M, Moser O, Rutkowski S, Warmuth-Metz M, Pietsch T, Kortmann RD, Faldum A, Fleischhack G. Treatment of recurrent primitive neuroectodermal tumors (PNET) in children and adolescents with high-dose chemotherapy (HDC) and stem cell support: results of the HITREZ 97 multicentre trial. J Neurooncol 2014; 120:635-42. [PMID: 25179451 DOI: 10.1007/s11060-014-1598-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Accepted: 08/19/2014] [Indexed: 11/29/2022]
Abstract
Early studies with high-dose chemotherapy for treatment of relapsed cerebral PNET had shown modest efficacy but considerable toxicity. The HIT97 national trial tested a nonrandomized but stratified relapse protocol using either intensive chemotherapy, potentially high dose, or oral chemotherapy. 72 patients (59 disseminated) whose primary treatment had been surgery (97 %), radiotherapy (88 %), and/or chemotherapy (95 %) were enrolled in the intensive chemotherapy arm at diagnosis of relapse or resistance. As a window for this study they received two courses of a 96-hour infusion with carboplatin and etoposide. A response (complete or partial remission) was documented by MRI. Responders received two more cycles of this therapy and stem cell collection, before they received HDC (carboplatin, etoposide, thiotepa) and stem cell support. All possibilities of local therapy were to be explored and applied. After two courses of chemotherapy there was a 52 % response rate (41/72 patients). The median PFS and OS for all 72 patients were 11.6 and 21.1 months. Patients with medulloblastoma had a longer PFS and OS (12.6 and 22.6 months) than those with other PNETs (3.1 and 12.3 months). Favourable prognostic features were no new signs of clinical impairment and localised disease at relapse diagnosis. For the 27 patients who received HDC the median PFS and OS were 8.4 and 20.2 months, respectively. HDC did not benefit patients with resistant cerebral PNET and was associated with profound haematological and mucosal toxicity (90-100 % grade III, IV), infections (50 % grade III and IV) and severe ototoxicity (50 % grade III, 12.5 % grade IV). Treatment related mortality was 8 %. There was low long-term survival and only 2/72 patients are in continuous remission. Adding HDC in patients who responded to the initial courses of chemotherapy did not improve survival. Patients with relapsed cerebral PNET who respond to conventional chemotherapy do not profit from further augmentation to HDC.
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Affiliation(s)
- U Bode
- Department of Pediatrics, Hematology/Oncology, Children`s Hospital, University of Bonn, Adenauerallee 119, 53113, Bonn, Germany,
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Stiff PJ, Unger JM, Cook JR, Constine LS, Couban S, Stewart DA, Shea TC, Porcu P, Winter JN, Kahl BS, Miller TP, Tubbs RR, Marcellus D, Friedberg JW, Barton KP, Mills GM, LeBlanc M, Rimsza LM, Forman SJ, Fisher RI. Autologous transplantation as consolidation for aggressive non-Hodgkin's lymphoma. N Engl J Med 2013. [PMID: 24171516 DOI: 10.1056/nejmoa13101077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The efficacy of autologous stem-cell transplantation during the first remission in patients with diffuse, aggressive non-Hodgkin's lymphoma classified as high-intermediate risk or high risk on the International Prognostic Index remains controversial and is untested in the rituximab era. METHODS We treated 397 patients who had disease with an age-adjusted classification of high risk or high-intermediate risk with five cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP plus rituximab. Patients with a response were randomly assigned to receive three additional cycles of induction chemotherapy (control group) or one additional cycle of induction chemotherapy followed by autologous stem-cell transplantation (transplantation group). The primary efficacy end points were 2-year progression-free survival and overall survival. RESULTS Of 370 induction-eligible patients, 253 were randomly assigned to the transplantation group (125) or the control group (128). Forty-six patients in the transplantation group and 68 in the control group had disease progression or died, with 2-year progression-free survival rates of 69 and 55%, respectively (hazard ratio in the control group vs. the transplantation group, 1.72; 95% confidence interval [CI], 1.18 to 2.51; P=0.005). Thirty-seven patients in the transplantation group and 47 in the control group died, with 2-year overall survival rates of 74 and 71%, respectively (hazard ratio, 1.26; 95% CI, 0.82 to 1.94; P=0.30). Exploratory analyses showed a differential treatment effect according to risk level for both progression-free survival (P=0.04 for interaction) and overall survival (P=0.01 for interaction). Among high-risk patients, the 2-year overall survival rate was 82% in the transplantation group and 64% in the control group. CONCLUSIONS Early autologous stem-cell transplantation improved progression-free survival among patients with high-intermediate-risk or high-risk disease who had a response to induction therapy. Overall survival after transplantation was not improved, probably because of the effectiveness of salvage transplantation. (Funded by the National Cancer Institute, Department of Health and Human Services, and others; SWOG-9704 ClinicalTrials.gov number, NCT00004031.).
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Affiliation(s)
- Patrick J Stiff
- From Loyola University Medical Center, Maywood, IL (P.J.S., K.P.B.); Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle (J.M.U., M.L.); Cleveland Clinic, Cleveland (J.R.C., R.R.T.); University of Rochester, Rochester, NY (L.S.C., J.W.F., R.I.F.); Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS (S.C.), University of Calgary-Tom Baker Cancer Centre, Calgary, AB (D.A.S.), and Margaret and Charles Juravinski Cancer Centre, Hamilton, ON (D.M.) - all in Canada; University of North Carolina at Chapel Hill, Chapel Hill (T.C.S.); Ohio State University Medical Center, Columbus (P.P.); Northwestern University, Chicago (J.N.W.); University of Wisconsin, Madison (B.S.K.); University of Arizona, Tucson (T.P.M., L.M.R.); Louisiana State University Health Sciences Center, Shreveport (G.M.M.); City of Hope Medical Center, Duarte, CA (S.J.F.); and Fox Chase Cancer Center-Temple Health, Temple University School of Medicine, Philadelphia (R.I.F.)
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13
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Stiff PJ, Unger JM, Cook JR, Constine LS, Couban S, Stewart DA, Shea TC, Porcu P, Winter JN, Kahl BS, Miller TP, Tubbs RR, Marcellus D, Friedberg JW, Barton KP, Mills GM, LeBlanc M, Rimsza LM, Forman SJ, Fisher RI. Autologous transplantation as consolidation for aggressive non-Hodgkin's lymphoma. N Engl J Med 2013; 369:1681-90. [PMID: 24171516 PMCID: PMC3985418 DOI: 10.1056/nejmoa1301077] [Citation(s) in RCA: 247] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND The efficacy of autologous stem-cell transplantation during the first remission in patients with diffuse, aggressive non-Hodgkin's lymphoma classified as high-intermediate risk or high risk on the International Prognostic Index remains controversial and is untested in the rituximab era. METHODS We treated 397 patients who had disease with an age-adjusted classification of high risk or high-intermediate risk with five cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) or CHOP plus rituximab. Patients with a response were randomly assigned to receive three additional cycles of induction chemotherapy (control group) or one additional cycle of induction chemotherapy followed by autologous stem-cell transplantation (transplantation group). The primary efficacy end points were 2-year progression-free survival and overall survival. RESULTS Of 370 induction-eligible patients, 253 were randomly assigned to the transplantation group (125) or the control group (128). Forty-six patients in the transplantation group and 68 in the control group had disease progression or died, with 2-year progression-free survival rates of 69 and 55%, respectively (hazard ratio in the control group vs. the transplantation group, 1.72; 95% confidence interval [CI], 1.18 to 2.51; P=0.005). Thirty-seven patients in the transplantation group and 47 in the control group died, with 2-year overall survival rates of 74 and 71%, respectively (hazard ratio, 1.26; 95% CI, 0.82 to 1.94; P=0.30). Exploratory analyses showed a differential treatment effect according to risk level for both progression-free survival (P=0.04 for interaction) and overall survival (P=0.01 for interaction). Among high-risk patients, the 2-year overall survival rate was 82% in the transplantation group and 64% in the control group. CONCLUSIONS Early autologous stem-cell transplantation improved progression-free survival among patients with high-intermediate-risk or high-risk disease who had a response to induction therapy. Overall survival after transplantation was not improved, probably because of the effectiveness of salvage transplantation. (Funded by the National Cancer Institute, Department of Health and Human Services, and others; SWOG-9704 ClinicalTrials.gov number, NCT00004031.).
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Affiliation(s)
- Patrick J Stiff
- From Loyola University Medical Center, Maywood, IL (P.J.S., K.P.B.); Southwest Oncology Group Statistical Center, Fred Hutchinson Cancer Research Center, Seattle (J.M.U., M.L.); Cleveland Clinic, Cleveland (J.R.C., R.R.T.); University of Rochester, Rochester, NY (L.S.C., J.W.F., R.I.F.); Queen Elizabeth II Health Sciences Centre and Dalhousie University, Halifax, NS (S.C.), University of Calgary-Tom Baker Cancer Centre, Calgary, AB (D.A.S.), and Margaret and Charles Juravinski Cancer Centre, Hamilton, ON (D.M.) - all in Canada; University of North Carolina at Chapel Hill, Chapel Hill (T.C.S.); Ohio State University Medical Center, Columbus (P.P.); Northwestern University, Chicago (J.N.W.); University of Wisconsin, Madison (B.S.K.); University of Arizona, Tucson (T.P.M., L.M.R.); Louisiana State University Health Sciences Center, Shreveport (G.M.M.); City of Hope Medical Center, Duarte, CA (S.J.F.); and Fox Chase Cancer Center-Temple Health, Temple University School of Medicine, Philadelphia (R.I.F.)
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Bains T, Chen AI, Lemieux A, Hayes-Lattin BM, Leis JF, Dibb W, Maziarz RT. Improved outcome with busulfan, melphalan and thiotepa conditioning in autologous hematopoietic stem cell transplant for relapsed/refractory Hodgkin lymphoma. Leuk Lymphoma 2013; 55:583-7. [DOI: 10.3109/10428194.2013.806659] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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15
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Kharfan-Dabaja MA, Nishihori T, Otrock ZK, Haidar N, Mohty M, Hamadani M. Monoclonal antibodies in conditioning regimens for hematopoietic cell transplantation. Biol Blood Marrow Transplant 2013; 19:1288-300. [PMID: 23618718 DOI: 10.1016/j.bbmt.2013.04.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 04/16/2013] [Indexed: 10/26/2022]
Abstract
Monoclonal antibodies are increasingly being incorporated in conditioning regimens for autologous or allogeneic hematopoietic cell transplantation (HCT). The benefit of adding rituximab to autologous HCT regimens is purportedly related to in vivo purging of clonal B cells. Randomized trials comparing the addition (or not) of rituximab to high-dose therapy regimens are lacking. No benefit of standard-dose radioimmunotherapy-based regimens for autografting in aggressive lymphomas was seen in a randomized controlled study. The incorporation of rituximab into allogeneic HCT regimens aims to improve responses while reducing nonrelapse mortality resulting from acute graft-versus-host disease. The optimal dose and administration schedule of rituximab in this setting are unknown, and potentially serious complications from increased infections owing to prolonged (and profound) cytopenias or persistent hypogammaglobulinemia are of concern. Radioimmunotherapy-based conditioning for allografting holds promise as a modality to optimize tumor control and synergize adoptive immunotherapy effects, but it remains experimental at this time. The addition of alemtuzumab to allogeneic HCT regimens is associated with prolonged lymphopenia and impaired immune reconstitution, high relapse rates, and serious infections. The optimal dose and schedule of alemtuzumab to avoid prolonged immune paresis remain elusive. It is anticipated that additional monoclonal antibodies will soon become available that can be incorporated into HCT regimens after safety and clinical efficacy are demonstrated.
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Affiliation(s)
- Mohamed A Kharfan-Dabaja
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, Florida 33612,
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Abstract
The role of high-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) in the treatment armamentarium of aggressive B- and T-cell non-Hodgkin lymphoma (NHL) is still a matter of debate. In the pre-Rituximab era, the PARMA study demonstrated the superiority of HDT/ASCT over conventional salvage chemotherapy in chemosensitive, relapsed patients. Subsequently, HDT/ASCT has become a standard approach for relapsed NHL. With the advent of Rituximab in the landscape of NHL, transplantation as part of first-line therapy has been challenged. However, no benefit in terms of disease-free or overall survival of HDT/ASCT over standard therapy was shown when Rituximab was added to both arms. Moreover, the superiority of HDT/ASCT over conventional salvage therapy in patients relapsing from first-line therapy including Rituximab was not confirmed. From these disappointing results, novel strategies, which can enhance the anti-lymphoma effect, at the same time reducing toxicity have been developed, with the aim of improving the outcome of HDT/ASCT in aggressive NHL. In T-cell lymphoma, few publications demonstrated that consolidation of complete remission with HDT/ASCT is safe and feasible. However, up to one-third of patients may never receive transplant, mostly due to progressive disease, and relapse still remains a major concern even after transplant.
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Carmustine infusion reactions are more common with rapid administration. Support Care Cancer 2012; 20:2531-5. [PMID: 22252549 DOI: 10.1007/s00520-011-1377-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Accepted: 12/29/2011] [Indexed: 10/14/2022]
Abstract
PURPOSE Carmustine is a nitrosurea alkylating agent predominantly used at Peter MacCallum Cancer Centre as part of the autologous stem cell transplant induction regimens Stanford BCNU and BEAM. Acute infusion reactions were anecdotally reported to be higher than the reported rates of 10%, and it was suggested that the rate of infusion being employed was excessive. Some references suggest maximum infusion rates of 3 mg/m(2)/min for carmustine, a rate which is exceeded in the 2-h infusions used for Stanford BCNU, but not with BEAM. METHODS A retrospective audit was conducted in 64 patients (57 Stanford BCNU, 7 BEAM) who had received these regimens between January 2009 and November 2010. RESULTS Rates of infusion reaction to carmustine were higher than literature values, with reactions in Stanford BCNU (94.7%) being significantly higher than for BEAM (28.6%; P = 0.0003). These findings have resulted in a change of administration of carmustine in Stanford BCNU from 2 to 3 h. Further studies plan to compare the incidence of infusion reactions before and after the change in administration rates. CONCLUSION Patients receiving rapid infusion of carmustine in the Stanford BCNU regimen for stem cell conditioning have a high rate of infusion reaction. A maximum rate of 3 mg/m(2)/min is recommended.
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High-dose thiotepa, etoposide and carboplatin as conditioning regimen for autologous stem cell transplantation in patients with high-risk non-Hodgkin lymphoma. Clin Exp Med 2011; 12:165-71. [PMID: 21928053 DOI: 10.1007/s10238-011-0157-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 08/25/2011] [Indexed: 01/28/2023]
Abstract
High-dose chemotherapy conditioning regimens followed by autologous stem cell transplantation generally provide good results in non-Hodgkin lymphoma. We have evaluated the effects of a high-dose regimen comprising thiotepa, etoposide and carboplatin. After debulking and mobilization with high-dose cyclophosphamide or other schedules, forty-five patients at various disease stages were conditioned with thiotepa, etoposide and carboplatin prior to autologous stem cell transplantation. The overall response rate was 77.8% (30 CR, 66.7%; 5 PR, 11.1%). Ten patients (22.2%) did not respond. Two patients (4.4%) died from transplant-related complications. The mean 5-year overall survival was 71.1%: 12 patients relapsed within the first 5 years of follow-up. The overall response rate and 5-year overall survival were better for patients with an International Prognostic Index (IPI) 1 at diagnosis than for those with IPI 2 and IPI 3 (P<0.005 for all). The thiotepa, etoposide and carboplatin conditioning regimen for autologous stem cell transplantation in non-Hodgkin lymphoma has a good anti-lymphoma effect and provides encouraging results in terms of response to treatment and 5-year overall survival. Its good tolerance and acceptable toxicity suggest that it may a very useful in the management of non-Hodgkin lymphoma.
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Safety and efficacy of high-dose ranimustine, cytarabine, etoposide and CY (MCVAC) regimen followed by autologous peripheral blood stem cell transplantation for high-risk diffuse large B-cell lymphoma. Bone Marrow Transplant 2010; 46:923-8. [DOI: 10.1038/bmt.2010.243] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Pavlů J, Auner HW, Ellis S, Szydlo RM, Giles C, Contento A, Rahemtulla A, Apperley JF, Naresh K, MacDonald DH, Kanfer EJ. LACE-conditioned autologous stem cell transplantation for relapsed or refractory diffuse large B-cell lymphoma: treatment outcome and risk factor analysis from a single centre. Hematol Oncol 2010; 29:75-80. [PMID: 20635327 DOI: 10.1002/hon.956] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2010] [Revised: 05/10/2010] [Accepted: 06/03/2010] [Indexed: 11/06/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a recognized treatment option for patients with relapsed diffuse large B-cell lymphoma. We have analysed 51 patients who underwent ASCT after LACE (lomustine (CCNU), cytarabine (Ara-C), cyclophosphamide, etoposide) conditioning for relapsed (n = 34, 67%) or primary refractory (n = 17, 33%) diffuse large B-cell lymphoma. With a median follow-up of 60 months (range 2-216) the probabilities of overall survival (OS) and progression-free survival (PFS) at 5 years were 47 and 42%, respectively. The cumulative treatment-related mortality was 10% (n = 5). Probabilities for OS and PFS at 5 years were 56 and 50% for patients with chemosensitive and 29 and 27% for patients with chemorefractory disease. In multivariate analysis abnormal pre-ASCT levels of C-reactive protein (>5 mg/L) were identified as a risk factor for worse OS, whereas abnormal pre-ASCT levels of C-reactive protein and chemoresistance predicted inferior PFS. LACE followed by ASCT is an effective treatment for approximately half of patients with chemosensitive relapsed diffuse large B-cell lymphoma, and a proportion of chemorefractory patients also benefit.
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Affiliation(s)
- Jiří Pavlů
- Department of Haematology, Imperial College at Hammersmith Hospital, London, UK
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Dickinson M, Hoyt R, Roberts AW, Grigg A, Seymour JF, Prince HM, Szer J, Ritchie D. Improved survival for relapsed diffuse large B cell lymphoma is predicted by a negative pre-transplant FDG-PET scan following salvage chemotherapy. Br J Haematol 2010; 150:39-45. [PMID: 20507301 DOI: 10.1111/j.1365-2141.2010.08162.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The utility of ([18F])fluoro-2-deoxy- d-glucose positron-emission tomography (FDG-PET) for predicting outcome after autologous stem cell transplantation (ASCT) for diffuse large B cell lymphoma (DLBCL) is uncertain - existing studies include a range of histological subtypes or have a limited duration of follow-up. Thirty-nine patients with primary-refractory or relapsed DLBCL with pre-ASCT PET scans were analysed. The median follow-up was 3 years. The 3-year progression-free survival (PFS) for patients with positive PET scans pre-ASCT was 35% vs. 81% for those who had negative PET scans (P = 0.003). The overall survival (OS) in these groups was 39% and 81% (P = 0.01), respectively. In a multivariate analysis, PET result, number of salvage cycles and the presence of relapsed or refractory disease were shown to predict a longer PFS; PET negativity (P = 0.04) was predictive of a longer OS. PET is useful for defining those with an excellent prognosis post-ASCT. Although those with positive scans can still be salvaged with current treatments, PET may useful for selecting patients eligible for novel consolidation strategies after salvage therapies.
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Affiliation(s)
- Michael Dickinson
- Division of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
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Dean RM, Pohlman B, Sweetenham JW, Sobecks RM, Kalaycio ME, Smith SD, Copelan EA, Andresen S, Rybicki LA, Curtis J, Bolwell BJ. Superior survival after replacing oral with intravenous busulfan in autologous stem cell transplantation for non-Hodgkin lymphoma with busulfan, cyclophosphamide and etoposide. Br J Haematol 2010; 148:226-34. [DOI: 10.1111/j.1365-2141.2009.07940.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ulrickson M, Aldridge J, Kim HT, Hochberg EP, Hammerman P, Dube C, Attar E, Ballen KK, Dey BR, McAfee SL, Spitzer TR, Chen YB. Busulfan and cyclophosphamide (Bu/Cy) as a preparative regimen for autologous stem cell transplantation in patients with non-Hodgkin lymphoma: a single-institution experience. Biol Blood Marrow Transplant 2009; 15:1447-54. [PMID: 19822305 DOI: 10.1016/j.bbmt.2009.07.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2009] [Accepted: 07/14/2009] [Indexed: 10/20/2022]
Abstract
High-dose chemotherapy with autologous stem cell transplantation (ASCT) has been established as a standard form of therapy for patients with non-Hodgkin lymphoma (NHL). While many high-dose chemotherapy combinations are used, no single regimen has proved superior over another. Here, we report our single center's experience in patients with NHL undergoing ASCT with the combination of busulfan and cyclophosphamide (Bu/Cy). This study is a retrospective analysis of 78 consecutive patients with NHL who underwent ASCT with Bu/Cy at Massachusetts General Hospital Cancer Center. Data were collected through review of electronic medical records. A total of 78 patients with NHL underwent ASCT with Bu/Cy preparative therapy between 1996 and 2006. Median follow-up for survivors was 5.0 years (range, 6 months to 12 years). Significant transplantation-associated complications included 9 documented bacterial infections, 4 cases of engraftment syndrome, 3 cases of hepatic veno-occlusive disease (VOD), 6 cases of cardiac complications, and 2 cases of pulmonary fibrosis. The 100-day treatment-related mortality (TRM) was 1%. At 3 years, progression-free survival (PFS) was 48% (95% confidence interval [CI]=37% to 59%) and overall survival (OS) was 65% (95% CI=53% to 74%). Our data indicate that in patients with NHL undergoing ASCT, Bu/Cy has efficacy and toxicity comparable to that of other reported regimens.
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Affiliation(s)
- Matthew Ulrickson
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Atta J, Chow KU, Weidmann E, Mitrou PS, Hoelzer D, Martin H. Dexa-BEAM as salvage therapy in patients with primary refractory aggressive Non-Hodgkin lymphoma. Leuk Lymphoma 2009; 48:349-56. [PMID: 17325896 DOI: 10.1080/10428190600880084] [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: 10/23/2022]
Abstract
Although aggressive NHL in relapse after remission can still be cured by second-line treatment followed by high-dose therapy and autologous stem cell transplantation, the long-term prognosis of patients who fail to obtain remission after first-line therapy remains extremely poor. We retrospectively evaluated a series of 29 consecutive patients with primary refractory high-grade NHL who were treated with Dexa-BEAM (DB) as uniform salvage therapy at a single institution. Twenty-nine patients with aggressive NHL primary refractory to CHOP or CHOP-like induction therapy with a median age of 47 (range, 22 - 64) years received 1 - 2 cycles of DB and were candidates for subsequent autologous stem cell (PBSC) mobilization and transplantation (PBSCT). Follow-up of all patients was updated in March 2004. Eight of 29 patients (28%) responded to one cycle of DB (1 complete/7 partial remissions); 2 of whom are alive after PBSCT (1 autologous/1 matched unrelated donor), 1 patient died after autologous PBSCT. Reasons for failure to proceed to high-dose therapy in spite of response to DB were recurrent progressive disease (n = 2), septicemia (n = 1), and allogeneic transplant-related mortality after mobilization failure to DB (n = 2). Twenty-one patients failed to respond to DB and died of progressive disease. Overall survival was 7% after 41 months. We conclude that Dexa-BEAM salvage therapy is not effective in patients with truly primary refractory high-grade NHL. The efficiency of rituximab combined with Dexa-BEAM or novel chemotherapeutic strategies needs to be established.
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Affiliation(s)
- Johannes Atta
- Department of Hematology, J. W. Goethe-University Hospital, Frankfurt, Germany.
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Robertson MJ, Abonour R, Hromas R, Nelson RP, Fineberg NS, Cornetta K. Augmented high-dose regimen of cyclophosphamide, carmustine, and etoposide with autologous hematopoietic stem cell transplantation for relapsed and refractory aggressive non-Hodgkin's lymphoma. Leuk Lymphoma 2009; 46:1477-87. [PMID: 16194894 DOI: 10.1080/10428190500158466] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Progressive disease is the major cause of treatment failure after autologous hematopoietic stem cell transplantation for relapsed or refractory non-Hodgkin's lymphoma. An augmented high-dose regimen of cyclophosphamide 7,200 mg/m2, carmustine 300 - 400 mg/m2, and etoposide 2,400 mg/m2 (CBV) was developed in an attempt to improve disease control post-transplant. Sixty-seven adult patients received augmented CBV followed by infusion of unpurged autologous peripheral blood stem cells. Thirty seven patients had relapsed after standard chemotherapy, 28 patients had primary refractory disease, and 2 patients had transformed lymphoma in first partial response. Treatment-related mortality was 4%. Actuarial four year overall survival and progression-free survival were 46+/-8% and 36+/-6%, respectively. Risk factors for disease progression were histologic involvement of marrow by lymphoma and infusion of increased numbers of CD34 + cells per kg in the stem cell autograft. The outcome for patients with relatively chemorefractory disease (defined as 25 - 49% reduction in tumor volume after salvage chemotherapy) was no different than that for patients with chemosensitive disease. Compared to standard high-dose CBV regimens, augmented CBV does not appear to have substantially improved disease control. Prospective study of the association between inferior progression-free survival and infusion of higher CD34 + cell doses in stem cell autografts is warranted.
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Affiliation(s)
- Michael J Robertson
- Bone Marrow and Stem Cell Transplantation Program, Indiana University Medical Center, 1044 West Walnut Street, Indianapolis, IN 46202, USA.
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Abstract
PET has become a cornerstone procedure in modern lymphoma management. This paper reviews, from a clinical point of view, the evidence for using PET in the different subtypes of lymphoma and the different steps of their management. The reader is given an overview of the current PET-based interventional lymphoma trials and an insight into possible future developments in the field, including new PET tracers.
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Affiliation(s)
- Martin Hutchings
- Departments of Oncology and Haematology, Rigshospitalet, The Finsen Centre-Copenhagen University Hospital, 9 Blegdamsvej, Copenhagen Ø, Denmark.
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Hutchings M, Barrington SF. PET/CT for Therapy Response Assessment in Lymphoma. J Nucl Med 2009; 50 Suppl 1:21S-30S. [DOI: 10.2967/jnumed.108.057190] [Citation(s) in RCA: 168] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Stiff P, Micallef I, McCarthy P, Magalhaes-Silverman M, Weisdorf D, Territo M, Badel K, Calandra G. Treatment with Plerixafor in non-Hodgkin's Lymphoma and Multiple Myeloma Patients to Increase the Number of Peripheral Blood Stem Cells When Given a Mobilizing Regimen of G-CSF: Implications for the Heavily Pretreated Patient. Biol Blood Marrow Transplant 2009; 15:249-56. [DOI: 10.1016/j.bbmt.2008.11.028] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2008] [Accepted: 11/13/2008] [Indexed: 10/21/2022]
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Study of conditioning regimens with or without high-dose radiotherapy before autologous stem cell transplantation for treating aggressive lymphoma. Int J Hematol 2008; 89:106-112. [PMID: 19067117 DOI: 10.1007/s12185-008-0217-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 10/16/2008] [Accepted: 11/05/2008] [Indexed: 10/21/2022]
Abstract
The aim and objective of the study is to compare the efficacy of conditioning regimens with or without high-dose radiotherapy for treating aggressive non-Hodgkin's lymphoma (NHL). Eighty-nine aggressive NHL patients who underwent high-dose therapy in combination with autologous stem cell transplantation (HDT/ASCT) between 1993 and 2006 were retrospectively studied. HDT was either high-dose chemotherapy alone (CT) or high-dose chemoradiotherapy (CRT). Overall, 37 patients in CT group and 52 in CRT group. The median radiotherapy DT in CRT group was 8 Gy. The median count of reinfused CD34+ cells was 6.26 x 10(6) and 22.16 x 10(6) cells/kg, respectively (p < 0.001). The median time of leukocyte engraftment was 11 days in CT group and 13 days in CRT group (p = 0.003), and the median platelet engraftment time was 12 days in CT group and 11 days in CRT group (p = 0.305). The median event-free survival (EFS) was 102 and 84 months in CT and CRT groups, respectively (p = 0.783), and the median overall survival (OS) was 102 and 121 months in CT and CRT groups, respectively (p = 0.857). Prolonged hospitalization favored EFS (p = 0.013) and OS (p = 0.011). In conclusion, when compared with CT, high-dose CRT does not improve prognosis.
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Lazarus HM, Carreras J, Boudreau C, Loberiza FR, Armitage JO, Bolwell BJ, Freytes CO, Gale RP, Gibson J, Hale GA, Inwards DJ, LeMaistre CF, Maharaj D, Marks DI, Miller AM, Pavlovsky S, Schouten HC, van Besien K, Vose JM, Bitran JD, Khouri IF, McCarthy PL, Yu H, Rowlings P, Serna DS, Horowitz MM, Rizzo JD. Influence of age and histology on outcome in adult non-Hodgkin lymphoma patients undergoing autologous hematopoietic cell transplantation (HCT): a report from the Center For International Blood & Marrow Transplant Research (CIBMTR). Biol Blood Marrow Transplant 2008; 14:1323-33. [PMID: 19041053 PMCID: PMC2638759 DOI: 10.1016/j.bbmt.2008.09.008] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2008] [Accepted: 09/12/2008] [Indexed: 12/29/2022]
Abstract
To compare the clinical outcomes of older (age > or =55 years) non-Hodgkin lymphoma (NHL) patients with younger NHL patients (<55 years) receiving autologous hematopoietic cell transplantation (HCT) while adjusting for patient-, disease-, and treatment-related variables, we compared autologous HCT outcomes in 805 NHL patients aged > or =55 years to 1949 NHL patients <55 years during the years 1990-2000 using data reported to the Center for International Blood and Marrow Transplant Research (CIBMTR). In multivariate analysis, older patients with aggressive histologies were 1.86 times (95% confidence interval [CI] 1.43-2.43, P < .001) more likely than younger patients to experience treatment-related mortality (TRM). Relative death risks were 1.33 times (CI 1.04-1.71, P = .024) and 1.50 times (CI 1.33-16.9, P < .001) higher in older compared to younger patients with follicular grade I/II and aggressive histologies, respectively. Autologous HCT in older NHL patients is feasible, but most disease-related outcomes are statistically inferior to younger patients. Studies addressing supportive care particular to older patients, who are most likely to benefit from this approach, are recommended.
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Affiliation(s)
- Hillard M Lazarus
- Department of Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, USA.
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Abstract
BACKGROUND Constituting approximately 30% of lymphoid malignancies, diffuse large B-cell lymphoma (DLBCL) is the most common aggressive lymphoma in adults worldwide. The clinical and biologic heterogeneity that exists in DLBCL suggests that this entity might actually be comprised of several distinct neoplasms that could require different therapeutic approaches. DLBCL was considered incurable until combination chemotherapy became available. OBJECTIVE Current treatment strategies for the treatment of untreated and relapsed advanced-stage DLBCL are reviewed; novel treatments for DLBCL are discussed. METHODS Relevant literature was identified using the PubMed search engine and by reviewing abstracts from major conference proceedings. RESULTS/CONCLUSION Recently, novel therapeutic strategies, including the incorporation of immunotherapy to combination chemotherapy, have improved outcome for patients with DLBCL with cure rates exceeding 50%, especially in younger patients.
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Affiliation(s)
- Maricer P Escalón
- University of Miami Sylvester Cancer Center, 1475 NW 12 Ave Suite 3400 (D8-4), Miami, FL 33136, USA.
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Hoppe BS, Moskowitz CH, Filippa DA, Moskowitz CS, Kewalramani T, Zelenetz AD, Yahalom J. Involved-Field Radiotherapy Before High-Dose Therapy and Autologous Stem-Cell Rescue in Diffuse Large-Cell Lymphoma: Long-Term Disease Control and Toxicity. J Clin Oncol 2008; 26:1858-64. [DOI: 10.1200/jco.2007.15.4773] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To analyze outcome, prognostic factors, and toxicities in patients with diffuse large-cell lymphoma (DLCL) who received involved-field radiotherapy (IFRT) before high-dose chemotherapy with autologous stem-cell rescue (ASCR). Patients and Methods Between January 1990 and August 2006, 164 patients with relapsed or refractory DLCL received IFRT at Memorial Sloan-Kettering Cancer Center (New York, NY) before high-dose chemotherapy and ASCR. IFRT was delivered to involved sites measuring more than 5 cm or to sites with residual disease more than 2 cm. Radiotherapy was administered in 1.5-Gy fractions twice daily to a total dose of 30 Gy. Progression-free survival and overall survival were calculated, and short- and long-term toxicity was assessed according to National Cancer Institute Common Toxicity Criteria (version 2.0). Median follow-up was 60 months (range, 2 to 187 months). Results Two- and 5-year progression-free survival was 62% and 53%; 2- and 5-year overall survival was 67% and 58%, respectively. Sixty-seven patients relapsed; only 10 patients relapsed completely within the radiotherapy field. There were seven early treatment-related mortalities and 11 secondary cancers (including four myelodysplastic syndromes), one of which occurred within the IFRT site and five after total-body irradiation. Conclusion Minimal treatment-related mortality and morbidity resulted from short, intensive, involved-field radiotherapy before high-dose chemotherapy and ASCR, which was incorporated into a salvage regimen for patients with relapsed/refractory DLCL. This chemoradiotherapy salvage regimen resulted in a low local relapse rate that could potentially translate into an improved total outcome.
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Affiliation(s)
- Bradford S. Hoppe
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Craig H. Moskowitz
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Daniel A. Filippa
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Chaya S. Moskowitz
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Tarun Kewalramani
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Andrew D. Zelenetz
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Joachim Yahalom
- From the Lymphoma Disease Management Team and the Departments of Radiation Oncology, Medical Oncology, Pathology, and Epidemiology & Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY
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Abstract
PURPOSE OF REVIEW The prognostic utility of midtreatment fluorine-18 fluorodeoxyglucose positron emission tomography (F-FDG PET) has become widely appreciated in aggressive B-cell non-Hodgkin's lymphoma and, more recently, in Hodgkin's lymphoma. Outcomes based on midtreatment FDG PET performed during primary and salvage therapy are reviewed and management strategies considered, with a focus on treatment intensification for poor-risk disease as identified by metabolic imaging. RECENT FINDINGS PET, when performed after as few as two cycles of primary chemotherapy, is strongly prognostic in certain aggressive lymphomas and provides information independently from validated prognostic indices. What constitutes a positive or negative scan is not always clear, particularly if there is minimal tracer uptake, and the causes of false positive and false negative scans must be considered. How to tailor therapy based on the midtreatment PET result is the focus of current trials and is presently being defined for both Hodgkin's and non-Hodgkin's lymphoma. SUMMARY Early PET has the strong potential to improve clinical outcomes by sparing good-risk patients from overly aggressive treatments, and by more accurately identifying poor-risk patients so as to guide changes in management. Treatment modifications on the basis of midtreatment PET are presently best made in clinical trial settings.
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Total body irradiation, etoposide, cyclophosphamide, and autologous peripheral blood stem-cell transplantation followed by randomization to therapy with interleukin-2 versus observation for patients with non-Hodgkin lymphoma: results of a phase 3 randomized trial by the Southwest Oncology Group (SWOG 9438). Blood 2008; 111:4048-54. [PMID: 18256325 DOI: 10.1182/blood-2007-09-111708] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
To determine the effect of posttransplantation immunotherapy with IL-2 on the progression-free survival (PFS) and overall survival (OS) of patients with non-Hodgkin lymphoma (NHL) after autologous stem-cell transplantation (PBSCT), patients with previously treated NHL were treated with cyclophosphamide, etoposide, total body irradiation (TBI), and PBSCT. Twenty-eight to 80 days after PBSCT, patients were randomized to IL-2 versus observation. Three hundred seventy-six eligible patients were registered (with 4-year PFS of 34% and 4-year OS of 52%), and 194 eligible patients were randomized to continuous infusion intravenous IL-2 (9 million units/m(2)/day for 4 days followed 5 days later by 1.6 million units/m(2)/day for 10 days) versus observation. In randomized patients, there was no significant difference in PFS (hazard ratio of IL-2 to observation = 0.90; P =.56) or in OS (hazard ratio of IL-2 to observation = 0.88; P =.55). There were no deaths related to IL-2 treatment. Grade 4 IL-2-related toxicities (n = 14) were reversible. These results confirm earlier SWOG findings that cyclophosphamide, etoposide, TBI, and PBSCT can be administered to patients with relapsed/refractory NHL with encouraging PFS and OS. Posttransplantation IL-2 given at this dose and schedule of administration had no significant effect on PFS or OS. This study is registered at www.clinicaltrials.gov as NCT00002649.
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Pham RN, Gooley TA, Keeney GE, Press OW, Pagel JM, Greisman HA, Bensinger WI, Holmberg LA, Petersdorf SH, Maloney DG, Gopal AK. The impact of histologic grade on the outcome of high-dose therapy and autologous stem cell transplantation for follicular lymphoma. Bone Marrow Transplant 2007; 40:1039-44. [DOI: 10.1038/sj.bmt.1705864] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Fernandez HF, Escalón MP, Pereira D, Lazarus HM. Autotransplant conditioning regimens for aggressive lymphoma: are we on the right road? Bone Marrow Transplant 2007; 40:505-13. [PMID: 17589535 DOI: 10.1038/sj.bmt.1705744] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
High-dose chemotherapy and autologous stem cell transplant (ASCT) is the standard approach for chemosensitive, relapsed aggressive non-Hodgkin's lymphoma (NHL). Various conditioning regimens have been used as treatment before ASCT and disease-free (DFS) and overall survival (OS) rates range from 34 to 60% and 26 to 46%, respectively. To date, few comparative randomized trials have been performed and no regimen has demonstrated superiority to another. Reduction of disease relapse remains the major hurdle for improving patient outcome and in vitro and in vivo purging of lymphoma cells has not necessarily enhanced results. Rituximab pre-mobilization and post-transplant appear to provide better response rates with OS approaching 87-91% at 2-3 years. Newer approaches with radioimmunotherapy may raise DFS to 78% and OS to 93%, albeit with short follow-up. Advances in the conditioning regimens and supportive care have reduced transplant-related mortality to less than 10%. In this review we discuss commonly utilized conditioning regimens, describe their pros and cons and address purging and present conditioning strategies. Owing to the poor outcome with conventional chemotherapy in mantle cell, Burkitt's and T-cell lymphoma, we propose the standard approach of front-line ASCT for these high-risk lymphoma patients. Finally, we will present novel strategies, which can enhance the anti-lymphoma effect, at the same time reducing toxicity, to improve the outcome of ASCT in NHL patients.
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Affiliation(s)
- H F Fernandez
- Division of Blood and Marrow Transplant, Department of Interdisciplinary Oncology, H Lee Moffitt Cancer Center and Research Institute, University of South Florida, Tampa, FL, USA.
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Kirby AM, Mikhaeel NG. The role of FDG PET in the management of lymphoma: what is the evidence base? Nucl Med Commun 2007; 28:335-54. [PMID: 17414883 DOI: 10.1097/mnm.0b013e3280895e23] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
[18F]Fluorodeoxyglucose positron emission tomography (18F-FDG PET) is playing an increasing role in the management of both Hodgkin and non-Hodgkin lymphoma, offering potential advantages in the accuracy of disease assessment at a number of points in the management pathway. This review evaluates the current level of confidence in the use of PET technology in (1) initial staging, (2) the assessment of early response to chemotherapy, (3) the assessment of residual masses at completion of initial treatment, (4) follow-up, and (5) radiotherapy planning.
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Affiliation(s)
- Anna M Kirby
- Department of Clinical Oncology, Guy's and St Thomas' NHS Trust, London, UK.
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Gopal AK, Rajendran JG, Gooley TA, Pagel JM, Fisher DR, Petersdorf SH, Maloney DG, Eary JF, Appelbaum FR, Press OW. High-dose [131I]tositumomab (anti-CD20) radioimmunotherapy and autologous hematopoietic stem-cell transplantation for adults > or = 60 years old with relapsed or refractory B-cell lymphoma. J Clin Oncol 2007; 25:1396-402. [PMID: 17312330 DOI: 10.1200/jco.2006.09.1215] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The majority of patients with relapsed or refractory B-cell non-Hodgkin's lymphoma (NHL) are older than 60 years, yet they are often denied potentially curative high-dose therapy and autologous stem-cell transplantations (ASCT) because of the risk of excessive treatment-related morbidity and mortality. Myeloablative anti-CD20 radioimmunotherapy (RIT) can deliver curative radiation doses to tumor sites while limiting exposure to normal organs and may be particularly suited for older adults requiring high-dose therapy. PATIENTS AND METHODS Patients older than 60 years with relapsed B-cell NHL (B-NHL) received infusions of tositumomab anti-CD20 antibody labeled with 185 to 370 Mbq (5 to 10 mCi) [131I]-tracer for dosimetry purposes followed 10 days later by individualized therapeutic infusions of [131I]tositumomab (median, 19.4 Gbq [525 mCi]; range, 12.1 to 42.7 Gbq [328 to 1,154 mCi]) to deliver 25 to 27 Gy to the critical normal organ receiving the highest radiation dose. ASCT was performed approximately 2 weeks after therapy. RESULTS Twenty-four patients with a median age of 64 years (range, 60 to 76 years), who had received a median of four prior regimens (range, two to 14 regimens), were treated. Thirteen patients (54%) had chemotherapy-resistant disease. The estimated 3-year overall and progression-free survival rates were 59% and 51%, respectively, with a median follow-up of 2.9 years (range, 1 to 6 years). All patients experienced expected myeloablation with engraftment of platelets (> or = 20 K/microL) and neutrophils ( 500/microL), occurring at a median of 9 and 15 days after ASCT, respectively. There were no treatment-related deaths, and only two patients experienced grade 4 nonhematologic toxicity. CONCLUSION Myeloablative RIT and ASCT is a safe and effective therapeutic option for older adults with relapsed B-NHL.
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Affiliation(s)
- Ajay K Gopal
- Department of Medicine, Division of Medical Oncology, University of Washington, Seattle Cancer Care Alliance, Seattle, WA 98195, USA.
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Schütt P, Passon J, Ebeling P, Welt A, Müller S, Metz K, Moritz T, Seeber S, Nowrousian MR. Ifosfamide, etoposide, cytarabine, and dexamethasone as salvage treatment followed by high-dose cyclophosphamide, melphalan, and etoposide with autologous peripheral blood stem cell transplantation for relapsed or refractory lymphomas. Eur J Haematol 2006; 78:93-101. [PMID: 17313557 DOI: 10.1111/j.1600-0609.2006.00796.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
High-dose chemotherapy (HD-CT) with autologous stem cell transplantation is considered to be the treatment of choice for relapsed high-grade non-Hodgkin's lymphoma (NHL) and Hodgkin's lymphoma (HL) patients, but the optimal treatment has not yet been defined. We evaluated a salvage treatment regimen consisting of conventional cycles with ifosfamide, etoposide, cytarabine, and dexamethasone (IVAD) followed by two cycles of HD-CT consisting of cyclophosphamide, melphalan, and etoposide (CMV) with autologous stem cell support in patients with relapsed or refractory NHL (n = 59) and HL (n = 16). Response to IVAD was complete remission (CR) in 16 patients (21%), partial remission (PR) in 39 patients (52%), stable disease (SD) in 18 patients (24%), and progressive disease (PD) in two patients (2.7%). Of 70 patients treated with HD-CT, 41 patients (59%) showed a CR, 20 patients a PR (29%), eight patients a SD (11%), and one patient a PD (1.4%). The 5-yr overall survival for the entire group of patients was 29%, and for patients with NHL and HL 25%, and 38%, respectively. The respective event-free survival probabilities at 5 yr were 22%, 16%, and 31%. Seven treatment-related deaths due to septicemia (three), cardiac arrhythmia (one), pneumonia (one), pneumonitis (one), and toxic epidermal necrolysis (one) were observed. In multivariate analysis, an International Prognostic Index of > or = 2 and resistant disease to first-line chemotherapy were poor independent prognostic factors for the subgroup of patients with NHL. In conclusion, these results indicate that IVAD/CMV is feasible as a salvage therapy for lymphoma patients. This treatment is currently evaluated with the addition of rituximab.
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Affiliation(s)
- P Schütt
- Department of Internal Medicine (Cancer Research), West German Cancer Center, University of Duisburg-Essen Medical School, Essen, Germany
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Stiff PJ, Emmanouilides C, Bensinger WI, Gentile T, Blazar B, Shea TC, Lu J, Isitt J, Cesano A, Spielberger R. Palifermin Reduces Patient-Reported Mouth and Throat Soreness and Improves Patient Functioning in the Hematopoietic Stem-Cell Transplantation Setting. J Clin Oncol 2006; 24:5186-93. [PMID: 16391299 DOI: 10.1200/jco.2005.02.8340] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PurposeTo describe patient-reported outcomes of mouth and throat soreness (MTS) and related sequelae on daily activities from a phase III study of palifermin in the autologous hematopoietic stem-cell transplantation (HSCT) setting and to compare patient self-evaluations with clinicians' assessments of oral mucositis using objective scales.Patients and MethodsPatients (n = 212) received palifermin (60 μg/kg/d) or placebo for 3 days before total-body irradiation (12 Gy), etoposide 60 mg/kg, and cyclophosphamide 100 mg/kg, and 3 days after HSCT. Patients completed a daily questionnaire (Oral Mucositis Daily Questionnaire [OMDQ]) evaluating MTS severity and its effects on daily functional activities. Patients' self-assessment data were compared with clinicians' assessments of oral mucositis using the objective scales.ResultsPalifermin reduced the incidence and duration of severe oral mucositis, as assessed by both clinicians and patients. Comparisons between patient and clinician assessments demonstrated that the average daily scores between mucositis grade and subjective (MTS) instruments were similar, although patients reported MTS onset, peak, and resolution earlier (1 to 3 days) than clinicians' assessments. Patients receiving palifermin reported statistically significant improvements (P < .001) in daily functioning activities (swallowing, drinking, eating, talking, sleeping) and required significantly less narcotic opioids (P < .001); improvement in the patient's overall physical and functional well-being was also reported. This was confirmed by the results of the Functional Assessment of Cancer Treatment questionnaire.ConclusionThese results support the clinical benefit of palifermin in the HSCT setting, providing evidence that a patient's self-assessment instrument (OMDQ) may serve as an alternative tool to assess oral mucositis severity in clinical trials.
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Aggarwal C, Gupta S, Vaughan WP, Saylors GB, Salzman DE, Katz RO, Nance AG, Tilden AB, Carabasi MH. Improved Outcomes in Intermediate- and High-Risk Aggressive Non-Hodgkin Lymphoma after Autologous Hematopoietic Stem Cell Transplantation Substituting Intravenous for Oral Busulfan in a Busulfan, Cyclophosphamide, and Etoposide Preparative Regimen. Biol Blood Marrow Transplant 2006; 12:770-7. [PMID: 16785066 DOI: 10.1016/j.bbmt.2006.03.016] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2005] [Accepted: 03/29/2006] [Indexed: 11/15/2022]
Abstract
Forty-nine patients with intermediate- and high-risk aggressive non-Hodgkin lymphoma underwent autologous hematopoietic stem cell transplantation (autoHSCT) using the regimen of busulfan (Bu), cyclophosphamide (Cy), and etoposide (E) that was originally developed for allogeneic HSCT. Eighteen patients treated before 1999 received Cy 2.5 g/m2 on days -3 to -2 and E 1800 mg/m2 on day -3 after oral (PO) administration of Bu 1 mg/kg every 6 hours x 4 days for a total of 16 doses beginning on day -7. After April 1999, 31 patients similar in all pretransplantation risk assessments received the same regimen except that intravenous (IV) Bu was substituted for PO Bu and pharmacokinetic-directed (PKD) dosing was attempted to achieve an area under the concentration time curve of 1000-1500 micromol/min for each dose. Nonrelapse mortality was 28% for PO Bu patients versus 3% for the IV PKD group (P = .01, chi-square test). Actuarial 5-year overall survivals were 28% for patients who received the PO Bu regimen and 58% for patients who received the IV Bu regimen (P = .010, log-rank test), and progression-free survivals were 17% and 50%, respectively (P = .008, log-rank test). After substitution of PKD IV Bu in the BuCyE regimen, we observed lower nonrelapse mortality with increased overall and progression-free survivals in patients with intermediate- and high-risk aggressive non-Hodgkin lymphoma who underwent autoHSCT.
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Affiliation(s)
- Charu Aggarwal
- Department of Internal Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA
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Mabed M, Al-Kgodary T. Cyclophosphamide, etoposide and carboplatine plus non-cryopreserved autologous peripheral blood stem cell transplantation rescue for patients with refractory or relapsed non-Hodgkin's lymphomas. Bone Marrow Transplant 2006; 37:739-43. [PMID: 16501587 DOI: 10.1038/sj.bmt.1705314] [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: 11/09/2022]
Abstract
A simplified schedule of high-dose chemotherapy consisting of cyclophosphamide (60 mg/kg/day for 2 days), etoposide (15 mg/kg/day for 2 days) and carboplatine (400 mg/m(2)/day for 2 days), together with autologous non-cryopreserved peripheral blood stem cells was used for treatment of relapsed (29 patients) and refractory (three patients) patients with non-Hodgkin's lymphoma (NHL). The use of such granulocyte colony-stimulating factor (G-CSF)-mobilized peripheral blood stem cells (PBSC) after high-dose myeloablative therapy resulted in a rapid, complete and sustained hematopoietic recovery. The median time to achieve an absolute neutrophil count greater than 0.5 x 10(9)/l was 12 days (range 8-17 days). The median time to self-sustained platelet count greater than 20 x 10(9)/l was 14 days (range 7-19 days). Fifteen of the 32 patients (49%) were alive and disease free at a median follow-up of 18 months (range 10-96 months) for all surviving patients. The estimated 2-year overall survival (OS) and disease free survival (DFS) for all patients were 50 and 43%, respectively. Twelve patients died of relapse or progressive disease, two patients died of infection and one patient died of cardiac cause. The median time to relapse was 12 months (5-27) from PBSC infusion. High-dose chemotherapy with short-duration chemotherapy and non-cryopreserved bone marrow (BM) is an effective and safe treatment modality for patients with relapsed or resistant NHL.
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Affiliation(s)
- M Mabed
- Hematology and Medical Oncology Unit, Faculty of Medicine, Mansoura University, Mansoura, Egypt.
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Flinn IW, Berdeja JG. Blood and bone marrow transplantation for patients with Hodgkin's and non-Hodgkin's lymphoma. Cancer Treat Res 2006; 131:251-81. [PMID: 16704172 DOI: 10.1007/978-0-387-29346-2_8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Affiliation(s)
- Ian W Flinn
- The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins Bunting-Blaustein Cancer Research Building, 1650 Orleans Street/Room 388, Baltimore, MD 21231-1000, USA
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Ferrara F, Viola A, Copia C, Schiavone EM, Celentano M, Pollio F, D'Amico MR, Palmieri S. Therapeutic results in patients with relapsed diffuse large B cell Non-Hodgkin's lymphoma achieving complete response only after autologous stem cell transplantation. Hematol Oncol 2006; 24:73-7. [PMID: 16550628 DOI: 10.1002/hon.773] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Forty patients with relapsed diffuse large B cell lymphoma (DLBCL) autografted in partial response (PR) (n = 23) or in refractory relapse (RR) (n = 17) achieved complete remission (CR) after autologous stem cell transplantation (ASCT). Salvage treatment consisted of ifosphamide, epirubicin and etoposide (IEV) in 33 patients and Cisplatinum, ARA-C and dexamethasone (DHAP) in 7 patients. All PR and 8 RR patients were conditioned with BEAM, while 9 RR cases received the BCV regimen. There were no significant differences between the two groups as age, serum LDH, duration of CR1 and IPI at relapse are concerned. Relapse rate after ASCT was 39% in PR group as opposed to 88% in RR group (p = 0.003). Median relapse free survival from ASCT was 6 months for RR patients as opposed to 34 months for PR patients (p = 0.003); median overall survival from ASCT was 10 months for RR subset as opposed to not reached for RR subgroup (p = 0.001). These data demonstrate that CR achieved after ASCT in DLBCL patients who are refractory to previous salvage therapy does not result in long-term disease control. Alternative preparative regimens, allogeneic SCT and/or monoclonal antibodies in the post-ASCT phase should be considered for RR patients despite CR achievement.
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MESH Headings
- Disease-Free Survival
- Female
- Humans
- Lymphoma, B-Cell/mortality
- Lymphoma, B-Cell/pathology
- Lymphoma, B-Cell/therapy
- Lymphoma, Large B-Cell, Diffuse/mortality
- Lymphoma, Large B-Cell, Diffuse/pathology
- Lymphoma, Large B-Cell, Diffuse/therapy
- Male
- Middle Aged
- Neoplasm Staging
- Recurrence
- Retrospective Studies
- Stem Cell Transplantation
- Survival Analysis
- Transplantation, Autologous
- Treatment Outcome
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Affiliation(s)
- Felicetto Ferrara
- Division of Hematology and Stem Cell Transplantation Unit, A. Cardarelli Hospital, Naples, Italy.
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Zinzani PL. Autologous hematopoietic stem cell transplantation in Non-Hodgkin's lymphomas. Acta Haematol 2005; 114:255-9. [PMID: 16269866 DOI: 10.1159/000088416] [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: 11/19/2022]
Abstract
Early studies on high-dose therapy followed by autologous bone marrow transplantation demonstrated the safety and efficacy of this approach in non-Hodgkin's lymphoma (NHL). As the procedure became easier and safer with the introduction of peripheral blood progenitor cells instead of marrow, the popularity of this procedure declined. In the last decade, autologous hematopoietic stem cell transplantation has played an important role in front-line and salvage treatments of indolent and aggressive NHL.
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Affiliation(s)
- Pier Luigi Zinzani
- L. and A. Seràgnoli Institute of Hematology and Oncology, University of Bologna, Bologna, Italy.
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Autologous hematopoietic stem cell transplantation for lymphoma: An evaluation of grafts source and minimal residual disease. Chin J Cancer Res 2005. [DOI: 10.1007/s11670-005-0044-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Forman SJ. Innovations in autologous transplantation for hematologic malignancy. Biol Blood Marrow Transplant 2005; 11:28-33. [PMID: 15682173 DOI: 10.1016/j.bbmt.2004.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Stephen J Forman
- Division of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, 1500 E. Duarte Road, Duarte, CA 91010, USA.
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Nademanee A, Forman S, Molina A, Fung H, Smith D, Dagis A, Kwok C, Yamauchi D, Anderson AL, Falk P, Krishnan A, Kirschbaum M, Kogut N, Nakamura R, O'donnell M, Parker P, Popplewell L, Pullarkat V, Rodriguez R, Sahebi F, Smith E, Snyder D, Stein A, Spielberger R, Zain J, White C, Raubitschek A. A phase 1/2 trial of high-dose yttrium-90-ibritumomab tiuxetan in combination with high-dose etoposide and cyclophosphamide followed by autologous stem cell transplantation in patients with poor-risk or relapsed non-Hodgkin lymphoma. Blood 2005; 106:2896-902. [PMID: 16002426 PMCID: PMC1895300 DOI: 10.1182/blood-2005-03-1310] [Citation(s) in RCA: 173] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We conducted a phase 1/2 trial of high-dose 90Y-ibritumomab tiuxetan in combination with high-dose etoposide (VP-16) 40 to 60 mg/kg (day -4) and cyclophosphamide 100 mg/kg (day -2) followed by autologous stem cell transplantation (ASCT) in 31 patients with CD20+ non-Hodgkin lymphoma (NHL). Patients underwent dosimetry (day -21) with 5 mCi (185 MBq) 111In-ibritumomab tiuxetan following 250 mg/m2 rituximab, followed a week later by 90Y-ibritumomab tiuxetan to deliver a target dose of 1000 cGy to highest normal organ. Bone marrow biopsy was done on day -7 to estimate radiation dose and stem cells were reinfused when the radiation dose was estimated to be less than 5 cGy. The median 90Y-ibritumomab tiuxetan dose was 71.6 mCi (2649.2 MBq; range, 36.6-105 mCi; range, 1354.2-3885 MBq). Histology included follicular lymphoma (n = 12), diffuse large B-cell (n = 14), and mantle cell (n = 5). The median number of prior chemo-therapy treatments was 2. The treatment was well tolerated. The median times to reach an absolute neutrophil count greater than 500/microL and platelet count more than 20,000/microL were 10 days and 12 days, respectively. There were 2 deaths and 5 relapses. At a median follow-up of 22 months, the 2-year estimated overall survival and relapse-free survival rates are 92% and 78%, respectively. We conclude that high-dose 90Y-ibritumomab tiuxetan can be combined safely with high-dose etoposide and cyclophosphamide without an increase in transplant-related toxicity or delayed engraftment.
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Affiliation(s)
- Auayporn Nademanee
- Division of Hematology and Hemapoietic Cell Transplantation, City of Hope National Medical Center, 1500 E Duarte Rd, Duarte, CA 91010, USA.
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Usui N, Yano S, Asai O, Dobashi N, Osawa H, Takei Y, Sugiyama K, Takahara S, Otubo H, Saito T, Okawa Y, Hagino T, Kaito K, Kobayashi M. Long-Term Follow-up High-Dose Chemotherapy (Drug-Only Program) Followed by Autologous Stem Cell Transplantation for Aggressive Non-Hodgkin's Lymphomas. ACTA ACUST UNITED AC 2005; 6:31-6. [PMID: 15989704 DOI: 10.3816/clm.2005.n.024] [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
PURPOSE To investigate the feasibility of high-dose chemotherapy (HDCT) followed by autologous stem cell transplantation (ASCT) for aggressive non-Hodgkin's lymphoma (NHL), we conducted HDCT with ASCT using a drug-only protocol without total body irradiation. Previously untreated and treated adult patients with aggressive lymphoma were enrolled onto this study. For the HDCT protocol, we developed the AECC regimen, a drug-only regimen consisting of etoposide, carboplatin, cyclophosphamide, and nimustine (ie, ACNU). Mobilized peripheral blood stem cells were used mainly as a source for ASCT and were used based on collection rates of CD34 cells. PATIENTS AND METHODS Fifty-six patients were enrolled and assessed for this study. The median length of follow-up was 6.5 years, with a range of 0.2-12.5 years. Retrospective immunophenotypic examination indicated that the majority of the patients were diagnosed with B-cell lymphoma. RESULTS Before HDCT, 37 patients still had disease (26 partial responses [PRs] and 11 cases of no response), and 19 patients exhibited a complete response (CR) before HDCT with ASCT. Among 56 patients, 37 (66%) exhibited a CR, including patients continuing their first CR and those experiencing a second or further CR, and 11 patients (19.6%) exhibited PR on HDCT with ASCT. Outcomes of patients without CR were significantly poorer than those of the patients with CR, and 7-year overall survival rates of patients with and without CR were 63% and 27.2%, respectively. No patients developed a second malignancy, including leukemia or myelodysplastic syndrome. CONCLUSIONS High-dose chemotherapy followed by ASCT is one of the available consolidation therapies for aggressive NHL, and additional involved-field irradiation could play a role in the management of patients with NHL who do not exhibit a CR after treatment with HDCT containing a drug-only program.
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Affiliation(s)
- Noriko Usui
- Division of Hematology and Oncology, Department of Internal Medicine, The Jikei University School of Medicine, Tokyo, Japan.
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