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Ohmachi K, Ogura M, Kagami Y, Imai Y, Hirose T, Kinoshita T, Nagai H, Ohnishi K, Hotta T. A multicenter, phase II study of full-dose THP-COP therapy for elderly patients with newly diagnosed, advanced-stage, aggressive non-Hodgkin lymphoma. J Clin Exp Hematop 2022; 62:202-207. [PMID: 36575000 PMCID: PMC9898716 DOI: 10.3960/jslrt.22026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
The cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP) regimen, containing doxorubicin (DXR), which is a key drug for aggressive non-Hodgkin lymphoma (NHL), is a standard chemotherapeutic regimen; however, its administration in elderly patients is often intolerable. Pirarubicin (tetrahydropyranyl adriamycin [THP]) is an anthracycline developed in Japan. We have conducted a phase II trial of a full-dose THP-COP (modified CHOP regimen with DXR replaced by THP) regimen for elderly patients with newly diagnosed, advanced-stage, aggressive NHL. Patients aged 70-79 years old with previously untreated NHL according to the Working Formulation (D through H and J), disease stage I with a bulky mass or stage II-IV, and performance status of 0-1 were eligible. The THP-COP regimen, which consisted of 750-mg/m2 cyclophosphamide, 50-mg/m2 THP, 1.4-mg/m2 vincristine (capped at 2.0 mg) on day 1, and 100-mg prednisolone daily on days 1 to 5, was delivered every 3 weeks for 6 cycles. The primary endpoint was complete response (CR) rate. Twenty-nine patients were enrolled in the study. The CR rate was 65.5% (95% confidence interval, 45.7-82.1%). The 3-year failure-free and overall survival rates were 54.1% and 53.9%, respectively. The most frequent observed grade 3 or 4 toxicity was neutropenia, which occurred in 80% of the patients. Grade 3 cardiac dysfunction was observed in one patient. The full-dose THP-COP regimen exhibited similar efficacy and safety, and a tendency for less cardiac toxicity, when compared with the standard CHOP regimen in elderly Japanese patients with newly diagnosed, advanced-stage, aggressive NHL.
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Affiliation(s)
- Ken Ohmachi
- Department of Hematology and Oncology, Tokai University School of Medicine, Isehara, Japan
| | - Michinori Ogura
- Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yoshitoyo Kagami
- Department of Hematology and Cell Therapy, Aichi Cancer Center Hospital, Nagoya, Japan
| | - Yosuke Imai
- Department of Internal Medicine, Niigata Cancer Center Hospital, Niigata, Japan
| | - Takayuki Hirose
- Department of Internal Medicine, Niigata Cancer Center Hospital, Niigata, Japan
| | - Tomohiro Kinoshita
- Department of Hematology and Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Hirokazu Nagai
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
| | - Kazunori Ohnishi
- Department of Hematology, Hamamatsu University School of Medicine, Hamamatsu, Japan
| | - Tomomitsu Hotta
- Department of Hematology, National Hospital Organization Nagoya Medical Center, Nagoya, Japan
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Diethelm-Varela B, Ai Y, Liang D, Xue F. Nitrogen Mustards as Anticancer Chemotherapies: Historic Perspective, Current Developments and Future Trends. Curr Top Med Chem 2019; 19:691-712. [PMID: 30931858 DOI: 10.2174/1568026619666190401100519] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/11/2019] [Accepted: 02/25/2019] [Indexed: 12/30/2022]
Abstract
Nitrogen mustards, a family of DNA alkylating agents, marked the start of cancer pharmacotherapy. While traditionally characterized by their dose-limiting toxic effects, nitrogen mustards have been the subject of intense research efforts, which have led to safer and more effective agents. Even though the alkylating prodrug mustards were first developed decades ago, active research on ways to improve their selectivity and cytotoxic efficacy is a currently active topic of research. This review addresses the historical development of the nitrogen mustards, outlining their mechanism of action, and discussing the improvements on their therapeutic profile made through rational structure modifications. A special emphasis is made on discussing the nitrogen mustard prodrug category, with Cyclophosphamide (CPA) serving as the main highlight. Selected insights on the latest developments on nitrogen mustards are then provided, limiting such information to agents that preserve the original nitrogen mustard mechanism as their primary mode of action. Additionally, future trends that might follow in the quest to optimize these invaluable chemotherapeutic medications are succinctly suggested.
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Affiliation(s)
- Benjamin Diethelm-Varela
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, United States
| | - Yong Ai
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, United States
| | - Dongdong Liang
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, United States
| | - Fengtian Xue
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland 21201, United States
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Kataoka T, Sakurashita H, Taogoshi T, Nishigakiuchi R, Murase T, Izumitani S, Saeki Y, Matsuo H. Comparison of Pegfilgrastim and Filgrastim for the Primary Prophylactic Effect for Preventing Febrile Neutropenia in Patients Undergoing Rituximab with Dose-adjusted EPOCH Chemotherapy. YAKUGAKU ZASSHI 2019; 139:629-633. [DOI: 10.1248/yakushi.18-00101] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Reddy P, Kanan S, Cowan A, Warren H, Till B, Shadman M, Cassaday R, Press O, Shustov A, Gopal A, Smith SD. Pegylated GCSF Can Be Used With First-Line da-EPOCH-R Without Compromising Dose Intensity, Safety, or Efficacy. Clin Lymphoma Myeloma Leuk 2017; 17:e87-e90. [PMID: 28870643 DOI: 10.1016/j.clml.2017.08.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 07/17/2017] [Accepted: 08/07/2017] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Infusional da-EPOCH-R (dose-adjusted etoposide, doxorubicin, and cyclophosphamide with vincristine, prednisone, and rituximab) is a dose-intensified regimen with a potential role in treating high-risk subtypes of aggressive B-cell non-Hodgkin lymphoma (B-NHL). Studies of da-EPOCH-R use daily injections of granulocyte colony-stimulating factor (GCSF) to tailor chemotherapy dosing, and whether 1-time administration of pegylated GCSF (peg-GCSF) is as efficacious has not been addressed. PATIENTS AND METHODS We reviewed aggressive B-NHL patients treated at our center with first-line da-EPOCH-R for clinician choice of growth factor, and analyzed dose level achieved, rate of unplanned hospitalizations, and patient outcomes. RESULTS Among 73 patients, 44 received peg-GCSF. Overall, 11 patients (15%) patients achieved dose level 4. Baseline characteristics between peg-GCSF and GCSF groups were similar. The proportion of patients who achieved dose level 4 was comparable in the peg-GCSF group (5 of 44 [11%]) and daily GCSF (6 of 29 [21%]; P = .24). The rate of unplanned hospitalizations, and event-free and overall survival, were also similar between groups. CONCLUSION We suggest routine use of peg-GCSF is an acceptable alternative to daily GCSF, for patients in whom da-EPOCH-R is selected as first-line treatment for aggressive B-NHL.
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Affiliation(s)
| | - Sandra Kanan
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA
| | - Andrew Cowan
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Houston Warren
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Brian Till
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Mazyar Shadman
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ryan Cassaday
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Oliver Press
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Andrei Shustov
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Ajay Gopal
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Stephen D Smith
- Department of Medicine, University of Washington/Seattle Cancer Care Alliance, Seattle, WA; Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA.
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Accordino MK, Wright JD, Vasan S, Neugut AI, Hillyer GC, Hershman DL. Factors and Costs Associated With Delay in Treatment Initiation and Prolonged Length of Stay With Inpatient EPOCH Chemotherapy in Patients With Hematologic Malignancies. Cancer Invest 2017; 35:202-214. [PMID: 28165774 DOI: 10.1080/07357907.2016.1276186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Reducing delays related to inpatient chemotherapy may reduce healthcare costs. Using a national database, we identified patients with lymphoma/leukemia with ≥1 etoposide, vincristine, doxorubicin, cyclophosphamide, and prednisone (EPOCH) chemotherapy claim and evaluated chemotherapy initiation delay (ID), >1 day from admission. Standard tests/procedures prior to initiation were evaluated. Among 4453 inpatient cycles, 19.7% had ID, odds ratio 2.28 (95% confidence interval: 1.83-2.85) with cycle 1 compared to cycle 2, and mean costs were higher in patients with ID than without ID (p < .0001). Prior to cycle 1, patients were more likely to undergo routine diagnostic procedures compared to subsequent cycles. Efforts to perform routine procedures prior to admission may reduce hospital length of stay and costs.
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Affiliation(s)
- Melissa K Accordino
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA
| | - Jason D Wright
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,c Department of Obstetrics and Gynecology, College of Physicians and Surgeons , Columbia University , New York , NY , USA
| | - Sowmya Vasan
- d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Alfred I Neugut
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Grace C Hillyer
- b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
| | - Dawn L Hershman
- a Department of Medicine College of Physicians and Surgeons , Columbia University , New York , NY , USA.,b Herbert Irving Comprehensive Cancer Center, College of Physicians and Surgeons , Columbia University , New York , NY , USA.,d Department of Epidemiology, Mailman School of Public Health , Columbia University , New York , NY , USA
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Limat S, Demesmay K, Fagnoni P, Voillat L, Bernard Y, Deconinck E, Brion A, Arveux P, Cahn JY, Woronoff-Lemsi MC. Cost Effectiveness of Cardioprotective Strategies in Patients with Aggressive Non-Hodgkin's Lymphoma. Clin Drug Investig 2012; 25:719-29. [PMID: 17532718 DOI: 10.2165/00044011-200525110-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE The cardiotoxicity of anthracyclines remains a key problem in patients with aggressive non-Hodgkin's lymphoma (NHL). With regard to the actual long-term prognosis of aggressive NHL, the development of cardioprotective strategies is mandatory for these patients. A cost-effectiveness analysis was carried out to determine the potential economic profile of dexrazoxane or liposome-encapsulated doxorubicin in patients with aggressive NHL treated with a CHOP regimen (cyclophosphamide, doxorubicin, vincristine, prednisone) as first-line therapy. METHODS A decision-analysis model described clinical events and economic consequences for theoretical patients who were to receive eight consecutive cycles of a CHOP regimen containing 50 mg/m(2) of doxorubicin as first-line chemotherapy. The timeframe of the model was the patient's lifetime. The probabilities were related to the cumulative dose of doxorubicin and age. The study was carried out from the perspective of the French healthcare system. Patients entered the model at 'choose' node: no cardioprotection versus cardioprotection with dexrazoxane or liposome-encapsulated doxorubicin. The model was based on a retrospective epidemiological study and on published data. The clinical end-point was life expectancy. Direct medical costs related to the cardioprotection and the treatment of congestive heart failure were considered. Monetary values for French prices in the year 2002 were used. Several univariate sensitivity analyses were carried out with varying clinical and economic parameters. RESULTS Per 100 patients, the two cardioprotective strategies provided similar benefits that were estimated as 24.5 and 13.4 life-years in 60- and 40-year-old patients, respectively. The cost per life-year saved with dexrazoxane was estimated as euro6931 and euro15 599 in 60- and 40-year-old patients, respectively, and euro22 940 and euro44 982, respectively, with liposome-encapsulated doxorubicin. Several sensitivity analyses showed the robustness of the model. CONCLUSION The results suggest the potential clinical and economic usefulness of cardioprotective therapies in patients with aggressive NHL. Prospective studies are needed to confirm these findings.
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Affiliation(s)
- Samuel Limat
- Department of Pharmacy, Besançon University Hospital, Besançon, FranceINSERM EPI 106, Dijon, France
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Talaulikar D, Shadbolt B, Dahlstrom JE, McDonald A. Routine use of ancillary investigations in staging diffuse large B-cell lymphoma improves the International Prognostic Index (IPI). J Hematol Oncol 2009; 2:49. [PMID: 19930611 PMCID: PMC2786909 DOI: 10.1186/1756-8722-2-49] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Accepted: 11/22/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The International Prognostic Index (IPI) is used to determine prognosis in diffuse large B-cell lymphoma (DLBCL). One of the determinants of IPI is the stage of disease with bone marrow involvement being classified as stage IV. For the IPI, involvement on bone marrow is traditionally defined on the basis of histology with ancillary investigations used only in difficult cases to aid histological diagnosis. This study aimed to determine the effect of the routine use of flow cytometry, immunohistochemistry and molecular studies in bone marrow staging upon the IPI. RESULTS Bone marrow trephines of 156 histologically proven DLBCL cases at initial diagnosis were assessed on routine histology, and immunohistochemistry using two T-cell markers (CD45RO and CD3), two B-cell markers (CD20 and CD79a) and kappa and lambda light chains. Raw flow cytometry data on all samples were reanalysed and reinterpreted blindly. DNA extracted from archived paraffin-embedded trephine biopsy samples was used for immunoglobulin heavy chain and light chain gene rearrangement analysis. Using immunophenotyping (flow cytometry and immunohistochemistry), 30 (19.2%) cases were upstaged to stage IV. A further 8 (5.1%) cases were upstaged using molecular studies. A change in IPI was noted in 18 cases (11.5%) on immunophenotyping alone, and 22 (14.1%) cases on immunophenotyping and molecular testing. Comparison of two revised IPI models, 1) using immunophenotyping alone, and 2) using immunophenotyping with molecular studies, was performed with baseline IPI using a Cox regression model. It showed that the revised IPI model using immunophenotyping provides the best differentiation between the IPI categories. CONCLUSION Improved bone marrow staging using flow cytometry and immunohistochemistry improves the predictive value of the IPI in patients with DLBCL and should be performed routinely in all cases.
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Affiliation(s)
- Dipti Talaulikar
- Department of Haematology, The Canberra Hospital, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
- Australian National University Medical School, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
| | - Bruce Shadbolt
- Australian National University Medical School, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
- Department of Epidemiology, The Canberra Hospital, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
| | - Jane E Dahlstrom
- Australian National University Medical School, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
- Department of Anatomical Pathology, The Canberra Hospital, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
| | - Anne McDonald
- National Capital Private Hospital, Yamba Drive, Garran, Canberra, ACT, 2605, Australia
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Talaulikar D, Dahlstrom JE, Shadbolt B, McNiven M, Broomfield A, Pidcock M. Occult bone marrow involvement in patients with diffuse large B-cell lymphoma: results of a pilot study. Pathology 2007; 39:580-5. [DOI: 10.1080/00313020701684417] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Leu L, Solimando DA, Waddell JA. Etoposide, Doxorubicin, Vincristine, Cyclophosphamide, Prednisone (EPOCH) for Treatment of Lymphomas. Hosp Pharm 2007. [DOI: 10.1310/hpj4211-1006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The increasing complexity of cancer chemotherapy now requires that pharmacists be familiar with these highly toxic agents. This column will review various issues related to preparation, dispensing, and administration of cancer chemotherapy, and review various agents, both commercially available and investigational, used to treat malignant diseases. The views expressed in this article are those of the author(s) and do not reflect the official policy of the Department of Army, Department of Defense, or US Government.
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Affiliation(s)
- Lily Leu
- Inova Fairfax Hospital, Fairfax, VA. Virginia Commonwealth University-Medical College of Virginia Campus School of Pharmacy, Richmond, VA
| | - Dominic A. Solimando
- Oncology Pharmacy Services, Inc., 4201 Wilson Blvd #110-545, Arlington, VA 22203
| | - J. Aubrey Waddell
- University of Tennessee College of Pharmacy, Pharmacy Department, Blount Memorial Hospital, 907 E. Lamar Alexander Parkway, Maryville, TN 37804
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Ohsawa M, Ikura Y, Fukushima H, Shirai N, Sugama Y, Suekane T, Hirayama M, Hino M, Ueda M. Immunohistochemical expression of multidrug resistance proteins as a predictor of poor response to chemotherapy and prognosis in patients with nodal diffuse large B-cell lymphoma. Oncology 2005; 68:422-31. [PMID: 16020972 DOI: 10.1159/000086984] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2004] [Accepted: 12/12/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIMS The aim of this study was to determine whether expression of P-glycoprotein (P-gp), multidrug-resistance-related protein 1 (MRP1), and lung resistance protein (LRP) was related to the response to induction chemotherapy and prognosis in untreated diffuse large B-cell lymphoma (DLBCL). METHODS We assessed immunohistochemical expression of P-gp, MRP1 and LRP, using formalin-fixed and paraffin-embedded specimens of lymph node in 41 patients with DLBCL. Association between expression of these three proteins and their impact on clinical outcome and prognosis was statistically evaluated. RESULTS P-gp was positive in 37% of subjects, MRP1 in 63%, and LRP in 68%. The complete remission rates achieved in the group expressing these multidrug resistance (MDR) proteins was significantly lower than in the group not expressing them (20 versus 58%; p = 0.025 in P-gp, 23 versus 80%; p < 0.001 in MRP1 and 32 versus 69%, p = 0.043 in LRP, respectively). Furthermore, the patients expressing LRP had a shorter overall survival rate than those that did not (median of 26 months versus median not reached; p = 0.013). CONCLUSIONS These findings suggest that the three MDR proteins are important predictive factors for the clinical outcome and prognosis in patients with DLBCL.
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MESH Headings
- ATP Binding Cassette Transporter, Subfamily B, Member 1/metabolism
- Adult
- Aged
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Drug Resistance, Multiple
- Drug Resistance, Neoplasm
- Female
- Humans
- Lymph Nodes/pathology
- Lymphoma, B-Cell/drug therapy
- Lymphoma, B-Cell/metabolism
- Lymphoma, Large B-Cell, Diffuse/drug therapy
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Male
- Middle Aged
- Neoplasm Proteins/metabolism
- Predictive Value of Tests
- Prognosis
- Survival Rate
- Treatment Outcome
- Vault Ribonucleoprotein Particles/metabolism
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Affiliation(s)
- Masahiko Ohsawa
- Department of Pathology, Osaka City University, Graduate School of Medicine, Osaka, Japan.
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Abstract
For nearly 20 years CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) has been the gold standard of therapy for aggressive non-Hodgkin's lymphomas (NHLs), curing = 30% of patients with diffuse large-cell NHL. A variety of strategies are being tested to identify regimens that might increase the disease-free survival rate for aggressive NHLs. One approach has been to intensify chemotherapy either by administering higher doses or by using shorter chemotherapy cycles. There are data suggesting that elderly patients benefit from CHOP given in 14-day cycles with granulocyte colony-stimulating factor. Based on in vitro observations that continuous exposure to cytotoxic agents can override multidrug-resistance pumps, several groups have studied combination chemotherapy regimens that include continuous 2- or 3-day intravenous infusions of cytotoxic agents. These studies have had short follow-up but encouraging early disease-free survival rates. There also has been interest in integrating monoclonal antibodies such as rituximab into therapies for aggressive NHLs. One randomized trial found CHOP/rituximab to be superior to CHOP alone in elderly patients with aggressive NHLs. With high-dose chemotherapy and stem cell support established as a salvage regimen for aggressive NHLs, many trials have evaluated the value of upfront high-dose therapy, especially in poor-prognosis patients. Other approaches to managing aggressive NHLs, which appear promising but are under investigation, are allogeneic transplants and lymphoma vaccines. An advance in the study of lymphoid malignancies is the development of a lymphoma classification system, the World Health Organization Classification of Lymphoid Malignancies, which recognizes the distinct molecular, morphologic, and genetic characteristics of differential lymphoma subtypes. It is anticipated that accurate and specific differential diagnosis, coupled with recognition of important clinical prognostic factors, will provide useful background for selecting and designing rational (and perhaps individualized) therapies for patients with aggressive NHLs.
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Affiliation(s)
- James O Armitage
- Department of Internal Medicine, University of Nebraska Medical Center, Omaha 68198-3332, USA.
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Wilson WH, Grossbard ML, Pittaluga S, Cole D, Pearson D, Drbohlav N, Steinberg SM, Little RF, Janik J, Gutierrez M, Raffeld M, Staudt L, Cheson BD, Longo DL, Harris N, Jaffe ES, Chabner BA, Wittes R, Balis F. Dose-adjusted EPOCH chemotherapy for untreated large B-cell lymphomas: a pharmacodynamic approach with high efficacy. Blood 2002; 99:2685-93. [PMID: 11929754 DOI: 10.1182/blood.v99.8.2685] [Citation(s) in RCA: 233] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
We hypothesized that incremental improvements in the cyclophosphamide-doxorubicin-vincristine-prednisone (CHOP) chemotherapy regimen through optimization of drug selection, schedule, and pharmacokinetics would improve outcome in patients with large B-cell lymphomas. A prospective multi-institutional study of administration of etoposide, vincristine, and doxorubicin for 96 hours with bolus doses of cyclophosphamide and oral prednisone (EPOCH therapy) was done in 50 patients with previously untreated large B-cell lymphomas. The doses of etoposide, doxorubicin, and cyclophosphamide were adjusted 20% each cycle to achieve a nadir absolute neutrophil count below 0.5 x 10(9)/L. The median age of the patients was 46 years (range, 20-88 years); 24% were older than 60 years; and 44% were at high-intermediate or high risk according to International Prognostic Index (IPI) criteria. There was a complete response in 92% of patients, and at the median follow-up time of 62 months, the progression-free survival (PFS) and overall survival (OS) rates were 70% and 73%, respectively. Neither IPI risk factors nor the index itself was associated with response, PFS, or OS. Doses were escalated in 58% of cycles, and toxicity levels were tolerable. Significant inverse correlations were observed between dose intensity and age for all adjusted agents, and drug clearance of doxorubicin and free etoposide was also inversely correlated with age (r = -0.54 and P(2) =.08 and r = -0.45 and P(2) =.034, respectively). Free-etoposide clearance increased significantly during successive cycles (P(2) =.015). Lymphomas with proliferation of at least 80% had somewhat lower progression and those expressing bcl-2 had significantly higher progression (P(2) =.04). Expression of bcl-2 may discriminate the recently described activated B-like from germinal-center B-like large-cell lymphomas and provide important pathobiologic and prognostic information. Dose-adjusted EPOCH may produce more cell kill than CHOP-based regimens. Dynamic dose adjustment may overcome inadequate drug concentrations, particularly in younger patients, and compensate for increased drug clearance over time.
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Affiliation(s)
- Wyndham H Wilson
- Center for Cancer Research, National Cancer Institute, Bethesda, MD 20892, USA
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Rutledge MR, Solimando DA, Waddell JA. Cyclophosphamide, Hydroxydaunomycin (Doxorubicin), Oncovin (Vincristine), and Prednisone (CHOP) Regimen for Advanced Non-Hodgkin's Lymphomas. Hosp Pharm 2002. [DOI: 10.1177/001857870203700102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column reviews various issues related to the preparation, dispensing, and administration of cancer chemotherapy, both commercially available and investigational.
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Affiliation(s)
- Matthew R. Rutledge
- Hematology-Oncology Pharmacy Section, Madigan Army Medical Center, Tacoma, Washington. At the time this paper was written, Major Rutledge was an oncology pharmacy resident at Walter Reed Army Medical Center, Washington, DC
| | - Dominic A. Solimando
- Hematology-Oncology Pharmacy Section, Madigan Army Medical Center, Tacoma, Washington. At the time this paper was written, Major Rutledge was an oncology pharmacy resident at Walter Reed Army Medical Center, Washington, DC
| | - J. Aubrey Waddell
- Hematology-Oncology Pharmacy Section, Madigan Army Medical Center, Tacoma, Washington. At the time this paper was written, Major Rutledge was an oncology pharmacy resident at Walter Reed Army Medical Center, Washington, DC
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Giles FJ, Shan J, Advani SH, Akan H, Aydogdu I, Aziz Z, Azim HA, Bapsy PP, Buyukkececi F, Chaimongkol B, Chen PM, Cheong SK, Ferhanoglu B, Hamza R, Khalid HM, Intragumtornchai T, Kim SW, Kim SY, Koc H, Kumar L, Kumar R, Lei KI, Lekhakula A, Muthalib A, Patel M, Poovalingam VP, Prayoonwiwat W, Rana F, Reksodiputro AH, Ruff P, Sagar TG, Schwarer AP, Song HS, Suh CW, Suharti C, Supindiman I, Tee GY, Thamprasit T, Villalon AH, Wickham NR, Wong JE, Yalcin A, Jootar S. A prospective randomized study of Chop versus Chop plus alpha-2B interferon in patients with intermediate and high grade non-Hodgkin's lymphoma: the International Oncology Study Group NHL1 Study . Leuk Lymphoma 2000; 40:95-103. [PMID: 11426633 DOI: 10.3109/10428190009054885] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
UNLABELLED The addition of a brief alpha interferon regimen to each CHOP induction cycle, plus one year of alpha interferon thrice weekly maintenance therapy, has no early effect on response rates or survival in patients with Intermediate or High grade cell NHL. BACKGROUND The CHOP (Cyclophosphamide, Adriamycin. Vincristine, Prednisone) regimen is the most widely used first-line therapy for patients with Intermediate or High Grade (IG/HG) non-Hodgkin's lymphoma (NHL). Alpha 2b interferon (INF) enhances response rates and improves survival in low-grade NHL. The International Oncology Study Group (IOSG) conducted a prospective randomized study comparing CHOP alone or combined with INF in patients with IG/HG-NHL. The primary study aim was to compare the objective response rates in these patient cohorts. PATIENTS AND METHODS Patients with a confirmed diagnosis of measurable NHL of International Working Formulation (IWF) groups D to H histology were randomized to receive CHOP alone or CHOP with 5Mu INF s.c. for 5 days on days 22 to 26 of each 28 day cycle with INF 5 million units (Mu) given three times per week subcutaneously for 52 weeks in those patients who responded to CHOP plus INF. RESULTS The overall response rates were equivalent in both groups: CHOP alone (214 patients) 81% (complete 55%, partial 26%); CHOP plus INF (221 patients) 80% (complete 54%, partial 26%). At 36 months, the actuarial survival rate was equivalent in both groups. CONCLUSIONS There is no apparent early advantage in terms of response or survival conferred by adding the study INF regimen to CHOP therapy for patients with IG/HG-NHL.
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Affiliation(s)
- F J Giles
- International Oncology Study Group, Houston, Texas, USA.
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Abstract
Preliminary results of new therapies in the areas of cytotoxic agents and immunotherapy for advanced indolent lymphomas have been encouraging. Long-term follow-up on high-dose therapy suggests a potential role for this modality in this group of lymphomas. In aggressive lymphomas, CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) continues to hold ground as first-line therapy when compared against other regimens. Several studies reinforce past findings that patients with chemosensitive relapse are better candidates for high-dose therapy. In relapsed or refractory disease, selected compounds appear to have activity as single agents and others have shown activity in combination therapy. Despite high treatment-related mortality rates, allogeneic transplantation in relapsed aggressive lymphoma warrants further investigation. Last, as patients are surviving longer, complications of therapy are having to be addressed.
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Affiliation(s)
- R J Hauke
- Section of Hematology/Oncology, University of Nebraska Medical Center, Omaha 68198-7680, USA.
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