OS03.6.A Rituximab in primary CNS lymphoma - long term follow-up of the phase III HOVON 105/ALLG NHL 24 Study

Background

The efficacy of rituximab in Primary CNS Lymphoma (PCNSL) is still under debate. We performed an international randomized phase III study to investigate the efficacy of rituximab when added to methotrexate, BCNU, teniposide and prednisolone (MBVP) in PCNSL. The primary endpoint, event-free survival (EFS) at one year, was similar in both treatment groups and was previously reported (Bromberg et al, Lancet Oncology 2019; 20: 216-228). Here we present long-term follow up results after a median follow-up of 82 months.

Material and Methods

between August 2010 and May 2016 200 newly-diagnosed, non-immunocompromised patients with PCNSL aged 18-70 years and WHO performance status 0-3 were randomized between treatment with MBVP chemotherapy with (arm B) or without (arm A) rituximab. The rituximab was given weekly in the first MBVP cycle, fortnightly in the second (in total 6 rituximab administrations). Responsive patients received consolidation with high-dose cytarabine, and patients aged ≤ 60 were subsequently treated with low-dose WBRT if in CR/CRu; in case of PR with an additional boost on the tumor. Patients > 60 were not irradiated. All patients gave written informed consent.

Results

The modified intention-to-treat (m-ITT) population consisted of 199 eligible patients, 55% were men. The median age was 61 yrs (range 26-70), the median WHO performance status 1 (range 0-3). The primary endpoint EFS at one year was 49% (95% CI 39-58)(MBVP) vs 55% (95% CI 44-64) (R-MBVP). The EFS at 5 years was 25% (17-34) vs 36% (27-46) respectively, hazard ratio (HR) 0.85, 95% CI 0.61-1.18, p=0.33 (adjusted for age and WHO performance status). The progression-free survival (PFS) at one and 5 years were 58% (47-67) and 29% (21-39) (MBVP) and 65% (54-73) and 43% (33-53) (R-MBVP) ) (HR 0.73, 95% CI 0.52-1.02, p=0.07). 80 patients were still alive. Overall survival (OS) at 5 years for MBVP and R-MBVP was 49% (39-59) and 53% (43-63) respectively. A total of 111 patients had progression or relapse, 63 after MBVP and 48 after R-MBVP. 79% of these patients received further treatment. The median OS after progression/relapse was 9.7 months (5.9-19.9) in the MBVP arm, and 6.1 months (2.4-13.1) in the R-MBVP arm (HR 1.25, 95% CI 0.83-1.87, p=0.29). 119 patients died, 64 in the MBVP arm and 55 in the R-MBVP arm. Causes of death were PCNSL in 69% of the patients (both arms), complication of treatment (6% vs 5%), secondary malignancy (5% vs 2%) and other or unknown causes (20% vs 24%). Age was the strongest prognostic factor for EFS, PFS and OS in multivariate analysis.

Conclusion

in the modified-ITT population we found no statistically significant benefit of the addition of rituximab to MBVP on EFS, PFS and OS in patients with PCNSL, even after a long follow-up of median 82 months. Therefore, the results of this study do not support the use of rituximab with MBVP in the treatment of primary CNS lymphoma.

Health-related quality of life after chemotherapy with or without rituximab in primary central nervous system lymphoma patients: results from a randomised phase III study

BACKGROUND

The impact of rituximab on health-related quality of life (HRQoL) in primary central nervous system lymphoma patients is not well known. We determined the impact of rituximab added to standard high-dose methotrexate-based treatment on HRQoL in patients in a large randomised trial.

PATIENTS AND METHODS

Patients from a large phase III trial (HOVON 105/ALLG NHL 24), randomly assigned to receive standard chemotherapy with or without rituximab and followed by 30 Gy whole brain radiotherapy (WBRT) in patients ≤60 years, completed the EORTC QLQ-C30 and QLQ-BN20 questionnaires before and during treatment, and up to 24 months of follow-up or progression. Differences between treatment arms over time in global health status, role functioning, social functioning, fatigue, and motor dysfunction were assessed. Differences ≥10 points were deemed clinically relevant. The effect of WBRT on HRQoL was analysed in irradiated patients.

RESULTS

A total of 160/175 patients eligible for the HRQoL study completed at least one questionnaire and were included. Over time, scores improved statistically significantly and were clinically relevant in both arms. Between arms, there were no differences on any scale (range: -3.8 to +4.0). Scores on all scales were improved to a clinically relevant extent at 12 and 24 months compared with baseline in both arms, except for fatigue and motor dysfunction at 12 months (-7.4 and -8.8, respectively). In irradiated patients (n = 59), scores in all preselected scales, except motor dysfunction, remained stable up to 24 months compared with shortly after WBRT, overall mean difference ranging between 0.02 and 4.570.

CONCLUSION

Compared with baseline, treatment resulted in improved HRQoL scores. The addition of rituximab to standard chemotherapy did not impact HRQoL over time. WBRT did not result in deterioration of HRQoL in the first 2 years.

Epstein-Barr virus infection or malignant lymphoma - what you see is not what you get

Infectious mononucleosis may mimic lymphoma, both clinically and histopathologically. We present a patient with neurological symptoms and lymphadenopathy, initially diagnosed as Epstein-Barr virus (EBV)-positive angioimmunoblastic T-cell lymphoma (AITL) with cerebrospinal fluid (CSF) localisation based on lymph node pathology and a 30-fold higher EBV load in the CSF compared with serum. However, the patient fully recovered spontaneously and EBV became negative in both CSF and serum, suggestive of a dramatic presentation of EBV meningoencephalitis.

OS10.3 Primary therapy and survival in over 70-year-old patients with primary central nervous system lymphoma: a contemporary, nationwide, population-based study in the Netherlands

BACKGROUND

Elderly patients with primary central nervous system lymphoma (PCNSL) have a poor prognosis. In this contemporary, nationwide, population-based study, we assessed the contribution of primary therapy on overall survival (OS) among elderly PCNSL patients in the Netherlands.

METHODS

All patients aged ≥ 70 years with cytologically and/or histologically proven PCNSL diagnosed between 2014–2016 were selected from the nationwide Netherlands Cancer Registry. Univariable analysis of OS was performed with the log-rank test. Multivariable Cox regression was applied to assess factors associated with OS, with adjustment for age (71–74, 75–79 and ≥80 years), sex, prior malignancy, primary therapy (no therapy, radiotherapy [RT] only, chemotherapy [CT]), and rituximab treatment.

RESULTS

Overall, 109 patients were registered; 39%, 39%, and 22% were aged 71–74, 75–79 and ≥80 years, respectively. Most patients received CT (45%), followed by no therapy (33%) and RT only (22%). With increasing age, the application of CT decreased (60%, 43%, and 24%), and RT only increased (10%, 26%, 26%) in the three age groups. CT consisted of methotrexate (MTX)-based or MTX only regimens in 98%. In patients treated with CT, Rituximab was added in 31%. During follow-up, 89 patients (82%) died. Median OS was 5.3 months (95% confidence interval [CI], 3.3–7.8), no difference was observed in median OS across the three age groups (6.8, 4.4, and 4.6 months, respectively; P=0.348). However, in the groups no therapy, RT only, and CT, median OS (95% CI) was 1.3 (1.0–2.0), 6.5 (4.4–12.5), and 20.3 (8.6–41.4) months (P<0.001), respectively. Moreover, 2 year OS (95%CI) was 49% (34–62) in patients treated with chemotherapy compared with 17% (5–34) in patients treated with RT. Median OS (95% CI) was 20.3 (8.6–41.4) in recipients of MTX-based regimens and 5.0 (2.4-not reached) months in recipients MTX only (P=0.185). In multivariable analysis, treatment with CT or RT was the only factor associated with OS: age group and the addition of Rituximab were not associated with OS.

CONCLUSION

In this contemporary population-based study, OS remained poor among patients with PCNSL aged over 70 years, irrespective of age group. Clinical condition likely influenced therapy choices but in those judged fit enough to receive CT, almost 50% survived 2 years. Therefore, future prospective intervention studies are warranted to assess which group of elderly patients benefit from CT or less intensive approaches.

Treatment of older patients with mantle-cell lymphoma

BACKGROUND

The long-term prognosis for older patients with mantle-cell lymphoma is poor. Chemoimmunotherapy results in low rates of complete remission, and most patients have a relapse. We investigated whether a fludarabine-containing induction regimen improved the complete-remission rate and whether maintenance therapy with rituximab prolonged remission.

METHODS

We randomly assigned patients 60 years of age or older with mantle-cell lymphoma, stage II to IV, who were not eligible for high-dose therapy to six cycles of rituximab, fludarabine, and cyclophosphamide (R-FC) every 28 days or to eight cycles of rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) every 21 days. Patients who had a response underwent a second randomization to maintenance therapy with rituximab or interferon alfa, each given until progression.

RESULTS

Of the 560 patients enrolled, 532 were included in the intention-to-treat analysis for response, and 485 in the primary analysis for response. The median age was 70 years. Although complete-remission rates were similar with R-FC and R-CHOP (40% and 34%, respectively; P=0.10), progressive disease was more frequent with R-FC (14%, vs. 5% with R-CHOP). Overall survival was significantly shorter with R-FC than with R-CHOP (4-year survival rate, 47% vs. 62%; P=0.005), and more patients in the R-FC group died during the first remission (10% vs. 4%). Hematologic toxic effects occurred more frequently in the R-FC group than in the R-CHOP group, but the frequency of grade 3 or 4 infections was balanced (17% and 14%, respectively). In 274 of the 316 patients who were randomly assigned to maintenance therapy, rituximab reduced the risk of progression or death by 45% (in remission after 4 years, 58%, vs. 29% with interferon alfa; hazard ratio for progression or death, 0.55; 95% confidence interval, 0.36 to 0.87; P=0.01). Among patients who had a response to R-CHOP, maintenance therapy with rituximab significantly improved overall survival (4-year survival rate, 87%, vs. 63% with interferon alfa; P=0.005).

CONCLUSIONS

R-CHOP induction followed by maintenance therapy with rituximab is effective for older patients with mantle-cell lymphoma. (Funded by the European Commission and others; ClinicalTrials.gov number, NCT00209209.).

Repetitive Dobutamine Stress Echocardiography for the Prediction of Anthracycline Cardiotoxicity

AIMS

To evaluate whether repetitive assessment of systolic and diastolic cardiac function by dobutamine stress echocardiography (DSE) can predict anthracycline cardiotoxicity.

METHODS AND RESULTS

Thirty-one patients (age, 57+/-13 years, 22 male) were studied before chemotherapy, with follow-ups during, at the end, and 6 months after chemotherapy. Left ventricular (LV) function was assessed by two-dimensional (2D) echocardiographic wall motion score index (WMSI) and by Doppler echocardiography of mitral valve inflow at rest and during DSE. Radionuclide ventriculography was used as an independent reference for ejection fraction (EF). A reduction of EF >/=5% occurred in 17 patients (group A) at the last follow-up. Patients without decreased EF comprised group B. Early/late diastolic velocity of mitral inflow (E/A ratio) at rest was lower in group A (0.91+/-0.2 vs 1.28+/-0.3, P<0.001), and it was an independent predictor of cardiotoxicity (adjusted for baseline patient characteristics and parameters of systolic and diastolic function). At follow-up, WMSI at rest paralleled radionuclide EF. Contractile reserve at low-dose DSE was preserved in group A.

CONCLUSIONS

WMSI measured by 2D echocardiography parallels radionuclide EF at follow-up. Assessment of contractile reserve has no incremental value for the early detection of cardiotoxicity. A baseline abnormal E/A ratio is an independent predictor of anthracycline cardiotoxicity.

CHOP compared with CHOP plus granulocyte colony-stimulating factor in elderly patients with aggressive non-Hodgkin's lymphoma

PURPOSE

To investigate whether the relative dose-intensity of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy could be improved by prophylactic administration of granulocyte colony-stimulating factor (G-CSF) in elderly patients with aggressive non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Patients aged 65 to 90 years (median, 72 years) with stage II to IV aggressive NHL were randomly assigned to receive standard CHOP every 3 weeks or CHOP plus G-CSF every 3 weeks on days 2 to 11 of each cycle.

RESULTS

In 389 eligible patients, the relative dose intensities (RDIs) of cyclophosphamide (median, 96.3% v 93.9%; P =.01) and doxorubicin (median, 95.4% v 93.3%; P =.04) were higher in patients treated with CHOP plus G-CSF. The complete response rates were 55% and 52% for CHOP and CHOP plus G-CSF, respectively (P =.63). The actuarial overall survival at 5 years was 22% with CHOP alone, compared with 24% with CHOP plus G-CSF (P =.76), with a median follow-up of 33 months. Patients treated with CHOP plus G-CSF had an identical incidence of infections, with World Health Organization grade 3 to 4 (34 of 1,191 cycles v 36 of 1,195 cycles). Only the cumulative days with antibiotics were fewer with CHOP plus G-CSF (median, 0 v 6 days; P =.006) than with CHOP alone. The number of hospital admissions and the number of days in hospital were not different.

CONCLUSION

In elderly patients, G-CSF improved the RDI of CHOP, but this did not lead to a higher complete response rate or better overall survival. G-CSF did not prevent serious infections.

[Lamivudine for the prevention of chronic hepatitis B exacerbations during chemotherapy for non-Hodgkin's lymphoma]

Two male patients, aged 54 years and 17 years respectively, were treated with chemotherapy for non-Hodgkin lymphoma. Both patients were chronic hepatitis-B-virus (HBV) carriers prior to the chemotherapy. One patients died as a result of the virus exacerbating during chemotherapy; the other patient received the antiviral drug lamivudine prior to the chemotherapy and finished the cures without any problems. Exacerbations of HBV replication followed by an increase in serum transaminase activity levels ('flares') occur naturally during the course of the viral infection. However, there is an elevated risk when a patient receives high doses of corticosteroids for a short period, as is the case in chemotherapy for non-Hodgkin's lymphoma. Lamivudine is registered for the treatment of chronic hepatitis B and can be used as a prophylactic prior to chemotherapy or to treat an exacerbation of the hepatitis. It is advisable to systematically test all patients with lymphoma for the presence of the HBsAg. If this is positive, prophylactic administration of lamivudine 100 mg once daily is strongly recommended if chemotherapy is indicated.

Etoposide, mitoxantrone and prednisone: a salvage regimen with low toxicity for refractory or relapsed non-Hodgkin's lymphoma

BACKGROUND AND OBJECTIVES

Relapsed non-Hodgkin's lymphoma (NHL) is preferably treated with high-dose therapy and stem cell support. However, not all patients qualify for intensive chemotherapy. We evaluated the efficacy and toxicity of a new salvage chemotherapy regimen designed for patients with relapsed or refractory NHL who are not appropriate candidates for high-dose therapy (HDT).

DESIGN AND METHODS

Seventy-nine patients received a regimen consisting of etoposide (350 mg/m(2) i.v. day 1), mitoxantrone (14 mg/m(2) i.v. day 1) and prednisone (80 mg/m(2) p.o. days 1-5) (EMP). The majority had aggressive NHL. Twenty-one patients were elderly, i.e. >60 years of age;

RESULTS

The overall response rate in the 79 patients was 38% as compared to 67% in the elderly. The progression-free survival was 54% and 30% at 12 months and 24 months, respectively. The toxicity of the regimen was relatively low. No toxic deaths have occurred. In 28 of 231 cycles (12%) a CTC-grade 2-4 infection was encountered. Twenty-one hospital admissions were necessary because of infection or fever. Other toxicity was rare. Toxicity was not greater in the elderly patients. WHO performance status 2-4 and elevated serum lactate dehydrogenase (LDH) concentrationv were adverse prognostic factors for response as well as for overall survival. Another adverse prognostic factor for response was age <60 years.

INTERPRETATION AND CONCLUSIONS

EMP is a new salvage regimen with a relatively low toxicity. It should be considered for patients with relapsed or refractory NHL who are not candidates for standard reinduction therapy and stem cell transplantation.

[Diagnosis and treatment of non-Hodgkin lymphoma in elderly patients]

Non-Hodgkin's lymphoma (NHL) is relatively frequent among elderly patients: more than half of the diagnoses in the Netherlands concern patients aged 65 years or above. The treatment depends on histological type, clinical stage and prognostic group. Increasingly, a treatment decision is made after determination of the prognostic group on the basis of the expected response and survival. In elderly patients intensive treatment frequently has more toxic effects. The expected gain in survival has to be weighed against more toxicity and loss of quality of life during and after the therapy. This is notably important for patients with low grade NHL, which requires only intermittent treatment. It is possible to cure some elderly patients with NHL of intermediate or high grade malignancy provided they are adequately treated with combination chemotherapy. Patients with low grade NHL or poor clinical condition may benefit temporarily from palliative treatment, in the planning of which quality of life has to be taken into account.

Eosinophilia and granulocytic dysplasia terminating in acute myeloid leukaemia after 24 years

Eosinophilia of variable duration, and subsequent progression to granulocytic sarcoma and acute myeloid leukaemia, has been infrequently reported in the literature. We report a patient with eosinophilia and normal cytogenetics who, after 24 years, showed transformation to a granulocytic sarcoma of the brain. Haematological counts were normal but the marrow revealed the cytogenetic abnormality trisomy 8 in 25% of mitoses. Subsequently an AML-M2 developed, showing a complex karyotype including the trisomy 8 in all metaphases. FISH analysis combined with cytological examination identified the trisomy 8 in blasts, eosinophils and dysplastic granulocytes only. Thus progressive leukaemic transformation selectively involved the myeloid compartment.