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Grover NS, Hucks G, Riches ML, Ivanova A, Moore DT, Shea TC, Seegars MB, Armistead PM, Kasow KA, Beaven AW, Dittus C, Coghill JM, Jamieson KJ, Vincent BG, Wood WA, Cheng C, Morrison JK, West J, Cavallo T, Dotti G, Serody JS, Savoldo B. Anti-CD30 CAR T cells as consolidation after autologous haematopoietic stem-cell transplantation in patients with high-risk CD30 + lymphoma: a phase 1 study. Lancet Haematol 2024; 11:e358-e367. [PMID: 38555923 DOI: 10.1016/s2352-3026(24)00064-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 02/14/2024] [Accepted: 02/16/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Chimeric antigen receptor (CAR) T cells targeting CD30 are safe and have promising activity when preceded by lymphodepleting chemotherapy. We aimed to determine the safety of anti-CD30 CAR T cells as consolidation after autologous haematopoietic stem-cell transplantation (HSCT) in patients with CD30+ lymphoma at high risk of relapse. METHODS This phase 1 dose-escalation study was performed at two sites in the USA. Patients aged 3 years and older, with classical Hodgkin lymphoma or non-Hodgkin lymphoma with CD30+ disease documented by immunohistochemistry, and a Karnofsky performance score of more than 60% planned for autologous HSCT were eligible if they were considered high risk for relapse as defined by primary refractory disease or relapse within 12 months of initial therapy or extranodal involvement at the start of pre-transplantation salvage therapy. Patients received a single infusion of CAR T cells (2 × 107 CAR T cells per m2, 1 × 108 CAR T cells per m2, or 2 × 108 CAR T cells per m2) as consolidation after trilineage haematopoietic engraftment (defined as absolute neutrophil count ≥500 cells per μL for 3 days, platelet count ≥25 × 109 platelets per L without transfusion for 5 days, and haemoglobin ≥8 g/dL without transfusion for 5 days) following carmustine, etoposide, cytarabine, and melphalan (BEAM) and HSCT. The primary endpoint was the determination of the maximum tolerated dose, which was based on the rate of dose-limiting toxicity in patients who received CAR T-cell infusion. This study is registered with ClinicalTrials.gov (NCT02663297) and enrolment is complete. FINDINGS Between June 7, 2016, and Nov 30, 2020, 21 patients were enrolled and 18 patients (11 with Hodgkin lymphoma, six with T-cell lymphoma, one with grey zone lymphoma) were infused with anti-CD30 CAR T cells at a median of 22 days (range 16-44) after autologous HSCT. There were no dose-limiting toxicities observed, so the highest dose tested, 2 × 108 CAR T cells per m2, was determined to be the maximum tolerated dose. One patient had grade 1 cytokine release syndrome. The most common grade 3-4 adverse events were lymphopenia (two [11%] of 18) and leukopenia (two [11%] of 18). There were no treatment-related deaths. Two patients developed secondary malignancies approximately 2 years and 2·5 years following treatment (one stage 4 non-small cell lung cancer and one testicular cancer), but these were judged unrelated to treatment. At a median follow-up of 48·2 months (IQR 27·5-60·7) post-infusion, the median progression-free survival for all treated patients (n=18) was 32·3 months (95% CI 4·6 months to not estimable) and the median progression-free survival for treated patients with Hodgkin lymphoma (n=11) has not been reached. The median overall survival for all treated patients has not been reached. INTERPRETATION Anti-CD30 CAR T-cell infusion as consolidation after BEAM and autologous HSCT is safe, with low rates of toxicity and encouraging preliminary activity in patients with Hodgkin lymphoma at high risk of relapse, highlighting the need for larger studies to confirm these findings. FUNDING National Heart Lung and Blood Institute, University Cancer Research Fund at the Lineberger Comprehensive Cancer Center.
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Affiliation(s)
- Natalie S Grover
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - George Hucks
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Pediatrics, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Marcie L Riches
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Anastasia Ivanova
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Biostatistics, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Dominic T Moore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Biostatistics, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Thomas C Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Mary Beth Seegars
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, NC, USA
| | - Paul M Armistead
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Kimberly A Kasow
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Pediatrics, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Anne W Beaven
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Christopher Dittus
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - James M Coghill
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Katarzyna J Jamieson
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Benjamin G Vincent
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Catherine Cheng
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Julia Kaitlin Morrison
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - John West
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Tammy Cavallo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Gianpietro Dotti
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Jonathan S Serody
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Program in Computational Medicine, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA
| | - Barbara Savoldo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA; Department of Pediatrics, University of North Carolina at Chapel Hill, Chapell Hill, NC, USA.
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2
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Tschernia NP, Heiling H, Deal AM, Cheng C, Babinec C, Gonzalez M, Morrison JK, Dittus C, Dotti G, Beaven AW, Serody JS, Wood WA, Savoldo B, Grover NS. Patient-reported outcomes in CD30-directed CAR-T cells against relapsed/refractory CD30+ lymphomas. J Immunother Cancer 2023; 11:e006959. [PMID: 37527906 PMCID: PMC10394544 DOI: 10.1136/jitc-2023-006959] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/03/2023] Open
Abstract
Chimeric antigen receptor (CAR)-T cells targeting CD30 have demonstrated high response rates with durable remissions observed in a subset of patients with relapsed/refractory CD30+ hematologic malignancies, particularly classical Hodgkin lymphoma. This therapy has low rates of toxicity including cytokine release syndrome with no neurotoxicity observed in our phase 2 study. We collected patient-reported outcomes (PROs) on patients treated with CD30 directed CAR-T cells to evaluate the impact of this therapy on their symptom experience. We collected PROs including PROMIS (Patient-Reported Outcomes Measurement Information System) Global Health and Physical Function questionnaires and selected symptom questions from the NCI PRO-CTCAE in patients enrolled on our clinical trial of CD30-directed CAR-T cells at procurement, at time of CAR-T cell infusion, and at various time points post treatment. We compared PROMIS scores and overall symptom burden between pre-procurement, time of infusion, and at 4 weeks post infusion. At least one PRO measurement during the study period was found in 23 out of the 28 enrolled patients. Patient overall symptom burden, global health and mental health, and physical function were at or above baseline levels at 4 weeks post CAR-T cell infusion. In addition, PROMIS scores for patients who participated in the clinical trial were similar to the average healthy population. CD30 CAR-T cell therapy has a favorable toxicity profile with patient physical function and symptom burden recovering to at least their baseline pretreatment health by 1 month post infusion. Trial registration number: NCT02690545.
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Affiliation(s)
- Nicholas P Tschernia
- Medical Oncology Service, National Institutes of Health, Bethesda, Maryland, USA
| | - Hillary Heiling
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Allison M Deal
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Catherine Cheng
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Caroline Babinec
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Megan Gonzalez
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - J Kaitlin Morrison
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Christopher Dittus
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Gianpietro Dotti
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Microbiology and Immunology, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Anne W Beaven
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Jonathan S Serody
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - William A Wood
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Barbara Savoldo
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Pediatrics, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
| | - Natalie S Grover
- Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Medicine, The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, USA
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3
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Alderuccio JP, Arcaini L, Watkins MP, Beaven AW, Shouse G, Epperla N, Spina M, Stefanovic A, Sandoval-Sus J, Torka P, Alpert AB, Olszewski AJ, Kim SH, Hess B, Gaballa S, Ayyappan S, Castillo JJ, Argnani L, Voorhees TJ, Saba R, Chowdhury SM, Vargas F, Reis IM, Kwon D, Alexander JS, Zhao W, Edwards D, Martin P, Cencini E, Kamdar M, Link BK, Logothetis CN, Herrera AF, Friedberg JW, Kahl BS, Luminari S, Zinzani PL, Lossos IS. An international analysis evaluating frontline bendamustine with rituximab in extranodal marginal zone lymphoma. Blood Adv 2022; 6:2035-2044. [PMID: 35196377 PMCID: PMC9006265 DOI: 10.1182/bloodadvances.2021006844] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/13/2022] [Indexed: 11/20/2022] Open
Abstract
Extranodal marginal zone lymphoma (EMZL) is a heterogeneous non-Hodgkin lymphoma. No consensus exists regarding the standard-of-care in patients with advanced-stage disease. Current recommendations are largely adapted from follicular lymphoma, for which bendamustine with rituximab (BR) is an established approach. We analyzed the safety and efficacy of frontline BR in EMZL using a large international consortium. We included 237 patients with a median age of 63 years (range, 21-85). Most patients presented with Eastern Cooperative Oncology Group (ECOG) performance status 0 to 1 (n = 228; 96.2%), stage III/IV (n = 179; 75.5%), and intermediate (49.8%) or high (33.3%) Mucosa Associated Lymphoid Tissue International Prognosis Index (MALT-IPI). Patients received a median of 6 (range, 1-8) cycles of BR, and 20.3% (n = 48) received rituximab maintenance. Thirteen percent experienced infectious complications during BR therapy; herpes zoster (4%) was the most common. Overall response rate was 93.2% with 81% complete responses. Estimated 5-year progression-free survival (PFS) and overall survival (OS) were 80.5% (95% CI, 73.1% to 86%) and 89.6% (95% CI, 83.1% to 93.6%), respectively. MALT-IPI failed to predict outcomes. In the multivariable model, the presence of B symptoms was associated with shorter PFS. Rituximab maintenance was associated with longer PFS (hazard ratio = 0.16; 95% CI, 0.04-0.71; P = .016) but did not impact OS. BR is a highly effective upfront regimen in EMZL, providing durable remissions and overcoming known adverse prognosis factors. This regimen is associated with occurrence of herpes zoster; thus, prophylactic treatment may be considered.
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Affiliation(s)
| | - Luca Arcaini
- Division of Hematology, Fondazione IRCCS San Mateo and Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | | | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | | | | | - Michele Spina
- Medical Oncology Division, Centro Riferimento Oncologico, Aviano, Italy
| | | | - Jose Sandoval-Sus
- Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | - Pallawi Torka
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Ash B. Alpert
- Center for Gerontology and Healthcare Research, Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, RI
| | | | - Seo-Hyun Kim
- Division of Hematology/Oncology, Rush University Medical Center, Chicago, IL
| | - Brian Hess
- Hollings Cancer Center at Medical University of South Carolina, Charleston, SC
| | | | - Sabarish Ayyappan
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | | | - Lisa Argnani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia “Seràgnoli”
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
| | - Timothy J. Voorhees
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC
| | - Raya Saba
- Washington University in St. Louis, St. Louis, MO
| | | | - Fernando Vargas
- Moffitt Cancer Center at Memorial Healthcare System, Pembroke Pines, FL
| | | | - Deukwoo Kwon
- Sylvester Comprehensive Cancer Center, Miami, FL
| | | | - Wei Zhao
- Sylvester Comprehensive Cancer Center, Miami, FL
| | - Dali Edwards
- Roswell Park Comprehensive Cancer Center, Buffalo, NY
| | - Peter Martin
- Division of Hematology/Oncology, Weill Cornell Medicine, New York, NY
| | - Emanuele Cencini
- Unit of Hematology, Azienda Ospedaliera Universitaria Senese and University of Siena, Siena SI, Italy
| | | | - Brian K. Link
- Division of Hematology, Oncology, and Blood & Marrow Transplantation, University of Iowa, Iowa City, IA
| | | | | | | | - Brad S. Kahl
- Washington University in St. Louis, St. Louis, MO
| | - Stefano Luminari
- CHIMOMO Department University of Modena and Reggio Emilia, Reggio Emilia, Italy; and
- Department of Hematology, Azienda USL IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Pier Luigi Zinzani
- IRCCS Azienda Ospedaliero-Universitaria di Bologna Istituto di Ematologia “Seràgnoli”
- Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale Università di Bologna, Bologna, Italy
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4
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Brem EA, Li H, Beaven AW, Caimi PF, Cerchietti L, Alizadeh A, Olin R, Henry NL, Dillon H, Little RF, Laubach C, LeBlanc M, Friedberg JW, Smith SM. SWOG 1918: A phase II/III randomized study of R-miniCHOP with or without oral azacitidine (CC-486) in participants age 75 years or older with newly diagnosed aggressive non-Hodgkin lymphomas - Aiming to improve therapy, outcomes, and validate a prospective frailty tool. J Geriatr Oncol 2022; 13:258-264. [PMID: 34686472 PMCID: PMC9879719 DOI: 10.1016/j.jgo.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 09/08/2021] [Accepted: 10/08/2021] [Indexed: 01/28/2023]
Abstract
Diffuse large B cell lymphoma (DLBCL) is an aggressive but potentially curable malignancy; however, cure is highly dependent on the ability to deliver intensive, anthracycline-based chemoimmunotherapy. Nearly one third of cases of DLBCL occur in patients over age 75 years, and advanced age is an important adverse feature in prognostic models. Despite this incidence in older patients, there is no clear accepted standard of care due to under-representation of this group in large randomized clinical trials. Furthermore, insufficient assessments of baseline frailty and prediction of toxicity hamper clinical decision-making. Here, we present an ongoing randomized study of R-miniCHOP chemoimmunotherapy with or without oral azacitidine (CC-486, Onureg) for patients age 75 and older with newly diagnosed DLBCL and associated aggressive lymphomas. The incorporation of an oral hypomethylating agent is based on increased tumor methylation as a biologic feature of older patients with DLBCL and a desire to minimize the injection burden for this population. This is the first randomized study in this population conducted in North America by the National Clinical Trials Network (NCTN) and will enroll up to 422 patients including 40 patients in a safety run-in phase. This study incorporates an objective assessment of baseline frailty (the FIL Tool) and a serial comprehensive geriatric assessment (CGA). Key correlative tests will include circulating tumor DNA (ctDNA) assays at pre-specified timepoints to explore if ctDNA quantity and methylation patterns correlate with response. S1918 has the potential to impact future trial design and to change the standard of care for patients 75 years and older with aggressive lymphoma given its randomized design, prospective incorporation of geriatric assessments, and exploration of ctDNA correlatives. Trial registration: The trial is registered with ClinicalTrial.gov Identifier NCT04799275.
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Affiliation(s)
| | - Hongli Li
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center University of North Carolina, Chapel Hill, NC
| | - Paolo F. Caimi
- Case Western Reserve University School of Medicine, Case Comprehensive Cancer Center, Cleveland, OH
| | | | - Ash Alizadeh
- Stanford University Medical Center, Stanford, CA
| | - Rebecca Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
| | | | | | - Richard F. Little
- National Cancer Institute, Cancer Therapy Evaluation Program (CTEP), Bethesda, MD
| | | | - Michael LeBlanc
- SWOG Statistics and Data Management Center, Seattle, WA,Fred Hutchinson Cancer Research Center, Seattle, WA
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Johnston PB, Cashen AF, Nikolinakos PG, Beaven AW, Barta SK, Bhat G, Hasal SJ, De Vos S, Oki Y, Deng C, Foss FM. Belinostat in combination with standard cyclophosphamide, doxorubicin, vincristine and prednisone as first-line treatment for patients with newly diagnosed peripheral T-cell lymphoma. Exp Hematol Oncol 2021; 10:15. [PMID: 33602316 PMCID: PMC7893947 DOI: 10.1186/s40164-021-00203-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [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] [Received: 10/05/2020] [Accepted: 01/22/2021] [Indexed: 12/22/2022] Open
Abstract
Background Belinostat is a histone deacetylase inhibitor approved for relapsed refractory peripheral T-cell lymphoma (PTCL). The primary objective of this study was to determine the maximum tolerated dose (MTD) of belinostat combined with CHOP (Bel-CHOP). Secondary objectives included safety/tolerability, overall response rate (ORR), and belinostat pharmacokinetics (PK). Methods Patients were ≥ 18 years with histologically confirmed, previously untreated PTCL. Patients received belinostat (1000 mg/m2 once daily) + standard CHOP for 6 cycles with varying schedules using a 3 + 3 design in Part A. Part B enrolled patients at MTD dose. Results Twenty-three patients were treated. One patient experienced DLT (Grade 3 non-hematologic toxicity) on Day 1–3 schedule, resulting in escalation to Day 1–5 schedule (n = 3). No DLTs were observed and Day 1–5 schedule with 1000 mg/m2 was declared as MTD. Twelve additional patients were enrolled in Part B using MTD. Median relative dose intensity was 98%. All patients experienced adverse events (AEs), including nausea (78%), fatigue (61%), and vomiting (57%). Serious AEs occurred in 43%, with febrile neutropenia (17%) and pyrexia (13%). Overall ORR was 86% with 71% reported CR at MTD. Belinostat PK parameters were similar to single-agent. Conclusions Bel-CHOP was well tolerated and MTD in CHOP combination was the same dose and schedule as single agent dosing. Trial Registration: ClinicalTrials.gov Identifier: NCT01839097.
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Affiliation(s)
| | - Amanda F Cashen
- Division of Oncology, Washington University Medical School, 660 S. Euclid Ave, Campus, Box 8007, St Louis, MO, 63110, USA
| | - Petros G Nikolinakos
- University Cancer and Blood Center, 3320 Old Jefferson Rd #700, Athens, GA, 30607, USA
| | - Anne W Beaven
- Duke University School of Medicine, 2592 Morris Bldg, Box 3406, Durham, NC, 27710, USA
| | - Stefan Klaus Barta
- Dept of Hematology/Oncology, Fox Chase Cancer Center, 333 Cottman Ave, Philadelphia, PA, 19111, USA
| | - Gajanan Bhat
- Spectrum Pharmaceuticals, 157 Technology Dr, Irvine, CA, 92618, USA
| | - Steven J Hasal
- Spectrum Pharmaceuticals, 157 Technology Dr, Irvine, CA, 92618, USA
| | - Sven De Vos
- Cancer Care, Ronald Reagan University of California At Los Angeles Medical Center, 2020 Santa Monica Blvd, Santa Monica, CA, 90404, USA
| | - Yasuhiro Oki
- Dept of Lymphoma/Myeloma, University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd, Unit 0429, Houston, TX, 77030, USA
| | - Changchun Deng
- Center for Lymphoid Malignancies, Columbia University Medical Center, 51 West 51st St, New York, NY, 10019, USA
| | - Francine M Foss
- Medical Oncology, Yale Cancer Center, 333 Cedar St, TMP 3, PO Box 208028, New Haven, CT, 06510, USA
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Ramos CA, Grover NS, Beaven AW, Lulla PD, Wu MF, Ivanova A, Wang T, Shea TC, Rooney CM, Dittus C, Park SI, Gee AP, Eldridge PW, McKay KL, Mehta B, Cheng CJ, Buchanan FB, Grilley BJ, Morrison K, Brenner MK, Serody JS, Dotti G, Heslop HE, Savoldo B. Anti-CD30 CAR-T Cell Therapy in Relapsed and Refractory Hodgkin Lymphoma. J Clin Oncol 2020; 38:3794-3804. [PMID: 32701411 PMCID: PMC7655020 DOI: 10.1200/jco.20.01342] [Citation(s) in RCA: 209] [Impact Index Per Article: 52.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2020] [Indexed: 12/11/2022] Open
Abstract
PURPOSE Chimeric antigen receptor (CAR) T-cell therapy of B-cell malignancies has proved to be effective. We show how the same approach of CAR T cells specific for CD30 (CD30.CAR-Ts) can be used to treat Hodgkin lymphoma (HL). METHODS We conducted 2 parallel phase I/II studies (ClinicalTrials.gov identifiers: NCT02690545 and NCT02917083) at 2 independent centers involving patients with relapsed or refractory HL and administered CD30.CAR-Ts after lymphodepletion with either bendamustine alone, bendamustine and fludarabine, or cyclophosphamide and fludarabine. The primary end point was safety. RESULTS Forty-one patients received CD30.CAR-Ts. Treated patients had a median of 7 prior lines of therapy (range, 2-23), including brentuximab vedotin, checkpoint inhibitors, and autologous or allogeneic stem cell transplantation. The most common toxicities were grade 3 or higher hematologic adverse events. Cytokine release syndrome was observed in 10 patients, all of which were grade 1. No neurologic toxicity was observed. The overall response rate in the 32 patients with active disease who received fludarabine-based lymphodepletion was 72%, including 19 patients (59%) with complete response. With a median follow-up of 533 days, the 1-year progression-free survival and overall survival for all evaluable patients were 36% (95% CI, 21% to 51%) and 94% (95% CI, 79% to 99%), respectively. CAR-T cell expansion in vivo was cell dose dependent. CONCLUSION Heavily pretreated patients with relapsed or refractory HL who received fludarabine-based lymphodepletion followed by CD30.CAR-Ts had a high rate of durable responses with an excellent safety profile, highlighting the feasibility of extending CAR-T cell therapies beyond canonical B-cell malignancies.
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Affiliation(s)
- Carlos A. Ramos
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Natalie S. Grover
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Anne W. Beaven
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Premal D. Lulla
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Meng-Fen Wu
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Biostatistics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Anastasia Ivanova
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Biostatistics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Tao Wang
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Biostatistics Shared Resource, Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Thomas C. Shea
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Cliona M. Rooney
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
- Department of Pathology and Immunology, and Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX
| | - Christopher Dittus
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Steven I. Park
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Adrian P. Gee
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Paul W. Eldridge
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kathryn L. McKay
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Birju Mehta
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
| | - Catherine J. Cheng
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Faith B. Buchanan
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Bambi J. Grilley
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
| | - Kaitlin Morrison
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Malcolm K. Brenner
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Jonathan S. Serody
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gianpietro Dotti
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Helen E. Heslop
- Center for Cell and Gene Therapy, Baylor College of Medicine, Houston Methodist Hospital and Texas Children’s Hospital; Dan L. Duncan Cancer, Baylor College of Medicine; Houston, TX
- Department of Medicine, Baylor College of Medicine, Houston, TX
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Barbara Savoldo
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Immunology and Microbiology, University of North Carolina at Chapel Hill, Chapel Hill, NC
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, NC
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7
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Voorhees TJ, Beaven AW. Therapeutic Updates for Relapsed and Refractory Classical Hodgkin Lymphoma. Cancers (Basel) 2020; 12:E2887. [PMID: 33050054 PMCID: PMC7601361 DOI: 10.3390/cancers12102887] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/16/2022] Open
Abstract
Hodgkin lymphoma (HL) is a B-cell malignancy representing approximately one in ten lymphomas diagnosed in the United States annually. The majority of patients with HL can be cured with chemotherapy; however, 5-10% will have refractory disease to front-line therapy and 10-30% will relapse. For those with relapsed or refractory (r/r) HL, salvage chemotherapy followed by autologous stem cell transplant (ASCT) is standard of care, but half of patients will subsequently have disease progression. Relapse following ASCT has been associated with exceedingly poor prognosis with a median survival of only 26 months. However, in recent years, novel agents including brentuximab vedotin (BV) and programmed cell death protein 1 monoclonal antibodies (anti-PD-1, nivolumab and pembrolizumab) have been shown to extend overall survival in r/r HL. With the success of novel agents in relapsed disease after ASCT, these therapies are beginning to show clinically meaningful response rates prior to ASCT. Finally, a new investigation in r/r HL continues to produce promising treatment options even after ASCT including CD30 directed chimeric antigen receptor T-cell therapy. In this review, we will discuss the recent advances of BV and anti-PD-1 therapy prior to ASCT, novel approaches in r/r HL after ASCT, and review active clinical trials.
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Affiliation(s)
| | - Anne W Beaven
- Department of Internal Medicine, Division of Hematology, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC 27514, USA;
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8
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Walburn T, Grover NS, Shen CJ, Ranganathan R, Dittus C, Beaven AW, Wang AZ, Wang K. Consolidative or palliative whole brain radiation for secondary CNS diffuse large B-Cell lymphoma. Leuk Lymphoma 2020; 62:68-75. [PMID: 32935601 DOI: 10.1080/10428194.2020.1821014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/05/2023]
Abstract
We analyzed 25 patients receiving whole brain radiation (WBRT) for secondary CNS lymphoma (SCNSL), grouped by consolidative intent (after complete/partial response, n = 13) vs. palliative intent (initial CNS treatment, primary refractory disease, or CNS progression, n = 12). Median WBRT dose for the consolidative and palliative cohorts were 24 Gy and 30 Gy, respectively. For 13 patients receiving consolidative WBRT, median OS was 24 months from WBRT and 2-year OS was 64%. Three patients had CNS relapse at 2, 9, and 24 months after consolidative WBRT. For 12 patients receiving palliative WBRT, median OS was 3 months from WBRT and two-year OS was 8%. All 10 patients with neurologic symptoms had documented improvement. In conclusion, consolidative WBRT after chemotherapy response led to reasonable long-term survival and may be an effective strategy for SCNSL, especially transplant-ineligible patients and/or isolated CNS recurrence. Palliative WBRT effectively improved neurologic symptoms, but survival was usually only months.
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Affiliation(s)
- Tyler Walburn
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Natalie S Grover
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Colette J Shen
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Raghuveer Ranganathan
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Christopher Dittus
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Anne W Beaven
- Department of Medicine, Division of Hematology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Andrew Z Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
| | - Kyle Wang
- Department of Radiation Oncology, University of North Carolina Hospitals, Chapel Hill, NC, USA
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9
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Voorhees TJ, Kannan KK, Galeotti J, Grover N, Vaidya R, Moore DT, Montgomery ND, Beaven AW, Dittus C. Identification of high-risk monomorphic post-transplant lymphoproliferative disorder following solid organ transplantation. Leuk Lymphoma 2020; 62:86-94. [PMID: 32933363 DOI: 10.1080/10428194.2020.1821006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 12/17/2022]
Abstract
Monomorphic post-transplant lymphoproliferative disorder (M-PTLD) occurring after solid organ transplant histologically resembles aggressive non-Hodgkin lymphomas, with diffuse large B-cell lymphoma being the most common. In a cohort of 40 patients with DLBCL-type M-PTLD, inferior progression free survival (PFS) was observed for Revised International Prognostic Index (R-IPI) >2 (p = 0.01) and high-risk pathologic features (p = 0.02), defined by double expressor lymphoma, MYC rearrangement, or increased copy number of either MYC or BCL2. Overall survival (OS) was inferior in R-IPI >2 (p = 0.002) and high-risk pathologic features (p = 0.003). Combining both R-IPI >2 and high-risk pathologic features resulted in well-delineated good, intermediate, and poor risk groups of DLBCL-type M-PTLD with respect to both PFS and OS (p < 0.001). Our results demonstrate a prognostic role for both the R-IPI score and presence of high-risk pathologic features in DLBCL-type M-PTLD.
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Affiliation(s)
- Timothy J Voorhees
- Division of Hematology and Oncology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Kavya K Kannan
- Division of Hematology and Oncology, Department of Internal Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Jonathan Galeotti
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Natalie Grover
- Division of Hematology and Oncology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Rakhee Vaidya
- Division of Hematology and Oncology, Department of Internal Medicine, Wake Forest University, Winston-Salem, NC, USA
| | - Dominic T Moore
- Division of Hematology and Oncology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Nathan D Montgomery
- Department of Pathology and Laboratory Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Anne W Beaven
- Division of Hematology and Oncology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, USA
| | - Christopher Dittus
- Division of Hematology and Oncology, Department of Internal Medicine, University of North Carolina, Chapel Hill, NC, USA
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10
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Kelsey CR, Broadwater G, James O, Chino J, Diehl L, Beaven AW, Chang C, Koontz BF, Prosnitz LR. Phase 2 Study of Dose-Reduced Consolidation Radiation Therapy in Diffuse Large B-Cell Lymphoma. Int J Radiat Oncol Biol Phys 2019; 105:96-101. [PMID: 30858144 PMCID: PMC10171462 DOI: 10.1016/j.ijrobp.2019.02.055] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 02/04/2019] [Accepted: 02/26/2019] [Indexed: 01/19/2023]
Abstract
PURPOSE To evaluate the feasibility of reducing the dose of consolidation radiation therapy (RT) in diffuse large B-cell lymphoma. METHODS AND MATERIALS This phase 2 study enrolled patients with diffuse large B-cell lymphoma, not otherwise specified and primary mediastinal (thymic) large B-cell lymphoma in complete response on positron emission tomography-computed tomography imaging after ≥4 cycles of a rituximab/anthracycline-containing combination chemotherapy regimen. Consolidation RT used a dose of 19.5 to 20 Gy. The primary endpoint was 5-year freedom from local recurrence. RESULTS Sixty-two patients were enrolled between 2010 and 2016. Stage distribution was as follows: I to II (n = 49, 79%) and III to IV (n = 13, 21%). Bulky disease (defined as ≥7.5 cm or ≥10 cm) was present in 23 (40%) and 16 (28%) patients, respectively. Chemotherapy was R-CHOP (then list the drugs) in 58 (94%) and R-EPOCH (then list the drugs) in 4 (6%) with a median of 6 cycles. With a median follow-up of 51 months, 7 patients developed disease progression (6 outside the RT field, 1 within the RT field). Freedom from local recurrence at 5 years was 98% (90% lower confidence bound, 88%). Progression-free and overall survival at 5 years were 83% and 90%, respectively. CONCLUSIONS With more effective systemic therapy (e.g., addition of rituximab) and more refined chemotherapy response assessment (e.g., positron emission tomography-computed tomography), the dose of RT in combined modality treatment programs may potentially be reduced to 20 Gy. This achieves excellent local control with the potential to decrease acute and long-term side effects.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Gloria Broadwater
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Olga James
- Department of Radiology, Division of Nuclear Medicine, Duke University Medical Center, Durham, North Carolina
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Louis Diehl
- Department of Medicine, Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina
| | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina Medical Center, Chapel Hill, North Carolina
| | - Catherine Chang
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Bridget F Koontz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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11
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Lansigan F, Costa CA, Zaki BI, Yen SP, Winer ES, Ryan H, Findley D, Metzler SR, Shaw L, Toaso B, MacKenzie TA, Chen Y, Beaven AW. Multicenter, Open-Label, Phase II Study of Bendamustine and Rituximab Followed by 90-Yttrium (Y) Ibritumomab Tiuxetan for Untreated Follicular Lymphoma (Fol-BRITe). Clin Cancer Res 2019; 25:6073-6079. [PMID: 31243122 DOI: 10.1158/1078-0432.ccr-18-3755] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Revised: 04/09/2019] [Accepted: 06/20/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Bendamustine and rituximab (BR) has been established as a superior frontline therapy over R-CHOP in the treatment of follicular lymphoma (FL). Yttrium-90 Ibritumomab tiuxetan (90YIT) is an effective consolidation strategy after chemotherapy induction. This prospective, single-arm, multicenter, phase II trial evaluated the response rate, progression-free survival (PFS), and tolerability of BR followed by consolidation with 90YIT in patients with untreated FL. PATIENTS AND METHODS The study included grade 1 to 3a FL patients aged ≥18 years, chemotherapy-naïve, and requiring treatment for stage II-IV disease. Study treatment included an initial rituximab treatment, followed by four cycles of BR. Patients were eligible for consolidation with 90YIT, 6 to 12 weeks after BR, if they obtained at least a partial response after induction had adequate count recovery and bone marrow infiltration < 25%. RESULTS Thirty-nine patients were treated. Eighty-two percent had an intermediate or high-risk Follicular Lymphoma International Prognostic Index score, and 6 of 39 (15%) were grade 3a. The response rate was 94.8%, and the complete response(CR)/CR unconfirmed (CRu) rate was 77% in the intention-to-treat analysis. The conversion rate from PR to CR/Cru after 90YIT was 81%. After median follow-up of 45 months, the PFS was 0.71 (95% confidence interval, 0.57-0.89). CONCLUSIONS This report demonstrates that four cycles of BR followed by consolidation with 90YIT achieve high response rates that are durable. In addition, consolidation with 90YIT results in a high conversion rate of PR to CR/CRu. A short course of BR followed by 90YIT is a safe and effective regimen for frontline treatment of FL.
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Affiliation(s)
| | - Cristiana A Costa
- Division of Hematologic Malignancies and Cell Therapy, Duke University Medical Center, Durham, North Carolina
| | - Bassem I Zaki
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Eric S Winer
- Division of Hematology/Oncology at Rhode Island Hospital and Warren Alpert Medical School at Brown University, Providence, Rhode Island
| | - Helen Ryan
- Maine Center for Cancer Medicine, Scarborough, Maine
| | - Darcie Findley
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sara R Metzler
- Division of Hematologic Malignancies and Cell Therapy, Duke University Medical Center, Durham, North Carolina
| | - Lynn Shaw
- Comprehensive Care Center, Rhode Island Hospital, Providence, Rhode Island
| | - Bonnie Toaso
- Duke University Medical Center, Durham, North Carolina
| | - Todd A MacKenzie
- Epidemiology and Biostatistics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Youdinghuan Chen
- Epidemiology and Biostatistics, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Anne W Beaven
- Division of Hematology/Oncology UNC Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina
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12
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Moskowitz AJ, Herrera AF, Beaven AW. Relapsed and Refractory Classical Hodgkin Lymphoma: Keeping Pace With Novel Agents and New Options for Salvage Therapy. Am Soc Clin Oncol Educ Book 2019; 39:477-486. [PMID: 31099645 DOI: 10.1200/edbk_238799] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The management of relapsed and refractory classic Hodgkin lymphoma (HL) has changed substantially since the approval of brentuximab vedotin (BV) and the checkpoint inhibitors nivolumab and pembrolizumab. For patients progressing after frontline treatment, second-line therapy followed by consolidation with autologous stem cell transplant (ASCT) remains the standard of care; however, although traditional combination chemotherapy regimens previously represented the only options for salvage, BV is now routinely incorporated into second-line therapy, and studies are evaluating checkpoint inhibitors in this setting as well. After ASCT, BV maintenance improves progression-free survival for patients at higher-risk, and studies are evaluating the role of post-ASCT maintenance with checkpoint inhibitors. Management of HL that progresses after ASCT remains a challenge. Although many patients achieve prolonged disease control with checkpoint inhibitors, the majority eventually progress and require additional therapy. Newer approaches, including CD30-directed chimeric antigen receptor-T-cell therapy, appear promising. Furthermore, allogeneic stem cell transplant remains an important consideration. Altogether, BV and checkpoint inhibitors have improved survival for patients with relapsed and refractory HL. However, the ideal place for these drugs in the treatment course of HL is still under investigation. Ongoing studies testing novel combinations and assessing for prognostic and predictive markers will ultimately define the optimal setting for these drugs in the treatment of relapsed and refractory HL.
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Affiliation(s)
| | | | - Anne W Beaven
- 3 Lineberger Comprehensive Cancer Center, University of North Carolina - Chapel Hill, Chapel Hill, NC
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13
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Torok JA, Wu Y, Chino J, Prosnitz LR, Beaven AW, Kim GJ, Kelsey CR. Chemotherapy or Combined Modality Therapy for Early-stage Hodgkin Lymphoma. Anticancer Res 2018; 38:2875-2881. [PMID: 29715111 DOI: 10.21873/anticanres.12533] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 03/01/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND/AIM Optimizing treatment of early-stage Hodgkin lymphoma (HL) requires balancing cure with potential acute and late toxicities from treatment. We reviewed our institutional experience with chemotherapy alone (ChT) versus combined modality therapy (CMT). MATERIALS AND METHODS Patients with stage I-II classical HL in a complete response (CR) by functional imaging after chemotherapy were included. Progression-free survival (PFS) and overall survival (OS) were calculated and a multivariate analysis (MVA) was performed. RESULTS A total of 136 patients with a CR to chemotherapy were identified. Consolidation radiation therapy (RT) was administered to 117 while 19 received no further therapy. PFS (5 years) was 97% with CMT and 84% with chemotherapy alone (p=0.02). Long-term (10 year) survival was no different (96 vs. 94%, p=0.8). On MVA, CMT improved PFS. Secondary malignancies were rare and no cardiac events were observed. CONCLUSION Consolidation RT results in superior PFS in early-stage Hodgkin lymphoma with minimal added toxicity.
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Affiliation(s)
- Jordan A Torok
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, U.S.A
| | - Junzo Chino
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | | | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina, Chapel Hill, NC, U.S.A
| | - Grace J Kim
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University, Durham, NC, U.S.A.
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14
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Hudson KE, Rizzieri D, Thomas SM, LeBlanc TW, Powell Z, Diehl L, Moore JO, DeCastro C, Beaven AW. Dose-intense chemoimmunotherapy plus radioimmunotherapy in high-risk diffuse large B-cell lymphoma and mantle cell lymphoma: a phase II study. Br J Haematol 2018; 184:647-650. [PMID: 29468651 DOI: 10.1111/bjh.15138] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
| | | | - Samantha M Thomas
- Duke University Medical Center, Durham, NC, USA.,Department of Biostatistics & Bioinformatics, Duke University, Durham, NC, USA
| | | | | | - Louis Diehl
- Duke University Medical Center, Durham, NC, USA
| | | | | | - Anne W Beaven
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
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15
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Song EJ, Torok J, Wu Y, Chino J, Prosnitz LR, Beaven AW, Kelsey CR. Consolidation Radiation Therapy for Patients With Advanced Hodgkin Lymphoma in Complete Metabolic Response According to PET-CT or Gallium Imaging. Clin Lymphoma Myeloma Leuk 2017; 18:145-151. [PMID: 29358045 DOI: 10.1016/j.clml.2017.12.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 12/26/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION The purpose of this study was to evaluate the role of consolidation radiation therapy (RT) in advanced Hodgkin lymphoma (HL) in the setting of a complete metabolic response (CR) to chemotherapy (ChT). PATIENTS AND METHODS Patients with stage III/IV HL treated with ChT alone or combined modality therapy (CMT) between 1992 and 2012 were reviewed. Only patients in a CR according to positron emission tomography-computed tomography (PET-CT) or gallium imaging were included. Clinical end points were estimated using the Kaplan-Meier method and a multivariate analysis using the Cox proportional hazards model was performed. RESULTS Ninety patients were identified (46 CMT; 44 ChT alone). Median follow-up was 50 months. ChT (median 6 cycles) consisted primarily of ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine; 74%) or an ABVD hybrid (10%). Post-ChT imaging consisted of PET-CT (71%) or gallium (29%). RT plans primarily included all initially involved sites of disease with a median dose of 21 Gy (range, 13-31 Gy). CMT was associated with improved 5-year progression-free survival (PFS; 88% vs. 65%, respectively; P < .001) and overall survival (97% vs. 78%, respectively; P = .002) compared with ChT alone. In multivariate analysis, age younger than 45 years (hazard ratio [HR], 0.23; 95% confidence interval [CI], 0.07-0.74; P = .013) and CMT (HR, 0.32; 95% CI, 0.11-0.96; P = .04) were independently associated with improved PFS. Secondary malignancies were comparable in both cohorts (5 with CMT, 4 with ChT), whereas cardiac events were slightly more frequent with CMT (5 vs. 2). CONCLUSION Low-dose RT, administered to all sites of original involvement, was associated with improved PFS, even in the setting of a metabolic CR after ABVD.
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Affiliation(s)
- Erin J Song
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Jordan Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, NC
| | - Junzo Chino
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC
| | - Anne W Beaven
- Department of Medicine, Division of Medical Oncology, University of North Carolina, Chapel Hill, NC
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC.
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16
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Sivaraj D, Green MM, Kang Y, Rizzieri D, Diehl LF, Beaven AW, Li Z, Garrett A, McIntyre J, Long GD, Chao NJA, Gasparetto C. Phase I/II dose expansion of a trial investigating bendamustine and pomalidomide with dexamethasone (BPd) in patients with relapsed/refractory multiple myeloma. J Clin Oncol 2017. [DOI: 10.1200/jco.2017.35.15_suppl.8008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8008 Background: The combination of bendamustine, pomalidomide, and dexamethasone (BPd) displays promising activity in heavily pretreated RRMM. In the Phase I portion, MTD was 120 mg/m2bendamustine/3mg pomalidomide/40mg dexamethasone. We report our combined findings from the additional phase II expansion cohort for the first phase I/II trial of BPd in patients with RRMM (NCT01754402). Methods: All patients had to be refractory to prior lenalidomide as well as be pomalidomide naïve, and must have relapsed or have been refractory to their most recent therapy. Treatment consisted of oral pomalidomide PO QD on days 1-21, intravenous (IV) bendamustine given over 30 minutes on day 1, and dexamethasone 40mg on days 1, 8, 15, and 22 of a 28-day cycle. Bendamustine was administered at 120 mg/m2 for cycle 1, day 1. Results: A total study population of 38 patients was enrolled, with 34 evaluable for toxicity and 32 for efficacy, with 7 patients still receiving treatment. Data cut-off was January 18, 2017. The median age was 67 years, median number of prior regimens was 5, median time from diagnosis was 3.6 years, and median follow-up was 11.7 months. 82% of patients had a prior stem cell transplant, 100% had prior bortezomib, 32% had prior carfilzomib, and all were lenalidomide refractory. Cytogenetic abnormalities included 6 patients with del(17p), 4 with t(4;14), 7 with del(13), and 7 with t(11;14). Patients received a median of 4 cycles of therapy. Best response assessments in 32 evaluable patients showed 3 sCR, 3 VGPR, 17 PR, 7 SD, and 2 PD for an ORR of 72%. The median PFS and OS were 9.6 months and 21.3 months respectively for the entire cohort, with 16 of 32 still alive at follow-up. Grade ≥3 drug-related AEs included fatigue (8%), neutropenia (45%), anemia (26%), thrombocytopenia (24%), and diarrhea (8%). 71% of patients experienced grade ≥3 AEs including neutropenia, anemia, and diarrhea. Conclusions: The BPd regimen is relatively tolerable and achieves a promising overall response rate (ORR of 72%) and durable responses in a heavily pre-treated lenalidomide–refractory population with prior bortezomib exposure, and a median of 5 lines of prior therapy. Clinical trial information: NCT01754402.
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Affiliation(s)
| | | | - Yubin Kang
- Medical University of South Carolina, Mt Pleasant, SC
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McKinney M, Moffitt AB, Gaulard P, Travert M, De Leval L, Nicolae A, Raffeld M, Jaffe ES, Pittaluga S, Xi L, Heavican T, Iqbal J, Belhadj K, Delfau-Larue MH, Fataccioli V, Czader MB, Lossos IS, Chapman-Fredricks JR, Richards KL, Fedoriw Y, Ondrejka SL, Hsi ED, Low L, Weisenburger D, Chan WC, Mehta-Shah N, Horwitz S, Bernal-Mizrachi L, Flowers CR, Beaven AW, Parihar M, Baseggio L, Parrens M, Moreau A, Sujobert P, Pilichowska M, Evens AM, Chadburn A, Au-Yeung RKH, Srivastava G, Choi WWL, Goodlad JR, Aurer I, Basic-Kinda S, Gascoyne RD, Davis NS, Li G, Zhang J, Rajagopalan D, Reddy A, Love C, Levy S, Zhuang Y, Datta J, Dunson DB, Davé SS. The Genetic Basis of Hepatosplenic T-cell Lymphoma. Cancer Discov 2017; 7:369-379. [PMID: 28122867 DOI: 10.1158/2159-8290.cd-16-0330] [Citation(s) in RCA: 129] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2016] [Revised: 01/13/2017] [Accepted: 01/23/2017] [Indexed: 12/18/2022]
Abstract
Hepatosplenic T-cell lymphoma (HSTL) is a rare and lethal lymphoma; the genetic drivers of this disease are unknown. Through whole-exome sequencing of 68 HSTLs, we define recurrently mutated driver genes and copy-number alterations in the disease. Chromatin-modifying genes, including SETD2, INO80, and ARID1B, were commonly mutated in HSTL, affecting 62% of cases. HSTLs manifest frequent mutations in STAT5B (31%), STAT3 (9%), and PIK3CD (9%), for which there currently exist potential targeted therapies. In addition, we noted less frequent events in EZH2, KRAS, and TP53SETD2 was the most frequently silenced gene in HSTL. We experimentally demonstrated that SETD2 acts as a tumor suppressor gene. In addition, we found that mutations in STAT5B and PIK3CD activate critical signaling pathways important to cell survival in HSTL. Our work thus defines the genetic landscape of HSTL and implicates gene mutations linked to HSTL pathogenesis and potential treatment targets.Significance: We report the first systematic application of whole-exome sequencing to define the genetic basis of HSTL, a rare but lethal disease. Our work defines SETD2 as a tumor suppressor gene in HSTL and implicates genes including INO80 and PIK3CD in the disease. Cancer Discov; 7(4); 369-79. ©2017 AACR.See related commentary by Yoshida and Weinstock, p. 352This article is highlighted in the In This Issue feature, p. 339.
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Affiliation(s)
- Matthew McKinney
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Andrea B Moffitt
- Duke Center for Genomics and Computational Biology, Duke University, Durham, North Carolina
| | - Philippe Gaulard
- Hôpital Henri Mondor, Department of Pathology, AP-HP, Créteil, France, INSERM U955, Créteil, France, and University Paris-Est, Créteil, France
| | - Marion Travert
- Hôpital Henri Mondor, Department of Pathology, AP-HP, Créteil, France, INSERM U955, Créteil, France, and University Paris-Est, Créteil, France
| | | | - Alina Nicolae
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Mark Raffeld
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Elaine S Jaffe
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Stefania Pittaluga
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | - Liqiang Xi
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
| | | | | | - Karim Belhadj
- Hôpital Henri Mondor, Department of Pathology, AP-HP, Créteil, France, INSERM U955, Créteil, France, and University Paris-Est, Créteil, France
| | - Marie Helene Delfau-Larue
- Hôpital Henri Mondor, Department of Pathology, AP-HP, Créteil, France, INSERM U955, Créteil, France, and University Paris-Est, Créteil, France
| | - Virginie Fataccioli
- Hôpital Henri Mondor, Department of Pathology, AP-HP, Créteil, France, INSERM U955, Créteil, France, and University Paris-Est, Créteil, France
| | | | | | | | | | - Yuri Fedoriw
- University of North Carolina, Chapel Hill, North Carolina
| | | | | | | | | | - Wing C Chan
- City of Hope Medical Center, Duarte, California
| | | | - Steven Horwitz
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Anne W Beaven
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | | | | | | | - Anne Moreau
- Pathology, Hôpital Hôtel-Dieu, Nantes, France
| | - Pierre Sujobert
- Faculté de Médecine Lyon-Sud Charles Mérieux, Université Claude Bernard, Lyon, France
| | | | | | - Amy Chadburn
- Presbyterian Hospital, Pathology and Cell Biology, Cornell University, New York, New York
| | | | | | | | - John R Goodlad
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Igor Aurer
- University Hospital Centre Zagreb, Zagreb, Croatia
| | | | - Randy D Gascoyne
- British Columbia Cancer Agency, University of British Columbia, Vancouver, Canada
| | - Nicholas S Davis
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Guojie Li
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Jenny Zhang
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Deepthi Rajagopalan
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Anupama Reddy
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Cassandra Love
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Shawn Levy
- Hudson Alpha Institute for Biotechnology, Huntsville, Alabama
| | - Yuan Zhuang
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina
| | - Jyotishka Datta
- Department of Statistical Science, Duke University, Durham, North Carolina
| | - David B Dunson
- Department of Statistical Science, Duke University, Durham, North Carolina
| | - Sandeep S Davé
- Duke Cancer Institute, Duke University Medical Center, Durham, North Carolina. .,Duke Center for Genomics and Computational Biology, Duke University, Durham, North Carolina
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18
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Seymour JF, Ma S, Brander DM, Choi MY, Barrientos J, Davids MS, Anderson MA, Beaven AW, Rosen ST, Tam CS, Prine B, Agarwal SK, Munasinghe W, Zhu M, Lash LL, Desai M, Cerri E, Verdugo M, Kim SY, Humerickhouse RA, Gordon GB, Kipps TJ, Roberts AW. Venetoclax plus rituximab in relapsed or refractory chronic lymphocytic leukaemia: a phase 1b study. Lancet Oncol 2017; 18:230-240. [PMID: 28089635 DOI: 10.1016/s1470-2045(17)30012-8] [Citation(s) in RCA: 245] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND Selective BCL2 inhibition with venetoclax has substantial activity in patients with relapsed or refractory chronic lymphocytic leukaemia. Combination therapy with rituximab enhanced activity in preclinical models. The aim of this study was to assess the safety, pharmacokinetics, and activity of venetoclax in combination with rituximab. METHODS Adult patients with relapsed or refractory chronic lymphocytic leukaemia (according to the 2008 Modified International Workshop on CLL guidelines) or small lymphocytic lymphoma were eligible for this phase 1b, dose-escalation trial. The primary outcomes were to assess the safety profile, to determine the maximum tolerated dose, and to establish the recommended phase 2 dose of venetoclax when given in combination with rituximab. Secondary outcomes were to assess the pharmacokinetic profile and analyse efficacy, including overall response, duration of response, and time to tumour progression. Minimal residual disease was a protocol-specified exploratory objective. Central review of the endpoints was not done. Venetoclax was dosed daily using a stepwise escalation to target doses (200-600 mg) and then monthly rituximab commenced (375 mg/m2 in month 1 and 500 mg/m2 in months 2-6). Adverse events were graded according to the National Cancer Institute Common Terminology Criteria for adverse events version 4.0. Protocol-guided drug cessation was allowed for patients who achieved complete response (including complete response with incomplete marrow recovery) or negative bone marrow minimal residual disease. Analyses were done per protocol for all patients who commenced drug and included all patients who received at least one dose of venetoclax. Data were pooled across dose cohorts. Patients are still receiving therapy and follow-up is ongoing. The trial is registered at ClinicalTrials.gov, number NCT01682616. FINDINGS Between Aug 6, 2012, and May 28, 2014, we enrolled 49 patients. Common grade 1-2 toxicities included upper respiratory tract infections (in 28 [57%] of 49 patients), diarrhoea (27 [55%]), and nausea (25 [51%]). Grade 3-4 adverse events occurred in 37 (76%) of 49 patients; most common were neutropenia (26 [53%]), thrombocytopenia (eight [16%]), anaemia (seven [14%]), febrile neutropenia (six [12%]), and leucopenia (six [12%]). The most common serious adverse events were pyrexia (six [12%]), febrile neutropenia (five [10%]), lower respiratory tract infection, and pneumonia (each three [6%]). Clinical tumour lysis syndrome occurred in two patients (resulting in one death) who initiated venetoclax at 50 mg. After enhancing tumour lysis syndrome prophylaxis measures and commencing venetoclax at 20 mg, clinical tumour lysis syndrome did not occur. The maximum tolerated dose was not identified; the recommended phase 2 dose of venetoclax in combination with rituximab was 400 mg. Overall, 42 (86%) of 49 patients achieved a response, including a complete response in 25 (51%) of 49 patients. 2 year estimates for progression-free survival and ongoing response were 82% (95% CI 66-91) and 89% (95% CI 72-96), respectively. Negative marrow minimal residual disease was attained in 20 (80%) of 25 complete responders and 28 (57%) of 49 patients overall. 13 responders ceased all therapy; among these all 11 minimal residual disease-negative responders remain progression-free off therapy. Two with minimal residual disease-positive complete response progressed after 24 months off therapy and re-attained response after re-initiation of venetoclax. INTERPRETATION A substantial proportion of patients achieved an overall response with the combination of venetoclax and rituximab including 25 (51%) of 49 patients who achieved a complete response and 28 (57%) of 49 patients who achieved negative marrow minimal residual disease with acceptable safety. The depth and durability of responses observed with the combination offers an attractive potential treatment option for patients with relapsed or refractory chronic lymphocytic leukaemia and could allow some patients to maintain response after discontinuing therapy, a strategy that warrants further investigation in randomised studies. FUNDING AbbVie Inc and Genentech Inc.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Bridged Bicyclo Compounds, Heterocyclic/administration & dosage
- Cohort Studies
- Drug Resistance, Neoplasm/drug effects
- Female
- Follow-Up Studies
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/drug therapy
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Male
- Maximum Tolerated Dose
- Middle Aged
- Neoplasm Grading
- Neoplasm Recurrence, Local/drug therapy
- Neoplasm Recurrence, Local/pathology
- Prognosis
- Remission Induction
- Rituximab/administration & dosage
- Salvage Therapy
- Sulfonamides/administration & dosage
- Survival Rate
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Affiliation(s)
- John F Seymour
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia.
| | - Shuo Ma
- Robert H Lurie Comprehensive Cancer Center, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | | | - Mary Ann Anderson
- Department of Clinical Haematology and BMT, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia; Division of Cancer and Haematology, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, VIC, Australia
| | | | | | - Constantine S Tam
- Peter MacCallum Cancer Centre, Melbourne, VIC, Australia; Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia
| | | | | | | | - Ming Zhu
- AbbVie, Inc, North Chicago, IL, USA
| | | | | | | | | | | | | | | | | | - Andrew W Roberts
- Victorian Comprehensive Cancer Centre, Parkville, Melbourne, VIC, Australia; Faculty of Medicine, University of Melbourne, Parkville, Melbourne, VIC, Australia; Department of Clinical Haematology and BMT, The Royal Melbourne Hospital, Parkville, Melbourne, VIC, Australia; Division of Cancer and Haematology, The Walter and Eliza Hall Institute of Medical Research, Parkville, Melbourne, VIC, Australia
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Abstract
Differences in quality of life (QOL) of long-term survivors of aggressive or indolent subtypes of non-Hodgkin lymphoma (NHL) have not been frequently evaluated. We assessed these differences by analyzing results of a large QOL survey of long-term NHL survivors. We hypothesized that the incurable nature of indolent NHL would relate to worse QOL in long-term survivors while the potentially cured long-term survivors of aggressive lymphoma would have better QOL. We found that QOL was similar between the two groups. Results suggest that patients with indolent NHL are coping well with their disease, yet experience some overall feelings of life threat.
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Affiliation(s)
- Anne W Beaven
- a Div. of Hematologic Malignancy and Cellular Therapy , Duke University Medical Center Durham , NC , USA
| | - Greg Samsa
- b Department of Biostatistics and Bioinformatics , Duke University Medical Center , Durham , NC , USA
| | - Sheryl Zimmerman
- c Cecil G. Sheps Center for Health Services Research and the School of Social Work , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
| | - Sophia K Smith
- d Duke University School of Nursing , Durham , NC , USA.,e Duke Cancer Institute , Durham , NC , USA
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20
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Roe MT, Cyr DD, Eckart D, Schulte PJ, Morse MA, Blackwell KL, Ready NE, Zafar SY, Beaven AW, Strickler JH, Onken JE, Winters KJ, Houterloot L, Zamoryakhin D, Wiviott SD, White HD, Prabhakaran D, Fox KAA, Armstrong PW, Ohman EM. Ascertainment, classification, and impact of neoplasm detection during prolonged treatment with dual antiplatelet therapy with prasugrel vs. clopidogrel following acute coronary syndrome. Eur Heart J 2015; 37:412-22. [PMID: 26637834 DOI: 10.1093/eurheartj/ehv611] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/15/2015] [Indexed: 12/19/2022] Open
Abstract
AIMS Studies have suggested increased cancer incidence associated with long-term dual antiplatelet therapy (DAPT) for acute coronary syndrome (ACS). We evaluated cancer incidence and treatment-related differences in an analysis of DAPT for ACS. METHODS AND RESULTS The Targeted Platelet Inhibition to Clarify the Optimal Strategy to Medically Manage Acute Coronary Syndromes trial enrolled 9326 participants with ACS, who received aspirin plus clopidogrel or prasugrel. Median treatment exposure was 15 months. Cancer history and screening procedures were collected. Suspected non-benign neoplasm events were reported and adjudicated. The primary outcome was detection of new, non-benign neoplasm. Factors associated with neoplasm events, the relationship of these events to cardiovascular and bleeding endpoints, and treatment-related differences in neoplasm detection were studied. Among 9240 participants who received ≥1 dose of study drug, 1.8% had a confirmed neoplasm event. The efficacy composite of cardiovascular death, myocardial infarction, or stroke occurred more frequently among those with a neoplasm event vs. those without (18.2 vs. 13.5%) as did Global Use of Strategies to Open Occluded Coronary Arteries severe/moderate bleeding (11.2 vs. 1.5%). Screening rates were substantially higher in North America and Western Europe/Scandinavia vs. other regions. Factors most strongly associated with detection of neoplasm events were older age, region, male sex, and current/recent smoking. Among the pre-specified population without a history of neoplasm or previous curative treatment for neoplasm (n = 9105), the incidence of neoplasm events was similar with prasugrel vs. clopidogrel (1.8 vs. 1.7%; HR = 1.04; 95% CI 0.77-1.42; P = 0.79). CONCLUSIONS Neoplasm events were infrequent during long-term DAPT after ACS, were associated with differential cancer-screening practices across regions, and the frequency of neoplasm detection was similar with prasugrel vs. clopidogrel. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00699998.
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Affiliation(s)
- Matthew T Roe
- Duke Clinical Research Institute, 2400 Pratt Street, Rm 7035, Durham, NC 27705, USA Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Derek D Cyr
- Duke Clinical Research Institute, 2400 Pratt Street, Rm 7035, Durham, NC 27705, USA
| | - Debra Eckart
- Duke Clinical Research Institute, 2400 Pratt Street, Rm 7035, Durham, NC 27705, USA
| | - Phillip J Schulte
- Duke Clinical Research Institute, 2400 Pratt Street, Rm 7035, Durham, NC 27705, USA
| | - Michael A Morse
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kimberly L Blackwell
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Neal E Ready
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - S Yousuf Zafar
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Anne W Beaven
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - John H Strickler
- Division of Medicine - Oncology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jane E Onken
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | | | | | - Stephen D Wiviott
- Brigham and Women's Hospital/Harvard Medical School, Boston, MA, USA
| | - Harvey D White
- Auckland City Hospital, Green Lane Cardiovascular Service, Auckland, New Zealand
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control and Public Health Foundation of India, New Delhi, India
| | - Keith A A Fox
- British Heart Foundation Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Paul W Armstrong
- Division of Cardiology, University of Alberta, Edmonton, AB, Canada
| | - E Magnus Ohman
- Duke Clinical Research Institute, 2400 Pratt Street, Rm 7035, Durham, NC 27705, USA Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
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21
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Advani RH, Ansell SM, Lechowicz MJ, Beaven AW, Loberiza F, Carson KR, Evens AM, Foss F, Horwitz S, Pro B, Pinter-Brown LC, Smith SM, Shustov AR, Savage KJ, Vose JM. A phase II study of cyclophosphamide, etoposide, vincristine and prednisone (CEOP) Alternating with Pralatrexate (P) as front line therapy for patients with peripheral T-cell lymphoma (PTCL): final results from the T- cell consortium trial. Br J Haematol 2015; 172:535-44. [PMID: 26627450 DOI: 10.1111/bjh.13855] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 10/06/2015] [Indexed: 12/18/2022]
Abstract
Peripheral T-cell lymphomas (PTCL) have suboptimal outcomes using conventional CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy. The anti-folate pralatrexate, the first drug approved for patients with relapsed/refractory PTCL, provided a rationale to incorporate it into the front-line setting. This phase 2 study evaluated a novel front-line combination whereby cyclophosphamide, etoposide, vincristine and prednisone (CEOP) alternated with pralatrexate (CEOP-P) in PTCL. Patients achieving a complete or partial remission (CR/PR) were eligible for consolidative stem cell transplantation (SCT) after 4 cycles. Thirty-three stage II-IV PTCL patients were treated: 21 PTCL-not otherwise specified (64%), 8 angioimmunoblastic T cell lymphoma (24%) and 4 anaplastic large cell lymphoma (12%). The majority (61%) had stage IV disease and 46% were International Prognostic Index high/intermediate or high risk. Grade 3-4 toxicities included anaemia (27%), thrombocytopenia (12%), febrile neutropenia (18%), mucositis (18%), sepsis (15%), increased creatinine (12%) and liver transaminases (12%). Seventeen patients (52%) achieved a CR. The 2-year progression-free survival and overall survival, were 39% (95% confidence interval 21-57) and 60% (95% confidence interval 39-76), respectively. Fifteen patients (45%) (12 CR) received SCT and all remained in CR at a median follow-up of 21·5 months. CEOP-P did not improve outcomes compared to historical data using CHOP. Defining optimal front line therapy in PTCL continues to be a challenge and an unmet need.
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Affiliation(s)
| | | | - Mary J Lechowicz
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Anne W Beaven
- Medicine-Oncology, Duke University Medical Center, Durham, NC, USA
| | - Fausto Loberiza
- Division of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Kenneth R Carson
- Division of Medical Oncology, Washington University School of Medicine, St. Louis, MO, USA
| | - Andrew M Evens
- Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, USA
| | | | - Steven Horwitz
- Hematology/Oncology, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
| | - Barbara Pro
- Medical Oncology, Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Sonali M Smith
- Center for Advanced Medicine, University of Chicago, Chicago, IL, USA
| | - Andrei R Shustov
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Kerry J Savage
- Centre for Lymphoid Cancer and Department of Medical Oncology, British Columbia Cancer Agency, Vancouver, BC, Canada
| | - Julie M Vose
- Division of Hematology/Oncology, University of Nebraska Medical Center, Omaha, NE, USA
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22
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Torok JA, Wu Y, Prosnitz LR, Kim GJ, Beaven AW, Diehl LF, Kelsey CR. Low-dose consolidation radiation therapy for early stage unfavorable Hodgkin lymphoma. Int J Radiat Oncol Biol Phys 2015; 92:54-9. [PMID: 25863754 DOI: 10.1016/j.ijrobp.2015.02.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 01/14/2015] [Accepted: 02/02/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE The German Hodgkin Study Group (GHSG) trial HD11 established 4 cycles of doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD) and 30 Gy of radiation therapy (RT) as a standard for early stage (I, II), unfavorable Hodgkin lymphoma (HL). Additional cycles of ABVD may allow for a reduction in RT dose and improved toxicity profile. METHODS AND MATERIALS Patients treated with combined modality therapy at the Duke Cancer Institute for early stage, unfavorable HL by GHSG criteria from 1994 to 2012 were included. Patients who did not undergo post-chemotherapy functional imaging (positron emission tomography or gallium imaging) or who failed to achieve a complete response were excluded. Clinical outcomes were estimated using the Kaplan-Meier method. Late effects were also evaluated. RESULTS A total of 90 patients met inclusion criteria for analysis. Median follow-up was 5 years. Chemotherapy consisted primarily of ABVD (88%) with a median number of 6 cycles. The median dose of consolidation RT was 23.4 Gy. Four patients had relapses, 2 of which were in-field. Ten-year progression-free survival (PFS) and overall survival (OS) were 93% (95% confidence interval [CI]: 0.82-0.97) and 98% (95% CI: 0.92-0.99), respectively. For the subset of patients (n=46) who received 5 to 6 cycles of chemotherapy and ≤ 24 Gy, the 10-year PFS and OS values were 88% (95% CI: 70%-96%) and 98% (95% CI: 85% - 99%), respectively. The most common late effect was hypothyroidism (20%) with no cardiac complications. Seven secondary malignancies were diagnosed, with only 1 arising within the RT field. CONCLUSIONS Lower doses of RT may be sufficient when combined with more than 4 cycles of ABVD for early stage, unfavorable HL and may result in a more favorable toxicity profile than 4 cycles of ABVD and 30 Gy of RT.
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Affiliation(s)
- Jordan A Torok
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina.
| | - Yuan Wu
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina
| | - Leonard R Prosnitz
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Grace J Kim
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
| | - Anne W Beaven
- Division of Hematologic Malignancy and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Louis F Diehl
- Division of Hematologic Malignancy and Cellular Therapy, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina
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23
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Abstract
Peripheral T-cell lymphomas (PTCL), with the exception of anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL), have a very poor prognosis. Although current first line chemotherapy continues to be a CHOP-like (cyclophosphamide, doxorubicin, vincristine, prednisone) regimen there is now data suggesting that the addition of etoposide in younger patients improves outcomes. Even for those patients who do have a response to therapy, the risk of relapse remains quite high. Although autologous transplant in first remission is often used, its role as consolidation therapy in first remission remains unclear and may preferentially benefit low-risk patients. In the relapsed setting, major advances have occurred with Food and Drug Administration (FDA) approval of 4 new agents (pralatrexate, romidepsin, belinostat, brentuximab vedotin) for relapsed/refractory PTCL since 2009. These 4 drugs represent the first agents ever approved specifically for this indication. Unfortunately, with the exception of ALCL for which brentuximab vedotin will likely substantially change our approach to treatment, there are still many patients for whom available drugs will not be effective, and it is for these patients that further advances are urgently needed.
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Boyle J, Beaven AW, Diehl LF, Prosnitz LR, Kelsey CR. Improving outcomes in advanced DLBCL: systemic approaches and radiotherapy. Oncology (Williston Park) 2014; 28:1074-1084. [PMID: 25510806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma. Approximately half of patients will present with advanced (stage III/IV) disease. The cornerstone of treatment is a combination of chemotherapy and immunotherapy, most commonly R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone). Efforts to improve upon R-CHOP-including more chemotherapy cycles, dose-dense chemotherapy, alternative drug combinations, high-dose chemotherapy with autologous stem cell transplant, and maintenance rituximab-have generally proved unsuccessful. There is a growing body of retrospective and prospective data, however, suggesting a benefit for consolidation radiation therapy (RT) in select patients with advanced DLBCL. Consolidation RT has been shown to improve outcomes for patients with advanced DLBCL generally, and in specific instances including initially bulky disease, bone involvement, or in the setting of a partial response to systemic therapy. In these settings consolidation RT is highly efficacious at achieving local disease control and improving overall outcomes.
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25
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Feldman T, Mato AR, Chow KF, Protomastro EA, Yannotti KML, Bhattacharyya P, Yang X, Donato ML, Rowley SD, Carini C, Valentinetti M, Smith J, Gadaleta G, Bejot C, Stives S, Timberg M, Kdiry S, Pecora AL, Beaven AW, Goy A. Addition of lenalidomide to rituximab, ifosfamide, carboplatin, etoposide (RICER) in first-relapse/primary refractory diffuse large B-cell lymphoma. Br J Haematol 2014; 166:77-83. [PMID: 24661044 PMCID: PMC4283736 DOI: 10.1111/bjh.12846] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2014] [Accepted: 02/17/2014] [Indexed: 12/22/2022]
Abstract
Relapsed/refractory diffuse large B-cell lymphoma (DLBCL) is associated with a poor prognosis. Outcomes are particularly poor following immunochemotherapy failure or relapse within 12 months of induction. We conducted a Phase I/II trial of lenalidomide plus RICE (rituximab, ifosfamide, carboplatin, and etoposide) (RICER) as a salvage regimen for first-relapse or primary refractory DLBCL. Dose-escalated lenalidomide was combined with RICE every 14 d. After three cycles of RICER, patients with chemosensitive disease underwent stem cell collection and consolidation with BEAM [BCNU (carmustine), etoposide, cytarabine, melphalan] followed by autologous stem cell transplantation (autoSCT). Patients who recovered from autoSCT toxicities within 90 d initiated maintenance treatment with lenalidomide 25 mg daily for 21 d every 28 d for 12 months. No dose-limiting or unexpected toxicities occurred with lenalidomide 25 mg plus RICE. Grade 3/4 haematological toxicities resolved appropriately, and planned dose density and dose intensity of RICER were preserved. No lenalidomide or RICE dose reductions were required in any of the three cycles. After two cycles of RICER, nine of 15 patients (60%) achieved a complete response, and two achieved a partial response (13%). Combining lenalidomide with RICE is feasible, and results in promising response rates (particularly complete response rates) in high-risk DLBCL patients.
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Affiliation(s)
- Tatyana Feldman
- John Theurer Cancer Center, Hackensack University Medical Center, Hackensack, NJ, USA
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Shanafelt T, Lanasa MC, Call TG, Beaven AW, Leis JF, LaPlant B, Bowen D, Conte M, Jelinek DF, Hanson CA, Kay NE, Zent CS. Ofatumumab-based chemoimmunotherapy is effective and well tolerated in patients with previously untreated chronic lymphocytic leukemia (CLL). Cancer 2013; 119:3788-96. [PMID: 23922059 DOI: 10.1002/cncr.28292] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Revised: 06/12/2013] [Accepted: 07/02/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Although rituximab-based chemoimmunotherapy (CIT) has substantially improved clinical outcomes in chronic lymphocytic leukemia (CLL), only 40% to 50% of patients achieve a complete remission (CR). There remains interest in identifying new approaches to improve the effectiveness of CIT. Ofatumumab is a fully human anti-CD20 monoclonal antibody with greater apparent single-agent activity than rituximab in CLL patients. METHODS Previously untreated CLL patients in need of therapy received 6 cycles of CIT induction with pentostatin, cyclophosphamide, and ofatumumab (PCO) followed by response assessment. RESULTS Of the 48 patients enrolled, 77% completed PCO induction. Adverse events during induction included grade 3+ hematologic toxicity (27%) and grade 3+ nonhematologic toxicity (23%). Median CD4 count after induction and 6 months later were 186 × 10(6)/L and 272 × 10(6) /L. The overall response rate was 96% (46 of 48 patients), and the CR rate was 46% (22 of 48 patients). Among the 38 patients who underwent minimal residual disease evaluation, 7 (18%) were negative for minimal residual disease. After median follow-up of 24 months, 10 (21%) patients have progressed and 8 (17%) have required retreatment. The efficacy and toxicity of ofatumumab-based CIT compare favorably to our historical trials of rituximab-based CIT using an identical chemotherapy backbone (n = 64). Time to retreatment also appeared longer for ofatumumab-based CIT (free of retreatment at 24 months: 86% [95% confidence interval = 75-99] versus 68% [95% confidence interval = 56-81] for rituximab-based CIT). CONCLUSIONS Ofatumumab-based CIT is well tolerated in patients with previously untreated CLL. The efficacy of ofatumumab-based CIT compares favorably to historical trials of rituximab-based CIT, suggesting randomized trials comparing ofatumumab-based CIT and rituximab-based CIT should be considered.
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Kelsey CR, Beaven AW, Diehl LF, Prosnitz LR. Combined-modality therapy for early-stage Hodgkin lymphoma: maintaining high cure rates while minimizing risks. Oncology (Williston Park) 2012; 26:1182-1193. [PMID: 23413599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Multiple randomized studies have demonstrated that chemotherapy, most commonly ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, dacarbazine), followed by consolidation radiation therapy is the most effective treatment program for early-stage Hodgkin lymphoma. With a combined-modality approach, the great majority of patients are cured of their disease. It is also apparent that both chemotherapy and radiation therapy can increase the risk of complications in the decades following treatment, with second cancers and cardiac disease being the most common. Most studies,evaluating such risks primarily include patients treated in decades past with what are now considered outdated approaches, including high-dose, wide-field radiation therapy. The treatment of Hodgkin lymphoma has evolved significantly, particularly in regard to radiation therapy. In combination with chemotherapy, much lower doses and smaller fields are employed, with success equivalent to that achieved using older methods. Many studies have shown a significant decline in both the rates of second cancers and the risk of cardiac disease with low-dose radiation confined to the original extent of disease. In favorable patients, as few as 2 cycles of ABVD have been shown to be effective. The current combined-modality approach seeks to maintain high cure rates but minimize risks by optimizing both chemotherapy and radiation therapy
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina, USA.
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Dorth JA, Prosnitz LR, Broadwater G, Diehl LF, Beaven AW, Coleman RE, Kelsey CR. Impact of Consolidation Radiation Therapy in Stage III-IV Diffuse Large B-cell Lymphoma With Negative Post-Chemotherapy Radiologic Imaging. Int J Radiat Oncol Biol Phys 2012; 84:762-7. [DOI: 10.1016/j.ijrobp.2011.12.067] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 12/16/2011] [Accepted: 12/20/2011] [Indexed: 10/28/2022]
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Dorth JA, Prosnitz LR, Broadwater G, Beaven AW, Kelsey CR. Radiotherapy dose-response analysis for diffuse large B-cell lymphoma with a complete response to chemotherapy. Radiat Oncol 2012; 7:100. [PMID: 22720801 PMCID: PMC3464871 DOI: 10.1186/1748-717x-7-100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 06/21/2012] [Indexed: 11/12/2022] Open
Abstract
Objective To examine the efficacy of different radiation doses after achievement of a complete response to chemotherapy in diffuse large B-cell lymphoma (DLBCL). Methods Patients with stage I-IV DLBCL treated from 1995–2009 at Duke Cancer Institute who achieved a complete response to chemotherapy were reviewed. In-field control, event-free survival, and overall survival were calculated using the Kaplan-Meier method. Dose response was evaluated by grouping treated sites by delivered radiation dose. Results 105 patients were treated with RT to 214 disease sites. Chemotherapy (median 6 cycles) was R-CHOP (65%), CHOP (26%), R-CNOP (2%), or other (7%). Post-chemotherapy imaging was PET/CT (88%), gallium with CT (1%), or CT only (11%). The median RT dose was 30 Gy (range, 12–40 Gy). The median radiation dose was higher for patients with stage I-II disease compared with patients with stage III-IV disease (30 versus 24.5 Gy, p < 0.001). Five-year in-field control, event-free survival, and overall survival for all patients was 94% (95% CI: 89-99%), 84% (95% CI: 77-92%), and 91% (95% CI: 85-97%), respectively. Six patients developed an in-field recurrence at 10 sites, without a clear dose response. In-field failure was higher at sites ≥ 10 cm (14% versus 4%, p = 0.06). Conclusion In-field control was excellent with a combined modality approach when a complete response was achieved after chemotherapy without a clear radiation dose response.
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Affiliation(s)
- Jennifer A Dorth
- Department of Radiation Oncology, University Hospitals Seidman Cancer Center and Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Brander DM, Beaven AW. Update on treatment of follicular non-Hodgkin's lymphoma: focus on potential of bortezomib. Patient Prefer Adherence 2012; 6:239-51. [PMID: 22536060 PMCID: PMC3333814 DOI: 10.2147/ppa.s23241] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Follicular lymphoma is predominantly managed as a chronic disease, with intermittent chemo/immunotherapy reserved for symptomatic progression. It is considered incurable with conventional treatments, and current therapeutic options are associated with significant toxicities that are especially limiting in older patients. Bortezomib (PS-341; Velcade(®)), a first-in-class drug targeting the proteolytic core subunit of the 26S proteasome, has emerged as a therapeutic alternative in follicular lymphoma, with promising preclinical data and efficacy in patients with other hematological malignancies. Several clinical trials were conducted with bortezomib for the treatment of non-Hodgkin's lymphoma. As a single agent, overall responses in follicular lymphoma varied greatly (16%-41%), with weekly bortezomib showing less neurotoxicity than twice-weekly regimens, but with concern about decreased responses. Combination with rituximab was projected to improve the efficacy of bortezomib, but this resulted in increased toxicities and questionable added benefit. Although the largest Phase III study in follicular lymphoma of bortezomib plus rituximab versus rituximab alone demonstrated a significant progression-free survival difference, the absolute difference was small (12.8 months versus 11 months). Combining bortezomib with established regimens, such as rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP), rituximab, cyclophosphamide, vincristine, and prednisone (R-CVP), or rituximab-bendamustine also did not show definite benefit, and many of these studies did not meet their primary endpoint when bortezomib failed to improve responses or survival to the degree anticipated. In a disease where the goal of treatment is palliative and affected patients often have other medical and treatment-related comorbidities, decisions regarding therapies which carry risks of additional toxicities must be considered carefully. Conclusive evidence of the ability of bortezomib to improve patient outcomes meaningfully and to justify the added toxicity is lacking, but limitations in cross-trial comparisons are recognized. Large randomized trials and investigations of combinations with promising novel targeted agents will aid in determining the role of bortezomib, if any, in the future treatment of follicular lymphoma.
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Affiliation(s)
- Danielle M Brander
- Correspondence: Danielle M Brander, DUMC Box 3841, Durham, NC 27710, USA, Fax +1 919 684 3309, Email
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Beaven AW, Shea TC, Moore DT, Feldman T, Ivanova A, Ferraro M, Ford P, Smith J, Goy A. A phase I study evaluating ibritumomab tiuxetan (Zevalin®) in combination with bortezomib (Velcade®) in relapsed/refractory mantle cell and low grade B-cell non-Hodgkin lymphoma. Leuk Lymphoma 2011; 53:254-8. [DOI: 10.3109/10428194.2011.608445] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Beaven AW, Moore DT, Sharf A, Serody JS, Shea TC, Gabriel DA. Infusional Mitoxantrone Plus Bolus Melphalan as a Stem Cell Transplant Conditioning Regimen for Multiple Myeloma. Cancer Invest 2011; 29:214-9. [DOI: 10.3109/07357907.2010.550663] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kelsey CR, Beaven AW, Diehl LF, Prosnitz LR. Radiation therapy in the management of diffuse large B-cell lymphoma: still relevant? Oncology (Williston Park) 2010; 24:1204-1212. [PMID: 21192559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of non-Hodgkin lymphoma in the United States. Historically, radiation therapy (RT) was the primary treatment for patients with localized disease. Several randomized trials have demonstrated that the addition of systemic therapy improves outcomes. Additional randomized trials have shown that the combination of RT and systemic therapy is superior to systemic therapy alone. The role of RT in advanced-stage DLBCL has not been firmly established, but some prospective phase III trials, as well as retrospective studies, suggest a benefit for advanced disease also. For patients with relapsed or primary refractory disease, autologous stem cell transplantation is the treatment of choice. Here too, consolidation RT appears to improve outcomes compared with autologous stem cell transplant alone. Finally, for patients with advanced DLBCL who are no longer responsive to systemic therapy, RT may provide rapid and durable palliation of local lymphoma-related symptoms.
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Affiliation(s)
- Chris R Kelsey
- Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Shea TC, Beaven AW, Moore DT, Serody JS, Gabriel DA, Chao N, Gockerman JP, Garcia RA, Rizzieri DA. Sequential high-dose ifosfamide, carboplatin and etoposide with rituximab for relapsed Hodgkin and large B-cell non-Hodgkin lymphoma: increased toxicity without improvement in progression-free survival. Leuk Lymphoma 2009; 50:741-8. [PMID: 19358012 DOI: 10.1080/10428190902853136] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Non-cross resistant drugs given at high-dose intensity may maximise tumor cell kill leading to improved patient outcomes. We investigated the feasibility and efficacy of administering ifosfamide, carboplatin and etoposide +/- rituximab as sequential high-dose single agents. Twenty-two patients with relapsed/refractory Hodgkin lymphoma (n = 9) or non-Hodgkin (n = 13) lymphoma (NHL) were included. Therapy included: cycle 1 ifosfamide (15 g/m(2)), cycle 2 etoposide (900 mg/m(2)) and cycle 3 carboplatin (area under the curve 15). Patients with NHL received rituximab (375 mg/m(2)) with cycles 1 and 2. Blood stem cell collection was performed after etoposide. Primary endpoints were overall response (complete response (CR) + PR) and ability to mobilise stem cells after etoposide. Secondary endpoints were to assess the toxicity of the regimen and to evaluate the ability of patients to proceed to stem cell transplant (SCT). Overall response rate was 54% with CR in 4/22 (18%) subjects and PR in 8/22 (36%). Median progression-free survival was 15 months and overall survival has not been reached at 40 months. Thirteen participants proceeded to SCT. Grade 3/4 thrombocytopenia and neutropenia occurred in 58% of cycles and 91% of subjects respectively. Forty-five percent of patients required hospitalisation for toxicity and two patients died from complications of therapy. Sequential dose intense ifosfamide, etoposide, carboplatin +/- rituximab was more toxic and no more effective than the same drugs given in a conventional fashion.
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Affiliation(s)
- Thomas C Shea
- Division of Hematology/Oncology, University of North Carolina School of Medicine, Chapel Hill, NC 27599, USA.
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Beaven AW, Shea TC. The Effect of Palifermin on Chemotherapyand Radiation Therapy–Induced Mucositis: A Review of the Current Literature. ACTA ACUST UNITED AC 2007; 4:188-97. [DOI: 10.3816/sct.2007.n.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Beaven AW, Shea TC. Recombinant human keratinocyte growth factor palifermin reduces oral mucositis and improves patient outcomes after stem cell transplant. Drugs Today (Barc) 2007; 43:461-73. [PMID: 17728847 DOI: 10.1358/dot.2007.43.7.1119723] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [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: 10/22/2022]
Abstract
Oral mucositis, the breakdown of the mucosal lining of the oropharynx, occurs as a result of a toxic insult to the normal epithelium of the oral mucosa. Typically this is seen after exposure to a toxic agent such as radiation or chemotherapy; therefore, it is a frequent problem for patients undergoing treatment for cancer. In clinical trials, mucositis has been reported in up to 98% of patients receiving high-dose chemotherapy followed by hematological stem cell transplant. When mucositis develops it causes severe patient symptoms such as pain, but it is also associated with inferior clinical outcomes including increased infection, narcotic use and even mortality. In clinical trials, palifermin, a recombinant humanized keratinocyte growth factor (rHuKGF), has demonstrated an ability to decrease the incidence and duration of mucositis. In the registrational phase III trial in patients undergoing stem cell transplant for hematological malignancies, only 63% of patients who received palifermin developed World Health Organization grade 3 or 4 mucositis compared to 98% of patients on the placebo arm (1). The patients on the palifermin arm also had a shorter duration of mucositis with significantly decreased pain, use of narcotics, need for total parenteral nutrition and febrile neutropenia. Based on these results, palifermin became the first drug that has been approved by the U.S. Food and Drug Administration (FDA) to decrease the incidence and duration of severe oral mucositis in patients with hematological malignancies receiving high-dose chemotherapy requiring hematopoietic stem cell support. The development of mucositis is also a problem for patients receiving treatment for nonhematological tumors. In clinical trials, mucositis has been reported in over 75% of patients receiving combined chemo-/radiotherapy for head and neck cancer or fluorouracil for metastatic colon cancer. Initial phase I and II clinical trials of palifermin have demonstrated a benefit in patients receiving chemotherapy with or without radiation therapy for solid tumors; however, large phase III trials need to be completed before palifermin can gain FDA approval for this indication.
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Affiliation(s)
- Anne W Beaven
- Division of Hematology/Oncology, University of North Carolina, Chapel Hill, NC 27710, USA.
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Beaven AW, Shea TC. Palifermin: a keratinocyte growth factor that reduces oral mucositis after stem cell transplant for haematological malignancies. Expert Opin Pharmacother 2006; 7:2287-99. [PMID: 17059384 DOI: 10.1517/14656566.7.16.2287] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [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: 11/05/2022]
Abstract
Mucositis occurs in < or = 98% of patients undergoing stem cell transplant for haematological malignancies and is associated with significant morbidity and mortality. Patients with severe mucositis have more pain, more difficulty with daily activities such as talking and eating, and are more likely to have bacteraemia. Palifermin is a keratinocyte growth factor that has been shown to decrease severity and duration of mucositis with a concurrent decrease in patient-reported symptoms and use of narcotics and total parenteral nutrition. Research is ongoing into palifermin's potential ability to decrease graft-versus-host disease and improve reconstitution of functional T lymphocytes after allogeneic stem cell transplant, to hasten wound healing and to reduce mucositis following external beam radiation therapy in solid tumour patients.
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Affiliation(s)
- Anne W Beaven
- University of North Carolina, Hematology/Oncology, Chapel Hill, NC 27599, USA.
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Beaven AW, Goldberg RM. Adjuvant therapy for colorectal cancer: yesterday, today, and tomorrow. Oncology (Williston Park) 2006; 20:461-9; discussion 469-70, 473-5. [PMID: 16739745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/09/2023]
Abstract
During the 1980s, the only drug routinely used to treat colorectal carcinoma was single-agent fluorouracil (5-FU), a drug that had shown no proven benefit in the adjuvant setting. Since then, significant improvements in the overall management of colorectal cancer have been made. This review will compare today's standard of care for adjuvant colorectal carcinoma to that practiced 20 years ago. The authors examine key questions asked about adjuvant therapy and the answers that ultimately changed clinical practice standards and improved overall survival for patients diagnosed with this disease. In addition, this review explores whether 5-FU should be given as part of a multidrug regimen and which route of administration is best when this drug is given. Further, the authors delve into both the use of locally directed therapies to the liver or peritoneum to improve outcomes and the selection of patients to receive adjuvant chemotherapy. Finally, a look to the future shows monoclonal antibodies to be an avenue of great promise infighting colorectal cancer.
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MESH Headings
- Administration, Oral
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antineoplastic Agents/administration & dosage
- Antineoplastic Agents/therapeutic use
- Camptothecin/administration & dosage
- Camptothecin/analogs & derivatives
- Camptothecin/therapeutic use
- Cetuximab
- Chemotherapy, Adjuvant/history
- Chemotherapy, Adjuvant/trends
- Colorectal Neoplasms/drug therapy
- Colorectal Neoplasms/mortality
- Colorectal Neoplasms/surgery
- Drug Therapy, Combination
- Fluorouracil/administration & dosage
- Fluorouracil/therapeutic use
- History, 20th Century
- History, 21st Century
- Humans
- Infusions, Intravenous
- Injections, Intravenous
- Irinotecan
- Leucovorin/administration & dosage
- Leucovorin/therapeutic use
- Liver Neoplasms/drug therapy
- Liver Neoplasms/secondary
- Organoplatinum Compounds/administration & dosage
- Organoplatinum Compounds/therapeutic use
- Oxaliplatin
- Patient Selection
- Randomized Controlled Trials as Topic
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Affiliation(s)
- Anne W Beaven
- Division of Hematology-Oncology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, 27599, USA
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