Results of a salvage treatment program for relapsing lymphoma: MINE consolidated with ESHAP

Allogeneic hematopoietic transplantation for chronic lymphocytic leukemia and lymphoma: potential for nonablative preparative regimens

There is increasing interest in the use of allogeneic blood and marrow transplants for chronic lymphocytic leukemia (CLL) and lymphomas. Numerous studies indicate efficacy in patients with advanced disease and demonstrate existence of a potent graft-versus-malignancy effect against these disorders. Allogeneic transplantation is most effective in CLL and low-grade lymphomas, but precise indications and timing of allogeneic transplants in these indolent disorders are not well defined. Allotransplantation is an effective, potentially curative approach, albeit with substantial risks; it is indicated in selected categories of patients. Allogeneic transplants are also promising for mantle cell lymphoma. In large-cell lymphoma, relapses are reduced in allogeneic compared with autologous transplants, but the benefit of allotransplantation has been offset by increased risk of treatment-related complications, and its indications are controversial. A promising new strategy is the use of less toxic, nonmyeloablative preparative regimens to achieve engraftment and allow development of graft-versus-malignancy effects that can produce durable remission in selected categories of lymphoid malignancies.

Liposomal vincristine in relapsed non-Hodgkin's lymphomas: early results of an ongoing phase II trial

OBJECTIVE

Vincristine is an active agent in lymphomas, but is often neurotoxic, and the resulting dose reductions have been associated with lower remission and survival rates in Hodgkin's disease. Liposomal vincristine (Onco-TCS) has prolonged half-life, reaches higher concentration in tumors and lymph nodes than in nerves, and administered at full doses appears to be less neurotoxic, and more active then free vincristine in mice bearing L-1210 and P-388 leukemias. We therefore explored its activity in relapsed non-Hodgkin's lymphomas (NHL) and acute lymphoblastic leukemia (ALL).

PATIENTS AND METHODS

Eligible patients had histologically proven relapse, age > or = 16 years, normal renal function, neutrophils > 500/microliter, platelets > 50,000/microliter, and no HIV infection, central nervous system disease, or serious neuropathy. Patients were treated with 2.0 mg/m2 of liposomal vincristine i.v. over 60 minutes q 14 days. Responders received up to 12 injections.

RESULTS

Of the 51 registered patients, 35 are currently evaluable for response. Median age was 62 years (range 19-86), and 21 were male. The median number of prior regimens was 3 (range 1-10) and had included vincristine in all patients, of whom 51% were refractory to their last regimen. Serum LDH was high in 46%, and beta 2-microglobulin > 3.0 mg/l in 63% of patients. Of the 155 administered injections, 138 (89%) were at the 2.0 mg/m2 level. The median injected dose was 3.8 mg (range 2.6-4.8 mg), and median number of injections was 4 (range 1-12). Responses were seen in 14 of 34 (41%) patients with NHL (95% confidence intervals (95% CI) 25%-59%). Response rates were 10% for indolent, 71% for transformed, and 47% for aggressive NHL, but the 95% confidence intervals overlapped. Median progression-free survival was 5.5 months for responders. Grade 3-4 motor or sensory neuropathy was seen in 11, and caused termination of therapy in five patients. All five had prior neuropathy, two had previously received paclitaxel, one platinum, and two paclitaxel and platinum. Fever was detected in three patients, but there were no toxic deaths.

CONCLUSIONS

Liposomal vincristine is active and well tolerated in this heavily pretreated population with relapsed NHL, but can be neurotoxic in a fraction of patients heavily exposed to prior neurotoxic agents. These data, if confirmed, would suggest a potential role for liposomal vincristine in the combination therapy of previously untreated patients with NHL.

The role of ifosfamide in the treatment of lymphomas

Over the last few decades, progress has been made in classification and treatment guidelines for patients with lymphoma with differing prognostic factors. As investigators look for alternatives to current standard therapy there has been a resurgence of interest in the alkylating agent ifosfamide. A basic tenet of lymphoma therapy has been to use combinations of non-cross resistant agents in an effort to avoid tumor resistance. Ifosfamide is at least partially non-cross resistant with cyclophosphamide, and because it is often only modestly myelosuppressive, it is useful in combination regimens. Other toxicities of ifosfamide, including urinary bladder toxicity and neurotoxicity, are generally predictive and seldom occur in clinical practice with standard ifosfamide doses and proper screening and preventive therapy. Several regimens incorporating ifosfamide in a variety of doses and schedules have demonstrated clinical efficacy in the treatment of lymphomas. Ifosfamide is most commonly used in regimens for patients with relapsed or refractory disease, although there has been interest in ifosfamide as part of initial therapy regimens. Ifosfamide is an active agent as part of combination therapy for patients with both indolent and aggressive relapsed lymphomas, and has also been used in high-dose therapy regimens followed by stem cell or bone marrow rescue. Future studies incorporating ifosfamide should be directed towards its use in outpatient regimens as initial therapy for patients with lymphoma and in regimens designed for patients with relapsed or refractory disease.

Feasibility of ESHAP + G-CSF as peripheral blood hematopoietic progenitor cell mobilisation regimen in resistant and relapsed lymphoma: a single-center study of 22 patients

The purpose was study the feasibility of ESHAP + G-CSF for peripheral blood hematopoietic progenitor cell (PBPC) mobilisation in resistant/relapsed Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL). Twenty-two consecutive patients with HD (8) and N-HL (14) received ESHAP chemotherapy and G-CSF (5 microg/Kg/d). When a minimum number of 10,000 peripheral blood CD34+ cells/mL was observed patients underwent leukapheresis until a CD34+ cell dose > or = 2.5x10(6)/Kg was collected or the PBPC peak was lost. Blood cells kinetics and toxicity were analysed. Data concerning the day of first apheresis, number of procedures per patient, and cellular yield of the aphereses were recorded. Correlation between the CD34+ cell content in the apheresis product and the two diagnosis groups was attempted. Twelve patients (54%) developed short-lived severe neutropenia (<0.5x10(9)/L). Thrombocytopenia (<25x10(9)/L) had a median duration of 1 day. Fever appeared in 4 patients and CN Staph bacteriemia in 2 cases. Bleeding events did not supervene and no deaths occurred. Aphereses started at day +15 (median) and the median number of apheresis/patient was 2. Seventeen patients underwent 1 or 2 leukaphereses. Thirteen patients (59%) achieved the CD34+ cell target in the first apheresis. NHL patients obtained statistically significant better CD34+ cell collections than HD. Only 2 HD patients failed to mobilise, 1 previously treated with high-dose therapy and autologous bone marrow transplantation. ESHAP + G-CSF has been shown to be feasible for PBPC mobilisation in resistant/relapsed lymphoma. Toxicity was low and CD34+ cell yield high, especially in N-HL. This mobilisation regimen should be further explored in a larger patient population.

Intensive chemotherapy with hematopoietic cell transplantation after ESHAP therapy for relapsed or refractory non-Hodgkin's lymphoma. Results of a single-centre study of 65 patients

This study was designed to assess the results of protracted courses of ESHAP (etoposide, cytarabine, cisplatin, methylprednisolone) therapy followed by intensive chemotherapy and hematopoietic cell transplantation (IC+HCT) for relapsed or refractory non-Hodgkin's lymphoma (NHL). Treatment consisted of 3 cycles of ESHAP; responsive patients (pts) then received 3 more cycles, and IC+HCT was used for pts in maintained partial (PR) or complete (CR) remission after the sixth ESHAP. Sixty-five pts entered the study. At enrollment, 27 pts had bone marrow (BM) and/or central nervous system (CNS) lymphomatous infiltration. Disease status was primary refractory lymphoma in 41 pts (63 %), and relapse in 24 pts (37 %). Results showed that two pts were not evaluable for the therapeutic response because of early treatment-related death. Thirty-nine (62 %) pts entered PR or CR after 3 cycles of ESHAP. Eleven pts subsequently had disease progression. Twenty-eight pts were in persistent CR or PR after 6 cycles of ESHAP. Refractory pts did not show a different response rate to relapsing pts (chi2= 1.73). Five pts were excluded from IC+HCT because of an inadequate graft or treatment-related toxicity. Twenty-three (35 %) pts completed the procedure. Five pts (22 %) relapsed after IC+HCT. The overall survival rate of the 39 responsive pts is 45 % at 60 months, with a median survival time of 30 months. Median survival among the 35 pts in whom second-line chemotherapy failed is 7.1 months, with a 4-year survival rate of 3 %. Despite the poor prognostic features of this group, 45% of pts responding to the first 3 cycles of chemotherapy are in prolonged remission, suggesting that rather than to transplant after just 2 cycles of salvage therapy, pursuing second-line chemotherapy may better discriminate between patients more likely to benefit from a subsequent transplant.

Dexamethasone, cytarabine, ifosfamide, and cisplatin as salvage therapy in non-Hodgkin lymphoma

The authors conducted a phase II study to evaluate a new combination of chemotherapeutic drugs that includes dexamethasone, cytarabine, ifosfamide, and cisplatin as salvage therapy in non-Hodgkin lymphoma after prior exposure to both adriamycin and etoposide. All drugs were administered intravenously over 4 consecutive days. The daily dose of dexamethasone was 20 mg twice daily. The maximal daily doses of cytarabine, ifosfamide, and cisplatin were 75 mg/m2, 1,200 mg/m2, and 20 mg/m2, respectively. Cycles were repeated every 3 weeks. A total of 31 patients were entered in the trial. Thirty patients were evaluable for response. A complete response was seen in 11 patients (37%), and a partial response was noted in six patients (20%). A significantly higher complete response rate was seen in patients with relapsing non-Hodgkin lymphoma compared with those who failed to achieve a complete response with the last chemotherapy (10/14 vs. 1/16; p < 0.013). A complete response continues in two patients who received consolidation with high-dose chemotherapy for more than 49 months and more than 60 months for each patient. Median time to treatment failure and median survival were 3.3 months and 7.5 months, respectively, for the entire group and 11 months and 30 months, respectively, for complete responders. Myelosuppression was pronounced but was usually of short duration. Neutropenic fever developed in 13 patients (42%) and in 15 of 96 cycles (16%). Platelet transfusions were required in seven patients (23%). There was one drug-related death associated with myelotoxicity. Nonhematologic toxicity was not dose limiting. The authors conclude that dexamethasone, cytarabine, ifosfamide, and cisplatin is active and a relatively tolerable regime for patients with non-Hodgkin lymphoma previously treated with adriamycin and etoposide.

ESHAP as salvage therapy for refractory non-Hodgkin's lymphoma: Taiwan experience

BACKGROUND

The ESHAP regimen, a combination of the chemotherapeutic drugs etoposide, methylprednisolone (solumedrol), high-dose cytarabine (ara-C) and cisplatin, has been shown to be active against refractory non-Hodgkin's lymphoma in therapeutic trials. We were interested in determining whether this regimen would be effective and tolerable for Chinese patients.

METHODS

Thirty-two patients with refractory/relapsed non-Hodgkins lymphoma (23 intermediate-grade and nine high-grade) were enrolled in this study. Etoposide was administered at a dose of 40 mg/m2/day as a 1 h intravenous infusion from day 1 to day 4, solumedrol 500 mg/day was given as a 15 min intravenous infusion from day 1 to day 5, ara-C 2 g/m2 was given as a 2 h intravenous infusion on day 5 and cisplatin was given at a dose of 25 mg/m2/day as a continuous infusion from day 1 to day 4. Clinical efficacy and toxicity were assessed on the basis of the WHO criteria.

RESULTS

Ten patients (31.3%, 95% Cl 15.2-47.4%) attained complete remission (CR) and seven had partial remission (PR). The overall response rate was 53.1% (95% Cl 35.8-70.4%). In eight of the 10 CR patients, the remission lasted for more than 8 months. The remaining two patients had CR of 5 and 6 months. The median duration of CR was 12.2 months (range 5-22 months). Myelosuppression with subsequent infections was the major toxicity. Severe leukopenia (WBC < 1000/microliter) lasted for an average of 12 days and thrombocytopenia (< 25,000/microliter) 18 days. One patient (3.1%) died of neutropenia-associated sepsis within 4 weeks after treatment. Non-myeloid toxicities included alopecia in 66% (28% grade 2, 22% grade 3), stomatitis in 72% (25% grade 2, 28% grade 3, 13% grade 4), hepatotoxicity in 9% (3% grade 2), renal toxicity in 13% (6% grade 2, 3% grade 3) and infection in 56% (18% grade 2, 25% grade 3, 13% grade 4). The majority of the responders relapsed within 2 years after ESHAP treatment. Median survival for all patients was 8.6 months.

CONCLUSIONS

ESHAP is an active and tolerable regimen in Chinese patients with relapsed/refractory lymphoma, but the duration of remission is brief and without significant impact on survival.

Ninety-six-hour paclitaxel infusion with mitoxantrone and ifosfamide/mesna and consolidation with ESHAP for refractory and relapsed non-Hodgkin's lymphoma

A prospective phase II study was carried out in 48 patients with relapsed or refractory non-Hodgkin's lymphoma using paclitaxel 27.5 mg/M2 i.v. by continuous infusion over 24 hours daily on days 1, 2, 3, and 4 in combination with mitoxantrone 8 mg/M2 i.v. on day 1 and ifosfamide/mesna 1.33 grams/M2 i.v. daily on days 1, 2, and 3 (MINT). Responding patients completed four cycles of MINT and were consolidated with etoposide, solumedrol [methylprednisolone], high-dose cytarabine [Ara-C], and platinum (ESHAP). Forty-eight patients were entered in the study between 1994 and 1996 at The University of Texas M. D. Anderson Cancer Center. Overall response after the first four cycles of MINT was 67% (16% complete response [CR]+ 51% partial response [PR]) and after consolidation with ESHAP it was 49% (26% CR + 23% PR). Variables associated with an improved CR rate and better failure-free survival included the number of prior treatments and the response to prior treatment. A comparison with a similar group of patients treated with mesna, ifosfamide, mitoxantrone, and etoposide (MINE)-ESHAP revealed no major differences in outcome.

Paclitaxel plus high-dose cyclophosphamide with G-CSF support in patients with relapsed and refractory aggressive non-Hodgkin's lymphoma

Based on the single-agent activity of both paclitaxel and cyclophosphamide in the treatment of non-Hodgkin's lymphoma (NHL), we conducted a phase II study to evaluate the efficacy of the combination of the two drugs in patients with refractory and relapsed aggressive NHL. All patients received 900 mg/m2 bolus of cyclophosphamide intravenously daily for 3 consecutive days with a concurrent infusion of 150 mg/m2 of paclitaxel over 72 h (50 mg/m2/d). 24 h after the completion of chemotherapy, patients received subcutaneous injections of 5 microg/kg of granulocyte-colony stimulating factor (G-CSF) daily until white cell count recovery. Treatment was repeated every 3 weeks. Patients who had at least a partial response (PR) after two courses continued to receive a maximum of four courses. Patients with responding disease were allowed to undergo high-dose chemotherapy followed by stem-cell/bone marrow transplantation if they were eligible. Of the 77 patients who were eligible for the study, 74 (96%) were evaluable for toxicity and treatment response. The overall response rate was 45% (95% CI 33-57%). Patients who received treatment after their disease relapsed from a complete response (CR) had an 81% response rate (38% CRs), whereas those with primary refractory disease had a 22% response rate. Toxicities of > grade 2 included alopecia (100%) and stomatitis (25%). Neutropenic fever of grade > 2 occurred after 18% of the courses, and platelet count of < or = 20 x 10(9)/l developed after 20% of the courses. Thus, the combination of paclitaxel plus high-dose cyclophosphamide is an effective new regimen in the treatment of refractory and relapsed NHL.

High-dose chemotherapy and hematopoietic stem cell transplantation for relapsed or refractory diffuse large-cell non-Hodgkin's lymphoma

The use of high-dose chemotherapy and transplantation for chemotherapy sensitive relapsed diffuse large-cell non-Hodgkin's lymphoma is now the gold standard for patients who are candidates for such therapy. Recent data also demonstrates the relative effectiveness of this approach for patients who are induction failures but are continuing to respond to conventional therapy at the time of transplantation. Newer approaches such as the use of novel agents to modify the transplant regimen, newer cytokines, or alternative sources of hematopoietic stem cells need to be tested in order to improve the outcome in patients with chemotherapy resistant disease.

Alternating triple therapy for the treatment of intermediate grade and immunoblastic lymphoma

BACKGROUND

CHOP is currently considered the gold standard of treatment for intermediate grade lymphomas. We designed a new regimen known as 'ATT' (alternating triple therapy) which uses three non-cross resistant combinations in alternating sequence for nine cycles.

MATERIALS AND METHODS

This is a phase II clinical trial with comparison to CHOP/CMED historical controls using prognostic factors. The tumor score system was used to evaluate the results of this trial. Two hundred sixty-eight eligible patients who had one or more of the following adverse features: bulky disease, elevated LDH or > 1 extranodal site were analyzed. Outcome measures consist of survival and failure free survival.

RESULTS

At a median follow-up of 32 months, there was no statistically significant difference in survival for those with favorable prognostic factors (tumor score < or = 2). However, there was a statistically significant difference in favor of ATT for those with unfavorable tumor scores. When we examined the failure-free survival of those with unfavorable tumor scores, we again observed a superiority for the ATT regimen over CHOP/CMED but the opposite was true for those with favorable tumor scores. We also found a statistically significant difference in favor of the ATT regimen when compared with CHOP/CMED for patients < or = 60 years old with a tumor score > or = 3, while no advantage was found for those > 60 years.

CONCLUSIONS

ATT appears more effective but only for patients < 60 years old with unfavorable tumor scores. In those older than 60 years with favorable tumor score, CHOP/CMED appears superior. ATT might be an adequate regimen for young patients with poor prognostic features while CHOP/CMED might be a better choice for those with good prognosis irrespective of age. For those > 60 years with unfavorable tumor scores neither ATT or CHOP/CMED were adequate treatment. Because of the phase II nature of this study, these conclusions should be considered as hypotheses which require prospective testing.

Dexamethasone, etoposide, ifosfamide, and cisplatin as second-line therapy in patients with aggressive non-Hodgkin's lymphoma

BACKGROUND

This study analyzed the long term results of a combination of dexamethasone, etoposide, ifosfamide, and cisplatin (DVIP) used at the study center as standard second-line combination therapy in patients with aggressive non-Hodgkin's lymphoma (NHL) after prior exposure to doxorubicin.

METHODS

All drugs were given intravenously for 4 consecutive days. The maximum daily doses of etoposide, ifosfamide, and cisplatin were 75 mg/m2, 1200 mg/m2, and 20 mg/m2, respectively. The dexamethasone dose was 20 mg twice daily. Cycles were repeated every 3 weeks.

RESULTS

Fifty-six patients were included in the study. Partial response was noted in 18 patients (32%) and complete response (CR) in 18 patients (32%). Pretreatment factors that predicted CR were CR with prior therapy (CR in 17 of 34 in patients with a recurrence vs. 1 of 21 in patients with primary refractory NHL) and age (CR in 12 of 25 patients age < or = 65 years vs. 6 of 31 patients age > 65 years). Median time to treatment failure (TTF) and median survival were 11.5 months and 30 months, respectively, for patients with a CR and 3.5 months and 8 months, respectively, for all patients. Five patients (9%) remained disease free for > 24 months. By multivariate analysis, age was the only independent prognostic factor for TTF, whereas age, serum lactate dehydrogenase, and number of extranodal sites were independent predictors for survival. Myelosuppression (median granulocyte nadir and median platelet nadir of 350/mm3 and 77,000/mm3, respectively) was the major toxicity. There was one possible drug-related death associated with myelosuppression.

CONCLUSIONS

DVIP is a relatively safe salvage combination therapy in patients with aggressive NHL. Response to first-line therapy and age are the most important predictors for prognosis after the administration of DVIP. This regimen is highly active in patients with recurrent NHL, but relatively ineffective in patients with primary refractory NHL.

Long-term follow-up of platinum-based lymphoma salvage regimens. The M.D. Anderson Cancer Center experience

Platinum-based regimens have been the most commonly used salvage therapy for non-Hodgkin's lymphoma (NHL). In this update of two of these regimens with long-term follow-up data, we provide evidence that the etoposide-containing regimen (ESHAP) is superior to a cisplatin-cytosine arabinoside-based regimen (DHAP) in response rate, survival, and time to treatment failure. In spite of this superiority, the long-term outcome for most patients with relapsed or refractory NHL remains unfavorable. Newer salvage regimens such as MINE-ESHAP, or, when feasible, high-dose chemotherapy with transplant, are probably better choices than either DHAP or ESHAP alone.

Low-grade lymphomas: new entities and treatment concepts

Therapy for patients with low-grade lymphomas has never been standardized. Recently, new entities have been described which are included in the REAL classification, and whether these entities should be regarded as separate diseases is not yet clear. Regardless, three new developments in the management of patients with low-grade lymphomas deserve special attention for treatment programs in the future. First, it appears that patients with stage I, II, and III low-grade lymphomas may enjoy very prolonged disease-free intervals after treatment with combination chemotherapy and radiation therapy programs. Although investigators disagree on prognostic factors, new features, such as beta 2-microglobulin appear to predict results better than any other feature, and future studies should address this prognostic factor in assessing their results. Second, for patients with advanced stage disease, administration of interferon as maintenance therapy prolongs the disease-free interval, and use of this drug should be further investigated. Finally, molecular studies using PCR for bcl-2 may be clinically relevant in detecting residual disease in patients with follicular lymphomas, and future studies should focus on the value of eliminating the residual disease from blood and marrow.