301
|
Hertzberg MS, Crombie C, Benson W, Taper J, Gottlieb D, Bradstock KF. Outpatient-based ifosfamide, carboplatin and etoposide (ICE) chemotherapy in transplant-eligible patients with non-Hodgkin's lymphoma and Hodgkin's disease. Ann Oncol 2003; 14 Suppl 1:i11-6. [PMID: 12736225 DOI: 10.1093/annonc/mdg703] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We have treated 38 transplant-eligible patients with relapsed/refractory non-Hodgkin's lymphoma and Hodgkin's disease using an outpatient-based regimen of ifosfamide, carboplatin and etoposide (ICE) for both salvage and peripheral blood stem cell mobilisation. Patients included relapsed or refractory diffuse large B-cell lymphoma (n = 17), follicular lymphoma (n = II), T-cell lymphoma (n = 2), mantle cell lymphoma (n = 2) and Hodgkin's disease (n = 6). Seven patients with diffuse large B-cell lymphoma and three patients with follicular lymphoma (26%) were considered chemorefractory. Cycles of ICE therapy were administered every 21 days as an outpatient and consisted of ifosfamide 5000 mg/m2 intravenously (i.v.) fractionated into three equally divided doses over 3 days, carboplatin [mg dose = 5 x area under the curve (AUC)] i.v. on day 1 and etoposide 100 mg/m2- i.v. daily for 3 days. Subsequently. granulocyte colony-stimulating factor (G-CSF)5 microg/kg subcutaneously (s.c.) was administered daily from day +5. Of the I I follicular lymphoma patients, 10 also received rituximab with ICE therapy. Median age of patients was 52 years (range 30-65). Patients received a mean of 2.6 cycles (range 1-4) of ICE. There were no toxic deaths and no significant non-haematological toxicities secondary to ICE therapy. Grade IV thrombocytopenia and grade IV neutropenia with at least one cycle of ICE were seen in 47% and 53% of patients, respectively. Median time to peripheral blood stem cell (PBSC) harvest was 14 days (range 10-20). while the median CD34+ cell yield was 5.2 x 10(6) cells/kg(range 2.3 x 10(6)-27.2 x 10(6)). Only one of the ICE-responders failed to mobilise PBSCs. The overall response rate to ICE was 87%. comprising 14 patients (37%) who achieved a complete response (CR) and 19 (50%) who achieved a partial response (PR). A total of 30 patients have undergone autologous stem cell transplantation(SCT) while two follicular lymphoma patients have received a non-myeloablative allogeneic SCT. Follow-up is short: however, the Kaplan-Meier estimate of the proportion of patients alive and event-free at a median follow-up of 11 months is 80% and 59%, respectively. Event-free survival for patients who achieved a CR after ICE and transplantation is 88% versus 45% for those who achieved a PR. These data confirm the efficacy and tolerability of fractionated ICE chemotherapy as both a salvage and mobilisation regimen that can be readily delivered in an outpatient setting.
Collapse
Affiliation(s)
- M S Hertzberg
- Department of Haematology, Westmead Hospital, Westmead, NSW 2145, Australia.
| | | | | | | | | | | |
Collapse
|
302
|
Gisselbrecht C. Hodgkin's lymphoma: what is next in salvage treatment? Ann Oncol 2003; 14 Suppl 1:i37-8. [PMID: 12736229 DOI: 10.1093/annonc/mdg707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Gisselbrecht
- Institut d'Hématologie, Hôpital Saint Louis, Paris, France.
| |
Collapse
|
303
|
Kewalramani T, Nimer SD, Zelenetz AD, Malhotra S, Qin J, Yahalom J, Moskowitz CH. Progressive disease following autologous transplantation in patients with chemosensitive relapsed or primary refractory Hodgkin's disease or aggressive non-Hodgkin's lymphoma. Bone Marrow Transplant 2003; 32:673-9. [PMID: 13130314 DOI: 10.1038/sj.bmt.1704214] [Citation(s) in RCA: 96] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
To determine the outcome of patients with chemosensitive relapsed or primary refractory Hodgkin's disease (HD) or aggressive non-Hodgkin's lymphoma (NHL) whose disease progresses after autologous stem cell transplantation (ASCT), we reviewed the records of 82 patients with HD and 139 patients with NHL transplanted between 1993 and 2000. Disease progression occurred in 25 patients with HD and 66 patients with NHL, with median times to progression (TTP) of 3.8 and 5.1 months, respectively. Median survival times following ASCT failure were 26 and 7.7 months for patients with HD and NHL, respectively. The second-line international prognostic index (sIPI) and the TTP (before or after 3 months from ASCT) independently were predictive of survival for NHL patients. In addition, treatment with rituximab for patients with B cell NHL was associated with improved survival (median 28.6 vs 4.1 months, P=0.003), independent of the sIPI and TTP. Prognostic factors for patients with HD were not identified. Only two patients, one of whom was among six patients who received second autologous transplants, remain disease-free. The uniformly poor outcome associated with disease progression after ASCT should prompt efforts to assess the feasibility and utility of detecting and treating post transplant residual disease during a minimal disease state, before overt progression.
Collapse
Affiliation(s)
- T Kewalramani
- Department of Medicine, Lymphoma and Hematology Services, Memorial Sloan-Kettering Cancer Center, New York, NY 10021, USA.
| | | | | | | | | | | | | |
Collapse
|
304
|
Gutierrez-Delgado F, Holmberg L, Hooper H, Petersdorf S, Press O, Maziarz R, Maloney D, Chauncey T, Appelbaum F, Bensinger W. Autologous stem cell transplantation for Hodgkin's disease: busulfan, melphalan and thiotepa compared to a radiation-based regimen. Bone Marrow Transplant 2003; 32:279-85. [PMID: 12858199 DOI: 10.1038/sj.bmt.1704110] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We evaluated prognostic factors and treatment outcome of patients with relapsed/refractory Hodgkin's disease (HD) receiving autologous stem cell transplantation (ASCT). In total, 92 patients received total body irradiation, cyclophosphamide and etoposide (TBI/CY/E) (n=42) or busulfan, melphalan and thiotepa (Bu/Mel/T) (n=50) supported with ASCT. A total of 33 (66%) patients receiving the Bu/Mel/T regimen had a prior history of dose-limiting irradiation. Mucositis, hepatic and pulmonary toxicities were the main causes of morbidity and mortality, irrespective of the conditioning regimen. The transplant-related mortality was 15%. With a median follow-up of 6 years (range 2.5-11), the cumulative probabilities of survival, event-free survival (EFS) and relapse at 6 years were 55, 51 and 32%. The 6-year Kaplan-Meier (KM) probabilities of EFS for patients with less advanced disease (patients in first chemotherapy-responsive relapse or second remission (n=42)) and more advanced disease (all other patients (n=50)) were 60 and 44%. No differences in toxicities and efficacy between the conditioning regimens were found. ASCT is an effective treatment for patients with refractory/relapsed HD. Female patients and patients with less advanced disease at transplant had a better outcome. Patients with prior irradiation benefited from the Bu/Mel/T regimen.
Collapse
Affiliation(s)
- F Gutierrez-Delgado
- Fred Hutchinson Cancer Research, Veterans Administration Hospital, University of Washington, Seattle, WA, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
305
|
Tarella C, Cuttica A, Vitolo U, Liberati M, Di Nicola M, Cortelazzo S, Rosato R, Rosanelli C, Di Renzo N, Musso M, Pavone E, Santini G, Pescarollo A, De Crescenzo A, Federico M, Gallamini A, Pregno P, Romano R, Coser P, Gallo E, Boccadoro M, Barbui T, Pileri A, Gianni AM, Levis A. High-dose sequential chemotherapy and peripheral blood progenitor cell autografting in patients with refractory and/or recurrent Hodgkin lymphoma: a multicenter study of the intergruppo Italiano Linfomi showing prolonged disease free survival in patients treated at first recurrence. Cancer 2003; 97:2748-59. [PMID: 12767087 DOI: 10.1002/cncr.11414] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The objective of the current study was to evaluate in a multicenter setting the feasibility and efficacy of a high-dose sequential (HDS) chemotherapy regimen that combined intensive debulking and high-dose therapy (HDT) with peripheral blood progenitor cell (PBPC) autografting in patients with refractory or recurrent Hodgkin lymphoma (HL). METHODS Data were collected from 102 patients with HL who were treated with the HDS regimen at 14 centers associated with the Intergruppo Italiano Linfomi. Twenty-four patients had primary refractory HL, 59 patients had their first recurrence of HL (within 1 year in 32 patients and > 1 year in 27 patients), and 19 patients had multiple disease recurrences. The HDS regimen included the sequential delivery of high-dose (hd) cyclophosphamide with PBPC harvesting, methotrexate, etoposide, then HDT (usually hd mitoxantrone plus L-phenylalanine mustard) with PBPC autografting. In addition, radiotherapy was delivered to 36 patients at sites of bulky or persistent disease. RESULTS Ninety-two patients (90%) completed the HDS program. There were five toxic deaths (treatment-related mortality rate, 4.9%) and six secondary malignan cies (five patients developed myelodysplastic syndrome/acute myelogenous leukemia, and one patient developed colorectal carcinoma). At a median follow-up of 5 years, the 5-year overall survival (OS) and event-free survival (EFS) projections were 64% (95% confidence interval [95% CI], 54-74%) and 53% (95% CI, 43-63%), respectively. Patients with their first recurrence had the most favorable outcome, with 5-year OS and EFS projections of 77% (95% CI, 66-88%) and 63% (95% CI, 50-76%), respectively. There were no significant differences between patients with early first recurrence and late first recurrence. The poorest outcome was observed in patients with refractory HL, with 5-year OS and EFS projections of 36% (95% CI, 16-55%) and 33% (95% CI, 14-52%), respectively. Patients who received HDS chemotherapy after multiple recurrences had an intermediate outcome. Multivariate analysis showed that refractory disease and systemic symptoms at the time of initial presentation were associated significantly associated with poor OS and EFS. CONCLUSIONS The use of HDS chemotherapy for patients with refractory and/or recurrent HL is feasible at the multicenter level. The combination of intensive debulking and HDT with PBPC autografting offers a good chance of prolonged disease free survival for patients with their first recurrence of HL.
Collapse
Affiliation(s)
- Corrado Tarella
- Dipartimento Medicina-Oncologia Sperimentale, Divisione Universitaria di Ematologia, Torino, Italy.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
306
|
Abstract
Although childhood Hodgkin disease is sensitive to the treatment regimens devised for Hodgkin disease in adults, long-term toxicity is enhanced in the developing individual. As a result, there have been dual goals in the design of clinical trials for pediatric Hodgkin disease: 1) to reduce long-term organ injury; and 2) to increase efficacy. Radiation dose and field has been reduced by enhanced reliance on chemotherapy, thus limiting the risks of hypoplasia, hypothyroidism, secondary cancers, and valvular and atherosclerotic heart disease. Multiagent, chemotherapeutic regimens for children have been developed to avoid the risks of sterility, leukemia, and cardiopulmonary toxicity. Newer approaches advocate for early dose intensity to limit cumulative therapy using response-based paradigms. Targeting molecular mechanisms specific for the Reed-Sternberg cell may allow for less toxic and more efficacious treatments in the future.
Collapse
Affiliation(s)
- Cindy L Schwartz
- Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, Maryland 21208, USA.
| |
Collapse
|
307
|
Affiliation(s)
- I Avivi
- University College London Hospitals, UK.
| | | |
Collapse
|
308
|
Josting A, Rudolph C, Reiser M, Mapara M, Sieber M, Kirchner HH, Dörken B, Hossfeld DK, Diehl V, Engert A. Time-intensified dexamethasone/cisplatin/cytarabine: an effective salvage therapy with low toxicity in patients with relapsed and refractory Hodgkin's disease. Ann Oncol 2002; 13:1628-35. [PMID: 12377653 DOI: 10.1093/annonc/mdf221] [Citation(s) in RCA: 148] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND An important variable affecting outcome in relapsed and refractory Hodgkin's disease (HD) is the potential of conventional salvage chemotherapy to reduce tumor volume before high-dose chemotherapy (HDCT) and autologous stem cell transplantation. Currently, the optimal salvage chemotherapy regimen for these patients is unclear. Since dexamethasone/cisplatin/cytarabine (DHAP) given at 3-4 week intervals has been shown to be very effective in patients with relapsed aggressive non-Hodgkin's lymphoma, we evaluated this regimen given at a median of 16-day intervals in patients with relapsed and refractory HD. PATIENTS AND METHODS Patients with relapsed or refractory HD were treated with two cycles of DHAP [dexamethasone 40 mg intravenously (i.v.) day 1-4, cisplatin 100 mg/m(2) i.v. as 24-h continuous infusion day 1, and cytarabine 2 g/m(2) i.v. 12q day 2]. Granulocyte colony-stimulating factor (G-CSF) was given at a dose of 5 micro g/kg from day 4 until day 13. Patients with partial remission (PR) or complete remission (CR) after two cycles of DHAP received sequential HDCT. RESULTS The median age of the 102 patients included was 34 years (range 21-64 years). Forty-two percent of the patients had late relapse, 29% early relapse, 12% multiple relapse and 16% primary progressive/refractory disease. The response rate (RR) after two cycles of DHAP was 89% (21% CR, 68% PR). The RRs for patients with late, early, multiple and progressive HD were 91%, 93%, 92% and 65%, respectively. Using the chi-square test for independence, remission status (relapsed HD versus progressive HD) and stage at relapse (stage I/II versus stage III/IV) were significant factors for response to DHAP. WHO grade 4 leukocytopenia and thrombocytopenia were the main toxic- ities occurring in 43% (mean duration 1.1 days, range 0-6) and 48% (mean duration 1.4 days, range 0-11) of all courses, respectively. Neither severe infections nor treatment-related deaths occurred. Peripheral blood stem cells (PBSCs) were collected after the first cycle DHAP in eight patients. The hematopoietic progenitors showed a very rapid increase from day 10 with a synchronous and impressive peak on day 12. A mean of 6.1 x 10(6)/kg CD34(+) cells were collected per apheresis. As originally recommended in the protocol, PBSCs were routinely collected during sequential HDCT in the remaining patients. CONCLUSIONS A brief tumor-reducing program with two cycles of DHAP given in short intervals supported by G-CSF is effective and well-tolerated in patients with relapsed and refractory HD. This regimen can be used to mobilize stem cells and select those patients with chemosensitive relapse who should subsequently be treated with HDCT.
Collapse
Affiliation(s)
- A Josting
- Klinik I für Innere Medizin, Universität zu Köln, Köln, Germany.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
309
|
Yahalom J. Changing role and decreasing size: current trends in radiotherapy for Hodgkin's disease. Curr Oncol Rep 2002; 4:415-23. [PMID: 12162917 DOI: 10.1007/s11912-002-0036-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Radiotherapy, the first cancer treatment modality that offered cure, is still considered to be the most effective "single agent" in treating Hodgkin's disease (HD). Yet, the role of radiotherapy in HD has changed dramatically with the advent of effective combination chemotherapy and the rising concern of long-term complications associated with successful treatment of HD. The new principles of integrating radiotherapy into a combined-modality regimen for HD at different prognostic stages are reviewed here, along with the effect of this new role on radiation field size and design.
Collapse
Affiliation(s)
- Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan-Kettering Cancer Center, Weill Medical College of Cornell University, 1275 York Avenue, New York, NY 10021, USA.
| |
Collapse
|
310
|
Abstract
Intensive therapy and autologous stem cell transplantation represent the standard of care in most patients whose Hodgkin disease has not been cured with conventional chemotherapy. With more prolonged follow-up of autografted patients, the problems with autologous stem cell transplantation are clear. In particular, recurrent disease and late transplant-related complications limit the effectiveness of this approach. A number of autologous stem cell transplantation studies have reported prognostic factors that will help identify patients at high risk for relapse. Several new approaches for decreasing recurrence rates are discussed, including novel immune strategies and re-evaluation of allogeneic stem cell transplantation. Although the risk of secondary malignancy and other causes of late morbidity and mortality after autologous stem cell transplantation is relatively low, current studies contribute to understanding of the pathogenesis of these complications and may diminish their impact in the future.
Collapse
Affiliation(s)
- Donna E Reece
- Department of Medical Oncology and Hematology, Princess Margaret Hospital, Toronto, Ontario, Canada.
| |
Collapse
|
311
|
Abstract
Approximately 75% of patients with Hodgkin's lymphoma can be cured with modern chemotherapy and radiation. Most patients are treated according to clinical stage and the associated prognostic factors. For patients with limited stage Hodgkin's lymphoma, combined modality treatment has replaced subtotal nodal irradiation as the preferred treatment option. This approach eliminates laparotomy and potentially decreases the long-term toxicity secondary to extended field irradiation and splenectomy. Furthermore, recent studies suggest that it may improve disease control and possibly survival. Multiple novel regimens have been tested in the past 20 years in patients with advanced Hodgkin's lymphoma including dose-intense regimens, but current evidence suggests that ABVD remains the treatment of choice outside clinical trials. Over the past decade, the treatment-related morbidity and mortality associated with autologous stem cell transplantation have reduced significantly and stem cell transplant is becoming the treatment of choice for most patients with primary refractory or recurrent Hodgkin's lymphoma. With longer follow-up, long-term complications, in particular secondary malignancy have become the leading cause of late treatment failure for patients with Hodgkin's lymphoma. To improve the overall outcome of patients with Hodgkin's lymphoma, future studies need to focus on reducing the therapy-related toxicity for patients with good risk disease as well as improving disease control for patients with poor risk disease through a risk-adapted approach.
Collapse
Affiliation(s)
- Henry C Fung
- Division of Hematology/Bone Marrow Transplantation, City of Hope National Medical Center, Duarte, CA 91010, USA.
| | | |
Collapse
|
312
|
Recent publications in hematological oncology. Hematol Oncol 2001. [PMID: 11574933 DOI: 10.1002/hon.673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
|
313
|
Kewalramani T, Moskowitz CH. Upfront transplantation for poor-risk aggressive non-Hodgkin lymphoma and Hodgkin's disease: who benefits? Curr Oncol Rep 2001; 3:271-8. [PMID: 11296139 DOI: 10.1007/s11912-001-0061-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
High-dose therapy with autologous stem-cell transplantation is the standard treatment for patients with relapsed or primary refractory Hodgkin's disease or non-Hodgkin lymphoma. The efficacy of the treatment in this setting has prompted extensive investigation of its role in upfront therapy for patients with a poor prognosis. Although the preliminary data appear promising, definitive results are still lacking, and upfront transplantation remains investigational. Newer regimens for the treatment of advanced-stage Hodgkin's disease appear to confer cure rates of approximately 85% to 90%. Thus, only a small minority of patients may potentially benefit from more aggressive therapy such as upfront transplantation. A reliable method of identifying these patients is yet to be determined. Upfront transplantation should be evaluated in these patients once they are identified.
Collapse
Affiliation(s)
- T Kewalramani
- Memorial Sloan-Kettering Cancer Center, Box 350, 1275 York Avenue, New York, NY 10021, USA
| | | |
Collapse
|