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

[Efficacy and survival analysis of DICE regimen for 97 patients with relapsed or refractory Non-Hodgkin's lymphoma]

Objective: To investigate the efficacy and survival of the DICE regimen (cisplatin, ifosfamide, etoposide, dexamethasone) for relapsed and refractory NHL. Methods: Clinical data of 97 relapsed and refractory NHL patients treated with DICE regimen in Peking University Cancer Hospital between Sep 1. 2008 and Dec 31. 2013 were retrospectively analyzed, and then we evaluate the efficacy and safety of DICE regimen. Results: ① There were 64 males and 33 females with a median age of 49 years. The most common pathological type was DLBCL (73.20%). There were 35 B-NHL patients used rituximab combined with DICE. Finally, a total of 26 patients underwent autologous stem cell transplantation (auto-HSCT) after the salvage chemotherapy. ② The overall response rate (ORR) was 47.42%, the complete response (CR) rate was 22.68%. The ORR of the relapsed/progressive group was higher than the refractory group [67.57% (25/37) vs 35.00% (21/60), χ2= 9.736, P=0.002]. ③The median follow-up of these 97 patients was 15.0 months (1.5-80.0 months). The expected median progression-free survival (PFS) and overall survival (OS) was 12.0 (95% CI 5.0-19.0) months, 26.0 (95% CI 6.0-45.9) months. ④There was no difference between the auto-HSCT group and no auto-HSCT group in the median OS [41.0 (95%CI 8.9-73.1) vs 22.0 (95%CI 8.5-35.5) months, P=0.361]. The patients who achieved CR and PR after DICE regimen had longer OS than those patients who in stable or progressive disease (56.0 vs 18.5 months, P <0.001). Patients who used DICE combined with rituximab had longer OS than patients who only used DICE regimen (51.5 vs 28.5 months, P=0.041). The multiple-factor analysis showed that the efficacy of DICE was an independent prognostic factor of OS [HR=4.24 (95%CI 2.12-8.50), P<0.001 ]. ⑤ The major adverse events included neutropenia (84.54% ) , thrombocytopenia (41.24% ), anemia (68.04%), and nausea/vomiting (65.98%), 14 patients (14.43%) had liver function abnormality, 1 patient had acute renal function injury during the treatment period. There was no chemotherapy-related death occurred. Conclusion: The DICE regimen is effective in refractory and relapsed NHL, and DICE is safe and well-tolerated. The high response rate of DICE regimen may correlate with good prognosis. For the B-NHL patients who used DICE combined with rituximab had longer OS than those patients who used DICE regimen only.

Salvage therapy for relapsed/refractory diffuse large B cell lymphoma

Diffuse large B cell lymphoma (DLBCL), the most common subtype of aggressive lymphoma, has considerable biologic and clinical heterogeneity. Despite recent therapeutic advances, up to 50% of patients relapse after standard chemoimmunotherapy. The International Prognostic Index (IPI) at relapse is of value in providing prognostic information on response to salvage chemotherapy and outcome after autologous hematopoietic cell transplantation (aHCT). Predictive biologic and gene expression markers, however, remain undefined, and require further clarification from additional molecular studies. To date, the standard of care in the management of relapsed/refractory DLBCL is salvage chemotherapy followed by an aHCT for those with chemotherapy-sensitive disease. Currently, there is no standard salvage chemotherapy regimen, and the use of immunotherapy for relapsed disease requires further evaluation. This review focuses on prognostic markers, current salvage therapies, and discusses the role of novel treatment in the management of relapsed/refractory DLBCL.

Lomustine (chloroethylnitrosourea [CCNU]), ifosfamide, bleomycin, vincristine, and cisplatin (CIBO-P) is an effective regimen for patients with poor prognostic refractory or multiple disease recurrent aggressive non-Hodgkin lymphoma

BACKGROUND

The current study was designed to assess the activity and safety of a novel combination therapy for patients with recurrent or refractory aggressive non-Hodgkin lymphoma (NHL).

METHODS

Forty-three consecutive patients with recurrent or refractory aggressive NHL were treated with lomustine (chloroethylnitrosourea [CCNU]; 60 mg/m2 on Day 1), ifosfamide (1.5 g/m(2 on Days 1, 2 and 21, 22), bleomycin (5 mg/m2 on Days 1, 5 and 21, 25), vincristine (1.4 mg/m2 on Days 1, 8 and 21, 28), and cisplatin (25 mg/m2 on Days 3, 4, 5 and 23, 24, 25), every 42 days (CIBO-P regimen).

RESULTS

Thirty-nine patients (91%) were evaluable for response. The median patient age was 63 years. Thirty-five percent of the patients had received > or = 2 lines of previous chemotherapy and 40% had elevated lactate dehydrogenase levels at the time of treatment initiation. The overall objective response rate was 77% (95% confidence interval [95% CI], 63-90%), including 19 (49%) complete (CR) and 11 (28%) partial responses. CIBO-P induced responses in primary refractory disease and in patients treated for second or subsequent disease recurrences. A CR with previous therapy was the most important factor associated with a significantly higher CR rate. The median duration of response was 6 months (95% CI, 4.4-7.7 months) and the median survival duration was 10.7 months (95% CI, 5.9-18.1 months). Five patients (11.6%) remained disease free for > or = 24 months. By multivariate analysis, a CR with previous therapy and average dose intensity of CIBO-P drugs were independent prognostic factors for time-to-treatment failure, whereas a CR with previous therapy and serum lactate dehydrogenase were independent predictors for survival. Myelosuppression was the most frequent serious complication of this regimen. However, none of the patients had hemorrhage with thrombocytopenia, and only 2 patients (5%) had febrile neutropenia.

CONCLUSIONS

In the current study, CIBO-P was a novel, highly active, and safe combination therapy for patients with refractory disease with a poor prognosis or for patients with multiply recurrent aggressive NHL.

Fatal hemophagocytic syndrome in a patient with panniculitis-like T-cell lymphoma and no clinical evidence of disease

Panniculitis-like T-cell lymphoma is an uncommon type of extranodal T-cell lymphoma which presents clinically with subcutaneous nodules. The clinical course can either be indolent or rapidly progressive, often complicated by hemophagocytic syndrome. We report a patient with primary subcutaneous disease and initial complete response to combination chemotherapy. The patient experienced an early relapse which responded to salvage chemotherapy. However, she died shortly thereafter with hemophagocytic syndrome, polymicrobial sepsis and systemic fungal infection. At autopsy there was no evidence of lymphoma in the bone marrow or other organs. We emphasize that a fatal hemophagocytic syndrome can occur despite minimal or even without evidence: of clinically active lymphoma as demonstrated by autopsy in this case.

Gemcitabine and Cisplatin in Refractory Malignant Lymphoma

<i>Objective:</i> We performed a pilot study to evaluate the effect of the high-dose gemcitabine-cisplatin combination in a brief weekly regimen in the treatment of primary refractory diffuse large cell lymphoma with high or high-intermediate clinical risk. <i>Methods:</i> Thirty patients refractory to first-line anthracycline-based chemotherapy were treated with a combination of gemcitabine (1.5 g/m² i.v.) and cisplatin (50 mg/m² i.v.) on days 1, 8, 22, 29, 42 and 49. No further treatment was administered. <i>Results:</i> Complete response rate was 53%; and only two relapses have been observed at the last follow-up. Thus actuarial disease-free survival at the 3-year follow-up was: 87% (95% confidence interval, CI: 70–93%) and overall survival 53% (95% CI: 44–63%). Toxicity was mild, and treatment was well tolerated. No treatment-related death was observed. <i>Conclusions:</i> The gemcitabine-cisplatin combination appears to be promising in the treatment of refractory lymphoma patients, with a low toxicity. However, a longer follow-up is needed to confirm the results. In our opinion, prolonged chemotherapy (6–8 cycles) did not improve outcome. At present, we are testing if the use of monoclonal antibodies (anti-CD20) employed as maintenance therapy may improve disease-free survival and overall survival.

Ifosfamide in hematological malignancies of adults

Ifosfamide is an alkylating agent with a broad spectrum of activity in solid tumors and hematological malignancies. In this review we will illustrate its use in the treatment of lymphomas and Hodgkin's disease and the results of the principal studies which have investigated ifosfamide-containing regimens. Ifosfamide has been mainly used, in combination with other drugs, as a component of salvage regimens for relapsed or primarily refractory lymphoma. These regimens induced a variable clinical response rate (complete remissions ranging from 6 up to 73% and overall response rate from 24 to 72%). High-dose ifosfamide, in combination with etoposide or mitoxantrone, showed a good potential for mobilization of peripheral stem cells while reducing the tumor burden. Ifosfamide-based regimens are also being evaluated in the treatment of newly diagnosed patients in sequential, response-based protocols, using many non-cross-resistant drugs.

Cisplatin, fludarabine, and cytarabine: a novel, pharmacologically designed salvage therapy for patients with refractory, histologically aggressive or mantle cell non-Hodgkin's lymphoma

BACKGROUND

Based on in vitro synergism, the combination of cytarabine (ara-C) and cisplatin is the basis of many salvage regimens for patients with aggressive non-Hodgkin lymphoma (NHL). However, patients with previously refractory disease are significantly less likely to respond, stimulating the search for novel salvage regimens. In vitro, fludarabine enhances the cytotoxicity of both ara-C and cisplatin, increasing ara-C incorporation into DNA and inhibiting repair of platinum/DNA adducts, suggesting that the combination of cisplatin, fludarabine, and ara-C (PFA) may have clinical utility.

METHODS

A Phase-II study of a 96 hour continuous infusion of cisplatin with two timed-sequential couplets of fludarabine and ara-C together with granulocyte colony stimulating factor was performed in 45 patients with previously refractory, histologically aggressive or mantle cell NHL.

RESULTS

Patients had predominantly diffuse large cell and/or immunoblastic NHL or its variants (80%), or they had mantle cell lymphoma (18%). Overall, 93% of patients had previously refractory disease, with a median International Prognostic Index score of 3. A median of 2 cycles per patient were delivered (range, 1-4 cycles) with significant myelosuppression; there were medians of 2 days of neutropenia < 0.5 x 10(9)/L (range, 0-12 days) and 3 days of thrombocytopenia < 20 x 10(9)/L (range, 0-24 days). This was more severe in older patients and was cumulative with successive cycles. Thirty-five percent of cycles were complicated by infections, nausea and emesis were prominent, but other nonhematologic toxicity was mild. Peripheral blood progenitor cells were mobilized adequately after the first cycle, but collections were impaired after more prolonged therapy. The overall response rate was 48% (7% of patients had complete responses, and 41% of patients had partial responses), with one toxic death due to tumor-lysis syndrome. Patients with mantle cell lymphoma were more likely to respond than patients with other histologies (88% vs. 39%, respectively; P = 0.019), although three of eight patients had relapsed rather than refractory disease. The median remission duration was 4 months, with 28% of potentially eligible patients able to proceed to subsequent high dose therapy. The actuarial 2 year survival rates were 20% +/- 6% overall and 50 +/- 18% for patients with mantle cell lymphoma.

CONCLUSIONS

Given the adverse outlook for these patients, the results are promising, particularly for patients with mantle cell lymphoma, and suggest that the addition of fludarabine as a potential biochemical modulator may enhance the activity of cisplatin and ara-C. This is associated with significant cumulative (but manageable) myelosuppression. This paradigm, in which a nucleoside analogue is used to inhibit the repair of platinum/DNA adducts, also may be applicable for the treatment of patients with other types of platinum-sensitive tumors.

Multimodal Treatment of Metastatic Thymic Carcinoma Including High-Dose Chemotherapy With Autologous Stem Cell Transplantation

Thymic carcinoma is a rare epithelial malignancy differentiated from thymoma by the presence of cytologically malignant cells. There are few reports of the treatment of locally advanced or metastatic thymic carcinoma. We describe a patient who sought treatment for thymic carcinoma metastatic to pleura, pericardium, retroperitoneum, and neck nodes. He was treated with neoadjuvant etoposide, ifosfamide, and cisplatin, and underwent resection. We then administered high-dose chemotherapy with autologous stem cell support, followed by radiation therapy. The patient remains in complete remission more than 4 years after diagnosis. To our knowledge, this is the first report of metastatic thymic carcinoma treated with neoadjuvant therapy and postoperative high-dose chemotherapy. Metastatic thymic carcinoma may be curable by aggressive combined therapies.

Phase II study of a high-dose ifosfamide-based chemotherapy regimen with growth factor rescue in recurrent aggressive NHL. High response rates and limited toxicity, but limited impact on long-term survival

The purpose of the study was to evaluate in patients with recurrent intermediate-grade NHL, the tolerance to and efficacy of an intensive salvage regimen consisting of high doses of ifosfamide, etoposide and mitoxantrone with G-CSF support, followed by autologous stem cell transplantation and to identify prognostic factors for survival in patients with recurrent aggressive lymphoma. Patients with recurrent intermediate-grade NHL under the age of 60 years were eligible. Induction consisted of ifosfamide 10 g/m(2) and etoposide 900 mg/m(2) with G-CSF 5 microg/kg twice a day. Upon recovery, patients underwent stem cell apheresis. Patients achieving complete remission (CR) underwent autologous stem cell transplantation using BEAM conditioning. Those with partial remission (PR) received treatment with ifosfamide 10 g/m(2), mitoxantrone 20 mg/m(2) and G-CSF 5 microg/kg. Those with CR received BEAM, those with PR received cyclophosphamide 4.5 g/m(2), etoposide 1200 mg/m(2) and cisplatin 135 mg/m(2) with stem cell rescue followed by BEAM. Antibiotic prophylaxis was given with all treatment cycles. The results were compared with those obtained in a prior study that used MINE-ESHAP salvage. Forty-four patients with recurrent intermediate-grade NHL were enrolled between March 1994 and September 1996. Median age was 50 years (24-61). Eleven patients had transformed lymphoma and seven had a T cell phenotype. Response rate to the high-dose ifosfamide regimen was 77% +/- 12% after two cycles and the complete response rate was 41% +/- 14%. Myelosuppression was profound but short. Median nadir ANC was 0 and the median duration of ANC <0.5 x 10(9)/l was 6 days (range 3-12). No severe infections occurred; 55% of the patients required blood transfusion and 42% required platelet transfusions. Myelosuppression and transfusion requirements were similar after the first and second cycles. Thirty-five of the 44 patients proceeded to autologous stem cell transplantation and one transplant-related death occurred. With a median follow-up of 52 months, progression-free survival at 2 years is 38% +/- 14% and survival is 52% +/- 15%. Data from these 44 patients were pooled with data on 53 patients who had received salvage treatment with MINE-ESHAP, for a multivariate analysis of prognostic factors. In multivariate analysis, serum LDH was strongly associated with survival. The use of a more intensive salvage regimen, did not result in a significant increase in long-term outcome, despite a high response rate. In conclusion, duration of treatment, response rates, treatment-related mortality and survival compare favorably with previous salvage regimens, but recurrence remains a major problem. Long-term survival in recurrent large cell lymphoma is influenced more by disease characteristics than by the type of salvage regimen used.

Chemotherapy in the elderly: pharmacologic considerations

BACKGROUND

The aging of the population has focused interest on the care of elderly cancer patients. A better understanding of the effects of chemotherapeutic agents on older patients with cancer will help to determine the appropriate use of chemotherapy for this age group.

METHODS

The authors review recent studies and present pharmacokinetic data on several chemotherapeutic agents, particularly those that have recently become available.

RESULTS

Agents such as gemcitabine, vinorelbine, the taxanes, anthracyclines, platinum compounds, topoisomerase I and II inhibitors, and the oral fluoropyrimidines appear to have a beneficial therapeutic index in elderly patients.

CONCLUSIONS

Careful attention to the physiologic changes associated with aging, along with dose adjustments for end-organ dysfunction (eg, renal and hepatic), is necessary to ensure the safe administration of antitumor chemotherapy to the elderly.

Ifosfamide, carboplatin, and etoposide: a highly effective cytoreduction and peripheral-blood progenitor-cell mobilization regimen for transplant-eligible patients with non-Hodgkin's lymphoma

PURPOSE

To evaluate a chemotherapy regimen that consisted of ifosfamide administered as an infusion with bolus carboplatin, and etoposide (ICE) supported by granulocyte colony-stimulating factor (G-CSF) for cytoreduction and stem-cell mobilization in transplant-eligible patients with primary refractory or relapsed non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

One hundred sixty-three transplant-eligible patients with relapsed or primary refractory NHL were treated from October 1993 to December 1997 with ICE chemotherapy at Memorial Sloan-Kettering Cancer Center. Administration of three cycles of ICE chemotherapy was planned at 2-week intervals. Peripheral-blood progenitor cells were collected after cycle 3, and all patients who achieved a partial response (PR) or complete response (CR) to ICE chemotherapy were eligible to proceed to transplantation. Event-free and overall survival, ICE-related toxicity, and the number of CD34(+) cells collected after treatment with ICE and G-CSF were evaluated.

RESULTS

All 163 patients were assessable for response, and there was no treatment-related mortality. A major response (CR/PR) was evident in 108 patients (66.3%); 89% of the responding patients underwent successful transplantation. Patient who underwent transplantation and achieved a CR to ICE had a superior overall survival to that of patients who achieved a PR (65% v 30%; P =.003). The median number of CD34(+) cells/kg collected was 8.4 x 10(6). The dose-limiting toxicity of ICE was hematologic, with 29.4% of patients developing grade 3/4 thrombocytopenia. There were minimal nonhematologic side effects.

CONCLUSION

ICE chemotherapy, with ifosfamide administered as a 24-hour infusion to decrease CNS side effects, and the substitution of carboplatin for cisplatin to minimize nephrotoxicity, is a very effective cytoreduction and mobilization regimen in patients with NHL. Furthermore, the quality of the clinical response to ICE predicts for posttransplant outcome.

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.

Induction of apoptosis by dexamethasone in the B cell lineage

The susceptibility to induction of apoptosis by the synthetic glucocorticoid, dexamethasone (Dex), was analysed at different stages of B cell maturation. Cells of the 70Z/3 pre-B cell line, expressing cytoplasmic mu chains, and LPS-stimulated 70Z/3 cells, expressing surface IgM, were used as a model of differentiation of pre-B cells into immature B cells. Cell proliferation and cell cycle progression were similarly inhibited by Dex (100 nM) in both naive 70Z/3 pre-B cells and in LPS-stimulated 70Z/3 cells. In contrast, Dex failed to affect apoptosis of naive 70Z/3 cells while it increased that of LPS-stimulated 70Z/3 cells. Splenic mature B lymphocytes were highly susceptible to Dex-induced apoptosis since subphysiological doses (5 nM) increased the frequency of apoptotic cells to more than 80%. On the other hand, the treatment of B lymphocytes with LPS, which led to proliferation and differentiation into immunoblasts, decreased the susceptibility to Dex-induced apoptosis. These effects were mediated by the glucocorticoid receptor since they were abrogated by the RU 486 antagonist. The response of B cells to glucocorticoids is thus dependent on their stage of differentiation.