Intensive therapy and autotransplantation in Hodgkin's disease

Heart rate variability and heart rate turbulence in patients with hematologic malignancies subjected to high-dose chemotherapy in the course of hematopoietic stem cell transplantation

BACKGROUND

In hematological malignancies, remissions and cures may be achieved by hematopoietic stem cell transplantation (HSCT) following high-dose chemotherapy (HDC). Cardiotoxicity of such therapy has not yet been fully elucidated. Noninvasive approaches allowing to evaluate an autonomic control of the heart function include analyses of both heart rate variability (HRV) and heart rate turbulence (HRT).

METHODS

In 38 patients with hematological malignancies, 24-hour electrocardiography Holter monitoring , with HRV and HRT analysis before HSCT (A test) and after HSCT (B test), was performed.

RESULTS

The 24-hour analysis of HRV demonstrated that SDNN, SDNNi, rMSSD, and pNN50 parameters were significantly lower after HSCT as compared to the results obtained before the transplantation (P < 0.05). For period of diurnal activity and for night hours, SDANN, SDNNi, rMSSD, and pNN50 were significantly lower in B test, as compared to the results of A test (P < 0.05). The analysis of HRT demonstrated that turbulence onset parameter was significantly higher, and turbulence slope parameter was significantly lower in B test, as compared to A test (P < 0.05). The multifactorial stepwise backward regression analysis indicated that administration of cyclophosphamide and carmustine and higher concentrations of blood cholesterol represented risk factors for decreased HRV. Cyclophosphamide and higher triglyceride levels represented independent risk factors for decreased HRT.

CONCLUSIONS

In patients with hematopoietic malignancies treated with HSCT, decreased HRV and HRT were observed after chemotherapy and stem cells administration.

Autologous stem cell transplantation followed by consolidation chemotherapy for relapsed or refractory Hodgkin's lymphoma

Relapse remains a major cause of treatment failure after autotransplantation (auto-PBSCT) for Hodgkin's disease (HD). The administration of non-crossresistant therapies during the post-transplant period may delay or prevent relapse. We prospectively studied the role of consolidation chemotherapy (CC) after auto-PBSCT in 37 patients with relapsed or refractory HD. Patients received high-dose gemcitabine-BCNU-melphalan and auto-PBSCT followed by involved-field radiation and up to four cycles of the DCEP-G regimen, which consisted of dexamethasone, cyclophosphamide, etoposide, cisplatin, gemcitabine given at 3 and 9 months post transplant alternating with a second regimen (DPP) of dexamethasone, cisplatin, paclitaxel at 6 and 12 months post transplant. The probabilities of event-free survival (EFS) and overall survival (OS) at 2.5 years were 59% (95% CI=42-76%) and 86% (95% CI=71-99%), respectively. In all, 17 patients received 54 courses of CC and 15 were surviving event free (2.5 years, EFS=87%). There were no treatment-related deaths during or after the CC phase. Post-transplant CC is feasible and well tolerated. The impact of this approach on EFS should be evaluated in a larger, randomized study.

Hodgkin's lymphoma: biology and treatment strategies for primary, refractory, and relapsed disease

Hodgkin's lymphomas belong to the most curable tumor diseases in adults. About 80% of patients in all anatomical stages and of all histological subtypes can be cured with modern treatment strategies. In spite of the great clinical progress, the pathogenesis of this peculiar lymphoproliferative entity has not been elucidated completely up until now. In Section I Drs. Stein, Hummel, and Zollinger describe the different pro-proliferative and antiapoptotic pathways and molecules involved in the transformation of the germinal center B-lymphocyte to the malignant Hodgkin-Reed-Sternberg cell. They use a comprehensive gene expression profiling (Affymetrix gene chip U133A) on B- and T-Hodgkin cell lines and state that the cell of origin is not the dominant determinant of the Hodgkin cell phenotype, but the transforming event. H-RS cells lack specific functional markers (B-T-cell receptors) and physiologically should undergo apoptosis. Why they do not is unclear and a matter of intensive ongoing research. In Section II Dr. Diehl summarizes the commonly used primary treatment strategies adapted to prognostic strata in early, intermediate and advanced anatomical stages using increasing intensities of chemotherapy (two, four, eight courses of chemotherapy such as ABVD) and additive radiation with decreased doses and field size. ABVD is without doubt the gold standard for early and intermediate stages, but its role as the standard regimen for advanced stages is challenged by recent data with time- and dose-intensified regimens such as the escalated BEACOPP, demonstrating superiority over COPP/ABVD (equivalent to ABVD) for FFTF and OS in all risk strata according to the International Prognostic Score. In Section III, Dr. Connors states that fortunately there is a considerably decreased need for salvage strategies in Hodgkin's lymphomas since primary treatment results in a more than 80% tumor control. Nevertheless, a significant number of patients experience either a tumor refractory to therapy or an early or late relapse. Therefore, one of the continuing challenges in the care for Hodgkin's lymphomas today is to find effective modes for a second tumor control. High-dose chemotherapy followed by autologous stem cell support has proved to be the treatment of choice when disseminated tumors recur after primary chemo- and or radiotherapy. Nodal relapses respond well to local radiation when they recur outfield of primary radiation without B-symptoms and in stages I-II at relapse. Allogeneic stem cell support needs further intensive evaluation in controlled studies to become an established alternative.

Allogeneic stem cell transplantation for the non-Hodgkin's lymphomas and Hodgkin's disease

Certain poor-prognosis patients with non-Hodgkin's lymphoma and Hodgkin's disease, usually with recurrent and/or refractory disease, are rarely curable with standard chemoradiotherapy. Autologous hematopoietic stem cell transplantation has been shown to result in improved long-term disease-free survival in some of these patients. Unfortunately, a number of patients are not suitable for autologous transplantation due to a damaged stem cell pool involvement or other disease processes of the marrow. These patients may benefit from allogeneic stem cell transplantation. In addition to the therapeutic effect of high-dose chemotherapy with or without total body irradiation, an immunologic [i.e. graft-versus-lymphoma (GVLym)] effect may be present in some patients undergoing allogeneic transplantation, resulting in a lower relapse rate than autotransplants. However, allografts are almost always associated with a higher non-relapse mortality due primarily to graft-versus-host disease (GVHD); unfortunately, GVHD and GVLym are difficult to separate. Thus, full exploitation of this GVLym effect may require the modification of commonly used conditioning regimens; if successful, these modifications may allow an additional decrement in the incidence of relapse without additional morbidity. Also, when combined with lesser intensity conditioning, such may permit patients who otherwise would not be candidates for standard transplant regimens to be allografted.

Detection of Clonal Hodgkin and Reed-Sternberg Cells With Identical Somatically Mutated and Rearranged VH Genes in Different Biopsies in Relapsed Hodgkin’s Disease

Hodgkin’s disease (HD) represents a malignant lymphoma in which the putative malignant Hodgkin and Reed-Sternberg (H-RS) cells are rare and surrounded by abundant reactive cells. Single-cell analyses showed that H-RS cells regularly bear clonal Ig gene rearrangements. However, there is little information on the clinical evolution of HD in a given patient. In this study, we used the single-cell polymerase chain reaction (PCR) to identify H-RS cells with clonal Ig gene rearrangements in biopsy specimens of patients with relapsed HD. The obtained clonal variable region heavy-chain (VH) gene rearrangements were used to construct tumor-clone-specific oligonucleotides spanning the complementarity determining region (CDR) III and somatically mutated areas in the rearranged VHgene. A number of biopsies were obtained during a period of 3 years from two HD patients. H-RS cells with identical VHrearrangements were detected in two separate infiltrated lymph nodes from one patient with nodular sclerosis HD. In a second patient with mixed cellularity HD subtype, clonal VH rearrangements with identical sequences were detected in infiltrated spleen and two lymph node biopsies. Despite the high sensitivity of the PCR method used (one clonal cell in 105 mononuclear cells), residual H-RS cells were not found in peripheral blood, leukapheresis material, purified CD34+ stem cells or bone marrow. The results show that different specimens from relapsed patients suffering from classical HD carry the same clonotypic IgH rearrangements with identical somatic mutations, demonstrating the persistence and the dissemination of a clonal tumor cell population. Thus, PCR assays with CDRIII-specific probes derived from clonal H-RS cells are of clinical importance in monitoring the dissemination of HD and tumor progression and could be useful for analysis of minimal residual disease after autologous stem cell transplantation.

© 1998 by The American Society of Hematology.

Detection of Clonal Hodgkin and Reed-Sternberg Cells With Identical Somatically Mutated and Rearranged VH Genes in Different Biopsies in Relapsed Hodgkin’s Disease

Hodgkin’s disease (HD) represents a malignant lymphoma in which the putative malignant Hodgkin and Reed-Sternberg (H-RS) cells are rare and surrounded by abundant reactive cells. Single-cell analyses showed that H-RS cells regularly bear clonal Ig gene rearrangements. However, there is little information on the clinical evolution of HD in a given patient. In this study, we used the single-cell polymerase chain reaction (PCR) to identify H-RS cells with clonal Ig gene rearrangements in biopsy specimens of patients with relapsed HD. The obtained clonal variable region heavy-chain (VH) gene rearrangements were used to construct tumor-clone-specific oligonucleotides spanning the complementarity determining region (CDR) III and somatically mutated areas in the rearranged VHgene. A number of biopsies were obtained during a period of 3 years from two HD patients. H-RS cells with identical VHrearrangements were detected in two separate infiltrated lymph nodes from one patient with nodular sclerosis HD. In a second patient with mixed cellularity HD subtype, clonal VH rearrangements with identical sequences were detected in infiltrated spleen and two lymph node biopsies. Despite the high sensitivity of the PCR method used (one clonal cell in 105 mononuclear cells), residual H-RS cells were not found in peripheral blood, leukapheresis material, purified CD34+ stem cells or bone marrow. The results show that different specimens from relapsed patients suffering from classical HD carry the same clonotypic IgH rearrangements with identical somatic mutations, demonstrating the persistence and the dissemination of a clonal tumor cell population. Thus, PCR assays with CDRIII-specific probes derived from clonal H-RS cells are of clinical importance in monitoring the dissemination of HD and tumor progression and could be useful for analysis of minimal residual disease after autologous stem cell transplantation.

© 1998 by The American Society of Hematology.

Treatment of relapsed Hodgkin's disease

High-dose chemotherapy with peripheral stem cell or bone marrow transplantation has quickly become accepted as the standard of care for patients with Hodgkin's disease (HD) who are chemotherapy induction failures or who relapsed after a short initial remission. The majority of studies would indicate that high-dose therapy is most effective when used early. As a result of promising pilot studies, high-dose therapy is also being used more frequently in patients at initial relapse after a long remission. Future approaches to improve the efficacy of high-dose therapy in marrow transplantation will require more effective chemotherapeutic agents. Recent studies with the taxanes and camptothecins suggest that these agents may be useful (Devizzi et al, 1994). Biological approaches with CD30 based antibodies and immunotoxins may also be helpful adjuncts to conventional-dose debulking regimens. Radio-immunoconjugates may augment the delivery of myelo-ablative doses of radiation therapy selectively to tumours. When patients relapse after high-dose therapy, there has been no standard approach to management. However, single agent chemotherapy (e.g. weekly low-dose vinblastine) has the potential for significant palliation, occasionally for prolonged periods.

Intensive therapy and autologous stem cell transplantation for Hodgkin's disease in first relapse after combination chemotherapy

Data from a number of transplant centers has shown that several intensive therapy regimens, supported by autologous stem cell transplantation, have the capability to produce durable responses in a proportion of patients with Hodgkin's disease progressive after combination chemotherapy. Although many questions regarding the optimal use of autotransplantation remain unanswered, the issue of the preferred timing at which to apply transplantation is of critical importance in planning therapeutic strategies for patients with this disease. This paper will focus on the timing options for autotransplantation in Hodgkin's disease. In the absence of a formal Phase III study comparing conventional salvage therapy versus autotransplantation in first relapse patients, the encouraging results from our center and others support the use of transplantation at the time of first relapse after combination chemotherapy. Non-relapse mortality is low in this setting, and the primary problem has been recurrent disease despite transplantation. Risk factors for both disease recurrence, as well as for the probability of progression-free survival, can be defined based on biologic features present at the time of first relapse after chemotherapy, and may provide a basis for improving the current transplant results for first relapse patients. Prolonged follow-up will be important to define the incidence and risk of late toxicities in autografted patients.

Autologous stem cell transplantation in the treatment of cancer

High-dose chemotherapy with haematopoietic stem cell rescue has proven to be an effective treatment in relapsed lymphoma and neuroblastoma. This treatment approach should be considered also in selected patients with leukaemia, multiple myeloma, breast cancer, ovarian cancer and testicular cancer. Relative contraindications include progression of the disease on appropriate conventional treatment, poor performance status, active infection as well as serious renal, pulmonary, liver and cardiac dysfunction. Increasing age should also be taken into consideration when autologous stem cell transplantation is planned. Every effort should be made to eliminate malignant cells that can be present in the stem cell containing population, which will be infused to the patient following myeloablative treatment.