Influence of dose intensity and density on therapeutic and toxic effects in Hodgkin's disease

Reduced relative dose intensity of primary chemotherapy does not influence prognosis of patients with Hodgkin lymphoma

AIMS

A retrospective analysis of patients with Hodgkin lymphoma (HL) was performed to assess their outcome regarding relative dose intensity (RDI) of chemotherapy administered in primary treatment.

METHODS

A total of 194 patients were divided into three groups with different RDI of primary chemotherapy (100%, 90-99% and <90%). Reduced RDI in two groups (90-99% and <90%) was caused by the delay of the interval between the administration of some chemotherapeutic courses. The probability of complete remission (CR), disease relapse, event-free survival (EFS) and overall survival (OS) as the basic parameters of patient outcome were statistically compared.

RESULTS

Multivariate analysis showed here were no significant differences in probability of CR (HR 0.9, 95% CI [0.75-1.08], P=0.5), risk of relapse (HR 1.34, 95% CI [0.92-1.94], P=0.11) or death (HR 1.52, 95% CI [0.94-2.5], P=0.13). There were also no significant differences in probability of EFS (mean 13 vs. 10 vs. 12 years, P=0.17; HR 1.54, 95% CI [0.91-2.6], P=0.22) or OS (mean 15 vs. 13 vs. 14 years, P=0.13; HR 1.52, 95% CI [0.93-2.5], P=0.13).

CONCLUSION

We found no significant impact of primary chemotherapy delay resulting in reduced RDI on outcome in HL patients.

Cyclophosphamide Dose Intensification during Induction Therapy for Intermediate-Risk Pediatric Rhabdomyosarcoma Is Feasible but Does Not Improve Outcome

PURPOSE

More than half of pediatric rhabdomyosarcoma cases have intermediate-risk features and suboptimal outcome (3-year failure-free survival estimates, 55 to 76%). Dose intensification of known active agents may improve outcome.

EXPERIMENTAL DESIGN

This pilot study evaluated the feasibility of dose intensification of cyclophosphamide in previously untreated patients ages < 21 years with intermediate-risk rhabdomyosarcoma. Induction therapy comprised four 3-week cycles of VAC: vincristine (V) 1.5 mg/m2 on days 0, 7, and 14; actinomycin D (A) 1.35 mg/m2 on day 0; and dose-intensified cyclophosphamide (C) on days 0, 1, and 2. The three cyclophosphamide dose levels tested were as follows: (a) 1.2 g/m2/dose; (b) 1.5 g/m2/dose; and (c) 1.8 g/m2/dose. Continuation therapy comprised nine additional cycles of VAC with 2.2 g/m2/cycle of C. Radiotherapy was administered at week 0 (parameningeal tumors with intracranial extension) or week 12 or 15 (all others).

RESULTS

Between October 1996 and August 1999, 115 eligible patients were enrolled. Three of 15 patients treated at dose level 2 experienced life-threatening dose-limiting toxicity (typhlitis +/- other severe toxicity). Dose level 1 was the maximum-tolerated dose, and 91 evaluable patients were treated at this level. The 3-year failure-free and overall survival estimates for patients treated at the maximum-tolerated dose were 52% (95% confidence interval, 41-64%) and 67% (95% confidence interval, 56-77%), respectively, at a median follow-up of 3 years.

CONCLUSIONS

A 64% increase in the standard cyclophosphamide dosage during induction (to 3.6 g/m2/cycle) was tolerated. However, outcomes were similar to those observed at lower dosages, suggesting that alkylator dose intensification does not benefit patients with intermediate-risk rhabdomyosarcoma.

FDA licensure of NEUMEGA to prevent severe chemotherapy-induced thrombocytopenia

This paper discusses background information and the body of clinical data that has been accumulated to demonstrate the efficacy and safety of NEUMEGA (recombinant human interleukin 11) when used to prevent severe chemotherapy-induced thrombocytopenia and reduce the need for platelet transfusions in patients with nonmyeloid malignancies. NEUMEGA is recommended to be used at a dose of 50 microg/kg s.c. once daily starting the day after chemotherapy ends until a platelet count of 50,000 cells/microl is achieved after the expected nadir.

Short term treatment with Escherichia coli recombinant human granulocyte-macrophage-colony stimulating factor prior to chemotherapy for Hodgkin disease

BACKGROUND

Granulocyte-macrophage-colony stimulating factor (GM-CSF) administration stimulates the proliferation of hemopoietic progenitors. Shortly (48-96 hours) after its discontinuation, feedback phenomena occur and the progenitor proliferation rate drops below baseline levels. As the quiescence of hyperplastic bone marrow suggests that hemopoietic cells may be refractory to the toxic effects of cytostatic drugs, the decision was made to test the hypothesis that GM-CSF given before chemotherapy may be myeloprotective.

METHODS

Fifty-six patients with newly diagnosed Stage II-IV Hodgkin disease, ages 18-77 years, were randomized to receive GM-CSF (5 microg/kg subcutaneously) or placebo from Day 7 to Day 4 before each chemotherapy administration (6 cycles of a hybrid of mechlorethamine, vincristine, procarbazine, and prednisone with doxorubicin, bleomycin, vinblastine, and dacarbazine). The treatment was considered a success if the delivery rate of chemotherapy was >90% after 3 cycles and >80% after 6 cycles.

RESULTS

Thirty patients received GM-CSF and 26 placebo. The dose intensity (85.2% vs. 79.6%) and the overall success in terms of delivery rate (56.7% vs. 50%) were higher in the GM-CSF group, although these differences were not statistically significant. The neutrophil nadirs were higher in the GM-CSF group during the first three cycles and subsequently similar in both groups.

CONCLUSIONS

No significant differences in terms of myelotoxicity or drug delivery were observed between the two treatment arms. Although the myeloprotective effect of the prechemotherapy administration of GM-CSF seems to be minimal, the data indicate a safe timing between GM-CSF discontinuation and further chemotherapy. Because cumulative myelotoxicity has been observed with other growth factors, given in the interval between the chemotherapy cycles, this may be relevant to the planning of rapid cycling.

Randomized multicentre trial of filgrastim as an adjunct to combination chemotherapy for Hodgkin's disease. West of Scotland Lymphoma Group

This study was intended to ascertain whether the adjunctive administration of filgrastim (r metHuG-CSF, Amgen) would influence the dose intensity of chemotherapy or the morbidity of myelosuppression in patients receiving MOPP or MOPP/EVAP hybrid chemotherapy for Hodgkin's disease. In a prospective randomized trial, two regimens for the treatment of Hodgkin's disease were compared. The substudy described here randomized patients receiving either regimen to receive filgrastim on the days when chemotherapy was not administered. During chemotherapy, parameters of myelosuppression were documented, including dose delays, the severity and duration of neutrophil and platelet nadirs, infective episodes, and resulting hospital admissions. In the MOPP arm, 13/25 eligible patients, and, in the MOPP/EVAP arm, 12/22 eligible patients, received filgrastim. The use of filgrastim made no statistically significant difference to the administered dose intensity for either MOPP (P = 0.57, 95% confidence interval (CI) 15-point increase to 8-point reduction) or MOPP/EVAP (P = 0.53; 95% CI 7-point increase to 11-point reduction). In patients receiving MOPP, filgrastim reduced the median duration of leucopenia (P = 0.007) and the severity of the white blood cell nadir (P = 0.036); however, no statistically significant effect (at the 5% level) was seen in platelet or haemoglobin nadirs, the number of days of in-patient hospitalization, the number of admissions for infective complications, the incidence, grade or duration of infections, or the incidence of febrile neutropenia. In patients receiving MOPP/EVAP, filgrastim had no significant effect on the duration or depth of leucopenia but was associated with a reduction in the median haemoglobin (P = 0.002) and platelet nadirs (P = 0.015). No effect on the above listed sequelae of myelosuppression was influenced by the administration of filgrastim. This study, although small, suggests that the routine use of filgrastim, aimed at influencing the administered dose intensity of conventional dose chemotherapy in Hodgkin's disease, is not warranted.

G-CSF (filgrastim) as an adjunct to MOPP/ABVD therapy in Hodgkin's disease

The main objective of this study was to assess to what extent filgrastim (G-CSF, Amgen-Roche) can facilitate administration of the full dose intensity of MOPP/ABVD chemotherapy to patients with Hodgkin's disease. Sixteen patients with Hodgkin's disease were treated with MOPP/ABVD and filgrastim support between January 1992 and March 1994. Twenty-five patients treated with MOPP/ABVD 1987-1991 served as historical controls. The two groups were well matched for age, gender, stage, performance status and histological subgroups, but in the study group more patients had B-symptoms (p < 0.05). Dose intensity (DI) was calculated in mg/m2/week and the intended average dose was designated as 1. The planned average DI was reached by 8/16 patients in the study group but by only 1/25 in the control group (p < 0.001). The reasons for decreased DI in the study group were neutropenia (n = 5), thrombocytopenia (2 pts) and neurotoxicity (n = 1). In the control group the reason for decreased DI was neutropenia (n = 24). In the study group 15/16 patients achieved Complete Response (CR), 2/15 relapsed and 15/16 were surviving after a median follow-up 31 (6-48) months. In the control group 25/25 patients attained CR, 5/25 relapsed and 20/25 were surviving after a median follow up 67 (12-100) months. No severe toxicity was observed during filgrastim therapy. To conclude, the dose intensity during MOPP/ABVD therapy was significantly higher if filgrastim was administered, but the additional benefit that this confers remains to be determined. A large scale, retrospective analyses of treatment response and actual dose-intensity should help answer this question and give guidance as to if and when hematopoietic growth factors should be administered to patients with Hodgkin's disease.

A trial of individual dose intensity and relative performance factors in tegafur maintenance chemotherapy for head and neck cancer

Tegafur (Sunfural-S), as masked compound of a 5-fluorouracil derivative, was administered orally as a maintenance chemotherapeutic agent at a dose of 600 mg/day in 98 cases of head and neck epithelial cancer. The effectiveness of the drug was evaluated by a statistical method involving two formulae: individual dose intensity (IDI) and relative performance (RP). When comparing patients rated above a reference IDI value of 1.0 with those rated below 1.0, it was not possible to predict patient survival or tumor-free rates. In contrast, the value of the RP did show such a correlation. These findings support the effectiveness of Tegafur as a maintenance chemotherapeutic treatment for head and neck cancer patients.

Etoposide in combination as first-line chemotherapy for advanced Hodgkin disease. A Cancer and Leukemia Group B study

BACKGROUND

In a pilot study, Cancer and Leukemia Group B (CALGB) incorporated etoposide into primary combination therapy for advanced Hodgkin disease.

METHODS

Thirty-six evaluable patients were treated with two or three courses of methotrexate, vincristine, prednisone, leucovorin, etoposide, and cyclophosphamide (MOPLEC), and then treated with five to seven additional courses of a known "curative" regimen: nitrogen mustard, vinblastine, prednisone, and procarbazine (MVPP).

RESULTS

After treatment with MOPLEC, there were 16 complete responders (44%) and 18 partial responders (50%). One patient had progressive disease and one patient was taken off study after an anaphylactic reaction to etoposide. After completing the entire protocol, 32 patients achieved complete remission (CR) (89%) and 3 achieved partial remission (PR) (8%). Five CR patients have relapsed and three additional patients have died in CR without recurrence. At 36 months, the estimated failure-free survival is 61% and overall survival is 72%.

CONCLUSIONS

This combination, which includes etoposide, is active for the primary treatment of advanced Hodgkin disease.

Novel combination of epirubicin, bleomycin, vinblastine and prednisone (EBVP II) before radical radiotherapy in localized stages (I-IIIA) of Hodgkin's disease. Early results in 100 consecutive patients. Pierre-et-Marie-Curie Group

A novel combination of epirubicin, bleomycin, vinblastine and prednisone (EBVP II) was scheduled to reduce the toxicity of chemotherapy and to improve its application in treatment of Hodgkin's disease. This combination followed a previous regimen given every 15 days (EBVP I) by the same cooperative group. EPVP II is given every 21 days with increased dosage and increased intensity of epirubicin. This regimen was given to 100 consecutive patients with favourable or unfavourable limited-stage disease (clinical stages I-IIIA) excluding very favourable stages I and II and stages IIIB and IV. Such patients first received three injections of EBVP II and were then radically irradiated; those with unfavourable prognosis factors received three subsequent injections of EBVP II. The present analysis reports the early results of such treatment and considers particularly toxicity and the obtention of complete remission, which is pre-eminent for a cure. EBVP II was given in full dosage in 99% of the primary set of three injections. The main toxicity was alopecia and to a lesser degree nausea and vomiting and veinitis. Complete remission was obtained in 76 patients before radiotherapy and in 20 others after radiotherapy. With a median follow-up of 30 months 1 patient died from Hodgkin's disease, 9 are alive after relapse and 90 with no evidence of disease. This treatment appears to be as efficient as previous chemotherapy, well tolerated and particularly easy to give. It deserves further comparison with other proved regimens taking into consideration the survival and quality of life of patients.

Treatment of Early Stage Hodgkin's Disease According to Risk Factors

Between January 1981 and December 1987, 95 patients with stage IA (34 patients), IIA (42 patients) and stage IIB (19 patients) Hodgkin's disease (HD) were evaluated in our institution. Thirty patients defined as "high risk" because of either bulky mediastinal disease, systemic symptoms or both were treated with combined modality therapy (CMT). The remaining 65 patients considered as "standard risk" because they presented at diagnosis without any known adverse prognostic factor, received radiotherapy (RT) only. The median follow-up was 39 months. The complete remission (CR) rate was 97% (92/95). The actuarial 3 year overall (OS) and disease free survival (DFS) were 93% and 72% respectively with no differences between the two groups of patients. All 65 "standard risk" patients achieved CR; thirteen (20%) relapsed after a median time of 22 months. Twenty seven of 30 "high risk" patients (90%) achieved CR and six of them (22%) had early relapses. No severe pancytopenia episodes or life-threatening complications occurred during therapy. As far as the risk of second neoplasms is concerned, we observed only a single case of acute non lymphoblastic leukemia 48 months after the completion of CMT. These results indicate that in unfavourable early stage HD, CMT is effective with a probability of more than a 70% DFS 3 years after therapy with an acceptable acute and late toxicity. Patients without "high" risk factors showed the expected response after RT. About 60% of the patients who failed RT could be salvaged by chemotherapy (CT) while refractory cases or patients who relapsed after CMT did poorly with a third line chemotherapeutic regimen. Therefore alternative therapeutic approaches including high dose CT followed by autologous bone marrow transplantation should be considered for this subset of patients.