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Banchi M, Cox MC, Bocci G. Metronomic chemotherapy in hematology: Lessons from preclinical and clinical studies to build a solid rationale for future schedules. Cancer Lett 2024; 591:216900. [PMID: 38636896 DOI: 10.1016/j.canlet.2024.216900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 03/05/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
Metronomic chemotherapy (mCHEMO), based on frequent, regular administration of low, but pharmacologically active drug doses, optimizes antitumor efficacy by targeting multiple targets and reducing toxicity of antineoplastic drugs. This minireview will summarize preclinical and clinical studies on cytotoxic drugs given at weekly, daily, or at continuous metronomic schedules alone or in combination with novel targeted agents for hematological malignancies, including lymphoma, multiple myeloma, and leukemia. Most of the preclinical in vitro and in vivo studies have reported a significant benefit of both mCHEMO monotherapy and combinatorial regimens compared with chemotherapy at the maximum tolerated dose. However, the combination of mCHEMO with targeted drugs is still little explored in the hematologic clinical setting. Data obtained from preclinical studies on low dose metronomic chemotherapy in hematological malignancies clearly suggested the possibility to clinically investigate more tolerable and effective strategies for the treatment of patients with advanced hematological malignancies, or at least for those frail and elderly patients, who are not eligible or resistant to standard treatments.
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Affiliation(s)
- Marta Banchi
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy
| | | | - Guido Bocci
- Dipartimento di Medicina Clinica e Sperimentale, Università di Pisa, Pisa, Italy.
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Ferhanoglu B, Ozbalak M. Sequencing novel agents in the treatment of classical Hodgkin lymphoma. Expert Rev Hematol 2023; 16:991-1015. [PMID: 37897182 DOI: 10.1080/17474086.2023.2276212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 10/24/2023] [Indexed: 10/29/2023]
Abstract
INTRODUCTION Classical Hodgkin lymphoma (cHL) is a curable disease, with durable remission achieved in about 80% of patients following first-line treatment. Three new drugs were introduced to the daily use in cHL: brentuximab vedotin (BV), nivolumab, and pembrolizumab. All three drugs were initially approved for the treatment of relapsed/refractory cHL (RRHL) and with their promising outcomes, they are now incorporated in different stages of the treatment. AREAS COVERED We performed a literature search using PubMed on all cHL studies investigating BV and CPIs within the past 10 years. We analyzed literature to presume the sequencing of these novel agents. EXPERT OPINION Addition of BV or nivolumab to AVD backbone in the frontline setting showed promising activity in advanced stage cHL. BV and CPIs combined with chemotherapy in the second-line treatment of cHL are evaluated in phase 2 studies and comparable results are reported. The results of BrECADD, with good efficacy and toxicity profile, should be followed. Pembrolizumab was shown to be more effective in RRHL compared to BV in patients who have relapsed post-ASCT or ineligible for ASCT. BV is used in post-ASCT maintenance in high-risk cases, although its role will be questioned as it is increasingly used in the frontline treatment.
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Affiliation(s)
- Burhan Ferhanoglu
- Department of Internal Medicine, Division of Hematology, Koc University School of Medicine, Istanbul, Turkey
| | - Murat Ozbalak
- Basaksehir Cam ve Sakura City Hospital, Division of Hematology, Istanbul, Turkey
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Epperla N, Hamadani M. Double-refractory Hodgkin lymphoma: tackling relapse after brentuximab vedotin and checkpoint inhibitors. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2021; 2021:247-253. [PMID: 34889401 PMCID: PMC8791097 DOI: 10.1182/hematology.2021000256] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The approval of brentuximab vedotin (BV) and checkpoint inhibitors (CPI) has revolutionized the management of relapsed/refractory classical Hodgkin lymphoma (cHL) patients. In recent years these agents have rapidly moved to earlier lines of therapy, including post-autologous hematopoietic cell transplant (auto-HCT) consolidation, pre-HCT salvage, and the frontline treatment setting. This shift in practice means that double-refractory (refractory to both BV and CPI) cHL is becoming an increasingly common clinical problem. In patients who are not eligible for clinical trials, conventional cytotoxic and targeted therapies (off label) may be a potential option. In patients who are transplant eligible, early referral to allogeneic HCT should be considered given the significant improvement in transplant outcomes in the contemporary era. Cellular therapy options including CD30.chimeric antigen receptor T cells, Epstein-Barr virus-directed cytotoxic T cells, and CD16A/30 bispecific natural killer cell engagers appear promising and are currently in clinical trials.
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Affiliation(s)
- Narendranath Epperla
- Division of Hematology, Department of Medicine, The James Cancer Hospital and Solove Research Institute, Ohio State University, Columbus, OH
| | - Mehdi Hamadani
- Blood and Marrow Transplant Program and Cellular Therapy Program, Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
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4
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Vinorelbine as substitute for vincristine in patients with diffuse large B cell lymphoma and vincristine-induced neuropathy. Support Care Cancer 2021; 29:5197-5207. [PMID: 33625586 PMCID: PMC8295169 DOI: 10.1007/s00520-021-06059-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/07/2021] [Indexed: 11/23/2022]
Abstract
Background A combination of rituximab with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is the standard first-line therapy for diffuse large B cell lymphoma (DLBCL), the most common aggressive lymphoma in adults. One of the major adverse effects of this regimen is vincristine-induced polyneuropathy which leads to discontinuation of vincristine in up to 30% of DLBCL-patients. Dose reduction of vincristine might worsen treatment outcomes of DLBCL but identification of treatment alternatives for patients exhibiting peripheral neuropathy during R-CHOP is an unmet need in hematology. Methods In this retrospective cohort study, comprising 987 patients with de novo DLBCL, we delineated the role of vinorelbine as a substitute for vincristine in R-CHOP by measuring improvements in neuropathy and outcome variables. Results Five-year overall survival (OS) and progression-free survival (PFS) were 72.6% and 63.1% in patients who received regular doses of vincristine, as compared to 60.6% and 51.7% in patients who received reduced doses of vincristine (p = 0.022 and p = 0.003, respectively). Of 199 patients who switched to vinorelbine, the majority experienced an improvement of neuropathy Furthermore, vinorelbine-switched patients showed favorable oncologic outcomes. Conclusion Replacement of vincristine by vinorelbine due to neuropathy is effective and safe, and results in a significant improvement in neuropathy as compared to treatment with R-CHOP. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-021-06059-2.
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Russler-Germain DA, Watkins MP, Bartlett NL. A forgotten friend: CCNU as palliative monotherapy in relapsed Hodgkin lymphoma. Leuk Lymphoma 2020; 62:486-488. [PMID: 33030388 DOI: 10.1080/10428194.2020.1830391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- David A Russler-Germain
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
| | - Marcus P Watkins
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
| | - Nancy L Bartlett
- Division of Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
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Barreca M, Stathis A, Barraja P, Bertoni F. An overview on anti-tubulin agents for the treatment of lymphoma patients. Pharmacol Ther 2020; 211:107552. [PMID: 32305312 DOI: 10.1016/j.pharmthera.2020.107552] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 04/14/2020] [Indexed: 01/19/2023]
Abstract
Anti-tubulin agents constitute a large class of compounds with broad activity both in solid tumors and hematologic malignancies, due to the interference with microtubule dynamics. Since microtubules play crucial roles in the regulation of the mitotic spindles, the interference with their function usually leads to a block in cell division with arrest at the metaphase/anaphase junction of mitosis, followed to apoptosis. This explains the reason why tubulin-binding agents (TBAs) proved to be extremely active in patients with cancer. Several anti-tubulin agents are indicated in the treatment of patients with lymphomas both alone and in combination chemotherapy regimens. The article reviews the literature on classic and more recent anti-tubulin agents, providing an insight into their mechanisms of action and their use in the treatment of lymphoma.
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Affiliation(s)
- Marilia Barreca
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Palermo, Italy; Institute of Oncology Research, Faculty of Biomedical Sciences, USI, Bellinzona, Switzerland
| | - Anastasios Stathis
- Oncology Institute of Southern Switzerland, Bellinzona, Switzerland,; Faculty of Biomedical Sciences, USI, Lugano, Switzerland
| | - Paola Barraja
- Department of Biological, Chemical and Pharmaceutical Sciences and Technologies (STEBICEF), University of Palermo, Palermo, Italy
| | - Francesco Bertoni
- Institute of Oncology Research, Faculty of Biomedical Sciences, USI, Bellinzona, Switzerland,; Oncology Institute of Southern Switzerland, Bellinzona, Switzerland,.
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Mehta-Shah N, Bartlett NL. Management of relapsed/refractory classical Hodgkin lymphoma in transplant-ineligible patients. Blood 2018; 131:1698-1703. [PMID: 29500171 PMCID: PMC6536701 DOI: 10.1182/blood-2017-09-772681] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Accepted: 11/07/2017] [Indexed: 11/20/2022] Open
Abstract
Addition of brentuximab vedotin, a CD30-targeted antibody-drug conjugate, and the programmed death 1 (PD-1) inhibitors nivolumab and pembrolizumab to the armamentarium for transplant-ineligible relapsed/refractory classical Hodgkin lymphoma has resulted in improved outcomes, including the potential for cure in a small minority of patients. For patients who have failed prior transplant or are unsuitable for dose-intense approaches based on age or comorbidities, an individualized approach with sequential use of single agents such as brentuximab vedotin, PD-1 inhibitors, everolimus, lenalidomide, or conventional agents such as gemcitabine or vinorelbine may result in prolonged survival with a minimal or modest effect on quality of life. Participation in clinical trials evaluating new approaches such as combination immune checkpoint inhibition, novel antibody-drug conjugates, or cellular therapies such as Epstein-Barr virus-directed cytotoxic T lymphocytes and chimeric antigen receptor T cells offer additional options for eligible patients.
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Affiliation(s)
- Neha Mehta-Shah
- Division of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
| | - Nancy L Bartlett
- Division of Medical Oncology, Department of Medicine, Siteman Cancer Center, Washington University School of Medicine, St. Louis, MO
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8
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Nikolaenko L, Chen R, Herrera AF. Current strategies for salvage treatment for relapsed classical Hodgkin lymphoma. Ther Adv Hematol 2017; 8:293-302. [PMID: 29051800 PMCID: PMC5638176 DOI: 10.1177/2040620717728000] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 07/31/2017] [Indexed: 12/25/2022] Open
Abstract
Hodgkin lymphoma (HL) is curable in 70-80% of patients with first-line therapy. However, relapses occur in a minority of patients with favorable early stage disease and are more frequent in patients with advanced HL. Salvage chemotherapy followed by high-dose chemotherapy and autologous stem cell transplant (ASCT) for patients with chemotherapy-sensitive disease is a standard treatment sequence for relapsed or refractory (rel/ref) HL. Patients who achieve complete response prior to ASCT have better survival outcomes. The choice of salvage chemotherapy therapy is becoming increasingly difficult in the era of novel agents, as there are no randomized studies to guide the choice of a second-line regimen. In this article, we will review current salvage therapy options, including combination chemotherapy and novel-agent-based salvage regimens for rel/ref HL.
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Affiliation(s)
- Liana Nikolaenko
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
| | - Robert Chen
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, 1500 East Duarte Road, Duarte, CA 91010, USA
| | - Alex F. Herrera
- Department of Hematology and Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, CA, USA
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Biasoli I, Spector N. New agents in relapsed/refractory Hodgkin's lymphoma. Rev Bras Hematol Hemoter 2017; 39:193-196. [PMID: 28830595 PMCID: PMC5568577 DOI: 10.1016/j.bjhh.2017.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/08/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Irene Biasoli
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil.
| | - Nelson Spector
- Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ, Brazil
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10
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Bond DA, Alinari L. Emerging treatment options for the management of Hodgkin's lymphoma: clinical utility of nivolumab. J Blood Med 2017; 8:41-54. [PMID: 28546779 PMCID: PMC5436782 DOI: 10.2147/jbm.s117452] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Classical Hodgkin's lymphoma (cHL) is a B-cell malignancy comprised of pathologic Reed Sternberg cells with a surrounding immune-tolerant inflammatory milieu. RS cells evade immune recognition in part through programmed death ligand 1 (PD-L1) overexpression, which is genetically programmed through copy number alterations, polysomy, and amplification of the 9p24.1 locus encoding PD-L1. By engaging with PD-1+ T-cells, PD-L1 delivers a potent immune suppressive signal promoting immunologic escape of the tumor cell. Enhancing antitumor immune response by targeting PD-1 with the monoclonal antibody nivolumab has proved to be effective in multiple solid tumors, but the highest response rates to date have been reported in patients with cHL, with over 65% of treated patients achieving an objective clinical response. In this review, we will summarize the published evidence regarding the activity of nivolumab in cHL as well as its current place in therapy. We will review the pharmacology, mechanism of action, and side effects of nivolumab as well as the emerging data indicating possible increased risk of graft versus host disease in patients treated with PD-1 inhibitors either pre- or post-allogeneic stem cell transplant. Given the remarkable single-agent activity and safety profile of PD-1 inhibitors in heavily pretreated patients with cHL, the possibility of employing nivolumab in combination with other active agents and earlier in therapy is a promising area of active investigation, and we will briefly summarize current clinical trials.
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Affiliation(s)
- David A Bond
- Department of Internal Medicine, Division of Hematology, Arthur G James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Lapo Alinari
- Department of Internal Medicine, Division of Hematology, Arthur G James Comprehensive Cancer Center, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Babashov V, Begen MA, Mangel J, Zaric GS. Economic evaluation of brentuximab vedotin for persistent Hodgkin lymphoma. ACTA ACUST UNITED AC 2017; 24:e6-e14. [PMID: 28270727 DOI: 10.3747/co.24.3369] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND We conducted a cost-effectiveness analysis of brentuximab vedotin for the treatment of relapsed and refractory Hodgkin lymphoma (hl) in the post-autologous stem-cell transplantation (asct) failure period, from the perspective of the Canadian health care payer. METHODS We developed a decision-analytic model to simulate lifetime costs and benefits of brentuximab vedotin compared with best supportive care for the treatment of patients with hl after failure of asct. Administrative data from Ontario were used to set the model parameters. RESULTS In the base case, treatment with brentuximab vedotin resulted in incremental quality-adjusted life-years (qalys) of 0.544 and an incremental cost of $89,366 per patient, corresponding to an incremental cost-effectiveness ratio (icer) of $164,248 per qaly gained. The icer was sensitive to the cost of brentuximab vedotin, the hazard ratio used to assess the efficacy of brentuximab vedotin treatment, and health state utilities. CONCLUSIONS In light of the available information, brentuximab vedotin has an icer exceeding $100,000 per qaly gained, which is a level often classified as having "weak evidence for adoption and appropriate utilization" in Canada. However, it is worth noting that provincial cancer agencies take into account not only the costs and associated icer, but also other factors such as a lack of alternative treatment options and the clinical benefits of expensive cancer drugs. Pricing arrangements should be negotiated, and risk-sharing agreements or patient access schemes should be explored.
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Affiliation(s)
- V Babashov
- Telfer School of Management, University of Ottawa, Ottawa, ON
| | - M A Begen
- Ivey Business School, Western University, London, ON;; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, and
| | - J Mangel
- Department of Medicine, Division of Hematology, Schulich School of Medicine and Dentistry, Western University, London, ON
| | - G S Zaric
- Ivey Business School, Western University, London, ON;; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, and
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Abstract
Despite the high first-line cure rates in patients with Hodgkin Lymphoma (HL) still 10%-20% of patients suffer from relapsed or refractory disease. High-dose chemotherapy (HDCT) followed by autologous stem cell transplant (ASCT) is standard of care for suitable patients with relapsed or refractory HL and allows for cure in approximately 50%. Due to the poor prognosis of high-risk patients even with HDCT and ASCT, consolidation strategies have been evaluated to improve the cure rates. For patients with recurrence after HDCT and ASCT, treatment is palliative in most cases. The anti-CD30 antibody-drug conjugate brentuximab vedotin (BV) has been shown to induce high response rates in these patients; however, durable responses were reported in a small percentage of patients only. For carefully selected patients with multiple relapses, dose-reduced allogeneic transplant (RICallo) is a potentially curative option. The role of RICallo will have to be re-evaluated in the era of anti-programmed death-1 (PD1) antibodies.
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Affiliation(s)
- Bastian von Tresckow
- German Hodgkin Study Group (GHSG), University Hospital of Cologne, Cologne, Germany
| | - Craig H Moskowitz
- Division of Hematologic Oncology, Memorial Sloan Kettering Cancer Center, New York, NY; Department of Medicine, Weill Medical College of Cornell University, New York, NY.
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Novakovic BJ. Immunotoxin - a new treatment option in patients with relapsed and refractory Hodgkin lymphoma. Radiol Oncol 2016; 49:315-9. [PMID: 26834516 PMCID: PMC4722920 DOI: 10.1515/raon-2015-0036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 08/16/2015] [Indexed: 11/27/2022] Open
Abstract
Background Even though Hodgkin lymphoma is a highly curable disease, some of the patients have either a refractory disease or experience a relapse following a successful primary therapy. Durable responses and remissions in patients with relapsed or refractory disease may be achieved in approximately one-half with salvage chemotherapy followed by high dose chemotherapy (HDT) and autologous hematopoietic cell rescue (SCT). On the other hand, patients who relapse after HDT and autologous SCT or those who have failed at least two prior multi-agent chemotherapy regimens and are not candidates for HDT have limited treatment options. Conclusions A new treatment option in this population is an immunotoxin Brentuximab vedotin composed of a CD30 directed antibody linked to the antitubulin agent monomethyl auristatin E. It has demonstrated a substantial effectiveness and an acceptable toxicity. In the pivotal study, the overall response rate was 75% with 34% of complete remissions. The median durations of response were 20.5 and 6.7 months for those with complete remission and all responding patients, respectively. The median overall survival was 40.5 months (3-years overall survival 54%) and the median progression-free survival 9.3 months. The most common non-hematologic toxicities were peripheral sensory neuropathy, nausea, and fatigue while the most common severe side effects were neutropenia, thrombocytopenia, anemia, and peripheral sensory neuropathy.
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Jezeršek Novaković B. Checkpoint inhibitors in Hodgkin's lymphoma. Eur J Haematol 2015; 96:335-43. [PMID: 26560962 DOI: 10.1111/ejh.12697] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2015] [Indexed: 12/11/2022]
Abstract
Hodgkin's lymphoma is unusual among cancers in that it consists of a small number of malignant Hodgkin/Reed-Sternberg cells in a sea of immune system cells, including T cells. Most of these T cells are reversibly inactivated in different ways and their reactivation may induce a very strong immune response to cancer cells. One way of reactivation of T cells is with antibodies blocking the CTLA-4 and especially with antibodies directed against PD-1 or the PD-L1 ligand thereby reversing the tumor-induced downregulation of T-cell function and augmenting antitumor immune activity at the priming (CTLA-4) or tissue effector (PD-1) phase. Immune checkpoint inhibitors have been evidenced as an additional treatment option with substantial effectiveness and acceptable toxicity in heavily pretreated patients with Hodgkin's lymphoma. Particularly, PD-1 blockade with nivolumab and pembrolizumab has demonstrated significant single-agent activity in this select population.
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15
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How I treat relapsed classical Hodgkin lymphoma after autologous stem cell transplant. Blood 2015; 127:287-95. [PMID: 26576863 DOI: 10.1182/blood-2015-10-671826] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Accepted: 11/16/2015] [Indexed: 12/25/2022] Open
Abstract
Despite the success of standard front-line chemotherapy for classical Hodgkin lymphoma (cHL), a subset of these patients, particularly those with poor prognostic factors at diagnosis (including the presence of B symptoms, bulky disease, advanced stage, or extranodal disease), relapse. For those patients who relapse following autologous stem cell transplant (SCT), multiple treatment options are available, including single-agent chemotherapy, combination chemotherapy strategies, radiotherapy, the immunoconjugate brentuximab, checkpoint inhibitors nivolumab and pembrolizumab, lenalidomide, everolimus, or observation in selected patients. In patients with an available donor, allogeneic SCT may also be considered. With numerous treatment options available, we advocate for a tailored therapeutic approach for patients with relapsed cHL guided by patient-specific characteristics including age, comorbidities, sites of disease (nodal or organ), previous chemosensitivity, and goals of treatment (long-term disease control vs allogeneic SCT).
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Jaffray M, Buchbinder N, Lutun A, Schneider P, Piquenot JM, Vannier JP. Salvage therapy with gemcitabine, vinorelbine, and pegylated liposomal doxorubicin for relapsed or refractory pediatric Hodgkin lymphoma. Results of a retrospective series of four children. Ann Hematol 2015; 94:1401-6. [DOI: 10.1007/s00277-015-2362-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 03/20/2015] [Indexed: 11/24/2022]
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Trippett TM, Schwartz CL, Guillerman RP, Gamis AS, Gardner S, Hogan S, London WB, Chen L, de Alarcon P. Ifosfamide and vinorelbine is an effective reinduction regimen in children with refractory/relapsed Hodgkin lymphoma, AHOD00P1: a children's oncology group report. Pediatr Blood Cancer 2015; 62:60-4. [PMID: 25308760 PMCID: PMC4465390 DOI: 10.1002/pbc.25205] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 07/03/2014] [Indexed: 11/11/2022]
Abstract
BACKGROUND We assessed the safety and efficacy of ifosfamide and vinorelbine (IV) as a less toxic and effective reinduction regimen for pediatric patients with relapsed or refractory Hodgkin Lymphoma. PROCEDURE This multi-center Children's Oncology Group phase II pilot study enrolled patients <30 years of age with biopsy-proven Hodgkin Lymphoma in relapse or refractory disease after front-line therapy. Treatment consisted of ifosfamide 3,000 mg/m(2) intravenous infusion over 24 hr on Days 1-4 and vinorelbine 25 mg/m(2) /dose intravenous push on Days 1 and 5 of each 21 day cycle with cytokine support. The study endpoints included estimation of key toxicities (cardiac, hepatic, or renal toxicity or toxic death), the rate of successful peripheral stem cell harvesting, and response after two cycles of therapy. RESULTS Sixty-six patients received a median of two cycles of IV. Sixty-four of 66 were heavily pretreated, 4 had refractory disease, 55% were male and 79% had nodular sclerosis HL. The primary toxicities were hematologic. Harvested peripheral stem cells were sufficient for autologous transplantation in 46 of 54 patients for whom stem cell collection was attempted. The overall response rate (72%; 95% CI 59-83%) permitted the majority of patients to undergo subsequent stem cell transplantation. CONCLUSIONS IV is a safe and effective re-induction regimen for salvage of pediatric patients with relapsed or refractory Hodgkin Lymphoma with an excellent response rate and success of post chemotherapy stem cell harvest. It avoids the use of etoposide, an agent associated with secondary malignancy after stem cell transplantation.
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Affiliation(s)
- Tanya M. Trippett
- Memorial Sloan Kettering Cancer Center, New York, New York,Correspondence to: Tanya M. Trippett, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, New York, NY 10065.
| | | | - R. Paul Guillerman
- Texas Children’s Cancer Center at Baylor College of Medicine, Houston, Texas
| | - Alan S. Gamis
- The Children’s Mercy Hospital & Clinics, Kansas City, Missouri
| | | | - Shirley Hogan
- University of Mississippi Medical Center, Jackson, Mississippi
| | - Wendy B. London
- Boston Children’s Hospital/Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lu Chen
- Children’s Oncology Group - Statistics and Data Center, Arcadia, California
| | - Pedro de Alarcon
- St. Jude Midwest Affiliate, University of Illinois College of Medicine, Peoria, Illinois
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Update on salvage options in relapsed/refractory hodgkin lymphoma after autotransplant. ISRN ONCOLOGY 2014; 2014:605691. [PMID: 25006506 PMCID: PMC4003874 DOI: 10.1155/2014/605691] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Accepted: 03/18/2014] [Indexed: 02/04/2023]
Abstract
Despite a high clinical success, relapse in Hodgkin lymphoma occurs in 10–30% of cases and 5–10% patients are nonresponsive to initial chemotherapy. The standard management of these patients includes high-dose chemotherapy followed by autologous stem cell transplant. However, 50% of patients ultimately relapse after autotransplant which poses a big challenge. Allogeneic stem cell transplantation offers the only chance of cure in these patients. For patients who are not candidates for allogeneic stem cell transplantation, achieving cure with other possible options is highly unlikely, and thus the treatment plan becomes noncurative. Various novel agents have shown promising results but the duration of response is short lived. A standard approach to deliver the most effective treatment for these patients is still lacking. This review focuses on the treatment options currently available for relapsed and refractory disease after autotransplant.
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Newland AM, Li JX, Wasco LE, Aziz MT, Lowe DK. Brentuximab vedotin: a CD30-directed antibody-cytotoxic drug conjugate. Pharmacotherapy 2013; 33:93-104. [PMID: 23307550 DOI: 10.1002/phar.1170] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Hodgkin lymphoma (HL) and systemic anaplastic large cell lymphoma (sALCL), which is a subtype of non-Hodgkin lymphoma, are relatively uncommon lymphoproliferative types of cancer. These malignancies are highly curable with initial treatment. Nonetheless, some patients are refractory to or relapse after first- and second-line therapies, and outcomes for these patients are less promising. Brentuximab vedotin is a CD30-directed antibody-cytotoxic drug conjugate that has demonstrated efficacy in response rates (objective response rates and complete response) when given to patients with refractory or relapsed HL and sALCL. Although not compared directly in clinical trials, the response rates with brentuximab vedotin are higher than those of several current treatments for refractory or relapsed HL and sALCL. Adverse effects associated with brentuximab vedotin are considered manageable. Nonetheless, several serious adverse effects (e.g., neutropenia, peripheral sensory neuropathy, tumor lysis syndrome, Stevens-Johnson syndrome, and progressive multifocal leukoencephalopathy, resulting in death) have been reported with its use. Despite a lack of survival and patient reported outcome data, the United States Food and Drug Administration (FDA) granted accelerated approval to brentuximab vedotin for the treatment of HL after failure of autologous stem cell transplantation or at least two combination chemotherapy regimens, and for sALCL after failure of at least one combination chemotherapy regimen. With this approval, brentuximab vedotin is the first FDA-approved agent for the treatment of HL in over three decades and the first agent specifically indicated to treat sALCL. Results of ongoing prospective trials should determine if brentuximab vedotin has a survival benefit when compared directly with standard treatment and if brentuximab vedotin is safe and efficacious when given earlier in the disease process, or when used with other chemotherapy for the treatment of HL and sALCL or other CD30-positive malignancies.
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Affiliation(s)
- Ashley M Newland
- Department of Pharmacy Services, Virginia Commonwealth University Health System/Medical College of Virginia Hospitals, Richmond, Virginia 23298, USA
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Bradley AM, Devine M, DeRemer D. Brentuximab vedotin: an anti-CD30 antibody-drug conjugate. Am J Health Syst Pharm 2013; 70:589-97. [PMID: 23515511 DOI: 10.2146/ajhp110608] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE The pharmacology, pharmacokinetics, clinical efficacy, and safety and tolerability of brentuximab vedotin are reviewed. SUMMARY Brentuximab vedotin is a potent antibody-drug conjugate composed of the monoclonal antibody cAC10, which targets the CD30 antigen on Hodgkin lymphoma and systemic anaplastic large-cell lymphoma (sALCL) cells; a highly stable valine-citrulline linker; and a potent chemotherapeutic agent monomethyl auristatin E, which inhibits microtubule polymerization. Brentuximab is indicated for patients with relapsed Hodgkin lymphoma after autologous stem-cell transplantation (ASCT), for patients who are not candidates for ASCT who have not responded to at least two multiagent chemotherapy regimens, and for patients with ALCL who have not responded to at least one multiagent chemotherapy regimen. In a Phase II, single-group, multicenter study, brentuximab produced an overall response rate of 75% in relapsed or refractory Hodgkin lymphoma. In another Phase II study, brentuximab demonstrated clinical benefit in sALCL, with 86% of patients achieving a response and 57% of patients achieving complete remission. Adverse events most commonly reported included nausea, fatigue, diarrhea, neutropenia, and peripheral sensory neuropathy. A Phase III study is currently ongoing in patients at high risk for residual Hodgkin lymphoma after ASCT. CONCLUSION Brentuximab vedotin, a novel antibody-drug conjugate combining a cytotoxic agent with a selective monoclonal antibody, is a therapeutic option for patients with relapsed or refractory Hodgkin lymphoma and sALCL. Phase I and II studies have shown brentuximab to have a manageable toxicity profile.
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Affiliation(s)
- Amber M Bradley
- College of Pharmacy, University of Georgia, 1120 15th Street, HM-1201, Augusta, GA 30912, USA.
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Furtado M, Rule S. Emerging Pharmacotherapy for Relapsed or Refractory Hodgkin's Lymphoma: Focus on Brentuximab Vedotin. Clin Med Insights Oncol 2012; 6:31-9. [PMID: 22253553 PMCID: PMC3256979 DOI: 10.4137/cmo.s6637] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hodgkins' lymphoma (HL) which has relapsed post or is refractory to autologous bone marrow transplant presents an ongoing treatment challenge. Development of monoclonal antibodies (mAb) for the treatment of HL has aimed to replicate the success of mAb therapy in the treatment on Non Hodgkins Lymphoma. The identification of CD30 as a potential target for treatment has led to the development of a new antibody-drug conjugate, brentuximab vedotin (SGN-35), which conjugates monomethyl auristatin E to an anti-CD30 antibody to deliver targeted toxicity to the malignant Reed Sternberg cells of HL. This review describes CD30 as an antibody target, and focuses on the antibody-drug conjugate brentuximab vedotin, including current knowledge of the mechanism of action, preclinical, clinical and pharmacokinetic data available for Brentuximab Vedotin.
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Affiliation(s)
| | - Simon Rule
- Department of Haematology, Derriford Hospital, Plymouth, UK
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Deutsch YE, Tadmor T, Podack ER, Rosenblatt JD. CD30: an important new target in hematologic malignancies. Leuk Lymphoma 2011; 52:1641-54. [DOI: 10.3109/10428194.2011.574761] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Klyuchnikov E, Bacher U, Kröger N, Kazantsev I, Zabelina T, Ayuk F, Zander AR. The Role of Allogeneic Stem Cell Transplantation in Relapsed/Refractory Hodgkin's Lymphoma Patients. Adv Hematol 2010; 2011:974658. [PMID: 20981158 PMCID: PMC2964008 DOI: 10.1155/2011/974658] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/17/2010] [Indexed: 11/17/2022] Open
Abstract
Despite the favorable prognosis of most patients with Hodgkin's Lymphoma (HL), 15-20% of patients remain refractory to chemoradiotherapy, and 20-40% experience relapses following autologous stem cell transplantation (SCT) being used as salvage approach in this situation. Long-term survival of only 20% was reported for patients who failed this option. As some authors suggested the presence of a graft versus HL effect, allogeneic SCT was introduced as a further option. Myeloablative strategies were reported to be able to achieve cure in some younger patients, but high nonrelapse mortality remains a problem. Reduced intensity conditioning, in turn, was found to be associated with high posttransplant relapse rates. As there is currently no standard in the management of HL patients who failed autologous SCT, we here review the literature on allogeneic stem cell transplantation in HL patients with a special focus on the outcomes and risk factors being reported in the largest studies.
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Affiliation(s)
- Evgeny Klyuchnikov
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
| | - Ulrike Bacher
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
| | - Nicolaus Kröger
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
| | - Ilya Kazantsev
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
- Clinic for Stem Cell Transplantation, St. Petersburg State, Pavlov's Medical University, St. Petersburg 197022, Russia
| | - Tatjana Zabelina
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
| | - Francis Ayuk
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
| | - Axel Rolf Zander
- Interdisciplinary Clinic for Stem Cell Transplantation, University Cancer Center Hamburg (UCCH), Martinistr. 52, 20246 Hamburg, Germany
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Dougherty DW, Friedberg JW. Gemcitabine and other new cytotoxic drugs: will any find their way into primary therapy? Curr Hematol Malig Rep 2010; 5:148-56. [PMID: 20437115 DOI: 10.1007/s11899-010-0054-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary treatment for classic Hodgkin lymphoma (HL) remains highly effective with chemotherapy alone or combined-modality therapy. The limitations of therapy have been related to toxicity and efficacy in subsets of patients. The introduction of a number of new and novel cytotoxic agents has provided opportunities for investigating their use in the treatment of HL. This article briefly reviews current primary treatment strategies for HL and examines the existing data for both new cytotoxic agents and other selected novel agents in the treatment of HL.
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Affiliation(s)
- David W Dougherty
- James P. Wilmot Cancer Center, Division of Hematology/Oncology, University of Rochester Medical Center, 601 Elmwood Avenue, Box 704, Rochester, NY 14642, USA
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25
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Lucas DM, Still PC, Pérez LB, Grever MR, Kinghorn AD. Potential of plant-derived natural products in the treatment of leukemia and lymphoma. Curr Drug Targets 2010; 11:812-22. [PMID: 20370646 PMCID: PMC2892601 DOI: 10.2174/138945010791320809] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2009] [Accepted: 01/20/2010] [Indexed: 12/13/2022]
Abstract
Hematologic malignancies account for a substantial percentage of cancers worldwide, and the heterogeneity and biological characteristics of leukemias and lymphomas present unique therapeutic challenges. Although treatment options exist for most of these diseases, many types remain incurable and the emergence of drug resistance is pervasive. Thus, novel treatment approaches are essential to improve outcome. Nearly half of the agents used in cancer therapy today are either natural products or derivatives of natural products. The enormous chemical diversity in nature, coupled with millennia of biological selection, has generated a vast and underexplored reservoir of unique chemical structures with biologic activity. This review will describe the investigation and application of natural products derived from higher plants in the treatment of leukemia and lymphoma and the rationale behind these efforts. In addition to the approved vinca alkaloids and the epipodophyllotoxin derivatives, a number of other plant compounds have shown promise in clinical trials and in preclinical investigations. In particular, we will focus on the discovery and biological evaluation of the plant-derived agent silvestrol, which shows potential for additional development as a new therapeutic agent for B-cell malignancies including chronic lymphocytic leukemia.
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Affiliation(s)
- David M Lucas
- Division of Medicinal Chemistry and Pharmacognosy, College of Pharmacy, The Ohio State University, 410 W. 12th Avenue, Columbus, OH 43210, USA.
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Blum KA, Johnson JL, Niedzwiecki D, Canellos GP, Cheson BD, Bartlett NL. Single agent bortezomib in the treatment of relapsed and refractory Hodgkin lymphoma: Cancer and leukemia Group B protocol 50206. Leuk Lymphoma 2009; 48:1313-9. [PMID: 17613759 DOI: 10.1080/10428190701411458] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Constitutive activation of nuclear factor-kappaB (NF-kappaB) has been described in patient-derived Reed - Sternberg cells and Hodgkin lymphoma (HL) cell lines and contributes to the proliferation and survival of HL. Therapeutic inhibition of the proteasome with bortezomib may inhibit over-expression of nuclear NF-kappaB by preventing degradation of IkappaB, which sequesters NF-kappaB in the cytoplasm. To evaluate this hypothesis, the Cancer and Leukemia Group B (CALGB) conducted a multi-institutional phase II trial of single agent bortezomib in patients with relapsed or refractory classical HL. Thirty patients received bortezomib 1.3 mg/m(2) on days 1, 4, 8, 11 and every 21 days for a median of 2 cycles (range, 1 - 8). Patients were heavily pre-treated with a median of four prior therapies, and 83% were previously transplanted. No responses were observed, 9 patients had stable disease, and 21 progressed. The median progression-free and overall survivals were 1.4 months [95% CI, (1.28, 1.91)] and 14.8 months [95% CI (11.2, 22.3)], respectively. Grade 3 - 4 adverse events, primarily thrombocytopenia, occurred in 15 patients. Therefore, although well tolerated, 1.3 mg/m(2) bortezomib administered biweekly has no single agent activity in relapsed/refractory classical HL.
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Affiliation(s)
- Kristie A Blum
- Division of Hematology - Oncology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA.
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Gemcitabine plus vinorelbine as an effective salvage chemotherapeutic regimen in advanced Hodgkin lymphoma. Hematol Oncol Stem Cell Ther 2009; 2:371-2. [DOI: 10.1016/s1658-3876(09)50030-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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28
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Cole PD, Schwartz CL, Drachtman RA, de Alarcon PA, Chen L, Trippett TM. Phase II study of weekly gemcitabine and vinorelbine for children with recurrent or refractory Hodgkin's disease: a children's oncology group report. J Clin Oncol 2009; 27:1456-61. [PMID: 19224841 PMCID: PMC2668553 DOI: 10.1200/jco.2008.20.3778] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2008] [Accepted: 12/12/2008] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The Children's Oncology Group conducted this phase II study to assess the efficacy and toxicity of gemcitabine and vinorelbine (GV) in pediatric patients with heavily pretreated relapsed/refractory Hodgkin's disease. Both agents have significant single-agent response rates in this setting. METHODS GV was given on days 1 and 8 of each 21-day treatment cycle: vinorelbine 25 mg/m(2)/dose administered via intravenous (IV) push before gemcitabine 1,000 mg/m(2)/dose IV over 100 minutes. Any patients who demonstrated a measurable response (complete response [CR], very good partial response [VGPR], or partial response [PR]) were considered to have experienced a response to GV. Response was evaluated after every two cycles. A two-stage minimax rule was used to test the null hypothesis that the response rate is RESULTS Thirty eligible patients with a median age of 17.7 years (range, 10.7 to 29.4 years) were enrolled. All patients had received at least two prior chemotherapy regimens, and 17 patients had undergone prior autologous stem-cell transplantation. Hematologic toxicity was predominant in all treatment cycles. Nonhematologic grade 3 to 4 toxicity, including elevated hepatic enzymes and hyperbilirubinemia, was less common. Pericardial and pleural effusions developed in one patient after cycles 4 and 5 of GV, consistent with gemcitabine-induced radiation recall. There were no toxic deaths. Measurable responses were seen in 19 (76%) of 25 assessable patients (95% exact binomial CI, 55% to 91%), including six CRs, 11 VGPRs, and two PRs. CONCLUSION GV is an effective and well-tolerated reinduction regimen for children with relapsed or refractory Hodgkin's disease.
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29
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Castagna L, Sarina B, Todisco E, Magagnoli M, Balzarotti M, Bramanti S, Mazza R, Anastasia A, Bacigalupo A, Aversa F, Soligo D, Giordano L, Santoro A. Allogeneic stem cell transplantation compared with chemotherapy for poor-risk Hodgkin lymphoma. Biol Blood Marrow Transplant 2009; 15:432-8. [PMID: 19285630 DOI: 10.1016/j.bbmt.2008.12.506] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2008] [Accepted: 12/22/2008] [Indexed: 11/19/2022]
Abstract
The aim of this study was to assess the role of allogeneic hematopoietic stem cell transplantation (HSCT) in patients with poor-risk Hodgkin's disease (HD) compared to chemotherapy. A donor was identified in 26 patients (14 HLA identical siblings and 10 alternative donors), and 24 received a transplant (Allo group). Twenty patients without a donor received different chemotherapy regimens and radiotherapy (CHEMO group). After a median follow-up of 28 months (range: 1-110), the 2-year overall survival (OS) was 71% in the ALLO group compared to 50% in the CHEMO group (P = .031). In the Allo group, the 2-year progression-free survival (PFS) was 47%. The 1-year nonrelapse mortality (NRM) in the ALLO group was 8% versus 0% in the CHEMO group. This study, suggests that allogeneic transplantation may prolong the survival in patients with a poor-risk HD.
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Affiliation(s)
- Luca Castagna
- Hematology Oncology Department, Istituto Clinico Humanitas, Rozzano, Milano, Italy.
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A multicenter study of gemcitabine-containing regimen in relapsed or refractory Hodgkin's lymphoma patients. Anticancer Drugs 2008; 19:309-15. [PMID: 18510178 DOI: 10.1097/cad.0b013e3282f46aec] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The aim of this study was to assess the efficacy of a gemcitabine-containing regimen in pretreated Hodgkin's lymphoma (HL) patients. Relapsed or refractory HL patients treated with gemcitabine, used alone or in combination with other cytotoxic agents, were retrospectively reviewed. Fifty-five patients were included in the study. Initial characteristics before gemcitabine administration were: Ann Arbor stage III-IV: 84%; International Prognostic Score less than 3 in 18/39 cases (46%); 31 primary refractory patients at the end of first-line therapy (56%); median number of previous chemotherapy regimens of 3. Twenty-nine patients received gemcitabine alone with a median maximal dose of 900 mg/m2 per injection (range: 300-1500 mg/m2). Gemcitabine was administered at a maximal dose of 1000 mg/m2 per injection (range: 650-1250) in combination with vinorelbine in 10 patients, oxaliplatin in 13 patients, and other drugs in three patients, with a median of six injections (range: 1-18). Reported toxicity was mainly hematologic. Overall response rate was 20% with 11% of complete remission. On univariate analysis, two adverse factors at progression were significant for response to gemcitabine-based regimen: stage III-IV disease and hemoglobin level was less than 10.5 g/dl. This study demonstrated the limited efficacy of gemcitabine-containing regimen in heavily pretreated HL patients.
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31
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Crump M. Management of Hodgkin lymphoma in relapse after autologous stem cell transplant. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2008; 2008:326-333. [PMID: 19074105 DOI: 10.1182/asheducation-2008.1.326] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Recurrence of Hodgkin lymphoma (HL) occurs in about 50% of patients after autologous stem cell transplantation (ASCT), usually within the first year, and represents a significant therapeutic challenge. The natural history of recurrent HL in this setting may range from a rapidly progressive to a more indolent course. Patients in this setting are often young, without comorbidities and able to tolerate additional therapies: expectations are often still high. The approach to treatment depends on clinical variables (time to relapse, perceived sensitivity to additional cytotoxic therapy, disease stage), prior history of radiation therapy, the availability of an HLA-identical donor, and the availability of new agents via clinical trials. Although very few of these patients can be cured, results from reported series, albeit often small and sometimes with relatively short follow-up, document that excellent disease control can be achieved with radiation, single or multiagent chemotherapy, and reduced-intensity allogeneic transplantation. The results of these approaches will be reviewed, and a treatment algorithm incorporating the use of standard or investigational agents or approaches will be discussed.
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Affiliation(s)
- Michael Crump
- Princess Margaret Hospital, University of Toronto, Toronto, Canada.
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32
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Magagnoli M, Spina M, Balzarotti M, Timofeeva I, Isa L, Michieli M, Capizzuto R, Morenghi E, Castagna L, Tirelli U, Santoro A. IGEV regimen and a fixed dose of lenograstim: an effective mobilization regimen in pretreated Hodgkin's lymphoma patients. Bone Marrow Transplant 2007; 40:1019-25. [PMID: 17906705 DOI: 10.1038/sj.bmt.1705862] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
We explored the efficacy of the IGEV regimen (ifosfamide, gemcitabine, vinorelbine and prednisone) combined with a fixed dose of lenograstim (263 mug/day) to mobilize peripheral blood stem cells (PBSCs) in 90 Hodgkin's lymphoma patients. The median total CD34+ cells/mul peak, colony-forming units granulocyte-macrophage and white blood cells for all individual collection sets were 85/mul, 12 x 10(4)/kg and 20 700/mul, respectively. An adequate number of CD34+ cells (more than 3 x 10(6) or 6 x 10(6) CD34+ cells/kg depending on whether single or tandem high-dose chemotherapy was used) were collected in 89 out of 90 (98.7%) mobilized patients, whereas the only failure reached 2.3 x 10(6) CD34+ cells/kg. The median CD34+ cell collections were 11 x 10(6)/kg (range 2.3-39 x 10(6)/kg) and 10 x 10(6)/kg (range 6-22.0 x 10(6)/kg) with a median of 1 and 2 leukaphereses for patients eligible for single high-dose treatment and for candidates for tandem transplant, respectively. Target yields were reached in 71.43 and 49.09% and additionally in 17.14 and 43.64% of cases after the first and second apheresis procedures, respectively. Hematological and non-hematological side effects were acceptable, and no toxic deaths occurred. Thirty-four patients received a single and 47 received tandem transplantation with rapid engraftment. These results confirm that the IGEV regimen with lenograstim support can be used successfully and safely to mobilize PBSCs.
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Affiliation(s)
- M Magagnoli
- Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Rozzano, Milan, Italy.
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Abstract
The majority of patients who are diagnosed with Hodgkin lymphoma (HL) will be cured with primary chemotherapy. For those who relapse, autologous stem cell transplantation (ASCT) has become the standard of care. Randomized clinical trials have demonstrated that approximately 50% of patients with chemosensitive relapsed HL can achieve long term disease free survival with ASCT. However, optimal therapy of those who have chemorefractory disease or who relapse after an ASCT has not been established. Reduced intensity allogeneic stem cell transplantation may benefit these patients, although a definite graft versus HL effect has not been demonstrated and treatment-related mortality remains relatively high. New salvage regimens that incorporate gemcitabine, vinorelbine, rituximab, and/or monoclonal antibodies against CD30 are being investigated.
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Affiliation(s)
- Amanda F Cashen
- Division of Oncology, Washington University School of Medicine, 660 S. Euclid Ave., St. Louis, MO 63110, USA.
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Abstract
Hematopoietic stem cell transplantation is an effective treatment for patients with relapsed or refractory Hodgkin lymphoma. Treatment outcome is better among patients who demonstrate sensitivity to salvage chemotherapy. Approximately half of the patients undergoing autologous stem cell transplantation will be cured and sequential high-dose therapy has been proposed as a means of improving these results further. Lifelong medical surveillance is required following transplantation to monitor for late toxicity, including second malignancy. For young patients who relapse following transplantation, reduced-intensity allogeneic transplantation has shown encouraging response rates, while second autologous stem cell transplantation, radiotherapy and palliative single-agent chemotherapy are other options. For patients with multiple relapses and chemotherapy refractory disease, novel approaches are necessary.
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Affiliation(s)
- Felicity Murphy
- Royal Marsden NHS Foundation Trust, Sutton, Surrey, SM2 5PT, UK.
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35
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Bartlett NL, Niedzwiecki D, Johnson JL, Friedberg JW, Johnson KB, van Besien K, Zelenetz AD, Cheson BD, Canellos GP. Gemcitabine, vinorelbine, and pegylated liposomal doxorubicin (GVD), a salvage regimen in relapsed Hodgkin's lymphoma: CALGB 59804. Ann Oncol 2007; 18:1071-9. [PMID: 17426059 DOI: 10.1093/annonc/mdm090] [Citation(s) in RCA: 202] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Because of high single-agent activity and modest toxicity, we hypothesized the combination of gemcitabine (G), vinorelbine (V), and pegylated liposomal doxorubicin (D) would be an effective salvage therapy for Hodgkin's lymphoma (HL). PATIENTS AND METHODS A total of 91 patients participated. GVD was administered on days 1 and 8 every 21 days at doses of G 1000 mg/m(2), V 20 mg/m(2), and D 15 mg/m(2) for transplant-naive patients, and G 800 mg/m(2), V 15 mg/m(2), and D 10 mg/m(2) for post-transplant patients. RESULTS The dose-limiting toxicity was mucositis for the transplant-naive patients and febrile neutropenia for post-transplant patients. The overall response rate (RR) for all patients was 70% [95% confidence interval (CI) 59.8, 79.7], with 19% complete remissions. The 4-year event-free and overall survival rates in transplant-naive patients treated with GVD followed by autologous transplant were 52% (95% CI 0.34, 0.68) and 70% (95% CI 0.49, 0.84), and in the patients in whom prior transplant failed, these were 10% (95% CI 0.03, 0.22) and 34% (95% CI 0.17, 0.52), respectively. CONCLUSIONS GVD is a well-tolerated, active regimen for relapsed HL with results similar to those reported for more toxic regimens. High RRs in patients in whom prior transplant failed confirms this regimen's activity even in heavily pretreated patients.
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Affiliation(s)
- N L Bartlett
- Siteman Cancer Center, Washington University School of Medicine, St Louis, MO 63110, USA.
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36
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Abstract
Hodgkin's disease is a rare malignancy that affects approximately 7,500 patients per year in the U.S., leading to an estimated 1,400 deaths. The relapse rate for this disease varies from around 5% for early-stage disease to 35% for patients with advanced disease. Patients who relapse after chemotherapy have about a 20% cure rate with conventional salvage chemotherapy. Two randomized phase III studies have shown an improved failure-free survival rate with high-dose chemotherapy and autologous stem cell support compared with conventional chemotherapy in relapsed patients. They failed to show any improvement in overall survival. For patients who experience failure with autologous transplant, the options of single-agent chemotherapy with gemcitabine, vinblastine, or vinorelbine can be used for palliation. Standard myeloablative allogeneic bone marrow transplant has a high mortality rate in this population. Allogeneic transplant regimens with reduced intensity are currently being studied in clinical trials. Further studies on the use of monoclonal antibodies and radiolabeled antibodies need to be conducted to define their role in the treatment of Hodgkin's disease.
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Affiliation(s)
- Brian J Byrne
- Duke University Medical Center, Box 3841, Durham, North Carolina 27710, USA.
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Lonial S, Arellano M, Hutcherson D, Langston A, Flowers C, Heffner LT, Winton E, Jo Lechowicz M, Waller EK. Results of a clinical phase I dose-escalation study of cytarabine in combination with fixed-dose vinorelbine, paclitaxel, etoposide and cisplatin for the treatment of relapsed/refractory lymphoma. Leuk Lymphoma 2007; 47:2155-62. [PMID: 17071490 DOI: 10.1080/10428190600774923] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Management of relapsed lymphoma depends upon the variables of chemosensitive disease and successful stem cell mobilization. The microtubule specific agents, paclitaxel and vinorelbine, have efficacy in relapsed lymphoma and can enhance stem cell mobilization. We performed a phase I dose-escalation study of cytarabine combined with fixed doses of vinorelbine, paclitaxel, etoposide and cisplatin (VTEPA) for patients with relapsed/refractory lymphoma. The regimen consisted of paclitaxel 175 mg/m2 and vinorelbine 30 mg/m2 on day 1; cisplatin 20 mg/m2 and etoposide 100 mg/m2 over 4 h on days 2 - 5. Cytarabine 2 g m/m2 over 4 h, in successive cohorts on 1, 2, or 3 consecutive days: cohort A day 5; cohort B days 4 - 5; and cohort C days 3 - 5. Sixteen patients (Hodgkin's disease, n = 6; non-Hodgkin's lymphoma, n = 10) were enrolled. Fourteen of 16 patients (88%) had refractory and seven patients (44%) had primary refractory disease. Major toxicities included hematologic toxicity, mucositis and infectious complications. Infectious complications (10/16 patients) included neutropenic fever, sepsis and fungal pneumonia. Dose-limiting toxicity was achieved in cohort C, which received three doses of cytarabine. There were 33% partial responses, 27% stable disease and 40% progressive disease following a single cycle of VTEPA. Two of 16 patients suffered treatment-related mortality. Five patients went on to receive autologous (n = 4) or allogeneic transplant (n = 1), and five out of seven patients in this heavily pretreated group who received VTEPA for mobilization of an autologous graft were successfully collected. The recommended dose of cytarabine for further evaluation in a phase II study is 2 g m/m2 for 2 consecutive days in combination with VTEPA. Treatment of subjects with relapsed/refractory lymphoma using VTEPA as second- or third-line salvage therapy produced remissions in some patients and permitted collection of grafts and subsequent autologous transplantation, supporting a planned phase II trial.
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Affiliation(s)
- Sagar Lonial
- Winship Cancer Institute, Emory University School of Medicine, Atlanta, Georgia, USA.
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Affiliation(s)
- Nancy L Bartlett
- Washington University, Siteman Cancer Center, Division of Medical Oncology 660 South Euclid Street, St. Louis, MO 63110, USA
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Abstract
The current data support the use of high-dose chemotherapy (HDCT) and autologous stem cell transplantation (ASCT) as standard procedure for the majority of patients with Hodgkin's disease (HD) relapsing or progressing after combination chemotherapy. Prognostic factors reflecting unfavourable prognostic features of the disease as well as resistance to conventional salvage therapy have been identified. Preliminary data suggests a high efficacy of high-dose sequential chemotherapies in these patients. An ongoing randomized trial is comparing standard HDCT versus sequential HDCT in patients with relapsed HD.
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Affiliation(s)
- Andreas Josting
- First Department of Internal Medicine and the German Hodgkin's Lymphoma Study Group, Germany.
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Whitehead RP, Moon J, McCachren SS, Hersh EM, Samlowski WE, Beck JT, Tchekmedyian NS, Sondak VK. A Phase II trial of vinorelbine tartrate in patients with disseminated malignant melanoma and one prior systemic therapy. Cancer 2004; 100:1699-704. [PMID: 15073859 DOI: 10.1002/cncr.20183] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Single-agent chemotherapy with dacarbazine continues to be the standard of care for the treatment of metastatic melanoma. However, there is a large population of patients who have failed first-line therapy and might benefit from additional treatment. In the current study, the authors evaluated the antitumor effects and toxicity of vinorelbine therapy in patients who had failed one prior systemic therapy. METHODS Patients were required to have a histologic diagnosis of melanoma and be of Stage IV with measurable disease, a Southwest Oncology Group (SWOG) performance status (PS) of 0-2, no evidence of brain metastases, and adequate bone marrow and liver function. Treatment was comprised of vinorelbine given at a dose of 30 mg/m(2)/week by intravenous bolus. RESULTS Twenty-four patients were registered to the study, 3 of whom were determined to be ineligible. The 21 eligible patients had a median age of 58 years with a SWOG PS of 0 in 7 patients, 1 in 13 patients, and 2 in 1 patient. There were no complete or partial responses observed, for a response rate of 0 of the 21 patients studied (95% confidence interval [95% CI], 0-16%); the study closed after the first stage of accrual. The estimated median progression-free survival was 2 months (95% CI, 1.5-3.3 months) and the estimated median overall survival was 6 months (95% CI, 3.7-8.3 months). There was one death due to febrile neutropenia reported, with six patients experiencing one or more Grade 4 toxicities, including neutropenia/granulocytopenia, leukopenia, dyspnea, and fatigue. CONCLUSIONS Despite impressive preclinical activity against melanoma, vinorelbine does not appear to have enough clinical activity to be of interest in previously treated patients with disseminated melanoma. The progression-free and overall survival results noted in previously treated patients in the current study were similar to results reported in prior SWOG Phase II trials in untreated patients. The group of previously treated patients may be used to evaluate new agents for the treatment of disseminated melanoma.
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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.
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Affiliation(s)
- Cindy L Schwartz
- Sidney Kimmel Cancer Center at Johns Hopkins, Baltimore, Maryland 21208, USA.
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Josting A, Raemakers JM, Diehl V, Engert A. New concepts for relapsed Hodgkin's disease. Ann Oncol 2002; 13 Suppl 1:117-21. [PMID: 12078892 DOI: 10.1093/annonc/13.s1.117] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- A Josting
- Department of Internal Medicine I, University Hospital Cologne and the German Hodgkin Lymphoma Study Group.
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Ochiai N, Shimazaki C, Inaba T, Fuchida SI, Okano A, Hatsuse M, Hirai H, Ashihara E, Fujita N, Nakagawa M. Effect of vinorelbine on the growth of human myeloma cell lines in vitro. Leuk Res 2002; 26:731-8. [PMID: 12191568 DOI: 10.1016/s0145-2126(01)00195-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Vinorelbine (NVB) is a newly synthesized vinca alkaloid that has been used to treat advanced malignant diseases including lung adenocarcinoma and lymphoma. The effect of NVB on myeloma, however, is unknown. We therefore examined the effect of NVB on the growth of human myeloma cell lines (RPMI8226, U266 and KPMM2) using the trypan blue dye exclusion test and Alamar blue assay. NVB inhibited the growth of myeloma cells of all three cell lines dose-dependently and this effect was intensified when NVB was combined with dexamethasone at 1.0 x 10(-6)mol/l. Flow cytometric analysis using annexin V (AN) and 7-amino-actinomycin D (7AAD) showed that NVB-induced apoptosis of these myeloma cells in all the cell lines. NVB appears to be a potent inducer of apoptosis in myeloma cells, and might have some benefit in the treatment of myeloma patients.
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Affiliation(s)
- Naoya Ochiai
- Second Department of Medicine, Kyoto Prefectural University of Medicine, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyoku, Kyoto 602-8566, Japan.
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Abstract
Significant progress has been made over the past decade in the classification, diagnosis, staging, prognosis, and treatment of Hodgkin's disease (HD). A new classification system has recognized differences in the natural history of certain subtypes. The introduction of positron emission tomography has improved the accuracy of non-invasive staging. New prognostic indices have led to the development of risk-adapted treatment strategies. The serious long-term side effects of extended-field radiotherapy have prompted the increasing use of chemotherapy in conjunction with limited radiotherapy for early-stage patients. Combination chemotherapy remains the treatment of choice for advanced HD, and new dose-intense regimens appear to have improved activity. Patients who relapse now have a more favorable prognosis with the availability of active salvage regimens, autologous stem cell transplantation, and novel biologic agents.
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Affiliation(s)
- Bradley C Ekstrand
- Division of Oncology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
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Lin TS, Avalos BR, Penza SL, Marcucci G, Elder PJ, Copelan EA. Second autologous stem cell transplant for multiply relapsed Hodgkin's disease. Bone Marrow Transplant 2002; 29:763-7. [PMID: 12040474 DOI: 10.1038/sj.bmt.1703546] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2001] [Accepted: 02/04/2002] [Indexed: 11/08/2022]
Abstract
Therapeutic options for patients with Hodgkin's disease who relapse after high-dose chemotherapy with autologous stem cell support are limited. Salvage chemotherapy is not curative, and allogeneic stem cell transplantation in this setting is associated with mortality rates of 40-65%. We report our institution's experience with second autologous transplants in this patient population. Five patients (median age 36) with relapsed Hodgkin's disease underwent a second autologous stem cell transplant at a median of 66 months after first transplant. Four patients received CBV, and one patient received BuCy as conditioning. Neutrophil and platelet engraftment occurred by days +10 and +16, respectively. All patients achieved a complete response, and no relapses have occurred after a median follow-up of 42 months. All four patients who received CBV developed interstitial pneumonitis, and two patients died of pulmonary complications 37 and 48 months following second transplant. Three patients remain alive and disease-free 41, 42 and 155 months after second transplant. These data indicate that second autologous transplantation should be considered for selected patients who relapse after a prolonged response to first autologous transplant. However, BCNU pneumonitis is the major toxicity in patients who have undergone previous mantle radiation and received busulfan with first transplant.
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Affiliation(s)
- T S Lin
- Arthur James Cancer Hospital and Richard Solove Research Institute at The Ohio State University, Bone Marrow Transplant Program, Division of Hematology and Oncology, Columbus, OH 43210, USA
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Aapro MS, Harper P, Johnson SA, Vermorken JB. Developments in cytotoxic chemotherapy: advances in treatment utilising vinorelbine. Crit Rev Oncol Hematol 2001; 40:251-63. [PMID: 11738948 DOI: 10.1016/s1040-8428(01)00167-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Vinorelbine is a third generation vinca alkaloid which has been in clinical development for 15 years. Recent exploration of its pre-clinical activity has revealed unexpected evidence of potential synergy with taxane compounds and early clinical results support the suggestion of enhanced efficacy particularly in breast cancer. The initial studies establishing the clinical activity of vinorelbine in breast cancer and non-small cell lung cancer have been extended to encompass a thorough evaluation of its contribution to combination chemotherapy for these disorders. In the treatment of breast cancer useful activity has been established for vinorelbine in combination with anthracyclines, anthracenediones, antimetabolites and the taxanes; additive toxicity is not a limiting factor. The activity of vinorelbine in the treatment of non-small cell lung cancer is significantly extended by incorporation into schedules utilising cisplatin and other agents. Vinorelbine has also demonstrated useful activity in the treatment of a wide range of other malignancies including prostatic carcinoma, multiple myeloma, cancer of the ovary, cervix and head and neck and malignant lymphomas.
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Affiliation(s)
- M S Aapro
- Clinique de Genolier, 1272 Genolier, Switzerland
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Magagnoli M, Sarina B, Balzarotti M, Castagna L, Timofeeva I, Nozza A, Bertuzzi A, Siracusano L, Sinnone M, Santoro A. Mobilizing potential of ifosfamide/vinorelbine-based chemotherapy in pretreated malignant lymphoma. Bone Marrow Transplant 2001; 28:923-7. [PMID: 11753545 DOI: 10.1038/sj.bmt.1703265] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2001] [Accepted: 08/23/2001] [Indexed: 11/08/2022]
Abstract
The mobilizing potential and therapeutic activity of ifosfamide/vinorelbine-containing regimens with G-CSF support were explored in patients with pretreated malignant lymphomas. Ten patients with non-Hodgkin's lymphoma (NHL) received ifosfamide and vinorelbine, and 17 with Hodgkin's disease (HD) received ifosfamide, vinorelbine and gemcitabine (IGEV regimen), as induction chemotherapy before high-dose chemotherapy (HDT) with peripheral blood stem cell (PBSC) support. Most of the patients had been heavily pretreated with various chemotherapy regimens +/- radiotherapy. The target yield was > or =3 x 10(6) CD34+ cells/kg of body weight in order to support the subsequent myeloablative chemotherapy. The optimal PBSC harvest occurred on days 11 and 12, with no difference in CD34+ cell mobilization kinetics between the ifos- famide/vinorelbine and IGEV regimens. The median number of CD34+ cells/kg body weight collected was 10.9 x 10(6) (range 1.76-61.1 x 10(6)). The median total CD34+ cell/microl, CFU-GM and white blood cells (WBC) for all individual collections was 81.5/microl, 10 x 10(4)/kg, and 17 900/microl, respectively. The target yield of CD34+ cells was reached in 24 of 27 patients. Hematological side-effects were acceptable and no treatment-related hospitalizations or toxic deaths occurred. Fifteen patients have so far received high-dose therapy and PBSC reinfusion with rapid engraftment. These results confirm that ifosfamide and vinorelbine-based chemotherapy regimen with G-CSF support can be successfully and safely used to mobilize PBSCs.
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Affiliation(s)
- M Magagnoli
- Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Rozzano, Milan, Italy
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Sarris AH, Psyrri A, Hagemeister F, Romaguera J, McLaughlin P, Rodriguez MA, Bachier C, Younes A, Mesina O, Oholendt M, Medeiros LJ, Samuels B, Adams LM, Cabanillas F. Infusional vinorelbine in relapsed or refractory lymphomas. Leuk Lymphoma 2000; 39:291-9. [PMID: 11342309 DOI: 10.3109/10428190009065828] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Vinorelbine (Navelbine is a semisynthetic vinca alkaloid devoid of serious neurotoxicity. When given weekly vinorelbine has documented activity against many tumors, including lymphomas. Since weekly schedules cannot be easily incorporated in combination regimens, we tested an infusional schedule of vinorelbine given every 21 days in adults with relapsed or refractory lymphoma. Patients with inadequate organ or bone marrow reserve, HIV or other serious infection, central nervous system disease, or prior stem cell or bone marrow transplantation were ineligible. In the phase I part, patients received a constant intravenous bolus of 8 mg/m(2), followed by intravenous continuous infusion over 24 hours daily for four days increasing from 10, 12, to 14 mg/m(2) /d in successive three-patient cohorts. Cycles were repeated every 21 days, and the daily continuous infusion dose was adjusted for toxicity. Dose-limiting mucositis and neutropenia were reached at the continuous dose of 14 mg/m(2) /d. Consequently, for the Phase II trial the starting continuous infusion dose was 12 mg/m(2) /d. After the first 19 patients were entered in the phase II study, the starting infusion dose was reduced to 10 mg/m(2) /d because of frequent grade (3/4) myelosuppression and mucositis. Forty-four patients were entered in the phase II study, of whom 41 are evaluable. Median age was 61 years, 23 were males, with clinically aggressive non-Hodgkin's lymphoma (NHL) in 22, indolent NHL in 18, and Hodgkin's Disease in one patient. The median number of prior regimens was 3 (range 1-11). The lymphoma was refractory to the initial regimen in nine patients, and to the regimen immediately before vinorelbine in 20 patients. Serum LDH was high in 2(1/4)1, and serum beta(2) -microglobulin > 3.0 mg / L in 16/31 patients. Responses were observed in four of 22 patients with aggressive NHL (18%, 95% confidence interval 5%-40%), and in six of 18 with indolent NHL (33%, 95% confidence interval 13%-59%). Median progression-free survival was 6 months for responders. During the Phase II trial 114 vinorelbine courses were administered. Neutrophil nadir was < 1000/microl in 65% and < 100/microl in 35% of courses, respectively. Platelet nadir was < 100,000/microl in 30% and < 20,000/microl in 8% of courses, respectively. Grade (3/4) mucositis was seen in 18% of courses, and neutropenic fever in 13%, and was complicated by death in one patient. We conclude that this dosage and schedule of vinorelbine has modest activity in patients with relapsed or refractory NHL. Myelosuppression is frequent but reversible, but there is no significant neurotoxicity. The role of vinorelbine in combination regimens for patients with relapsed lymphomas, particularly those of indolent histology, should be further investigated.
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Affiliation(s)
- A H Sarris
- Department of Lymphoma and Myeloma, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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Santoro A, Bredenfeld H, Devizzi L, Tesch H, Bonfante V, Viviani S, Fiedler F, Parra HS, Benoehr C, Pacini M, Bonadonna G, Diehl V. Gemcitabine in the treatment of refractory Hodgkin's disease: results of a multicenter phase II study. J Clin Oncol 2000; 18:2615-9. [PMID: 10893294 DOI: 10.1200/jco.2000.18.13.2615] [Citation(s) in RCA: 161] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To explore the use of gemcitabine for the treatment of patients with relapsing or refractory Hodgkin's disease. PATIENTS AND METHODS Eligible patients had measurable disease and more than one previous chemotherapy regimen. Patients previously treated with high-dose chemotherapy with autologous bone marrow or peripheral stem-cell support were not included. Gemcitabine, 1,250 mg/m(2), was administered as a 30-minute intravenous infusion on days 1, 8, and 15 of each 28-day cycle of therapy. The dosing schedule remained fixed, and any dose of gemcitabine that could not be given on time was omitted. Patients who had not experienced any hematologic or nonhematologic toxicity after one complete cycle of therapy were permitted to have subsequent doses increased by 20%: that is, from 1, 250 mg/m(2) to 1,500 mg/m(2). RESULTS Of the 23 enrolled patients, 22 were assessable for response; all 23 patients were included in the efficacy analysis. Disease status for two patients (9%) reached a state of complete remission, and seven patients (30%) achieved a partial response, for an overall response rate of 39% (95% confidence interval, 19.7% to 61.5%). The likelihood of achieving a response was not influenced by a patients' main pretreatment characteristics or by their response to their last prior chemotherapy. The median duration of response was 6.7 months (range, 2 to 33+ months), and the median overall survival time was 10.7 months (range, 4 to 34.7+ months). In general, toxicities were mild; no treatment-related deaths occurred, and only one life-threatening adverse event was reported for this study. CONCLUSION Gemcitabine was shown to be active in heavily pretreated patients with Hodgkin's disease, producing a response rate of 39%. Additionally, drug-related toxicities were mild, which thus suggests the possible inclusion of gemcitabine in an earlier phase of treatment.
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Affiliation(s)
- A Santoro
- Istituto Clinico Humanitas, Rozzano-Milano, Italy.
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50
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Affiliation(s)
- R K Gregory
- Department of Medicine, Royal Marsden NHS Trust and Institute of Cancer Research, London, UK
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