Methyl-GAG, ifosfamide, methotrexate and etoposide (MIME) as salvage therapy for Hodgkin's disease: a prospective study

Optimal treatment for relapsing patients with Hodgkin lymphoma

Relapsed or refractory classical Hodgkin lymphoma (HL) remains a therapeutic challenge. Patients with relapsed HL should be identified according to their prognostic factors at relapse (duration of remission and extranodal disease or stage). Patients with refractory disease, defined as progression during induction treatment or within 90 days after the end of treatment, have the worst prognosis. Following non-crossresistant salvage chemotherapy to achieve cytoreduction, high-dose therapy (HDT) and autologous stem cell transplantation has been shown to be better than conventional-dose chemotherapy for first-relapse/refractory HL. For patients with very unfavorable relapse or primary refractory HL, outcome remains poor with HDT. For these patients, the role of tandem HDT or allogeneic stem cell transplantation will be discussed. In this setting, novel investigational treatments will be presented.

Salvage therapy in Hodgkin's lymphoma

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.

APE chemotherapy for children with relapsed Hodgkin disease: a Pediatric Oncology Group trial

BACKGROUND

MOPP (mechlorethamine, vincristine, procarbazine, prednisone) and ABVD (doxorubicin, bleomycin, vinblastine, and dacarbazine) are effective therapies for Hodgkin disease (HD) that may cause long-term toxicities in children. APE (cytosine arabinoside, cisplatin, etoposide) is a non-cross-resistant regimen with limited toxicities. We evaluated this regimen for patients with recurrent or refractory disease.

METHODS

Patients with recurrent Hodgkin disease who were <or=21 years of age and had previously received standard alkylating agent and doxorubicin-based therapy, were treated with APE chemotherapy (cytosine arabinoside 750 mg/m(2), cisplatin 15 mg/m(2), etoposide 20 mg/m(2)) every 12 hr, administered three or four times per cycle. Response, Event-free survival (EFS), and overall survival (OS) were assessed.

RESULTS

Thirty-one patients in first (n = 25) or second (n = 6) relapse of Hodgkin disease were eligible and evaluable. APE chemotherapy was well-tolerated, with the major toxicity consisting of short duration, grade 3/4 hematopoietic toxicity. The CR/PR response rate was 68% (42% CR, 26% PR). Allowing subsequent stem cell transplantation in some patients, 4-year EFS and OS were 27% +/- 8% and 49% +/- 9%, with 8-year EFS and OS of 23% +/- 9% and 34% +/- 10%.

DISCUSSION

APE is an efficacious regimen with minimal toxicity. Novel regimens are necessary to: (1) re-induce remission, (2) treat newly diagnosed patients, and (3) augment therapy in patients with slow response to standard regimens. This regimen had minimal toxicity and an excellent response rate that facilitated long term survival, often in conjunction with transplantation. The Children's Oncology Group is using a similar regimen to augment therapy for slow responders on a current Hodgkin disease trial.

Long-term results of conventional-dose salvage chemotherapy in patients with refractory and relapsed Hodgkin's disease (Croatian experience)

BACKGROUND

The aim of this study was to analyze outcome of patients with Hodgkin's disease (HD) in whom first-line chemotherapy with mustine/vincristine/procarbazine/prednisone (MOPP) had failed.

PATIENTS AND METHODS

From January 1982 to December 1989 among 210 patients treated with MOPP and radiotherapy to initial bulky sites, 65 patients were primary refractory to or relapsed after initial treatment.

RESULTS

Twenty-nine of 65 patients (44%) were primary refractory to initial chemotherapy, 20 relapsed within 12 months after complete remission (CR) and 16 relapsed after CR that lasted more than 12 months. Patients with primary refractory HD and early relapse (<12 months after CR) were treated with doxorubicin/bleomycin/vinblastine/darcarbazine. In patients with late relapse (>12 months after CR) MOPP was repeated. The median follow-up for all patients was 115 months. The overall response rate was 63%. Thirty-three patients (51%) achieved a second CR and eight patients (12%) partial response. Remission rate was greatest in patients with late relapse (CR >12 months) (75 versus 55% for early relapse versus 35% for primary refractory HD) (P <0.01). At 10 years, overall and failure-free survival rates were 21 and 16%, respectively. Patients who were in first remission longer than 12 months had a superior overall survival (37 versus 18% for early relapse) and failure-free survival (24 versus 10% for early relapse). No patient with primary refractory HD was alive beyond 52 months after initial treatment failure (P <0.01). Main prognostic factors were duration of the first remission and tumor bulk at relapse.

CONCLUSIONS

Our results confirm previous observations that a significant proportion of patients with HD who experience induction treatment failure cannot be cured with conventional treatment and probably need more aggressive therapy.

A population-based study of the outcome for patients with first relapse of Hodgkin's lymphoma

BACKGROUND

Our aims were to evaluate the response to salvage treatment in relation to initial treatment and to evaluate prognostic factors at the time of relapse in an unselected population of relapsing patients with Hodgkin's lymphoma (HL).

PATIENTS AND METHODS

In total, 124 patients younger than 60 yr of age with initial diagnosis of HL in Sweden relapsed between 1985 and 1995.

RESULTS

Fifty-eight patients relapsed after initial treatment with radiotherapy (RT) only, 62 after combination chemotherapy (CT), of whom 30 had received additional involved-field RT, and four after a short course of CT followed by extended-field RT. For 37 patients among the 58 relapsers after initial RT treated according to the recommendations of the National guidelines, the 5-yr Hodgkin-specific survival (HLS) was 85%, overall survival (OS) 73% and event-free survival (EFS) 62%, which is not inferior to survival in patients with primarily advanced stages. It was poorer in the 21 patients who initially had received RT only, even though they had been recommended for more extensive treatment. For patients initially treated with a full course (6-8 cycles) of CT the 5-yr HLS was 60%, OS 58% and EFS 22%. Bulky disease and age at diagnosis strongly affected survival in a multivariate analysis.

CONCLUSIONS

Patients initially treated with RT who relapse have a favourable outcome, provided they have been treated according to the recommendations of the guidelines at the time of diagnosis. Initially bulky disease and, as a consequence, additional RT as part of the initial treatment negatively affect survival at relapse in patients initially treated with a full course of CT.

Guanidino-containing drugs in cancer chemotherapy: biochemical and clinical pharmacology

The pharmacology and clinical application of three guanidino-containing compounds are reviewed in this commentary with special focus on a new member of this group of drugs, CHS 828 [N-(6-(4-chlorophenoxy)hexyl)-N'-cyano-N"-4-pyridylguanidine]. m-Iodobenzylguanidine (MIBG) and methylglyoxal bis(guanylhydrazone) (MGBG) have been extensively studied, preclinically as well as clinically, and have established use as anticancer agents. MIBG has structural similarities to the neurotransmitter, norepinephrine, and MGBG is a structural analog of the natural polyamine spermidine. CHS 828 is a pyridyl cyanoguanidine newly recognized as having cytotoxic effects when screening antihypertensive compounds. Apart from having the guanidino groups in common, there are many differences between these drugs in both structure and their mechanisms of action. However, they all inhibit mitochondrial function, a seemingly unique feature among chemotherapeutic drugs. In vitro in various cell lines and primary cultures of patient tumor cells and in vivo in various tumor models, CHS 828 has cytotoxic properties unlike any of the standard cytotoxic drugs with which it has been compared. Among these are non-cross-resistance to standard drugs and pronounced activity in tumor models acknowledged to be highly drug-resistant. Similar to MIBG, CHS 828 induces an early increase in extracellular acidification, due to stimulation of the glycolytic flux. Furthermore, ATP levels decrease, and the syntheses of DNA and protein are shut off after approximately 30 hr of exposure, indicating active cell death. CHS 828 is now in early clinical trials, the results of which are eagerly awaited.

Pharmacokinetic behaviour of phenylglyoxal bis(guanylhydrazone) (PGBG) after intravenous administration in rabbits

Phenylglyoxal bis(guanylhydrazone) (PGBG) is a synthesized analogue of methylglyoxal bis(guanylhydrazone) (MGBG), which has demonstrated anti-parasitic activity in rabbits. The pharmacokinetic behaviour of PGBG after intravenous administration (10 mg/kg bodyweight) was studied in five rabbits. Plasma concentrations of PGBG were measured by high-performance liquid chromatography. Plasma PGBG concentrations decreased rapidly and were not detectable beyond 90 min after treatment. The mean [+/- standard deviation (SD)] volume of distribution at steady state (Vdss) was 2.19 +/- 0.47 l/kg and the mean plasma clearance value (Cl) was 29.99 +/- 3.98 ml/min kg. This drug is rapidly eliminated from the body in rabbits, having a short elimination half-life (0.93 h) and mean residence time (1.21 h).

Low-dose continuous chemotherapy (LBCMVD-56) for refractory and relapsing lymphoma

BACKGROUND

Although lymphoid malignancies are generally chemosensitive, relapse is common. The use of high-dose therapy can make subsequent cytotoxic therapy intolerable. There is a need to develop regimens with low acute toxicity which are suitable for use in patients post-high dose therapy and following the failure of standard protocols.

PATIENTS AND METHODS

Twenty-six patients with lymphomas, fifteen of whom had received high-dose therapy, were treated with a novel regimen consisting of low-dose lomustine, chlorambucil, daily subcutaneous bleomycin, vincristine and methotrexate with dexamethasone on an eight-week cycle (LBCMVD-56). A median of three cycles was given.

RESULTS

The overall response rate at 12 weeks was 67% (21% complete remission (CR)) with a median overall survival of 13 months. A symptomatic response was seen in 72%. Previous high-dose therapy did not compromise the response rate. Toxicity was acceptable with grade 3-4 haematological toxicity seen in 27% of cycles, gastrointestinal toxicity seen in 11% and pulmonary toxicity seen in 8%. Thirty-one percent of patients required hospitalisation at some point during this treatment most commonly for neutropenic sepsis.

CONCLUSIONS

LBCMVD-56 is an inexpensive, outpatient-based regimen with low acute toxicity and a high response rate in this heavily pre-treated group of patients.

Hodgkin's disease and non-Hodgkin's lymphoma

The development of new classification schemes and prognostic analyses for lymphomas has helped to identify patients at high risk for relapse who may benefit from intensification of primary therapy. Conventional salvage therapy for relapsed follicular or low-grade lymphomas now includes monoclonal antibody therapy. The combination of chemotherapy and monoclonal antibody therapy may improve outcomes for patients with advanced-stage aggressive non-Hodgkin's lymphomas. Confirmatory randomized trials are now in progress. Therapy for Hodgkin's disease continues to evolve toward the most efficacious programs, which also minimize the long-term probability of toxicity. The combination of high-dose chemotherapy and stem cell transplantation is probably the most effective therapy for patients with relapsed or refractory Hodgkin's disease.