Phase I trial of infusional cyclophosphamide, doxorubicin, and etoposide plus granulocyte-macrophage colony stimulating factor (GM-CSF) in non-Hodgkin's lymphoma

Rituximab and CHOP chemotherapy plus GM-CSF for previously untreated diffuse large B-cell lymphoma in the elderly: a Wisconsin oncology network study

PURPOSE

Human recombinant granulocyte-macrophage colony-stimulating factor (GM-CSF) may potentiate rituximab activity by upregulating CD20 expression and activating effector cells necessary for antibody-dependent cellular cytotoxicity. GM-CSF was combined with standard rituximab + CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) chemotherapy (R-CHOP) in the treatment of elderly patients with de novo diffuse large B-cell lymphoma (DLBCL).

PATIENTS AND METHODS

Thirty-eight patients over the age of 60 years with newly diagnosed DLBCL were treated with R-CHOP every 21 days for 6-8 cycles and GM-CSF 250 µg/m2 per day on days 3-10. Patients were evaluated for response after cycles 4, 6, and 8. The primary endpoint was the rate of complete response, and secondary endpoints were progression-free survival (PFS), event-free survival, and overall survival (OS).

RESULTS

Thirty-eight patients were enrolled, with a median age of 72 years, and 29% of patients having high-risk disease (International Prognostic Index [IPI] score ≥ 4). A complete or unconfirmed complete response (CR) was achieved in 53% of patients. After a median follow-up of 51.1 months, the 3-year PFS and OS were 78% and 84%. Twenty-one percent of patients discontinued protocol treatment because of chemotherapy-related toxicity and 16% because of GM-CSF toxicity. Dose intensity for planned chemotherapy cycles was 81.1%.

CONCLUSION

These data suggest that survival outcomes may be modestly improved when GM-CSF is combined with R-CHOP in the treatment of elderly DLBCL. GM-CSF had toxicity precluding planned administration in 16% of patients, which may limit usefulness of this agent. Further investigation of GM-CSF in combination with rituximab-containing chemotherapy is warranted.

Treatment of Burkitt lymphoma in children and adults: Lessons from Africa

Modern chemotherapy for childhood Burkitt lymphoma has its origins in Africa, where treatment evolved from one or two doses of single agents, which were curative in some patients, to combinations of non-cross-resistant drugs. Subsequently, in Europe and the United States, high-dose methotrexate, high-dose cytarabine, etoposide, and ifosfamide were found to be active in children with recurrent disease and were incorporated into primary therapy for patients with high-risk disease. These third-generation protocols produce overall cure rates around 90%. Therapy regimens for adults with Burkitt lymphoma have been developed by modifying second-generation pediatric protocols, and few investigators have used the third-generation pediatric regimens that include higher doses of methotrexate and additional agents. The weight of evidence strongly suggests that high-dose therapy with stem cell rescue in first remission cannot substitute for intensive therapy from the outset. Tolerance of intensive regimens by the elderly is a legitimate concern, but it seems appropriate to modify therapy only when necessary in individual patients. The value of rituximab and granulocyte colony-stimulating factor in patients undergoing intensive therapy (particularly the elderly) is worthy of further exploration. Because childhood diffuse large-B-cell leukemia (DLBCL) responds equally well to therapy for Burkitt lymphoma, more intensive therapy and intensive support might also give better results in at least a subset of adults with advanced DLBCL-perhaps defined on the basis of limited molecular profiling, which has provided new information about the categories of aggressive B-cell lymphomas.