Salvage chemotherapy using a combination of fludarabine and cyclophosphamide for refractory or relapsing indolent and aggressive non-Hodgkin's lymphomas

Bortezomib in combination with fludarabine plus cyclophosphamide for patients with relapsed or refractory mantle-cell lymphoma: results of the LYM-4003 study

This study aimed to identify the maximum-tolerated dose (MTD) of cyclophosphamide when combined with bortezomib and fludarabine (B-FC) in a phase 1b trial, and to assess the efficacy and safety of this combination in a phase 2 trial in patients with relapsed or refractory MCL (rrMCL). Forty patients were enrolled between April 8, 2011, and October 10, 2015. The MTD of cyclophosphamide was identified to be 250 mg/m² days 1-2. At a median follow-up of 31.6 months (13.5-47.4), among 32 patients in phase 2, 10 (31%) had a complete response and 13 (41%) had a partial response. The median progression-free survival was 21 months (95% CI 7.3-34.7), and the median overall survival was 32.4 months (95% CI 17.8-47.0). Grade 3-4 hematologic AEs included neutropenia (27%) and thrombocytopenia (39%). The B-FC regimen has satisfactory responses and manageable toxicities in rrMCL patients (ClinicalTrials.gov NCT01322776).

Safety and efficacy of axicabtagene ciloleucel in refractory large B-cell lymphomas

Aggressive large B-cell lymphomas represent a diverse population of diseases that are typically treated with anti-CD20 based immunochemotherapy. While this treatment is effective for a large proportion of patients, those that become refractory to induction therapy or experience disease relapse suffer an inferior overall prognosis, and novel treatment options are needed. Adoptive T-cell immunotherapy in the form of chimeric antigen receptor (CAR) T-cell therapy is one of the most revolutionary breakthroughs in the past several decades for the treatment of relapsed/refractory aggressive large B-cell lymphomas. Based on data from the pivotal ZUMA-1 study, axicabtagene ciloleucel (axi-cel) became the first-in-class anti-CD19 directed CAR T-cell therapy approved for patients with diffuse large B-cell lymphoma and other aggressive B-cell lymphoma variants. In this review, we provide an overview of CAR T-cell therapy, including its biology, manufacturing, and treatment course. In addition, we highlight the available efficacy data, review pertinent safety concerns, including cytokine release syndrome and neurologic toxicity, as well as provide an overview of emerging therapeutic strategies in the cellular therapy arena.

Axicabtagene ciloleucel (KTE-C19), an anti-CD19 CAR T therapy for the treatment of relapsed/refractory aggressive B-cell non-Hodgkin's lymphoma

Adoptive T-cell immunotherapy is a rapidly growing field and is shifting the paradigm of clinical cancer treatment. Axicabtagene ciloleucel (axi-cel) is an anti-CD19 chimeric antigen receptor T-cell therapy that was initially developed at the National Cancer Institute and has recently been commercially approved by the US Food and Drug Administration for relapsed or refractory aggressive non-Hodgkin’s lymphomas including diffuse large B-cell lymphoma and its variants. The ZUMA-1 Phase I and II clinical trials formed the basis of the US Food and Drug Administration approval of this product, and we discuss the particulars of the clinical trials and the pharmacology of axi-cel. In addition, we review the CD19 chimeric antigen receptor T-specific toxicities of cytokine release syndrome and neurotoxicity, which remain the challenges to the safe delivery of this important therapy for aggressive B-cell lymphomas with poor prognosis.

Purine Analogue Combinations for Indolent Lymphomas

Indolent lymphomas are a group of lymphoid malignancies with differing patterns of behavior and responses to treatment. The progress in treating patients with hairy cell leukemia (HCL) using nucleoside analogues can be used as a model for other indolent B-lymphoproliferative disorders, such as follicular lymphoma. Recent advancements in therapeutic options available for these patients include combination therapy with agents that have differing mechanisms of action and non-overlapping toxicity. It has been shown that patients who are candidates for aggressive therapy might receive benefit, including disease-free survival and overall survival, from combination purine analogue therapy. Using these more aggressive therapeutic approaches earlier in the disease course and as maintenance therapy may further enhance outcomes. With the advent of these new therapies along with the molecular evaluation of these regimens, we may be nearing the time where the goal for more advanced indolent lymphoma will be to achieve a cure.

The combination of fludarabine, cyclophosphamide, and granulocyte-macrophage colony-stimulating factor in the treatment of patients with relapsed chronic lymphocytic leukemia and low-grade Non-Hodgkin's lymphoma

PURPOSE

The goal of this study was to evaluate the efficacy of the fludarabine/cyclophosphamide combination in patients with relapsed chronic lymphocytic lymphoma (CLL) and low-grade non-Hodgkin's lymphoma (NHL) and to assess the impact of adding granulocyte-macrophage colony-stimulating factor (GM-CSF) to this regimen in a randomized fashion.

PATIENTS AND METHODS

Thirty-four patients (CLL, n=16; low-grade NHL, n=18) were enrolled. The median number of previous treatments was 2. Patients received <or=6 cycles of fludarabine at 30 mg/m2 per day and cyclophosphamide at 300 mg/m2 per day on days 1-3 of a 28-day cycle. Patients were randomized to supportive care or to receive GM-CSF at 250 mg/m2 per day, starting 24 hours after completion of chemotherapy and continuing up to 48 hours before the next cycle. Those who had received >6 months of previous therapy with an alkylating agent or had preexisting cytopenias received a 25% dose reduction. Twenty-two patients (65%) were randomized to receive GM-CSF. Patients completed a median of 5 cycles of treatment (range, 1-6 cycles). Twenty-seven patients (80%) received >or=3 cycles of treatment and were evaluated for response.

RESULTS

Seven patients (26%) exhibited a complete response; 6 of the 7 had low-grade NHL. Fourteen patients (52%) exhibited a partial response, and 6 patients (22%) had stable disease. Notably, 6 of the 7 patients who exhibited complete response and 9 of 14 patients with partial responses were randomized to the GM-CSF arm. The duration of response ranged from 4 months to 26 months. The toxicities were mainly hematologic. Nineteen patients (70%) experienced >or=1 episode of grade 3/4 neutropenia, but only 4 (15%) experienced febrile neutropenia; 3 of those patients were assigned to the GM-CSF arm.

CONCLUSIONS

The combination of fludarabine and cyclophosphamide is a well-tolerated and effective treatment regimen for patients with relapsed CLL and low-grade NHL. A higher percentage of complete responses were noted in patients with low-grade NHL compared with patients with CLL. Granulocyte-macrophage colony-stimulating factor did not seem to decrease the incidence of febrile neutropenia. However, the higher number of complete and partial responses noted on the GM-CSF arm is intriguing and warrants further investigation.

Fludarabine phosphate-CVP in patients over 60 years of age with advanced, low-grade and follicular lymphoma: a dose-finding study

The aim of this study was to establish a safe and effective regimen of fludarabine phosphate, cyclophosphamide, vincristine and prednisone (F-CVP) as first-line treatment for elderly patients with advanced, low-grade non-Hodgkin's lymphoma. Twenty-three patients >60 years were assigned successively to eight treatment cycles (Dose level 1: low F, low CV [n=4]; 2A: high F, low CV [n=8]; 2B: low F, high CV [n=4]; 3: high F, high CV [n=7]). High and low levels were: F, 25 and 20mg/m(2), respectively (Days 1-5); C, 750 and 500 mg/m(2), respectively (Day 1); and V, 1.4 and 1mg/m(2), respectively (Day 1). Patients received P at 40 mg/m(2) on Days 1-5. Response was assessed after Cycles 2, 4, 6 and 8. At level 3, dose-limiting toxicity (opportunistic infections and neutropenia) became evident, particularly after Cycle 6. Further patients were recruited at Dose level 2A. All regimens proved effective, with an OR rate of 78% (65% CR), and 3-year survival of 65% (+/-10%). Among 18 responders, 51% were still in response at 3 and 5 years. The study shows that this combination therapy is highly effective. The addition of F to CVP at Dose level 2A was feasible and increased the CR rate, with good tolerability in elderly patients.

Significant thrombocytopenia associated with the addition of rituximab to a combination of fludarabine and cyclophosphamide in the treatment of relapsed follicular lymphoma

Fludarabine in combination with cyclophosphamide is an effective treatment for newly diagnosed as well as relapsed follicular lymphoma. The anti-CD20 antibody rituximab has been employed successfully for the same indications. No such data were available on a combined use of these agents. Therefore, we conducted a phase II study to evaluate the safety and efficacy of a combination of rituximab (375 mg/m2), fludarabine (4 x 25 mg/m2) and cyclophosphamide (1 x 750 mg/m2), for the treatment of relapsed follicular lymphoma. An unexpected, severe hematologic toxicity with significant, prolonged thrombocytopenias WHO grade III/IV in 6 (35%) of 17 patients treated in total occurred, leading to early termination of the trial. Cytologic and serologic analyses point toward a direct toxic effect. Older patients (mean age 64.7 vs. 56.5 yr) were significantly (P = 0.02) more likely to suffer from this toxicity, whereas no other clinical or hematologic parameter differed statistically between the patients suffering from thrombocytopenia and those who did not. The addition of rituximab to fludarabine/cyclophosphamide employed at doses given above in relapsed follicular lymphoma may have led to this increase in thrombocytopenias. Therefore, caution should be exercised when combining these drugs for the treatment of patients with relapsed follicular lymphoma, especially when treating older patients.

Fludarabine and cyclophosphamide using an attenuated dose schedule is a highly effective regimen for patients with indolent lymphoid malignancies

BACKGROUND

Preclinical data have supported the use of fludarabine and cyclophosphamide (FC) in combination for the treatment of indolent lymphoid malignancies. Previously reported schedules were highly effective, but were complicated by significant myelotoxicity and infectious complications. In the current study, the authors analyzed their experience with an attenuated dose regimen to determine whether equivalent efficacy could be achieved with reduced toxicity.

METHODS

Sixty-four patients with indolent lymphoid malignancies were treated with intravenous fludarabine at a dose of 25 mg/m(2) and cyclophosphamide at a dose of 250 mg/m(2), each given on Days 1-3 for a median of 4 cycles. The median age of the patients was 60 years. Nineteen percent of the patients were previously untreated, and 45% had refractory disease; the patients had received a median of 2 prior therapies. With regard to histology, 41% of the patients had chronic lymphocytic leukemia or its variants, whereas the remainder of patients had low-grade non-Hodgkin lymphoma, predominantly follicule center cell lymphoma.

RESULTS

A total of 237 cycles were delivered. The principal toxicities reported were neutropenia (NCI CTC Grade 4 in 17% of cycles) and infection (Grade >/= 3 in 6% of cycles). The overall response rate and complete response rate were 86% and 29%, respectively. No significant difference could be discerned with regard to response rates for patients with untreated, recurrent, or refractory disease.

CONCLUSIONS

The FC schedule used in the current study was found to be highly effective in patients with indolent lymphoid malignancies. Toxicity was lower compared with higher dose schedules, whereas efficacy appeared to be equivalent.

Cyclophosphamide and Fludarabine with or without Rituximab (CF ± R) for Chronic Lymphocytic Leukemia or Non-Hodgkin's Lymphoma

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column focuses on the commercially available and investigational agents used to treat malignant diseases and reviews issues related to the preparation, dispensing, and administration of cancer chemotherapy.

Treatment of Waldenstrom's macroglobulinemia with the combination of fludarabine and cyclophosphamide

Fludarabine is an active agent for the treatment of Waldenstrom's macroglobulinemia (WM) and its combination with cyclophosphamide has been effective in many patients with low-grade lymphoma and chronic lymphocytic leukemia. Based on these data, we administered the combination of fludarabine (25 mg/m2 i.v. day 1-3) and cyclophosphamide (250 mg/m2 i.v. day 1-3,) to 11 patients with WM. Most patients had features indicating poor prognosis including median age of 73 years (range 60-84 years), hemoglobin <100 g/l in 73%, B2-microglobulin >3 mg/l in 64%, symptomatic hyperviscosity in 55% of patients. Only 2 patients were previously untreated, 7 were primary refractory and 2 were relapsing on treatment. The fludarabine-cyclophosphamide combination (FC) was administered every 4 weeks for a total of four courses. Partial response, defined by at least 50% reduction of serum monoclonal protein and of tumor infiltrate at all involved sites was documented in 6 patients (55%) (The median time to response was 4 months). Responding patients demonstrated resolution of disease-related symptoms and correction of anemia. Median time to progression for all patients was 24 months. With a mean follow-up of 28 months, two of six responding patients have progressed so far. The probability of 2-year survival is 70%. This regimen was relatively well tolerated. Complications included neutropenia grade 3 or 4 in 3 patients and thrombocytopenia grade 3 or 4 in 2 patients. There were five infectious episodes including two episodes of neutropenic fever. We conclude that the FC combination appears to be active in patients with WM most of whom were resistant to treatment and had poor prognostic factors. The addition of rituximab to FC requires further investigation.

Non-Hodgkin's lymphoma: the evolving role of purine analogues

Indolent non-Hodgkin's lymphoma is the commonest form of lymphoma in the USA and Europe, with a long natural history with multiple responses and relapses. Indolent lymphomas include follicular lymphomas (the more frequent subtype), immunocytoma, and small lymphocytic lymphomas according to the Revised European-American Lymphoma classification. The tendency has been to use simple oral medication until patients have more advanced aggressive disease but new agents such as the purine analogues have led to re-evaluation of this approach. The newer purine analogues -- fludarabine, 2-chlorodeoxyadenosine (cladribine) and deoxycoformycin (pentostatin) -- are a group of potently lymphotoxic antimetabolite molecules. Their activity in the indolent non-Hodgkin's lymphomas, in particular in the follicular subtype, may be due to their unique ability as antimetabolites to inhibit resting as well as dividing cells. Within the last decade they have moved from salvage therapy to front-line studies. Further insight into the mechanism of action of the purine analogues will to lead to further advances in this group of diseases.

Cyclophosphamide/fludarabine (CF) is active in the treatment of mantle cell lymphoma

The purpose of this study was to determine the efficacy and toxicity of the cyclophosphamide and fludarabine (CF) regimen in patients with newly diagnosed and relapsed/refractory mantle cell lymphoma (MCL). Thirty patients with pathologically confirmed MCL were treated with the CF regimen. Ten (33%) had no prior therapy, six (20%) had one previous regimen, and 14 (47%) received two or more prior regimens. Ninety cycles of CF with a median of 3 cycles/patient (range, 1-5 cycles) were administered to patients with MCL. Nine patients (30%) had a complete response (CR) and 10 (33%) had a partial response (PR) for an overall response rate (RR) of 63%. The median failure-free survival (FFS) and overall survival (OS) was 4.8 months and 17.5 months, respectively. When patients were analyzed based upon the number of previous treatments (0, 1, or 2 or more), those with no previous treatment (n=10) had an overall response of 100%, with 70% CR. The median FFS was 28.1 months and the median OS for this group has not been reached at 42.3+ months. Hematologic and infectious toxicity were the major toxicities encountered with the CF regimen. Grade 3-4 neutropenia, thrombocytopenia and anemia were seen in 50%, 37%, and 36% of patients, respectively. There were 13 episodes of grade 3 infections. There was no treatment related mortality, In conclusion, the high response rate associated with the CF regimen merits further investigation in previously untreated patients with MCL, particularly in those who are not candidates for aggressive therapy.

Does intensive treatment with high dose chlorambucil and prednisone as first line and cladribine as second line influence the survival of the patients with chronic lymphocytic leukemia?

Cladribine (2-CdA) and fludarabine are the new purine analogs introduced in the treatment of chronic lymphocytic leukemia (CLL). Despite the high response rate, their influence on survival is still uncertain. The aim of this study was a retrospective analysis and comparison of the response rate and survival of CLL patients treated with high dose chlorambucil (HDChl) as first and 2-CdA as second line, with an historical group of patients never treated with purine analogs who received standard doses of chlorambucil (SDChl). We analyzed 347 patients with CLL treated between January 1985 and January 2000. Group A (190 patients) received HDChl (12 mg/m(2) ) with prednisone (P) 30 mg/m(2) daily for 7 days monthly as first line and in refractory or early relapsed patients 2-CdA (0.12 mg/kg/day) for 5 days with or without P (30mg/m(2) ) as second line. Group B (157 patients) received continuous SDChl (4-8 mg/m(2) /day) and P as first line and COP or CHOP as second line. The overall response rate (OR) for the first line was 48,4% in group A and 38,9% in group B (p=0.09). 148 patients in group A and 52 in group B received the second line treatment and the second OR was 19.6% and 13.5%, respectively (p=0.4). At the time of analysis, 124 patients died in group A and 139 in group B. Median survival was 65 months and 50 months, respectively. In group A, survival was longer in advanced Rai stage patients (p=0.001) but in early Rai stage was similar for both groups (p=0.4). We suggest that intensive treatment with HDChl as first line and 2-CdA as second line should be applied in more advanced rather than in less advanced stages of CLL until the final results of randomized clinical trials are available.

Therapeutic potential of purine analogue combinations in the treatment of lymphoid malignancies

The main purine analogues with activity against lymphoid malignancies are fludarabine, cladribine and pentostatin, all of which are active against slowly proliferating cells through their inhibition of DNA repair and therefore have significant synergistic activity with cytotoxic agents which cause DNA damage. Combinations of purine analogues and alkylating agents or platinum compounds result in markedly increased activity but at the expense of more severe haematological toxicity, while evidence of synergy with anthracyclines/anthracenediones is apparent in the treatment of malignant lymphoma. Interaction between fludarabine or cladribine with deoxycytidine kinase results in a significant enhancement of the activity of cytarabine. Unexpected evidence of clinical synergy is also apparent in combinations of purine analogues and anti-CD20 monoclonal antibodies.

A phase II study to evaluate the combination of fludarabine, mitoxantrone and dexamethasone (FMD) in patients with follicular lymphoma

BACKGROUND

'Molecular response' is being investigated as a therapeutic goal in follicular lymphoma (FL). High response rates in FL with the fludarabine combination 'FMD' have been associated with 'molecular remission'. A phase II study of FMD in FL was therefore conducted.

PATIENTS AND METHODS

Fifty-four patients, ten of whom were newly diagnosed received FMD. Forty-four percent of the previously treated patients had 'chemoresistant' disease. Treatment comprised: fludarabine 25 mg/m2 days 1-3, mitoxantrone 10 mg/m2 day 1, and dexamethasone 20 mg days 1-5. Blood/bone marrow was collected for quantitation of t(14;18) by 'real-time' PCR.

RESULTS

The overall response rate was 37 of 54 (69%), complete responses being seen in 11 patients (20%), with no difference between newly diagnosed and the previously treated patients. However, the response rate in 'chemosensitive' relapse was 84% compared to 44% in patients in whom the last prior regimen had failed. Molecular responses were seen in 17 of 25 and PCR negativity in 8 of 25, although molecular and clinical responses did not always correlate. Toxicity was moderate, 19 patients required admission. However, in 6 of 12 patients, subsequent G-CSF mobilised stem cell harvests failed.

CONCLUSIONS

FMD was well tolerated but with a lower than expected response rate. Molecular responses were seen in the majority of responding patients however, 'molecular remission' was rare.

Phase I/II study of 2-chloro-2'-deoxyadenosine with cyclophosphamide in patients with pretreated B cell chronic lymphocytic leukemia and indolent non-Hodgkin's lymphoma

Because of their substantial in vitro synergy, we conducted a dose-escalation study of cyclophosphamide (CP) added to 2-chloro-2'-deoxyadenosine (CdA) in patients with previously treated chronic lymphocytic leukemia and non-Hodgkin's lymphoma. CdA was given at a fixed dose (5.6 mg/m2/day) as a 2-h intravenous (i.v.) infusion, immediately followed by a 1-h i.v. infusion of CP, for 3 days. The initial daily CP dose was 200 mg/m2, and was escalated by 100 mg/m2 increments in successive cohorts of three to six patients to determine the maximum-tolerated dose (MTD). Additional patients were included at the MTD to extend toxicity and response analysis. Twenty-six patients received 68 cycles of chemotherapy. The MTD of CP after CdA 5.6 mg/m2, was 300 mg/m2. Acute neutropenia was the dose-limiting toxicity of this regimen, which was otherwise well tolerated. Delivery of repeated cycles was not feasible in eight patients (31%) because of prolonged thrombocytopenia. Severe infections were seen in three of 68 cycles (4%). The overall response rate was 58% (15 of 26; 95% CI, 36-76%), with 15% complete responses and 42% partial responses. These data show the feasibility of the association of CdA with CP. Given the response rate observed, further studies of this regimen are warranted in untreated patients, in particular with chronic lymphocytic leukemia and with Waldenström macroglobulinemia.