Yttrium-90 ibritumomab tiuxetan as a single agent in patients with pretreated B-cell lymphoma: evaluation of the long-term outcome

A pioneer experience in Malaysia on In-house Radio-labelling of (131)I-rituximab in the treatment of Non-Hodgkin's Lymphoma and a case report of high dose (131)I-rituximab-BEAM conditioning autologous transplant

Radioimmunotherapy is an established treatment modality in Non-Hodgkin's lymphoma. The only two commercially available radioimmunotherapies - (90)Y-ibritumomab tiuxetan is expensive and (131)I-tositumomab has been discontinued from commercial production. In resource limited environment, self-labelling (131)I-rituximab might be the only viable practical option. We reported our pioneer experience in Malaysia on self-labelling (131)I-rituximab, substituting autologous haematopoietic stem cell transplantation (HSCT) and a patient, the first reported case, received high dose (131)I-rituximab (6000MBq/163mCi) combined with BEAM conditioning for autologous HSCT.

Short duration immunochemotherapy followed by radioimmunotherapy consolidation is effective and well tolerated in relapsed follicular lymphoma: 5-year results from a UK National Cancer Research Institute Lymphoma Group study

We report a phase II study to evaluate the efficacy and toxicity of abbreviated immunochemotherapy followed by (90) Y Ibritumomab tiuxetan ((90) Y-IT) in patients with recurrent follicular lymphoma. Of the 52 patients enrolled, 50 were treated with three cycles of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisolone) or R-CVP (rituximab, cyclophosphamide, vincristine, prednisolone), followed by (90) Y-IT regimen (15 MBq/kg, maximum 1200 MBq) preceded by two infusions of 250 mg/m(2) rituximab. The overall response rate was 98% with complete response (CR) 30% and partial response (PR) 68%. 18 patients with a PR following chemotherapy improved to a CR following (90) Y-IT: a conversion rate of 40%. Seven patients with PR following (90) Y-IT subsequently improved to a CR 12-18 months later, leading to an overall CR rate of 44%. With a median follow-up of 5 years, median progression-free survival was 23·1 months and overall survival was 77·5% at 5 years. High trough serum rituximab levels (median 112 μg/ml; range 52-241) were attained after four doses of rituximab, prior to (90) Y-IT; this was not found to influence response rates. The treatment was well tolerated with few (13·5%) grade 3 or 4 infective episodes and manageable haematological toxicity. Abbreviated immunochemotherapy followed by (90) Y-IT is an effective and well-tolerated treatment in recurrent follicular lymphoma patients previously exposed to rituximab.

TRIAL REGISTRATION

clinicaltrials.gov identifier: NCT00637832.

Z-BeEAM (Ibritumomab tiuxetan, Bendamustine, Etoposide, Cytarabine, Melphalan) before autologous stem cell transplantation is safe and efficient for refractory large B-cell lymphoma

Background

Refractory or relapsed large B-cells lymphoma are usually treated with a high dose chemotherapy regimen followed by an autolougous stem cells transplantation. BEAM (carmustine, etoposide, cytarabine, melphalan) or more recently Z-BEAM (ibritumomab tiuxetan and BEAM) are commonly used regimens, but recently carmustine availability became difficult. The purpose of this study was to evaluate the feasibility and the safety of replacing carmustine by bendamustine in a new Z-BeEAM regimen (ibritumomab tiuxetan, bendamustine, etoposide, cytarabine, melphalan) prior to autologous stem cell transplantation.

Findings

This study was a retrospective analyze of six patients, with a median age of 60, treated by Z-BeEAM before autologous stem cell transplantation. We did not put in evidence any additional toxicities compared to conventional induction chemotherapy. The main toxicities were mucositis (3 grade III among 6 patients), gastrointestinal (2 grade III vomiting and 2 grade III diarrhea) and neutropenia (6 grade IV). Engraftment was successfully achieved for all patients. At the time of analysis of this study all patients were alive and in complete response based on the PET-CT evaluation.

Conclusions

BeEAM plus ibritumomab tiuxetan combined regimen before autologous stem cell transplantation is feasible and safe in aggressive relapsing large B-cell lymphoma.

Does tumoral (111)In-ibritumomab accumulation correlate with therapeutic effect and outcome in relapsed or refractory low-grade B-cell lymphoma patients undergoing (90)Y-ibritumomab radioimmunotherapy?

OBJECTIVES

The aim of this study was to determine whether tumoral (111)In-ibritumomab accumulation on pre-treatment imaging correlates with therapeutic responses and progression-free survival (PFS) in patients with non-Hodgkin's lymphoma (NHL) undergoing (90)Y-ibritumomab radioimmunotherapy (RIT).

METHODS

This was a retrospective study of 39 patients with low-grade B-cell NHL treated with RIT. We classified the patients into positive and negative groups according to the presence or absence of tumoral (111)In-ibritumomab accumulation on pre-treatment (111)In-ibritumomab examinations. We then determined the correlation between the (111)In-ibritumomab imaging findings and the patients' therapeutic responses and PFS.

RESULTS

Tumoral (111)In-ibritumomab accumulation was positive in 64.1% and negative in 35.9% of the patients. The (111)In-positive patients had a significantly higher overall response rate (ORR) compared to the (111)In-negative patients (100.0% vs. 78.6%, p = 0.02). The (111)In-negative patients with advanced disease (stages III/IV) had a significantly lower ORR (40%) and a significantly higher rate of progressive disease (40.0%) compared to those of the (111)In-negative patients with limited disease (stages I/II) (100% and 0%, p = 0.009 each). However, these two groups had similar 2-year PFS rates (65.0% vs. 50.0%, p = 0.80).

CONCLUSIONS

(111)In-ibritumomab imaging findings seem to correlate with ORR and the progressive disease rate after RIT, but not with PFS.

KEY POINTS

All 39 NHL patients had tumoral accumulation on pretreatment FDG-PET/CT. 64.1% of NHL patients had tumoral accumulation on a pretreatment (111) In-ibritumomab examination. (90) Y-ibritumomab RIT resulted in high overall response and complete remission rates. (111) In-ibritumomab avidity of lymphoma lesions could predict a strong therapeutic effect. (111) In-ibritumomab imaging findings did not correlate with progression-free survival.

Radioimmunotherapy for first-line and relapse treatment of aggressive B-cell non-Hodgkin lymphoma: an analysis of 215 patients registered in the international RIT-Network

PURPOSE

Very few reliable clinical data about the use of radioimmunotherapy in aggressive B-cell lymphoma exist.

METHODS

Patients with aggressive B-cell lymphoma registered in the international RIT-Network were analysed with regard to prior treatment, response and side effects. The RIT-Network is a web-based registry that collects observational data from radioimmunotherapy-treated patients with malignant lymphoma across 13 countries.

RESULTS

This analysis included 215 with aggressive B-cell lymphoma out of 232 patients registered in the RIT-Network. Histological subtypes were as follows: 190 diffuse large B-cell, 15 primary mediastinal, 9 anaplastic large cell, and 1 intravascular lymphoma. The median age of the patients was 62 years (range 17 - 88), with 27% above the age of 70 years. Radioimmunotherapy was mainly used as consolidation after first-line or second-line chemotherapy (56.1%), as part of third-line to eighth-line therapy for relapse (16.4%), and in refractory disease (12.2%). Grade IV neutropenia and thrombopenia and grade III anaemia were observed. The median time to recovery of blood count was 81 days (range 0 - 600 days). The overall response rate was 63.3%. The complete response rate was 76.4 % in patients treated as part of first-line therapy, and 44.3% in patients with relapse. Mean overall survival in first-line therapy patients was 32.7 months and 14.0 months in patients with relapse or refractory disease, respectively.

CONCLUSION

Most patients with aggressive B-cell lymphoma in the RIT-Network received radioimmunotherapy as consolidation after first-line therapy with excellent complete remission and overall survival rates compared to published data. In relapsed aggressive B-cell lymphoma, radioimmunotherapy is a safe and feasible treatment leading to satisfactory response rates with acceptable toxicity.

An update on radioimmunotherapy for lymphoma

SUMMARY Radioimmunotherapy is a promising treatment for B-cell lymphoma. 90Y-ibritumomab tiuxetan (Zevalin®) and 131I-tositumomab (Bexxar®) combine the potent antilymphoma effect of radiation with the specificity of antibody targeting. They have shown efficacy in follicular lymphoma in the setting of relapsed or refractory disease as consolidation regimens after first-line therapy, and in the front-line setting as single agents. Given their tolerability, they are actively being investigated as therapies or adjuncts for elderly patients with relapsed or high-risk diffuse large B-cell lymphoma. They have been added to autologous and allogeneic stem cell transplant preparatory regimens in early clinical trials with acceptable safety and efficacy. Early concerns over excess rates of treatment-related myelodysplastic syndrome and acute myelogenous leukemia have not come to fruition, but these questions remain to be fully answered. Ultimately, these are promising treatments for a variety of B-cell lymphomas. They are also models for the development of new radioimmunotherapies.

RIT with Y90-Ibritumomab Tiuxetan in Follicular Non-Hodgkin Lymphoma: Evaluation of Recent Outcomes in a Single Institution

Background. Based on historical data we reviewed our hospital clinical database to analyse our updated information and therapy outcomes of follicular non-Hodgkin lymphoma (F-NHL) patients treated with ⁹⁰Y-Ibritumomab tiuxetan. Patients and Methods. Between 2005 and 2011, 56 F-NHL patients were included in a clinical protocol conducted by a multidisciplinary team and treated in the same centre. All patients received 0.3 or 0.4 mCi/kg IV (88%) of ⁹⁰Y-IT; response evaluation was performed 12 weeks after. Results. M/F 44.6%/55.4%, mean age 61.45 years (30–85); ECOG 0-1 96.9%. According to FLIPI score, distribution were good: 58.5%, intermediate: 29.2%, and poor: 12.3%. Previous therapies: >2: 40% (26). ORR was 94.6% (53/56). CR: 85.7%; CR according to previous disease: relapsed disease: 90% (27/30), refractory disease: 42.85% (3/7), consolidation with CR: 92.85% (13/14), and consolidation with PR: 100% (5/5). Global PR and NR were 8.9% (5) and 5.3% (3), respectively. Mean OS 63.86 months with a mean follow-up time of 57 months (2–73). Mean TTP: 52.65 months (95% CI: 43.83–61.48). Median OS and TTP were not achieved. No hospital submissions or deaths were registered. Conclusions. This study confirms the safety and high efficacy of ⁹⁰Y-IT in F-NHL patients, RIT in early stage of disease could improve outcomes.

Efficacy and safety of yttrium-90 ibritumomab tiuxetan in Japanese patients with non-Hodgkin lymphoma

PURPOSE

The aim of this study was to evaluate the efficacy and side effects of radioimmunotherapies with Zevalin(®) (RIT-Z) in Japanese patients with low-grade B-cell non-Hodgkin lymphoma (NHL).

MATERIALS AND METHODS

Sixty-two patients with NHL were enrolled. Based on histology, 49 of the patients had follicular lymphoma and 23 had other lesions. The response was assessed at 8-12 weeks after RIT-Z injection with PET/CT.

RESULTS

The overall response rate was 85 %. Thirty-seven (60 %) patients achieved complete remission, 16 (26 %) had partial remission, 4 (6 %) had stable disease, and 5 (8 %) had progressive disease. There was a significant correlation between the response to RIT-Z, frequency of chemotherapy, and history of prior treatment with fludarabine. There was no significant difference in efficacy according to lymphoma type, years since last chemotherapy, patient age, or disease stage at RIT-Z. Thrombocytopenia of grade 4 was significantly correlated with disease stage at RIT-Z and history of prior treatment with fludarabine. There was also no significant correlation between hematotoxicity and lymphoma type, frequency of chemotherapy, years since last chemotherapy, patient age, or history of bone marrow transplant. Anemia was significantly correlated with frequency of chemotherapy, history of bone marrow transplant, and history of prior treatment with fludarabine.

CONCLUSIONS

The response rate was high, and we were able to decrease the hematologic side effects by using RIT-Z earlier.