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Zarling LC, Stevenson PA, Soma LA, Martino CH, Percival MEM, Halpern AB, Ghiuzeli CM, Becker PS, Oehler VG, Cooper JP, Orozco JJ, Hendrie PC, Walter RB, Estey EH, Cassaday RD. Hyper-CVAD versus dose-adjusted EPOCH as initial treatment for adults with acute lymphoblastic leukemia. Eur J Haematol 2023; 111:863-871. [PMID: 37670560 DOI: 10.1111/ejh.14089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/10/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVES We recently performed a single-arm phase II trial of DA-EPOCH in adults with acute lymphoblastic leukemia (ALL). We sought to compare these results to those with standard Hyper-CVAD. METHODS We created a retrospective matched cohort of patients who received Hyper-CVAD (n = 69) at our center and otherwise met eligibility criteria for the DA-EPOCH trial (n = 53). RESULTS Our outcomes support the use of Hyper-CVAD over DA-EPOCH in Ph- disease for both overall survival (OS; HR 0.18, p = .004) and event-free survival (EFS; HR 0.51, p = .06). In contrast, outcomes were similar in Ph+ disease (OS HR 0.97, p = .96; EFS HR 0.65, p = .21). Rates of morphologic remission and measurable residual-disease negativity were similar between the regimens. Hyper-CVAD was associated with significantly more febrile neutropenia (OR 1.9, p = .03) and a greater incidence of Grade 4 or 5 adverse events (20% vs. 6%). Average transfusions per cycle of both red blood cells (p < .001) and platelets (p < .001) were five-fold higher with Hyper-CVAD. CONCLUSIONS Our findings support continued use of Hyper-CVAD for Ph- ALL but suggest that DA-EPOCH may be a reasonable alternative for Ph+ ALL. These data also highlight a potential role for DA-EPOCH in resource-limited settings or when more intense therapy is not feasible.
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Affiliation(s)
- Lucas C Zarling
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
| | - Philip A Stevenson
- Clinical Statistics Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Lorinda A Soma
- Department of Pathology, City of Hope National Medical Center, Duarte, California, USA
| | - Christen H Martino
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Mary-Elizabeth M Percival
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Anna B Halpern
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Cristina M Ghiuzeli
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Pamela S Becker
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
- Department of Hematology & Hematopoietic Cell Transplantation, City of Hope National Medical Center, Duarte, California, USA
| | - Vivian G Oehler
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Jason P Cooper
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Johnnie J Orozco
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Paul C Hendrie
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Roland B Walter
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Elihu H Estey
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
| | - Ryan D Cassaday
- Department of Medicine, University of Washington, Seattle, Washington, DC, USA
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, DC, USA
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Mitrovic Z, Dujmovic D, Jaksic O, Kinda SB, Gacina P, Perisa V, Prka Z, Dreta B, Galusic D, Holik H, Pejsa V, Aurer I. Dose-adjusted EPOCH and rituximab ( DA-EPOCH-R) in older patients with high-risk aggressive diffuse large B-cell lymphoma: a real-life multicenter study by the Croatian Cooperative Group for Hematologic diseases (KroHem). Eur J Haematol 2023; 110:725-731. [PMID: 36941738 DOI: 10.1111/ejh.13957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 02/23/2023] [Accepted: 03/16/2023] [Indexed: 03/23/2023]
Abstract
PURPOSE DA-EPOCH-R is a regimen used for treatment of high-risk diffuse large B-cell lymphoma (DLBCL), designed to overcome resistance to standard R-CHOP by combining prolonged exposure of lymphoma cells to cytotoxic agents and dose-adjustment based on toxicity. Data on outcomes of older patients are scarce. PATIENTS AND METHODS We collected data on patients with newly diagnosed high-risk DLBCL older than 60 years treated with DA-EPOCH-R. High-risk patients were defined by the age-adjusted international prognostic index score 2 or 3. RESULTS A total of 120 patients were included. Median age was 69 years (range 60-82). Response rate was 74%; with 59% complete responses. Dose of DA-EPOCH-R was escalated in 50 patients (42%). Three-year progression-free survival (PFS) and overall survival (OS) was 53% and 58%, respectively, with treatment-related mortality (TRM) of 13%. In univariate analysis favorable prognostic factors were performance status (PS) (0-2 vs. 3-4), age (<70 vs. ≥70 years), and center. In multivariate analysis, PS and center retained prognostic significance. Patients with PS 0-2 had a 3-year PFS and OS 58% and 64%, respectively, with TRM of 6%. CONCLUSION DA-EPOCH-R is efficacious in sufficiently fit older high-risk DLBCL patients. Patients with poor PS have unacceptable toxicity and require less intensive therapy.
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Affiliation(s)
- Zdravko Mitrovic
- Division of Hematology, Department of Medicine, University Hospital Dubrava, Zagreb, Croatia
- Medical School University of Zagreb, Zagreb, Croatia
| | - Dino Dujmovic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb
| | - Ozren Jaksic
- Division of Hematology, Department of Medicine, University Hospital Dubrava, Zagreb, Croatia
- Medical School University of Zagreb, Zagreb, Croatia
| | - Sandra Basic Kinda
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb
| | - Petar Gacina
- Division of Hematology, Department of Internal Medicine, University Hospital Center Sisters of Mercy and School of Dental Medicine, University of Zagreb, Zagreb, Croatia
| | - Vlatka Perisa
- Division of Hematology, Department of Internal Medicine, University Hospital Center Osijek and Medical School University of Osijek, Osijek, Croatia
| | - Zeljko Prka
- Division of Hematology, Department of Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Barbara Dreta
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb
| | - Davor Galusic
- Division of Hematology, Department of Internal Medicine, University Hospital Center Split and Medical School University of Split, Split, Croatia
| | - Hrvoje Holik
- Division of Internal Medicine, Dr. Josip Bencevic General Hospital, Slavonski Brod, Croatia
| | - Vlatko Pejsa
- Division of Hematology, Department of Medicine, University Hospital Dubrava, Zagreb, Croatia
- Medical School University of Zagreb, Zagreb, Croatia
| | - Igor Aurer
- Medical School University of Zagreb, Zagreb, Croatia
- Division of Hematology, Department of Internal Medicine, University Hospital Center Zagreb
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Matsuda S, Suzuki R, Takahashi T, Suehiro Y, Tomita N, Izutsu K, Fukuhara N, Imaizumi Y, Shimada K, Nakazato T, Yoshida I, Miyazaki K, Yamaguchi M, Suzumiya J. Dose-adjusted EPOCH with or without rituximab for aggressive lymphoma patients: real world data. Int J Hematol 2020; 112:807-816. [PMID: 32880824 DOI: 10.1007/s12185-020-02984-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/11/2020] [Accepted: 08/25/2020] [Indexed: 10/23/2022]
Abstract
CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) -/+ rituximab (R) is the standard chemotherapeutic regimen for aggressive lymphoma, but is insufficient for aggressive lymphoma with adverse prognostic factors. Dose-adjusted (DA)-EPOCH (etoposide, doxorubicin, cyclophosphamide, vincristine, and prednisolone) -/+ R demonstrates excellent efficacy against some aggressive lymphoma. Thus, we conducted a retrospective study to evaluate the feasibility and efficacy of this therapy in clinical practice. We enrolled 149 patients from 17 institutions diagnosed between 2007 and 2015. The median follow-up period for survivors was 27 months (range 0.2-123). The complete response (CR) rate of newly diagnosed patients was 79% (95% CI 68-87%). All patients were hospitalized to receive this therapy and 94% of patients also received granulocyte-colony-stimulating factor support. There were no treatment-related deaths. Febrile neutropenia (FN) and grade 3 or 4 infection occurred in 55% and 28% of patients, respectively. There were no significant differences in FN or infection between young (≤ 65 years) and elderly patients (> 65 years). In newly diagnosed diffuse large B-cell lymphoma-not otherwise specified patients (n = 46), the CR rate was 80% (95% CI 64-91%) and the 2-year OS rate was 81% (95% CI 66-90%). In the present study, DA-EPOCH -/+ R exhibited excellent efficacy and feasibility for aggressive lymphoma.
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Affiliation(s)
- Shinichiro Matsuda
- Innovative Cancer Center/Oncology-Hematology, Shimane University Hospital, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
| | - Ritsuro Suzuki
- Innovative Cancer Center/Oncology-Hematology, Shimane University Hospital, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
| | - Tsutomu Takahashi
- Innovative Cancer Center/Oncology-Hematology, Shimane University Hospital, 89-1 Enya, Izumo, Shimane, 693-8501, Japan
| | - Youko Suehiro
- Department of Hematology, National Hospital Organization Kyushu Cancer Center, Fukuoka, Japan
| | - Naoto Tomita
- Department of Hematology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Koji Izutsu
- Department of Hematology, Toranomon Hospital, Tokyo, Japan
| | - Noriko Fukuhara
- Department of Hematology, Tohoku University Hospital, Sendai, Japan
| | | | - Kazuyuki Shimada
- Department of Hematology, Nagoya University Hospital, Nagoya, Japan
| | - Tomonori Nakazato
- Department of Hematology, Yokohama Municipal Citizens Hospital, Yokohama, Japan
| | - Isao Yoshida
- Department of Hematologic Oncology, National Hospital Organization Shikoku Cancer Center, Ehime, Japan
| | - Kana Miyazaki
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Motoko Yamaguchi
- Department of Hematology and Oncology, Mie University Graduate School of Medicine, Tsu, Japan
| | - Junji Suzumiya
- Innovative Cancer Center/Oncology-Hematology, Shimane University Hospital, 89-1 Enya, Izumo, Shimane, 693-8501, Japan.
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