RITUXIMAB, BUT NOT A CHANGE FROM IMVP (IFOSFAMIDE ...
TREATMENT OF RELAPSED OR REFRACTORY AGGRESSIVE NON-HODGKIN LYMPHOMA WITH TWO IFOSFAMIDE-BASED REGIMENS, IMVP AND ICE
Igor Aurer1, Zdravko Mitrović1, Damir Nemet1, Ivo Radman1, Dubravka Sertić1, Ranka Serventi-Seiwerth1, Ranka Štern-Padovan2, Fedor Šantek3, Marin Nola4, Mirando Mrsić1, Boris Labar1
1 Division of Hematology, Department of Internal Medicine, University Hospital Center Rebro and Medical School, Zagreb, Croatia
2 Department of Radiology, University Hospital Center Rebro and Medical School, Zagreb, Croatia
3 Department of Oncology, University Hospital Center Rebro and Medical School, Zagreb, Croatia
4 Department of Pathology, University Hospital Center Rebro and Medical School, Zagreb, Croatia
Corresponding author:
Dr. Igor Aurer, Division of Hematology, Department of Internal Medicine, University Hospital Center Rebro, Kišpatićeva 12, 10000 Zagreb, Croatia; tel: 385-1-2388-675; fax: 385-1-2421-892; e-mail: aurer@mef.hr
SUMMARY
We report the outcomes of 45 patients with relapsed or refractory aggressive NHL treated with a combination of ifosfamide, carboplatinum and etopoisde (ICE) and 28 patients treated with a combination of ifosfamide, methotrexate and etoposide (IMVP) during two 5-year periods. The response rate (RR) to ICE was 47%, 2-year overall survival (OS) 31% and 2-year event-free survival (EFS) 22%. These results were similar to those obtained with IMVP (RR 39%, 2-year OS 23%, 2-year EFS 13%; p=0,355 for RR, 0,275 for OS, 0,668 for EFS). Higher IPI scores and refractoriness to treatment were negative prognostic factors, immunophenotype (B vs. T) had no influence on prognosis. Changing from IMVP to ICE, does not substantially improve outcomes of patients with relapsed or refractory aggressive NHL. Patients with relapsed/refractory aggressive B-NHL do not have a superior outcome in comparison to those with T-NHL if treated with chemotherapy alone.
Key words:
Lymphoma, non-Hodgkin; Lymphoma, B-cell; Lymphoma, diffuse; Lymphoma, large-cell; Lymphoma, T-cell; Ifosfamide; Methotrexate; Etoposide; Carboplatinum
INTRODUCTION
Patients with aggressive non-Hodgkin’s lymphomas (NHL) failing front line treatment have a very poor outcome unless they receive high-dose therapy and autologous stem-cell transplantation (1-5). However, this approach is of proven benefit only in patients with chemosensitive disease. In order to increase the number of responders, a large number of intensive treatment regimens containing various cytotoxic drugs have been designed (6-9). They are broadly divided into platinum (e.g. DHAP, combination of dexamethasone, cytarabine and cisplatin) and ifosfamide based regimens. Randomised comparisons have never been performed and results reported by different centres using the same regimen vary widely (10).
IMVP (ifosfamide, methotrexate, etoposide) is a representative of the so-called first-generation ifosfamide regimens which have been largely replaced by more intensive second-generation regimens, like ICE (ifosfamide, carboplatinum, etoposide). Specially, ICE has become very popular since a large phase II study with encouraging results from the Memorial Sloan Kettering Cancer Center (MSKCC), New York, USA, was reported (9).
In 2001, after analyzing our results with IMVP (11), we decided to change our salvage regimen for aggressive NHL to ICE. Here we report our five-year experience with this approach and compare it to the results obtained with our previous regimen.
PATIENTS AND METHODS
Patient Characteristics
Between April 1997 and June 2001, 28 consecutive patients with relapsed or refractory aggressive NHL were treated with IMVP. This group has been described in detail previously (11). Between June 2001 and October 2006, 45 consecutive patients with aggressive NHL were treated with ICE. Patient characteristics at the time of starting IMVP or ICE are listed in Table 1. All patients received at least one anthracycline containing regimen. Four patients treated with ICE and none treated with IMVP failed a rituximab-containing regimen. Three patients treated with IMVP and none treated with ICE were previously autografted. None of the patients was known to be HIV positive.
All patients were staged prior to treatment. Staging included careful palpation of peripheral nodes, CT scanning of the thorax, abdomen and pelvis and a bone marrow biopsy.
Chemotherapy
IMVP consisted of ifosfamide 1000mg/m2 days 1-5, methotrexate 30mg/m2 i.v. days 3 and 10, etoposide 100mg/m2 i.v. days 1 to 3 (9,10). Uromitexan (MESNA) was given (250 mg/m2 thrice daily) for uroprotection during ifosfamide treatment. Cycles were repeated every three to four weeks.
The ICE treatment schedule comprised etoposide 100 mg/m2 iv on days 1 to 3, ifosfamide and uromitexan 5000 mg/m2 by continuous 24-hour infusion on day 2 and carboplatinum AUC 5 (maximum 800 mg) iv on day 2 (9). Two cycles were repeated in an interval of three to five weeks.
Treatment was given in an in-patient setting. If there were no complications, patients were discharged after the end of chemotherapy.
Supportive Care
Ondansetron and dexamethasone were given for prevention of nausea and vomiting prior to and during chemotherapy. Prophylactic antibiotics, antifungal agents and filgrastim were administered at the discretion of the attending physician.
Toxicity
Toxicity was graded using the National Cancer Institute “Common Toxicity Criteria” (12).
Outcome and Response Criteria
Restaging was performed after two cycles of ICE and two to three cycles of IMVP. Patients were carefully examined and radiological examinations and biopsies positive prior to treatment start were repeated. Response was determined according to standard criteria (13). Complete remission and complete remission-unconfirmed were considered complete responses (CR). CR and partial remission (PR) were considered responses, while stable and progressive disease were considered treatment failures. Overall (OS) and event-free survival (EFS) were calculated from the date of start of ICE or IMVP until last follow-up, death or event respectively. SD or PD after two or three cycles of treatment, relapse, disease progression and death from any cause were considered events.
Further Treatment
Patients who responded and did not have prohibitive toxicity went on to receive a third cycle chemotherapy used for stem-cell mobilization. Patients treated with IMVP generally received mini-BEAM (carmustine, etoposide, cytarabine and melphalan) and those treated with ICE, HDIM (ifosfamide and uromitexan 5000mg/m2 daily by continuous 24-hour infusion for 2 days and mitoxantrone 20 mg/m2 iv on day 1) (14). Responders with an adequate stem cell collection were autografted (15). Generally, in non-responders different treatment regimens were tried in order to obtain a response and continue with autografting. Eight patients receiving IMVP were autografted and 3 allografted. Twenty six patients receiving ICE were autografted, 19 after responding to ICE and seven after responding to other chemotherapy regimens or as part of an experimental transplant program. None of the patients treated with ICE was allografted. BEAM (carmustine, etoposide, cytarabin, melfalan) was used for conditioning. Areas that were not in CR prior to autografting were irradiated with 36 Gy following hematopoietic recovery after transplantation.
Data Analysis
Statistical evaluation was performed using the Statistica, version 7, program (StatSoft, Tulsa, OK, USA). OS and EFS were estimated using the method of Kaplan & Meier. Fisher’s exact test was used for 2x2 table analyses and log-rank test for survival comparisons. The assumed level of significance was 0.05. Confidence intervals (CI) were calculated at a probability of 95%.
Ethics
This analysis was performed with the approval of the Ethical Committee of the Medical School, University of Zagreb.
RESULTS
Comparison between groups
There was a trend for higher IPI scores (16) in the group treated with IMVP (p=0,0528). The proportion of patients with refractory disease was similar. There were more patients with T-NHL in the group treated with ICE.
Toxicity
Hematologic toxicity of ICE was frequent (Table 1). Sixteen out of 45 patients developed significant hematologic toxicity. There were 12 episodes of neutropenic fever, one patient died. Three patients developed serious non-hematologic, non-infectious toxicity: two ifosfamide-induced neurotoxicity and one supraventricular paroxismal tachycardia with hypotension.
The incidence and severity of toxicity was not significantly different from that seen with IMVP (p=0,4278) (Table 1). In the latter group 12 patients had significant hematologic toxicity, 9 neutropenic fever (one died) and one serious non-hematologic, non-infectious toxicity (tumor-lysis syndrome).
None of the patients developed a second cancer. There were no cases of severe late treatment-related toxicity in survivors or reactivation of chronic viral infections.
Response and Survival
The overall response rate (RR) to ICE was 47%±15% (Table 1). Six patients achieved CR and 15 PR. Median OS of the whole group was 7 months. Median EFS of responders was 7 months (Fig. 1 and 2). Actuarial 2-year OS was 31% and 2-year EFS 22%. Median follow-up of survivors was 13 months. At the time of analysis, 19 patients were still alive.
The results obtained with IMVP were similar (p=0,355 for RR, p=0,275 for OS and 0,668 for EFS) (Table 1). RR was 39%±18%, 6 patients achieved CR and 5 PR. Median OS of the whole group was 6 months and median EFS of responders 6 months (Fig. 1 and 2). Actuarial 2-year OS was 23 % and 2-year EFS 13%. Median follow-up of survivors was 24 months. At the time of the analysis, 7 patients were still alive.
Patients with lower IPI scores had a RR of 50%±16%, 2-year OS of 32% and 2-year EFS of 31%, while those with higher IPI scores had a RR of 36%±16%, 2-year OS of 21% and 2-year EFS of 17% (Table 2). The difference was significant for OS (p=0.01055) but not for RR (p=0.1759) and EFS (P=0.14339).
Patients with relapsed disease had superior outcomes in comparison to those with refractory disease (Table 2). Overall response rates were 57%±16% vs. 31%±15%, respectively (p=0,0340) and 2-year EFS 28% vs. 19% (p=0,04108). Two year OS was 37% in the group of patients with relapsed and 20% with refractory disease. This difference did not reach statistical significance (p=0,15132).
Outcomes were similar in patients with B vs. T-cell NHL. Response rates were 41%±15% and 48%±18% respectively (p= 0,6318), and 2-year OS 38% and EFS 24% in both groups (p=0,68546 and 0,55976 respectively).
DISCUSSION
To our knowledge, besides the original report from the MSKCC (9), there are three other papers reporting results with the same or very similar chemotherapy regimens (17-19). The reported RRs vary twofold between 44% and 89%. The differences in OS are even more pronounced. In one study, 65% of patients were alive after 2 years (17). In another, median survival was 17 months and 2-year survival 42% (9). In the third, median survival was 7 months (18). The fourth did not report survival data (19). Our response and survival results belong to the lower end of the spectra. Such wide differences can best be explained by patient selection. Another possible contributing factor are differences in dose-density. Most papers failed to report the actual dose-density. The original ICE regimen was given every two weeks. In some patients we had to delay the treatment due to placement problems, i.e. insufficient hospital beds. However, even if everything was done according to schedule, in most of our patients treatment had to be delayed, because their blood counts recovered only after three weeks. We are not aware of any published data on differences in feasibility of dose-dense regimens in patient populations with different ethnic backgrounds. However, problems are occassionally reported at international meetings by hematologists from countries outside of Europe, North America and Australia with dose-dense regimens such as CHOP-14. This suggests that there might be genetically determined differences in sensitivity to chemotherapy and that dose-dense treatment regimens might not be equally feasible in all ethnic groups. Additional studies are neede to explore this question.
Patients with T-NHL, except those with ALK positive anaplastic-large cell lymphoma, have a significantly inferior outcome in comparison to patients with aggressive B-NHL (20). The 5-year survival rate of T-NHL patients is below 30%, while it is 50-60% for patients with aggressive B-NHL. However, this difference is mostly due to better results of front-line treatment in the latter group. There are few data comparing the outcomes of relapsed/refractory patients. Our study suggests that, once they fail front-line treatment, the prognostic advantage of B-cell NHLs is lost, at least if they are treated with chemotherapy alone. This is in accordance with the results of the original MSKCC report (9), the only study of ICE with a sufficient number of T-NHL patients.
Outcomes of patients with relapsed or refractory aggressive NHL treated with ICE were, in our hands, similar to those treated with IMVP. Also, there were no differences in toxicity between the two regimens. This study suffers from the usual shortcomings of retrospective studies. However, we do not believe that the lack of differences between the newer and the older treatment can be attributed to different patient selection or supportive care. Patients receiving IMVP had higher IPI scores than those receiving ICE and supportive care has, if anything, improved. These factors would increase and not decrease any real difference existing between IMVP and ICE. Our results therefore suggest that the difference in efficacy between first and second generation ifosfamide-based salvage chemotherapy regimens might not be as big as expected. Recently published studies indicate that the addition of immunotherapy is more important than choice of chemotherapy. MSKCC has reported a phase II trial indicating that the addition of rituximab, a monoclonal antibody directed against the CD20 antigen present on B-NHL, to ICE further improves the outcomes of patients with relapsed and refractory B-NHL (21). This has been proven in a recently reported randomized trial from the Netherlands (22). Thus it seems that rituximab is the most important new agent emerging in the last decade, not only for front-line, but also for salvage treatment of aggressive B-NHL.
However, even with the addition of rituximab, many patients with relapsed and refractory aggressive NHL die of their disease. Therefore, the quest to define optimal salvage chemotherapy should continue. In order to obtain reliable results, possible candidate regimens must be compared in randomized trials. One such large trial is underway, comparing rituximab + ICE to rituximab + DHAP (23).
ACKNOWLEDGEMENT
Supported by grants 108-007 and 108-1081872-1908 from the Croatian Ministry of Science, Education and Sport
Presented in part at the 12th Congress of the European Hematology Association, Vienna, Austria, 2007.
REFERENCES
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11. Aurer I, Duraković N, Radman I et al. Combination of ifosfamide, methotrexate, and etoposide (IMVP) as a salvage therapy for relapsed and refractory aggressive non-Hodgkin lymphoma: retrospective study. Croat Med J 2002; 43:550-4.
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14. Nemet D, Radman I, Aurer I et al. High-dose ifosfamide and mitoxantrone as cytoreductive and mobilization protocol for relapsed and refractory lymphoma. Blood 2003; 102:416b-417b.
15. Nemet D. Autologous hematopoietic stem cell transplantation in the treatment of malignant lymphomas. Liječ Vjesn 1999; 121(Suppl. 3):94-9.
16. The international non-Hodgkin’s lymphoma prognostic factors project. A predictive model for aggressive non-Hodgkin’s lymphoma. N Engl J Med 1993; 329:987-94.
17. Hertzberg MS, Crombie C, Benson W, Taper J, Gottlieb D, Bradstock KF. Outpatient fractionated ifosfamide, carboplatin and etoposide as salvage therapy in relapsed and refractory non-Hodgkin's and Hodgkin's lymphoma. Ann Oncol 2006; 17(Suppl.4): iv25-iv30.
18. Itoh K, Igarashi T, Ohtsu T et al. Toxicity and efficacy of ifosfamide, carboplatin and etoposide (modified ICE) as a salvage chemotherapy in Japanese patients with relapsed or refractory aggressive non-Hodgkin's lymphoma. Int J Hematol 1998; 68:431-7.
19. Jerkeman M, Leppä S, Kvaløy S, Holte H. ICE (ifosfamide, carboplatin, etoposide) as second-line chemotherapy in relapsed or primary progressive aggressive lymphoma – the Nordic Lymphoma Group experience. Eur J Haematol 2004; 73:179-82.
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21. Kewalramani T, Zelenetz AD, Nimer SD et al.. Rituximab and ICE as second-line therapy before autologous stem cell transplantation for relapsed or primary refractory diffuse large B-cell lymphoma. Blood 2004; 103:3684-8.
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FIGURE LEGENDS
Figure 1
Title: Overall survival of NHL patients treated with ICE and IMVP.
ICE – full line; IMVP – dashed line. Crosses indicate censored patients.
Figure 2
Title: Event-free survival of NHL patients treated with ICE and IMVP.
ICE - full line; IMVP - dashed line. Crosses indicate censored patients.
TABLE 1 Patients' characteristics and outcomes
|Treatment |IMVP |ICE |
|Gender (M / F) |13 / 15 |25 / 20 |
|Age (median / range) [years] |47 / 15-68 |44 / 17-64 |
|NHL type |14 / 8 / 0 / 6 |21 / 1 / 9 / 14 |
|(DLBCL / FL gr.III / PTCL / ALCL) | | |
|Stage (I / II / III / IV) |1 / 5 / 4 / 11 |1 / 14 / 10 / 20 |
|IPI (0-1 / 2 / 3 / 4-5) |9 / 2 / 13 / 4 |16 / 13 / 11 / 5 |
|Disease status (relapsed / refractory) |14 / 14 |23 / 22 |
|Time from diagnosis to treatment (median / range) [months] |12.5 / 3-60 |12 / 2-83 |
|No. of treatment lines (median / range) |2 / 1-5 |1 / 1-6 |
|B symptoms |22 |24 |
|Toxicity gr. 3 & 4 | | |
|hematologic |16 |12 |
|infectious | | |
|other | | |
| |12 |9 |
| |3 |1 |
|Treatment related mortality |1 |1 |
|Response rate |47% |39% |
|2-year overall survival |31% |23% |
|2-year event-free survival |22% |13% |
Abbreviations:
DLBCL – diffuse large B-cell lymphoma
FL gr. III – follicular lymphoma grade III
PTCL – peripheral T-cell lymphoma
ALCL - anaplastic large cell lymphoma
TABLE 2 Outcomes according to IPI and disease status prior to treatment
| |IPI 0-2 |IPI 3-5 |Relapse |Refractory |
|Response rate |50 % |36 % |57 %* |31 %* |
|2-year OS |32 %* |21 %* |37 % |20 % |
|2-year EFS |31 % |17 % |28 %* |19 %* |
OS – overall survival
EFS – event-free survival
* - statistically significant difference (p ................
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