Federica Quirini

Gemcitabine as single agent in pretreated T-cell lymphoma patients: evaluation of the long-term outcome

BACKGROUND Peripheral T-cell lymphoma unspecified (PTCLU) and mycosis fungoides (MF) often show resistance to conventional chemotherapy. Gemcitabine should be considered a suitable option. We report the long-term update of 39 pretreated T-cell lymphoma patients treated with gemcitabine. PATIENTS AND METHODS From May 1997 to September 2007, 39 pretreated MF and PTCLU patients received gemcitabine. Inclusion criteria were as follows: histologic diagnosis of MF or PTCLU; relapsed/refractory disease; age > or =18 years; and World Health Organization performance status of two or less. Nineteen patients had MF and 20 PTCLU. All patients with MF had a T3-T4, N0, and M0 disease and patients with PTCLU had stage III-IV disease. Gemcitabine was given on days 1, 8, and 15 on a 28-day schedule (1200 mg/m(2)/day) for a total of three to six cycles. RESULTS Overall response rate was 51% (20 of 39 patients); complete response (CR) and partial response (PR) rates were 23% (9 of 39 patients) and 28% (11 of 39 patients), respectively. Patients with MF had a CR rate of 16% and a PR rate of 32% compared with a CR rate of 30% and a PR rate of 25% of PTCLU patients. Among the CR patients, 7 of 9 are in continuous complete response with a variable disease-free interval (15-120 months). CONCLUSION In our experience, gemcitabine proved to be effective in pretreated MF and PTCLU patients, even in the long term.

Combination of Lenalidomide and Rituximab in Elderly Patients With Relapsed or Refractory Diffuse Large B-Cell Lymphoma: A Phase 2 Trial

BACKGROUND Diffuse large B-cell lymphoma (DLBCL) is the most common subtype of aggressive non-Hodgkin lymphoma and despite recent chemotherapeutic advances up to half of all patients relapse. Here we report the results from a phase 2, single-arm, single-center trial evaluating the safety and efficacy of lenalidomide plus rituximab in elderly patients with relapsed or refractory DLBCL. PATIENTS AND METHODS Between March and June 2009, elderly patients (65 years of age or older) with relapsed/refractory DLBCL who had been heavily pretreated were recruited. Oral lenalidomide (20 mg/d for 21 days of each 28-day cycle) was initiated for four cycles and rituximab (375 mg/m(2)) was administered on day 1 and day 21 of each 28-day cycle for four cycles. After this induction phase, patients achieving a complete response (CR), partial response (PR), or stable disease (SD) were given lenalidomide maintenance therapy at the same schedule for another 8 months. RESULTS A total of 23 patients with a median of three prior treatments (range, 2 to 8) were included. The overall response rate (CR + PR) at the end of the induction phase was 35% (n = 8). Ten patients (7 CR, 1 PR, and 2 SD patients) were eligible for lenalidomide maintenance and 8 of these patients achieved a CR. Adverse events were manageable and the most common included neutropenia and thrombocytopenia. CONCLUSION Oral lenalidomide in combination with rituximab is active in elderly patients with relapsed/refractory DLBCL with a high percentage of patients achieving a continuous CR after lenalidomide maintenance.

Midtreatment 18F-fluorodeoxyglucose positron-emission tomography in aggressive non-Hodgkin lymphoma.

The use of 18F‐fluorodeoxyglucose positron‐emission tomography (PET) scan has increased considerably in the clinical management of non‐Hodgkin lymphoma patients, and its role as a prognostic factor during chemotherapy has been established recently.

Lenalidomide monotherapy for relapsed/refractory peripheral T-cell lymphoma not otherwise specified

Current therapeutic strategies for peripheral T-cell lymphoma, not otherwise specified (PTCL-nos) remain poorly defined; they are extrapolated from treatment paradigms of B-cell lymphomas. In particular, patients with aggressive PTCL are traditionally treated with an anthracycline-containing regimen, and complete response rates of 50–70% have been reported [1–3]. However, 5-year overall survival (OS) for patients with PTCL-nos was 20–30%. Autologous stem cell transplant (ASCT) seems to offer long-term disease control in only 30–40% of cases if performed in a status of remission [4,5]. In recent years, there have been a plethora of new agents that have shown promising activity in the treatment of patients with PTCL. Pralatrexate, a new antifolate, showed an overall response rate (ORR) of 29%, with 9% of patients achieving complete remission (CR) in a prospective single-arm multicenter study [6] of relapsed/refractory PTCL. Among histone deacetylase inhibitors (HDACIs), a phase II trial of romidepsin in patients with PTCL who had failed at least one systemic therapy showed an ORR of 31% (with a CR rate of 8%) [7]. Gemcitabine, a nucleoside analogous, has been studied as a single agent in relapsed patients with PTCL, and showed an ORR of 59% with 12% CRs [8,9]. Lenalidomide is an immunomodulatory agent with potent anticancer properties. A phase II trial of lenalidomide in PTCL was reported by Dueck and co-workers [10] in which 24 patients with T-cell lymphoma were enrolled; the ORR was 30%, without CRs. On the strength of these findings we decided to investigate the efficacy and safety of lenalidomide monotherapy in pretreated patients with PTCL-nos. Patients aged 18 years or older with biopsy-proven, bidimensionally measurable, stage II, III or stage IV PTCL-nos were considered eligible for this prospective, single-arm, open-label, bi-centric non-randomized phase II trial. Patients were to be relapsed ( 1) or refractory and should have a World Health Organization (WHO) performance status 2. All diagnostic biopsies were reviewed by an expert pathologist (S.P.) in accordance with the WHO classification [11]. All the patients underwent full medical history, physical examination, complete blood cell and platelet counts, a computed tomography (CT) scan of the neck, chest, abdomen, and pelvis, whole-body F-fluorodeoxyglucose (FDG)-positron emission tomography (PET) scan, and a bone marrow biopsy. Disease stage was established according to the Ann Arbor staging system. Patients were also tested for kidney and liver function (including hepatitis B and C viruses [HBV and HCV]) and were subjected to electrocardiography. All patients signed a written informed consent, approved in accordance with institutional guidelines, including the Declaration of Helsinki. The study was approved by the institutional review board.

Hairy cell leukemia: Evaluation of the long-term outcome in 121 patients

Historically, the first treatment choices for hairy cell leukemia (HCL) were splenectomy and alpha‐interferon. Recently, purine analogues (pentostatin and cladribine) changed radically the treatment modality, inducing complete and durable responses in the majority of patients.

A phase II trial of short course fludarabine, mitoxantrone, rituximab followed by 90Y-ibritumomab tiuxetan in untreated intermediate/high-risk follicular lymphoma

BACKGROUND A prospective, single-arm, open-label, multicenter, nonrandomised phase II trial to evaluate efficacy and safety of short fludarabine, mitoxantrone, and rituximab (FMR) induction followed by radioimmunotherapy, in untreated, intermediate/high-risk follicular non-Hodgkins lymphoma (NHL) patients. PATIENTS AND METHODS Fifty-five patients were treated using a sequential treatment schedule of four induction cycles of FMR chemoimmunotherapy, and a subsequent consolidating single administration of (90)Y-ibritumomab tiuxetan ((90)Y-IT), 8-14 weeks later. Patients were eligible for radioimmunotherapy if at least in partial response (PR) after induction, with normal platelet and granulocyte counts and a bone marrow infiltration ≤ 25%. Primary study end points were response rate and hematologic toxic effects; secondary end points were overall survival (OS) and progression-free survival (PFS). RESULTS All the 55 patients received four induction cycles with an overall response rate of 96% (38 complete responses [CR] and 15 PR). Fifty-one patients (38 in CR and 13 in PR) received (90)Y-IT. By the end of the treatment, 49/55 patients achieved a CR. With a median follow-up of 21 months, the estimated 3-year PFS was 81% and the 3-year OS 100%. CONCLUSIONS This study has established feasibility, tolerability, and efficacy of a regimen composed by short FMR induction with (90)Y-IT consolidation in untreated intermediate/high-risk follicular NHL patients.

Bortezomib as salvage treatment for heavily pretreated relapsed lymphoma patients: a multicenter retrospective study

Current treatments for non‐Hodgkin lymphomas are not optimally effective. Among new agents, bortezomib seems to play a pivotal role in the regulation of several cell pathways involved in the development of lymphomas. After results were obtained with clinical trials, we aimed to observe treatment with bortezomib in everyday clinical practice. We performed a multicenter retrospective analysis to assess the efficacy of bortezomib in heavily pretreated (median number of previous therapies 4, range 2–6) lymphoma patients in an off‐label setting. Bortezomib therapy was scheduled for 4–6 cycles (1.3 mg/m2 biweekly). Data from 50 patients were collected: 22% had a complete remission, 26% obtained a partial response and the remaining 52% was non‐responder. According to histotype, we observed an overall response rate (ORR) of 51.6% in mantle cell lymphomas, an ORR of 60% among follicular lymphoma patients, and an ORR of 50% in the indolent nonfollicular lymphomas. None of diffuse large B‐cell lymphoma patients obtained a response. Extra‐hematological toxicity was really mild, and peripheral neuropathy occurred in only 5 patients; hematological toxicity was grades 3–4 thrombocytopenia in nine patients and grades 3–4 neutropenia in only three patients. In conclusion, treatment with bortezomib as single agent resulted safe and effective in a subset of heavily pretreated lymphoma patients with usually poor outcome. New future hypotheses of investigation are indicated. Copyright

Allotransplant in relapsed or refractory aggressive T-cell lymphomas: retrospective monocentric analysis of 14 patients.

Relapsed and refractory T-cell lymphomas represent a great challenge for clinicians because of their scarce tendency to show a response to further conventional treatments and – as a consequence – their relatively dismal prognosis. Rescue strategies in this setting are represented by high dose programs followed by stem cell transplant. Although autologous stem cell transplant (auto-SCT) is feasible and safe in relapsed patients, particularly if chemosensitive [1], outcomes data are still controversial, especially for cutaneous T-cell lymphomas (CTCL) and T-lymphoblastic lymphoma (T-LBL), with disappointing results reported in some studies [2]. It has been demonstrated that myeloablative (MA) allogeneic stem cell transplant (allo-SCT) in aggressive peripheral T-cell lymphomas (not otherwise specifi ed, PTCL-NOS) is associated with a lower relapse rate than auto-SCT; however, the higher transplant-related mortality (TRM) associated with the allograft off sets any survival benefi t [3 – 5]. On the other hand, a few authors [3,6,7] have reported that reduced intensity conditioning (RIC) allo-SCT is feasible and, at the same time, less toxic than MA conditioning. Th e role of allo-SCT has been increasingly explored also in the setting of CTCL, and in particular in those patients presenting with S é zary syndrome and advanced mycosis fungoides (MF) [8 – 11]. Moreover, various chemotherapy programs that integrate consolidation with either autoor allo-SCT have been proposed for T-LBL [12], in which adult patients show a higher relapse rate if compared to pediatric T-LBL, but just a few cases of long responders after allo-SCT have been reported so far [13]. Th e rationale behind allo-SCT rests on both the fact that allogeneic hematopoietic stem cells are free of tumor contamination, and that a graft-versus-lymphoma eff ect can be hypothesized, since donor-derived immune cells are potentially capable of mediating an antitumor eff ect [14]. Studies have also suggested that disease status at transplant is a major predictor of success [3]: a high percentage (almost 70%) of patients who are in remission at the time of transplant can be cured of their disease, while only 25 – 30% of refractory patients may take advantage of this procedure [6]. Additionally, there are no diff erences in the relapse rates if MA allo-SCT is compared to RIC regimens, but a higher rate of non-relapse mortality with the MA approach still exists. Herein we present a retrospective monocentric analysis of 14 patients with relapsed or refractory aggressive T-cell lymphomas who received allo-SCT at the Institute of Hematology and Medical Oncology “ Lorenzo e Ariosto Ser à gnoli ” , University of Bologna, Italy, between June 1983 and June 2008. Patients ’ characteristics are listed in Table I. A predominance of male patients (78.6%) was noted, with a median age at diagnosis of 35 years (range, 15 – 53 years) and of 38 years (range, 16 – 54 years) at allo-SCT. Th e median time elapsed from disease diagnosis to transplant was 11 months, ranging from 3 to 80 months. All patients were previously treated (the median number of prior therapies was 3, range, 1 – 8). An auto-SCT was performed in fi ve (35.7%) patients, with one patient receiving two consecutive autologous stem cell reinfusions because of documented relapse after the fi rst transplant. At the time of transplant, one patient was in complete response (CR) and fi ve patients were in partial response (PR), whereas seven showed disease progression (PD) and one a stable disease (SD). Nine (64.3%) patients received a MA conditioning regimen, while fi ve (35.7%) underwent a RIC regimen. After allo-SCT, eight patients (57.1%) obtained a CR whereas three (21.4%) achieved a PR, with an overall response rate of 78.5%. More specifi cally, four patients previously in PR could convert their status to CR once transplanted, while four and two patients in PD could improve their response status to CR and PR, respectively. Th e only patient in CR before alloSCT showed a PD once transplanted, and ultimately died. According to histology, the CR subset of patients was represented by four out of seven (57.1%) cases of T-LBL, three out of fi ve (60.0%) PTCL-NOS and one of the two patients (50.0%) with MF. Th e three PR patients were one T-LBL, one PTCLNOS and the remaining patient aff ected by MF, respectively. L eu k L ym ph om a D ow nl oa de d fr om in fo rm ah ea lth ca re .c om b y M ic hi ga n U ni ve rs ity o n 10 /2 9/ 14