Transplantation, (1998) 21, 1171–1175  1998 Stockton Press All rights reserved 0268–3369/98 $12.00 http://www.stockton-press.co.uk/bmt Busulfan, and as high-dose conditioning therapy in patients with malignant and prior dose-limiting radiation therapy

¨ ¨ ¨ ¨ N Kroger1, M Hoffknecht1,MHanel2, W Kruger1, W Zeller1, M Stockschlader1, M de Wit1, HJ Weh3, H Kabisch1, R Erttmann1 and AR Zander1

1Bone Marrow Transplantation, 3Department of Oncology/Hematology University Hospital Hamburg-Eppendorf and 2Department of Internal Medicine, Hematology Chemnitz, Germany

Summary: High-dose and/or radiotherapy with periph- eral blood stem cell support is increasingly used in patients Relapse after transplant for malignant with high-risk or relapsed malignant non-Hodgkin’s lym- remains the main cause of treatment failure. Most con- phoma.1–3 Recently, a randomized trial confirmed the ditioning regimens contain total body irradiation (TBI). superiority of high-dose chemotherapy followed by auto- We investigated the toxicity and efficacy of an intensi- logous bone marrow transplantation over standard salvage fied chemotherapy conditioning regimen without TBI in therapy for relapsing chemosensitive non-Hodgkin’s lym- patients with relapsed or high-risk malignant lym- phoma.4 Total body irradiation (TBI) is part of many fre- phoma who had received prior radiation therapy and quently used conditioning regimens. The most frequent sin- were therefore not eligible for TBI. Twenty patients gle cause of treatment failure has been relapse. In an with a median age of 38 (18–56) and relapsed or high- attempt to decrease the relapse rate, etoposide was added to risk malignant non-Hodgkin’s lymphoma (NHL, n = 16) the TBI/cyclophosphamide regimen because of its known or Hodgkin’s disease (HD, n = 4) underwent high-dose activity against lymphoma.5–7 However, patients with prior chemotherapy consisting of busulfan (16 mg/kg), cyclo- dose-limiting radiation therapy need alternative radiation- phosphamide (120 mg/kg) and etoposide 30 mg/kg free preparative regimens. The combination of busulfan (n = 8) or 45 mg/kg (n = 12) followed by peripheral stem plus cyclophosphamide (Bu/Cy) has been widely used in cell support (n = 14), autologous bone marrow (n = 3), patients with hematological malignancies. Initially, studies allogeneic (n = 2) or syngeneic (n = 1) transplantation. using busulfan (16 mg/kg) and cyclophosphamide All but two had chemosensitive disease before high-dose (200 mg/kg) provided an effective alternative to TBI plus chemotherapy. The main toxicity – according to the cyclophosphamide in the treatment of AML.8 Modification Bearman score – was mucositis II in 18 (90%) patients; of this regimen by lowering the cyclophosphamide dose to five patients (25%) suffered a grade I hepatic toxicity. 120 mg/kg appears to be equally effective and less toxic.9 GI toxicity I occurred in three (15%) and renal toxicity Studies with Bu/Cy also demonstrated significant antitumor I in two patients (10%). Sixty percent of the patients activity in patients with lymphoid malignancy10–13 but – developed transient dermatitis with erythema and three similiar to TBI containing therapies – treatment failure was of them (15%) had skin desquamation; one patient mainly due to relapse. We therefore conducted a study to experienced asymptomatic pancreatitis. Toxicity was increase efficacy by adding etoposide (30 or 45 mg/kg) to slightly higher in patients treated with 45 mg/kg etopo- high-dose busulfan, cyclophosphamide in patients with side. One patient (5%) died of treatment-related veno- malignant lymphoma who had received prior radiotherapy occlusive disease. After a median follow-up of 50 months and were not eligible for a TBI containing regimen. We (24–84) the disease-free and overall survival were 50% have previously reported the efficacy of Bu/Cy/etoposide and 55%. One of the nine relapsing patients developed as preparative therapy in allogeneic bone marrow transplan- secondary AML 18 months after transplant. High-dose tation of patients with AML.14 busulfan, cyclophosphamide and etoposide is an effec- tive regimen resulting in long-term disease-free survival in 50% of patients with relapsed malignant lymphoma Patients and methods and prior radiation therapy. The toxicity is moderate with a low treatment-related mortality (5%). Patient selection Keywords: malignant lymphoma; high-dose chemo- therapy; etoposide; busulfan; cyclophosphamide. Between November 1991 and April 1995, 20 patients with non-Hodgkin’s lymphoma (NHL) or Hodgkin’s disease ¨ (HD) who had received prior dose-limiting radiotherapy Correspondence: Dr med N Kroger, Bone Marrow Transplantation, Uni- versity Hospital Hamburg-Eppendorf, Martinistrasse 52, D-20246 Ham- received high-dose busulfan, cyclophosphamide and etopo- burg, Germany side followed by peripheral blood stem cell support Received 1 October 1997; accepted 15 January 1998 (n = 14), autologous bone marrow (n = 3) or allogeneic High-dose Bu/Cy/etoposide for malignant lymphoma ¨ N Kroger et al 1172 (n = 2)/syngeneic (n = 1) bone marrow transplantation. Table 1 Patient characteristics (n = 20) Inclusion criteria included prior administration of radio- therapy greater than 20 Gy to the or mediastinum or Gender: male/female 10/10 greater than 30 Gy as extended or involved field to other Median age (years) 38 (range 18–56) regions. Histology Further eligibility criteria were age less than 60 years, High grade 12 ECOG performance status 0 or 1, adequate cardiac and pul- Low grade (follicular) 2 monary function and creatinine of less than 2.0 mg/dl. Mantle cell lymphoma 2 NHL was classified according to the Kiel and the REAL Hodgkin’s disease 4 15,16 Disease status classifications. The transplant protocol was approved by CR the local ethics commission and all patients gave written 1st CR 1 informed consent. 2nd CR 4 3rd CR 3 4th CR 1 Patient characteristics 5th CR 1 PR The study included 20 patients with a median age of 38 2nd PR 4 years (range 18–56) and the following histologies: high- 3rd PR 2 grade lymphoma (n = 12), follicular lymphoma (n = 2), 4th PR 2 = 3 Relapse 2 mantle cell lymphoma (n 2) and Hodgkin’s disease Stage at initial diagnosis (n = 4). Before high-dose chemotherapy 10 patients were I1 in complete remission (1st CR: n = 1; 2nd CR: n = 4, 3rd II 7 CR: n = 3; 4th CR: n = 1; 5th CR: n = 1), eight in partial III 2 = = = IV 10 remission (2nd PR: n 4; 3rd PR: n 2; 4th PR n 2;) and Stem cell source two patients were transplanted in 3rd relapse. Ten patients PBSC 14 had had stage IV disease, but none had bone marrow Autologous BM 3 involvement. The median number of prior chemotherapy Allogeneic BM 2 regimens was 2.5 (range 1–5) (Table 1). Syngeneic BM 1 Median follow-up (months) 50 (range 24–84) Treatment regimen VP 16 dose 30 mg/kg 8 A total dose of busulfan of 16 mg/kg was administered 45 mg/kg 12 − Prior radiotherapy orally in four divided doses daily for 4 days (days 8to Mediastinum 9 −5). Etoposide (30 mg/kg n = 8 or 45 mg/kg n = 12) was Abdomen 4 administered on day −4 either undiluted over 6 h or split Supra- and infradiaphragmal 4 and diluted over 1 h. There was no randomization in terms Involved field Ͼ30 Gy 6 of etoposide dose: 30 mg/kg was given to patients with Median prior 2.5 extended prior radiotherapy, eg to liver or mediastinum. Cyclophosphamide 60 mg/kg was given intravenously over 1 h for 2 days (days −3 and −2). was given to score.18 The maximum score for each organ system was prevent busulfan induced until 2 days after stop- recorded. Skin toxicity was described as mild in cases of ping busulfan. Uroepithelial prophylaxis was achieved with erythema or as more severe in cases of desquamation. hyperhydration and mesna. Bone marrow or peripheral Attempts were made to exclude from this evaluation toxi- blood stem cells were infused 24–48 h after the last cyclo- cities due to GVHD. phosphamide administration (day 0).

Results Stem cell source Patients received hematopoietic stem cells from autologous All patients were evaluable for toxicity and response. (n = 3), allogeneic (n = 2), syngeneic (n = 1) marrow or = from G-CSF-mobilized peripheral blood (n 14). The tech- Transplant-related toxicity nique for PBSC harvest following G-CSF application, cryo- preservation, CD34+ cell counting and progenitor cell assay One patient (5%) died of causes other than malignancy has been described elsewhere.17 All patients received G- before day 100 after transplant. She developed severe hep- CSF beginning on day +1 post transplant (10 ␮g/kg n = 16; atic toxicity, which fulfilled the Seattle criteria of veno- 5 ␮g/kg n = 4) until engraftment. occlusive disease (VOD) of the liver.19 Before transplan- tation she had received radiotherapy to the abdomen, which is one of the major risk factors in developing VOD. All Regimen-related toxicity patients developed mucositis, 90% of them grade II that Regimen-related toxicity affecting the renal, hepatic, car- required intravenous analgesics. Skin toxicity was mild in diac, pulmonary, the gastrointestinal, the CNS system and 60% of patients with localized erythema mainly of palmar mucous membranes were graded using the Bearman or plantar surfaces, only three (15%) experienced moderate High-dose Bu/Cy/etoposide for malignant lymphoma ¨ N Kroger et al 1173 toxicity with local desquamation. All cases of mucositis and skin toxicity resolved completely. Hepatic toxicity grade I 1.0 with maximum serum of 3.9 mg/dl was seen in six (30%), renal toxicity grade 1 in two and mild diarrhea 0.8 (grade I) in three patients (15%). Patients treated with 45 mg/kg etoposide experienced a slightly higher degree of 0.6 50% toxicity than patients treated with 30 mg/kg (Table 2). One DFS patient experienced asymptomatic pancreatitis. All patients 0.4 developed fever, and in 16 patients no origin of fever could be detected (FUO), while in three patients blood cultures 0.2 were positive for Staphyloccocus (n = 2) and Enterococcus = (n 1). Pneumonia caused fever in one patient. None of 0.0 the patients developed cardiac, pulmonary or CNS toxicity. 020406080 Hematopoietic engraftment Months All patients achieved a leukocyte count greater than 1.0/nl Figure 1 Disease-free survival after high-dose Bu/Cy/etoposide chemo- after a median of 11 days (range 9–30). Eighteen patients therapy. were evaluable for engraftment: 15 patients ach- ieved a self-sustained platelet count greater than 50/nl at a 1.0 median of 30 days (range 11–178). Three patients died without achieving a sustained platelet count greater than 50/nl (days +35, +105, +658). The median reinfused CD34+ 0.8 cell count for peripheral stem cell transplantation was 2.51 × 106/kg (range 0.51–14.2); the median number of 0.6 55% 4 CFU-GM was 2.1 × 10 /kg (range 0.77–19.6) and the OS median number of mononuclear cells was 5.4 × 108/kg 0.4 (range 1.5–12.4). 0.2 Response, relapse and survival 0.0 After a median follow-up of 50 months (range 24–84) nine patients (45%) relapsed and seven patients died because of 020406080 relapse; one patient with relapse developed secondary acute Months myeloid and died. The overall survival and the Figure 2 Overall survival after high-dose Bu/Cy/etoposide chemo- disease-free survival are 55 and 50%, respectively (Figures therapy. 1 and 2). Five of 10 patients who were in complete remission before high-dose chemotherapy relapsed, and five are in continuous complete remission (CCR). One of in CCR. One of two patients transplanted in relapse died eight patients who were in partial remission before high- of early relapse and the other one remains in CCR. dose chemotherapy died of treatment-related hepatic tox- Relapses occurred in the 45 mg/kg (n = 6) as well as in icity, four experienced relapses, but four (50%) still remain the 30 mg/kg (n=3) etoposide group.

Discussion Table 2 Toxicity (according to the Bearman scorea) for 30 or 45 mg/kg etoposide (VP16) Despite the proven benefit of high-dose chemotherapy in Toxicity VP16 30 mg/kg VP16 45 mg/kg relapsing non-Hodgkin’s lymphomas, there is no clear evi- (n = 8) (n = 12) dence of any superior high-dose regimen. Optimal regimens should be well tolerated and highly effective. TBI as part Mucositisa I2—of many preparative regimens used is excluded in patients II 6 12 who have had prior dose-limiting radiotherapy. Due to the Livera I24 IV 1 — promising results of TBI, cyclophosphamide and etoposide GI-tracta I11as the preparative regimen in high-dose therapy of malig- Renal I 1 1 nant lymphomas.5,20 we investigated the substitution of bus- Skin ulphan for TBI in patients with malignant lymphoma and Erythema 3 9 prior dose-limiting radiotherapy. The feasibility and toxi- Desquamation — 3 Asymptomatic — 1 city of high-dose busulfan, cyclophosphamide and etopo- pancreatitis side has been mainly evaluated in allogenic bone marrow Fever 8 12 transplantation and has a high treatment-related mortality, mainly due to GVHD, aspergillosis and failure of High-dose Bu/Cy/etoposide for malignant lymphoma ¨ N Kroger et al 1174 engraftment.21,22 A study with Bu/Cy/etoposide (40 mg/kg) References was conducted by Crilley et al23 in 84 patients with hemato- logic malignancy and autologous or allogeneic bone mar- 1 Haioun C, Lepage E, Gisselbrecht C et al. Benefit of autolog- row transplantation. Mucositis and skin symptoms were ous bone marrow transplantation over sequential chemo- noted as frequent extramedullary toxicities. Toxic death therapy in poor risk aggressive non Hodgkin’s lymphoma: because of VOD or pulmonary hemorrhage occurred in 8% update results of the prospective study LNH87–2. J Clin Oncol 1997; 15: 1131–1131. of patients. Taking into account the extended prior treat- 2 Kessinger M, Bierman PJ, Vose JM et al. High dose cyclopho- ment with chemotherapy and irradiation, the toxicity profile sphamide, and etoloside followed by autologous of Bu/Cy/etoposide in our study was moderate, with only peripheral stem cell transplantation for patients with relapsed one (5%) treatment-related death due to VOD. The extra- Hodgkin’s disease. Blood 1991; 77: 2322–2325. ¨ medullary toxicity in terms of mucositis, skin and liver 3 Haas R, Karcher R, Mohle R et al. Sequential high-dose ther- problems seems to be higher in the 45 mg/kg than in the apy with peripheral blood progenitor cell support in low grade 30 mg/kg group. However, the only toxic death due to non-Hodgkin’s lymphoma. J Clin Oncol 1994; 12: 1685– VOD occurred in one patient treated with etoposide 30 1692. mg/kg. The toxicity results were comparable to those seen 4 Philip T, Guglielmi C, Hagenbeek A et al. Autologous bone with the busulfan/cyclophosphamide regimen which has marrow transplantation as compared with salvage chemo- therapy in relapses of chemosensitive non-Hodgkin’s lym- been proven effective as the high-dose conditioning regi- phoma. New Engl J Med 1995; 333: 1540–1545. men in treatment of relapsed/refractory lymphomas, and 5 Weaver CH, Petersen FB, Appelbaum FR et al. High-dose 10–13 has a low therapy-related mortality rate. In comparison fractionated total body irradiation, etoposide, and cyclophos- to Bu/Cy alone, the addition of etoposide seems to increase phamide followed by autologous stem cell support in patients mucositis and skin toxicity, which, however, resolved com- with malignant lymphoma. J Clin Oncol 1994; 12: 2559– pletely. Other -based regimens such as BEAM24 2566. or CBV25,26 reported a high non-relapse mortality of up to 6 Horning SJ, Negrin RS, Chao NJ et al. Fractionated total body 33%. Twenty-three percent of patients who had received irradiation, etoposide, and cyclophosphamide plus autograft- carmustin at a dose of 600 mg/m2 died of idiopathic pneu- ing in Hodgkin’s disease and non-Hodgkin’s lymphoma. J monia syndrome.25 Therefore, it is notable that no pulmon- Clin Oncol 1994; 12: 2552–2558. 7 Gulati S, Yahalom J, Acaba L et al. Treatment of patients ary toxicity was observed in our study despite prior radi- with relapsed or resistant non-Hodgkin’s lymphoma using ation to the mediastinum. The overall survival and the total body irradiation, etoposide, and cyclophosphamide and disease-free survival of 55 and 50% of the Bu/Cy/etoposide autologous bone marrow transplantation. J Clin Oncol 1992; regimen reflect promising antilymphoma activity. Five of 10: 936–941. 10 patients who were in complete remission before high- 8 Santos GW, Tutschka Pj, Brookmeyer et al. Marrow trans- dose chemotherapy are in continous complete remission plantation for acute non-lymphomic leukemia after treatment (CCR). Four of eight patients who converted from PR to with busulfan and cyclophosphamide. New Engl J Med 1983; CR after HDT remain in CCR. Similiar results were 309: 1347–1353. reported by the TBI/Cy/etoposide regimens but with a 9 Tutschka PJ, Copelan EA, Klein JA et al. Bone marrow trans- higher regimen-related mortality of 8–17%.7,20,25 However, plantatiom for leukemia following new busulfan and cyclo- phosphamide regime. Blood 1987; 70: 1382–1388. due to the small number of patients in most studies a com- 10 Van der Jagt RHC, Appelbaum RF, Petersen FB et al. Busul- parison to other TBI- or non-TBI-containing regimens such fan and cyclophosphamide as a preparative regime for bone as CBV, BEAM or Bu/Cy is not appropriate since the out- marrow transplantation in patients with prior chest radio- come could also be influenced by the sorts of patient rather therapy. Bone Marrow Transplant 1991; 8: 211–215. than only by the preparative regimen. One patient in our 11 Avalos BR, Klein JL, Kapoor N et al. Preparation for marrow study developed secondary AML 18 months after trans- transplantation in Hodgkin’s and non-Hodgkin’s lymphoma plant, which has been described infrequently following using Bu/Cy. Bone Marrow Transplant 1993; 12: 133–138. high-dose chemotherapy for Hodgkin’s disease.27 Because 12 Ballester OF, Agaliotis DP, Hiemenz JW et al. Phase I–II of the heavy pretreatment with chemotherapy and radiation study of high-dose busulfan and cyclophosphamide following therapy in this patient, the occurrence of secondary AML autologous blood stem cell transplantation in hematological 28 malignancies. Bone Marrow Transplant 1996; 18: 9–14. is unlikely to be related to high-dose chemotherapy alone. 13 de Magalhaes-Silverman M, Lister J, Rybka W et al. Busulfan It can be concluded that busulfan, cyclophosphamide and and cyclophosphamide (Bu/Cy) as preparative regimen for etoposide (30–45 mg/kg) as the high-dose preparative regi- patients with lymphoma. Bone Marrow Transplant 1997; 19: men is well tolerated, with low extramedullary toxicity and 777–781. ¨ treatment-related mortality in patients with malignant lym- 14 Zander AR, Berger C, Kroger N et al. High-dose chemo- phoma and prior radiotherapy. This regimen is also effec- therapy with busulfan, cyclophosphamide, and VP16 as con- tive, resulting in long-term disease-free survival in 50% of ditioning regimen for allogenic bone marrow transplantation patients, and warrants further investigations. for patients with AML in first complete remission. Clin Can- cer Res 1997; 3: 2671–2675. 15 Lennert K, Feller AC. Histopathologie der Non-Hodgkin Lym- phome. Springer Verlag: Berlin, Heidelberg, New York, 1990. Acknowledgements 16 Harris NL, Jaffe ES, Stein H et al. A revised European–Amer- ican classification of lymphoid neoplasms: a proposal from We thank the staff of the BMT unit for providing excellent care the International Lymphoma Study Group. Blood 1994; 84: of our patients, and the medical technicians for their work in the 1361–1392. ¨ BMT laboratory. 17 Zeller W, Gutensohn K, Stockschlader M et al. Increase of High-dose Bu/Cy/etoposide for malignant lymphoma ¨ N Kroger et al 1175 mobilized CD34-positive peripheral blood progenitor cells in phamide and etoposide in 84 patients undergoing autologous patients with Hodgkin’s disease, non-Hodgkin’s lymphoma, and allogenic bone marrow transplantation. Bone Marrow and cancer of the testis. Bone Marrow Transplant 1996; 17: Transplant 1995; 15: 361–365. 709–713. 24 Chopra R, McMillan AK, Linch DC et al. The place of high- 18 Bearman SI, Appelbaum FR, Buckner CD et al. Regimen dose BEAM therapy and autologous bone marrow transplan- related toxicity in patients undergoing bone marrow transplan- tation in poor risk Hodgkin’s disease. A single center eight tation. J Clin Oncol 1988; 6: 1562–1568. year study of 155 patients. Blood 1993; 81: 1137–1142. 19 McDonald GB, Hinds MS, Fisher LD et al. Veno-occlusive 25 Weaver CH, Appelbaum FR, Petersen FB et al. High-dose disease of the liver and multiorgan failure after bone marrow cyclophosphamide, carmustine, and etoposide followed by transplantation: a cohort study of 355 patients. Ann Intern Med autologous bone marrow transplantation in patients with 1993; 118: 255–267. lymphoid malignancies who have received dose-limiting radi- 20 Horning SJ, Negrin RS, Chao NJ et al. Fractionated total body ation therapy. J Clin Oncol 1993; 11: 1329–1335. irradiation, etoposide, and cyclophosphamide plus autograft- 26 Reece DE, Barnett MJ, Connors JM et al. Intensive chemo- ing in Hodgkin’s disease and non-Hodgkin’s lymphoma. J therapy with cyclophosphamide, carmustine, and etoposide Clin Oncol 1994; 12: 2552–2558. followed by autologous bone marrow transplantation for 21 Spitzer TR, Cottler-Fox M, Torrisi J et al. Escalating doses of relapsed Hodgkin’s disease. J Clin Oncol 1991; 9: 1871–1877. etoposide with cyclophosphamide and fractionated total body 27 Chao NJ, Nademanee AP, Long GD et al. Importance of bone irradiation or busulfan as conditioning for bone marrow trans- marrow cytogenetic evaluation before autologous bone mar- plantation. Bone Marrow Transplant 1989; 4: 559–565. row transplantation for Hodgkin’s disease. J Clin Oncol 1991; 22 Vaughan WP, Dennison JD, Reed EC et al. Improved results 9: 1575–1579. of allogenic bone marrow transplantation for advanced hema- ¨ tologic malignancy using busulfan, cyclophosphamide and 28 Stockschlader M, Fiedler W, Zander A et al. Philadelphia etoposide as cytoreductive and immunosuppressive therapy. chromosome-positive secondary acute myeloid leukemia fol- Bone Marrow Transplant 1991; 8: 489–495. lowing high-dose chemotherapy with peripheral blood pro- 23 Crllley P, Topolsky D, Styler MJ et al. Extramedullary toxi- genitor cell support for relapsed low-grade non-Hodgkin’s city of a conditioning regimen containing busulfan, cyclophos- lymphoma. Ann Hematol 1996; 73: 291–293.