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High-Dose Carmustine, Etoposide, and Cyclophosphamide Followed by Allogeneic Hematopoietic Cell Transplantation for Non-Hodgkin Lymphoma

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High-Dose Carmustine, Etoposide, and Cyclophosphamide Followed by Allogeneic Hematopoietic Cell Transplantation for Non-Hodgkin Lymphoma Biology of Blood and Marrow Transplantation 12:703-711 (2006) ᮊ 2006 American Society for Blood and Marrow Transplantation 1083-8791/06/1207-0002$32.00/0 doi:10.1016/j.bbmt.2006.02.009 High-Dose Carmustine, Etoposide, and Cyclophosphamide Followed by Allogeneic Hematopoietic Cell Transplantation for Non-Hodgkin Lymphoma Lisa Y. Law,1 Sandra J. Horning,2 Ruby M. Wong,3 Laura J. Johnston,1 Ginna G. Laport,1 Robert Lowsky,1 Judith A. Shizuru,1 Karl G. Blume,1 Robert S. Negrin,1 Keith E. Stockerl-Goldstein1 1Division of Blood and Marrow Transplantation, 2Division of Oncology, and 3Department of Health, Research and Policy, Stanford University Medical Center, Stanford, California Correspondence and reprint requests: Keith E. Stockerl-Goldstein, Division of Blood and Marrow Transplantation, 300 Pasteur Drive, H3249, Stanford University Medical Center, Stanford, CA 94305 (e-mail: [email protected]). Received August 28, 2005; accepted February 27, 2006 ABSTRACT Allogeneic hematopoietic cell transplantation (HCT) has been shown to be curative in a group of patients with aggressive non-Hodgkin lymphoma (NHL). A previous study has demonstrated equivalent outcomes with a conditioning regimen based on total body irradiation and another not based on total body irradiation with preparative therapy using cyclophosphamide, carmustine, and etoposide (CBV) in autologous HCT. We investigated the safety and efficacy of using CBV in an allogeneic setting. Patients were required to have relapsed or be at high risk for subsequent relapse of NHL. All patients had a fully HLA-matched sibling donor. Patients received carmustine (15 mg/kg), etoposide (60 mg/kg), and cyclophosphamide (100 mg/kg) on days ؊6, ؊4, and ؊2, respectively, followed by allogeneic HCT. All patients were treated with cyclosporine and methylprednisolone as prophylaxis for graft-versus-host disease (GVHD). Thirty-one patients (median age, 46 years) who were felt to be inappropriate candidates for autologous transplantation were enrolled. Each subject had a median of 3 previous chemotherapy regimens. All patients engrafted. Fifteen of 31 patients are alive. Median follow-up time was 11.5 months (range, .4-126). There were 8 deaths due to relapse. Nonrelapse -veno ,(1 ؍ diffuse alveolar hemorrhage (n ,(2 ؍ GVHD (n ,(3 ؍ included infection (n (8 ؍ mortality (n ؍ and leukoencephalopathy (n ,(1 ؍ occlusive disease in the setting of concurrent acute GVHD of the liver (n 1). Probabilities of event-free survival and overall survival were, respectively, 44% (95% confidence interval, 26%-62%) and 51% (33%-69%) at 1 year and 44% (26%-62%) and 47% (29%-65%) at 5 years. Probability of relapse was 33% (15%-51%) at 1 year and 5 years. Probability of nonrelapse mortality was 31% (13%-49%) at 1 year and 5 years. Incidences were 29% for acute GVHD and 39% for chronic GVHD. None of the 12 patients who developed chronic GVHD has disease recurrence. Patients who had required >3 previous chemotherapy regimens before HCT had an increased probability of relapse. CBV is an effective preparative regimen for patients with aggressive NHL who undergo allogeneic HCT. © 2006 American Society for Blood and Marrow Transplantation KEY WORDS Cyclophosphamide, carmustine, and etoposide ● Non-Hodgkin lymphoma ● Allogeneic hemato- poietic cell transplantation INTRODUCTION chemotherapy. For those who relapse, high-dose che- Non-Hodgkin lymphoma (NHL) is a malignant motherapy followed by autologous hematopoietic cell disease with increasing incidence [1]. With conven- transplantation (HCT) has been shown to improve tional chemotherapy, 40% to 50% of patients may be survival [3]. Despite such treatment, relapse remains cured [2]; however, many patients relapse after initial the major cause of failure. Several potential reasons 703 704 L. Y. Law et al. for relapse can be identified. One possibility is that the (2) serum creatinine level Ͼ2 mg/dL or creatinine hematopoietic cells that have been collected may con- clearance Ͻ60 mL/min, (3) previous bone marrow tain clonogenic tumor cells, which could be reinfused transplantation procedure, (4) major organ dysfunc- during the HCT procedure. Two studies using sensi- tion that might increase the risk of the transplantation tive molecular assays have found that the bone marrow procedure, or (5) severe psychological or medical ill- is frequently contaminated with malignant cells in ness. All patients and donors gave written informed low- and intermediate-grade lymphomas [4,5]. consent as required by the institutional review board High-dose chemotherapy with allogeneic HCT of Stanford University. has been used extensively for myeloid and lymphoid leukemias with significant improvement in survival Study Definitions compared with standard chemotherapy [6-9]. The use of allogeneic HCT has been investigated in patients Patients without clinical or radiologic evidence of with refractory NHL and achieved results superior to disease or bone marrow involvement with lymphoma that expected with standard chemotherapy regimens were defined as being in complete remission (CR), and [10-12]. Its efficacy has been attributed to a graft- patients with measurable residual disease were defined versus-lymphoma (GVL) effect and possibly to a graft as being in partial remission (PR). Patients who did that is free of tumor cells [13]. Various preparative not respond to standard chemotherapy at initial pre- regimens have been used in the allogeneic setting, sentation were classified as having induction failure with most being based on total body irradiation (TBI). (IF). Relapse was defined by evidence of radiographic We previously reported a study that demonstrated or clinical progression in a new site or growth of acceptable toxicity and survival equivalent to a non- disease in any previously involved sites. TBI preparatory regimen of cyclophosphamide, car- Patients were considered to have bone marrow mustine (BCNU), and etoposide (VP-16; CBV) for involvement if they had NHL demonstrated in the patients with NHL who received autografts compared bone marrow at any time before allogeneic HCT. with a TBI-based regimen. This regimen has an out- Nonrelapse mortality (NRM) included death from come equivalent to those containing TBI with less any cause except relapse. The day of allogeneic HCT toxicity [14]. In addition, we previously described our was defined as day 0 for all survival and relapse anal- experience with allogeneic HCT using a regimen of yses. Event-free survival (EFS) was calculated by scor- TBI, VP-16, and cyclophosphamide for patients with ing relapse or death from any cause as an event. advanced or refractory leukemias and lymphomas [15,16]. Because of the decreased toxicity of CBV Patient Characteristics compared with a TBI-based regimen and equivalent disease control in autografting, this study investigated Patient characteristics are listed in Table 1. Thirty- the safety, toxicity, efficacy, and tolerability of this one patients were treated in this study. Of these, 21 same regimen (CBV) in an allogeneic setting using were men and 10 were women, with a median age of cyclosporine (CSP) and methylprednisolone (PSE) as 46 years. Histologic classification was based on the prophylaxis for graft-versus-host disease (GVHD) in Working Formulation, which was the principal clas- patients who had relapsed or were at high risk for sification system in use during the period under study subsequent relapse of NHL. [17]. Patients were categorized into 4 groups accord- ing to histologic NHL subtype: low grade (n ϭ 2), intermediate grade (n ϭ 21), high grade (n ϭ 3), and ϭ MATERIALS AND METHODS transformed (n 5). Most patients had stage 4 disease at the time of transplantation (n ϭ 24). Thirty-nine Patient Eligibility percent (12 of 31) of patients had bone marrow in- Between February 1992 and March 2004, 31 adult volvement and 58% (18 of 31) had extranodal disease. patients with relapsed NHL or a high risk for subse- Among the 31 patients, 8 were in CR (3 in first CR quent relapse of NHL with fully HLA-matched re- and 5 in the second or subsequent CR), 15 were in PR, lated donors received allogeneic HCT at Stanford and 8 had IF. For those who had chemosensitive University (Stanford, Calif). The first 4 patients re- disease (CR and PR) at the time of transplant (n ϭ 23), ceived bone marrow grafts. The subsequent 27 pa- a large proportion had Ͼ1 relapse previously, with 5, tients received granulocyte colony-stimulating factor 3, and 2 patients in their second, third, and fourth (G-CSF), mobilized, allogeneic peripheral blood he- recurrences, respectively. Most patients were heavily matopoietic cells. No graft was manipulated. pretreated before HCT, with 10 having had Ͼ3 previous Eligible patients were 18 to 60 years old with regimens. Thirteen of the 31 patients had previous ra- morphologically confirmed NHL. Exclusion criteria diation, and 3 received radiation to the mediastinal area. were (1) hepatic dysfunction that was defined by a Among the 21 patients with intermediate-grade histol- serum transaminase level Ͼ2.5 times the normal value, ogy, 5 had IFs and 5 had short disease-free intervals, CBV and Allogeneic HCT in Patients with NHL 705 Table 1. Patient and Donor Characteristics under anesthesia for the first 4 patients [18]. Begin- ning in July 1999, patients received G-CSF, “mobi- Patients, n 31 lized,” allogeneic hematopoietic cells. HLA-matched Age, y donors received G-CSF at a dose of 16 ␮g/kg/d sub- Median 46 Ϫ Ϫ Range 20-60 cutaneously beginning on day 5. On day 1, the Gender first apheresis collection began in the afternoon for a Male 21 3- to 4-hour apheresis procedure. The goal was 5 ϫ ϩ Female 10 106 CD34 cells/kg of recipient weight. If this goal Histology High grade was not achieved in the first apheresis procedure, a Burkitt 2 second apheresis was performed on the morning of 6 ϩ T-cell lymphoblastic lymphoma 1 day 0. A minimum dose of 2 ϫ 10 CD34 cells/kg of Intermediate recipient weight was required for the allografting pro- Diffuse large B-cell cell 10 cedure.
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