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©Ferrata Storti Foundation Letters to the Editor linked to GC resistance in childhood ALL. Since the dif- ference in expression of the receptor is rather small (~2- Malignant Lymphomas fold) compared to the >1000-fold difference in resistance to prednisolone between the tested patients, it is likely Adapted CHOP plus rituximab in non-Hodgkin’s that other mechanisms may have a more pronounced lymphoma in patients over 80 years old contribution to GC resistance in pediatric ALL. Other putative causes of resistance may be identified by gene 9,10 expression profiling. Treatment of very old patients with non- Hodgkin’s lymphoma remains controversial. Wim J.E. Tissing,* Melchior Lauten,° Jules P.P. Meijerink,* Indeed, patients over 80 years old are usually not Monique L. den Boer,* Jan Willem Koper,# @ included in trials. We show here that addition of Peter Sonneveld, Rob Pieters* rituximab to reduced-dose CHOP chemotherapy *Dept. of Pediatric Oncology/Hematology, Erasmus MC-Sophia seems to be a good compromise between toxicity Children’s Hospital, Erasmus University Medical Center, and efficacy, allowing clinicians to treat very elder- Rotterdam, The Netherlands: °Dept. of Pediatric Hematology and ly patients with a curative intent. Oncology, Hannover Medical School, Hannover, Germany; # @ Dept.of Endocrinology and Dept. of Haematology, haematologica 2005; 90:1281-1283 Erasmus MC, Rotterdam, The Netherlands (http://www.haematologica.org/journal/2005/9/1281.html) Key words: glucocorticoid, resistance, isoforms, acute lymphoblastic leukemia, children. The study of cancer and aging is emerging as a critical Correspondence: J.P.P. Meijerink, Erasmus MC-Sophia Children’s issue in oncologic care. Although approximately one third Hospital, Erasmus University Medical Center, Dept. of Pediatric of the cases of non-Hodgkin’s lymphoma (NHL) occur in Oncology and Hematology, Dr Molewaterplein 60, 3015 GJ, patients older than 75 years of age,1 very few data are avail- Rotterdam, the Netherlands. Phone: international +31.10.4089379. able concerning the optimal treatment in this age group. Fax: international +31.10.4089433. Indeed, the number of very elderly patients in published E-mail: [email protected] trials is small and patients over 80 years old are not usual- References ly included. The value of the cyclophosphamide, adriamycin, vin- 1. Lauten M, Stanulla M, Zimmermann M, Welte K, Riehm H, cristine and prednisone (CHOP) plus rituximab (R-CHOP) Schrappe M. Clinical outcome of patients with childhood combination therapy in both aggressive and indolent B-cell acute lymphoblastic leukaemia and an initial leukaemic blood blast count of less than 1000 per microliter. Klin Padiatr 2001; lymphoma has been demonstrated in several clinical tri- 213:169-74. als.2-4This study was designed to retrospectively assess the 2. Den Boer ML, Harms DO, Pieters R, Kazemier KM, Gobel U, safety and the efficacy of R-CHOP in patients over 80 Korholz D, et al. Patient stratification based on prednisolone- years old. The medical records of all NHL patients more vincristine-asparaginase resistance profiles in children with acute lymphoblastic leukemia. J Clin Oncol 2003;21:3262-8. than 80 years old who were treated with R-CHOP 3. Tissing WJ, Meijerink JP, den Boer ML, Pieters R. Molecular between March 2001 and November 2003 at two French determinants of glucocorticoid sensitivity and resistance in hematology departments were retrospectively analyzed. acute lymphoblastic leukemia. Leukemia 2003;17:17-25. The diagnosis of NHL was made according to the World 4. Lauten M, Cario G, Asgedom G, Welte K, Schrappe M. Protein 5 expression of the glucocorticoid receptor in childhood acute Health Organization classification. All slides from tissue lymphoblastic leukemia. Haematologica 2003;88:1253-8. biopsies were reviewed by an experienced hematologic 5. Haarman EG, Kaspers GJL, Pieters R, Rottier MMA, Veerman pathologist. Response was classified according to the AJP. Glucocorticoid receptor α, β and γ expression vs in vitro International Workshop criteria.6 Radiographic studies, glucocorticod resistance in childhood leukemia. Leukemia 2004;18:530-7. including scans were reviewed by a reference radiologist 6. Stam RW, den Boer ML, Meijerink JP, Ebus ME, Peters GJ, blinded to the previously reported response data. Overall Noordhuis P, et al. Differential mRNA expression of Ara-C- survival (OS) was defined as the interval from the start of metabolizing enzymes explains Ara-C sensitivity in MLL therapy to the time of death or the last follow-up. Event- gene-rearranged infant acute lymphoblastic leukemia. Blood 2003;101:1270-6. free survival (EFS) was calculated from the beginning of 7. de Lange P, Segeren CM, Koper JW, Wiemer E, Sonneveld P, therapy to the time of disease progression or death due to Brinkmann AO, et al. Expression in hematological malignan- any cause. According to our department’s policies, patients cies of a glucocorticoid receptor splice variant that augments over 80 years old without unstable cardiac disease or any glucocorticoid receptor-mediated effects in transfected cells. Cancer Res 2001;61:3937-41. detectable sign of heart failure (e.g., reduced left ventricu- 8. Beger C, Gerdes K, Lauten M, Tissing WJ, Fernandez-Munoz lar ejection fraction on echocardiography) at the time of I, Schrappe M, et al. Expression and structural analysis of glu- diagnosis are eligible for treatment with an anthracycline- cocorticoid receptor isoform γ in human leukaemia cells using containing regimen. an isoform-specific real-time polymerase chain reaction approach. Br J Haematol 2003;122:245-52. During the study period, 29 over 80-year olds with B-cell 9. Holleman A, Cheok MH, den Boer ML, Yang W, Veerman AJ, NHL were referred to our departments. Two patients were Kazemier KM, et al. Gene-expression patterns in drug-resist- treated with radiotherapy only (localized follicular lym- ant acute lymphoblastic leukemia cells and response to treat- phoma) and three with a CVP regimen (systolic congestive ment. N Engl J Med 2004;351:533-42. 10. Lugthart S, Cheok MH, Den Boer ML, Yang W, Holleman A, heart failure). The study population consisted of 24 Cheng C, et al. Identification of genes associated with patients. Their main characteristics are listed in Table 1. All chemotherapy crossresistance and treatment response in these patients were treated with a CHOP regimen plus childhood acute lymphoblastic leukemia. Cancer Cell 2005; concurrent rituximab, delivered on day 1, every 21 days. 7:375-86. The standard doses of 50 mg/m2 of doxorubicin and 750 mg/m2 cyclophosphamide were reduced in 22 patients (92%) and 3 patients (12.5%), respectively. The median rel- ative dose intensities calculated for doxorubicin and cyclophosphamide were 63% and 86%, respectively. haematologica/the hematology journal | 2005; 90(9) | 1281 | Letters to the Editor Table 1. Patients’ characteristics. Overall survival 1.0 No. of Patients Age, years % 0.8 ) Median (Range) 83 (80-88) % ( g n 0.6 Sex i v i Male 10 41.5 v r Female 14 58.5 u s 0.4 n o Performance status (ECOG) i t 0 2 8.3 r o 1 12 50 p 0.2 o r 2 8 33.3 P 3 2 8.3 0.0 Histological diagnosis Diffuse large B-cell lymphoma 19 79 0 10 20 30 40 Mantle-cell lymphoma 3 12.5 Time (months) Follicular lymphoma 2 8.5 Disease status at initiation of therapy Event-free survival Newly diagnosed 18 75 1.0 Relapsed/refractory 6 25 Stage ) 0.8 % I 2 8.5 ( II 5 21 e e r III 8 33 f - 0.6 t IV 9 37.5 n e v No. of extranodal sites e 0.4 n 0 12 50 o i t 1729r o 2521p ≥ o 0.2 r Bone marrow involvement P Yes 5 21 0.0 No 6 25 Unknown 13 54 0 10 20 30 40 Time (months) Age-adjusted IPI score 014 1 5 21 2 2 8.5 Figure 1. Kaplan-Meier plot of overall survival and event-free sur- 3 3 12.5 vival for all patients (N=24) Not available 13 54 that old age was the sole cause in 20 cases and poor per- formance status was the cause in the other two cases. Doses were reduced in all cases from the first cycle, on the Several studies have reported that elderly patients are basis of the clinician’s decision. A total of 125 cycles were able to tolerate full-dose doxorubicin-containing regi- administered with a mean of 5.2 courses (range 1–8) per mens.7-8 However none of these studies has focused on patient. Eight patients (33%) received at least one course of very elderly patients (≥80 years). Moreover, although gran- granulocyte colony-stimulating factors during their treat- ulocyte colony-stimulating factor may allow completion of ment. The overall response rate was 79% with 15 patients therapy in elderly NHL patients, and may reduce the dura- (62.5%) achieving a complete or unconfirmed complete tion and severity of neutropenia, significant differences in response and four (16.5%) a partial response. After a medi- hospitalization, infections, and in particular, survival, have an follow-up of 23 months, the 2-year OS and EFS were not been clearly demonstrated in this population.9 So, dose 63% and 50%, respectively (Figure 1). Considering only reduction, especially for doxorubicin given its hematotoxi- newly diagnosed patients with diffuse large B-cell lym- city, seems to be a reasonable option. The 2-year OS of phoma (n=15), the 2-year OS and EFS were 76% and 63% in our study population was much higher than the 62.5%, respectively. The toxicity, mainly hematologic, was 30% in an unselected group of NHL patients more than 80 manageable, febrile neutropenia occurred in 6% of the years old in whom treatment was considered as optimal by courses and there were no toxic deaths.
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