Original Article | Published:

Lymphoma

Prolonged survival in poor-risk diffuse large B-cell lymphoma following front-line treatment with rituximab-supplemented, early-intensified chemotherapy with multiple autologous hematopoietic stem cell support: a multicenter study by GITIL (Gruppo Italiano Terapie Innovative nei Linfomi)

Leukemia volume 21, pages 18021811 (2007) | Download Citation

Abstract

A prospective multicenter program was performed to evaluate the combination of rituximab and high-dose (hd) sequential chemotherapy delivered with multiple autologous peripheral blood progenitor cell (PBPC) support (R-HDS-maps regimen) in previously untreated patients with diffuse large B-cell lymphoma (DLB-CL) and age-adjusted International Prognostic Score (aaIPI) score 2-3. R-HDS-maps includes: (i) three APO courses; (ii) sequential administration of hd-cyclophosphamide (CY), hd-Ara-C, both supplemented with rituximab, hd-etoposide/cisplatin, PBPC harvests, following hd-CY and hd-Ara-C; (iii) hd-mitoxantrone (hd-Mito)/L-Pam + 2 further rituximab doses; (iv) involved-field radiotherapy. PBPC rescue was scheduled following Ara-C, etoposide/cisplatin and Mito/L-Pam. Between 1999 and 2004, 112 consecutive patients aged <65 years (74 score 2, 38 score 3) entered the study protocol. There were five early and two late toxic deaths. Overall 90 patients (80%) reached clinical remission (CR); at a median 48 months follow-up, 87 (78%) patients are alive, 82 (73%) in continuous CR, with 4 year overall survival (OS) and event-free survival (EFS) projections of 76% (CI 68–85%) and 73% (CI 64–81%), respectively. There were no significant differences in OS and EFS between subgroups with Germinal-Center and Activated B-cell phenotype. Thus, life expectancy of younger patients with aaIPI 2-3 DLB-CL is improved with the early administration of rituximab-supplemented intensive chemotherapy compared with the poor outcome following conventional chemotherapy.

Introduction

The outcome of B-cell diffuse large B-cell lymphoma (DLB-CL) patients has definitely improved since the introduction of the anti-CD20 rituximab, which can be effectively combined into conventional chemotherapy regimens.1, 2 Indeed, rituximab-supplemented cyclophosphamide, doxorubicin, vincristine, prednisone (CHOP) is now considered the most effective treatment option for DLB-CL. However, despite the inclusion of rituximab, there is still a marked difference in the outcome between patients with adverse IPI prognostic factors and those without.3, 4 An effective treatment is still lacking for poor-risk patients, and intensive therapy with autologous stem cell transplant remains a reasonable option.5, 6 Indeed, two recent trials have shown feasibility and efficacy of chemotherapy schedules characterized by early dose intensity and autograft in poor prognosis aggressive lymphoma.7, 8 Furthermore, although rituximab efficacy has chiefly been proved in combination with conventional chemotherapy, it may also improve autograft-based programs, particularly as an in vivo purging agent before peripheral blood progenitor cell (PBPC) harvests.9, 10, 11, 12, 13 Thus, rituximab-supplemented intensive programs with autograft might represent an effective alternative to R-CHOP in DLB-CL patients with unfavorable clinical presentation.

To further investigate these issues, a multicenter, prospective trial was launched in 1999 by six hematological centers affiliated to GITIL (Gruppo Italiano Terapie Innovative nei Linfomi), evaluating applicability and efficacy of a rituximab-supplemented, early-intensified high-dose (hd) chemotherapy regimen, delivered with multiple autologous PBPC support, in patients with DLB-CL presenting with unfavorable prognostic features, namely an age-adjusted (aa) IPI score of 2 or 3. The schedule is identified as R-HDS-maps to emphasize its main characteristics, that is, rituximab, early hd-chemotherapy and multiple autologous progenitor support. The R-HDS-maps chemotherapy program is essentially based on the sequential administration of hd drugs, according to the HDS approach described in several previous studies.14, 15, 16, 17, 18 However, compared to the original HDS schedule, the R-HDS-maps is characterized by the introduction of: (i) a hd Ara-C course; (ii) multiple autologous PBPC re-infusions, following hd-Ara-C, following hd-etoposide given with cisplatin, and in the conclusive phase following hd-mitoxantrone (hd-Mito) and L-Pam, as well; (iii) six rituximab doses, given primarily for in vivo purging purposes. Results here reported show that R-HDS-maps is feasible at the multicenter level, with acceptable toxicity, and leads to prolonged survival in a high proportion of patients. These observations give further support to the use of early-intensified chemotherapy regimens, possibly supplemented with rituximab, in younger patients with high-risk DLB-CL.

Patients and methods

Inclusion criteria

Between November 1999 and September 2004, a multicenter study protocol was performed by GITIL (Gruppo Italiano Terapie Innovative nei Linfomi) to verify the feasibility and efficacy of a rituximab-supplemented hd-chemotherapy program, with multiple autologous PBPC support (R-HDS-maps regimen) in high-risk aggressive B-cell lymphoma. Patients were eligible if they were aged between 18 and 60 years and had CD20+, DLB-CL.19, 20 Patients aged between 60 and 65 years could be included in the study protocol based on the personal decision of the responsible physician. Patients should have received no previous chemotherapy or extended-field radiotherapy and have an age-adjusted International Prognostic Score (aaIPI) of 2 or 3, absence of concurrent severe heart, kidney, lung or liver disease was also required, unless if disease related, as well as negativity for HBsAg and for HIV and HCV antibodies. Informed consent was obtained from each patient and the Institutional Review Boards of all the participating centers approved the study protocol.

Patient characteristics

Patient enrollment was closed in September 2004; 112 consecutive patients presenting with the above detailed clinical characteristics have been included in the prospective R-HDS-maps trial at six Italian hematological centers affiliated to the GITIL. Main features of the enrolled patients are described in Table 1. Their median age was 48 (range 18–65, with eight patients aged between 60 and 65 years). Eighty-one percent had Ann Arbor stage III or IV disease and all had an unfavorable clinical presentation, as evaluated by aaIPI grading, with score 2 in 74 (66%) and score 3 in 38 (34%) patients. The rigorous selection of poor-risk patients is confirmed by the high incidence of patients with bone marrow (BM) involvement (31%) or with 2 extranodal sites of disease (30%). Although central nervous system (CNS) involvement was not an exclusion criterium, none of the enrolled patients had evidence of lymphoma in the CNS at presentation.

Table 1: Main patient characteristics

Histology and immunohistochemistry on tissue microarray

All patients had a B-cell, CD20+ aggressive lymphoma, the classic diffuse large B-cell subtype was by far the most frequent (79%).19, 20 Other histologic subtypes included primary mediastinal B-cell lymphoma (10%), DLB-CL with signs of histologic transformation (8%), T-cell rich DLB-CL (3%) (Table 1). To assess the distribution of the recently identified germinal-center B-cell (GCB) and activated B-cell (ABC) subgroups, immunohistochemical analysis were performed using the tissue microarray (TMA) technology.21, 22 Paraffin block from diagnostic material was available from 74 of the 112 enrolled patients. Hematoxylin and eosin–stained (H&E) sections from each paraffin-embedded, formalin-fixed block were used for both diagnostic review and localization of the most representative areas for the construction of TMA. Sections (5 μm) from each TMA were stained with H&E to check the appropriateness of each core and then stained with antibodies to CD20, CD10, bcl-6, MUM1, bcl-2 and CD138. Each stain was evaluated independently by at least two pathologists (GI, DN, AF) for the determination of percentage of positively stained tumor cells. Cases were considered positive if 30% or more of the tumor cells were stained with an antibody. The subgroup determination of DLCL in germinal center B-cell-like (GCB), or activated B-cell-like (ABC) phenotypes was established as described previously.23 As reported in Table 2, ABC subtypes were more frequently observed compared with GCB (53% vs 42%, respectively); subgroup classification could not be defined in four cases.

Table 2: Distribution of germinal-center B-cell (GCB) and activated B-Cell (ABC) subgroups among 74 patients with diagnostic material assessable for immunohistochemistry on tissue microarray constructs

Treatment schedule

The R-HDS-maps is a further modified regimen based on the original HDS schedule described elsewhere.16, 17, 18 Briefly, the new regimen consists of initial debulking with three APO (doxorubicin, vincristine, prednisone) courses, with the first doxorubicin administration at 50 mg/m2 and the subsequent two at a full dose of 75 mg/m2.24 The subsequent hd consists of the sequential administration, at 15–20 day intervals, of: (i) cyclophosphamide (hd-CY) 7 g/m2 (day 1)+rituximab 375 mg/m2 (day +2 and +10), followed by PBPC harvest; (ii) Ara-C 2 g/m2 b.i.d. for 6 days, reinfusion of 1–3 × 106 autologous CD34+ cells/kg (day 7) and then rituximab 375 mg/m2 (day +8 and day +18); a second PBPC harvest is scheduled after hd-Ara-C if inadequate harvesting is obtained after hd-CY; (iii) etoposide 2.4 g/m2 day +1 +cisplatin 100 mg/m2 day +2; to accelerate hematological recovery, again small aliquots of PBPC are re-infused following etoposide/cisplatin. The final hd phase includes Mito 60 mg/m2 on day –5, melphalan (L-PAM) 180 mg/m2 on day –2 and PBPC autograft on day 0.25 A minimum of 5 × 106 CD34+ cells/kg were required for autograft with PBPC alone. Patients failing to meet this minimum had to be placed off therapy. Two additional rituximab doses are scheduled at engraftment, approximately on days +30 and +37. Involved-field radiotherapy is scheduled on areas of previously bulky lesions or residual lesions, within 2–3 months following autograft. The whole R-HDS-maps program is summarized in Figure 1.

Figure 1
Figure 1

Schematic representation of the R-HDS-maps schedule. APO course consisted of doxorubicin on days 1 (50 mg/m2), 14 and 28 (75 mg/m2), vincristine 1.2 mg/m2 on days 1, 14 and 28, prednisone 50 mg/m2 days 1–22, then discontinued with tapering. hd, high-dose; CY, Cyclophosphamide (7 g/m2); PBPC, peripheral blood progenitor cells; hd-Ara-C: 2 g/m2 b.i.d. for 6 days; VP16, etoposide (2.4 g/m2); cddP, cisplatin (100 mg/m2); Mito, mitoxantrone (60 mg/m2); L-PAM, melphalan (180 mg/m2); IF-RT, involved field radiotherapy. PBPC harvest is scheduled after hd-CY; a second, additional harvest is scheduled after hd-Ara-C if required. Aliquots of CD34+ cells are re-infused after hd-Ara-C, after VP16/cddP (1–3 × 106 CD34+ cells/kg) and after Mito/L-Pam (5 × 106 CD34+ cells/kg). Rituximab is given at 375 mg/m2/dose.

Supportive care

During the hd phase and up to complete hematologic recovery following autograft, neutropenic patients received anti-fungal prophylaxis with fluconazole 200 mg/day and oral decontamination of the intestinal tract; in addition, all patients were placed under anti-pneumocistis prophylaxis with sulphametoxazole 1600 mg+Trimetoprim 320 mg twice in week and anti-herpes virus prophylaxis with acyclovir 1600 mg/day until day +90 after autotransplant. Neutropenic patients received broad-spectrum intravenous antibiotics for the management of febrile neutropenia. Since hd-CY administration, patients were monitored weekly for the presence of CMV p65-positive white blood cells up to 3 months after the last rituximab administration after transplant. Gancyclovir or foscarnet pre-emptive treatment was started if p65-positive cells were confirmed in two different examinations. Gammaglobulin intravenous infusions (0.4 g/kg) were scheduled for patients with IgG levels below normal values. Red cell and platelet transfusions were given to maintain hemoglobin levels above 8 g/dl and platelet count above 10 × 109/l. Blood products were irradiated. During the final autografting phase, patients were managed in laminar airflow rooms. To accelerate neutrophil recovery, lenogastrim or filgrastim at 5 μg/kg/day was administered subcutaneously following hd-drug administration and during the autografting phase, as well, until achievement of stable neutrophil counts of at least 1000/μl for three consecutive days.26

Evaluation and statistics

Clinical response was assessed by complete restaging at 2 months after autograft, thereafter at 3-month intervals for the first year and then at 6-month intervals. Following the Cheson criteria,27 clinical remission (CR) was defined as the absence of any clinical signs of disease, while partial remission (PR) was defined as 50% or better tumor reduction. For patients with uncertain CR, reassessment was performed 2 months later to define the response; moreover, total body PET scan was performed in those centers where the PET scan was available at the time the study was carried on. Patients achieving less than PR were considered as having stable disease. Progressive disease was defined as 50% or more tumor increase or the appearance of new lesions. All patients who entered treatment were considered evaluable for response and outcome. Thus, the following long-term outcome parameters were evaluated on an intention-to-treat basis: overall survival (OS), from the start of therapy up to the date of death or last follow-up alive; progression-free survival (PFS) from the start of therapy until disease progression or death from lymphoma; disease-free survival (DFS) from the first recording of a CR to the date of progression; event-free survival (EFS) from the start of therapy up to the first adverse event, that is relapse or progression, treatment-related death or last follow-up alive.27 Again, all patients entered the study program were considered evaluable on an intent-to treat analysis. To obtain sufficient information on treatment efficacy and feasibility at the multicenter level, a minimum of 100 evaluable patients were scheduled when protocol started. Patient enrollment was closed in September 2004 and at that time 112 consecutive patients had been enrolled and are now evaluable for toxicity and response. The closing date for analysis was June 2006. OS, DFS, PFS and EFS were calculated by the Kaplan and Meier method.28 The log-rank test was used to compare survival curves.

Results

Clinical response

Response to treatment is summarized in Table 3. In spite of the intensive program, 15 patients (13.4%) had stable or progressive disease and 2 (1.8%) went into PR. These patients underwent salvage programs with multiple regimens, including allogeneic transplant, with poor response, and overall only two of these patients are still alive, one in CR and one in PR, both rescued with allogeneic transplant. Unfortunately, five patients (4.5%) died from fatal toxicities during the hd-phase or shortly after autograft. Overall, re-evaluation at conclusion of the treatment program showed 90 patients (80.4%) alive and in CR. Three patients who died from treatment-related toxicity were in CR, when the fatal toxic episode occurred; however, they are considered as failures and are not included in the CR group.

Table 3: Response to treatment

Long-term outcome

The survival projections are shown in Figure 2a–d. At present 87 of 112 (78%) patients are alive. At a median follow-up of 48 months, the estimated 4-year OS projection is 76 % (CI 68–85%). Among the 90 patients in CR at the end of treatment, there have been 6 relapses and the 4-year DFS and PFS projections are 93 (CI 88–98%) and 79% (CI 71–86%), respectively (Figures 2b and c). Overall, at a median follow-up of 46 months, 82 patients are alive with no sign of disease progression, with a 4-year EFS projection of 73% (CI 64–81%) (Figure 2d).

Figure 2
Figure 2

Kaplan–Meyer estimate of probability of overall survival (OS) (a), disease-free survival (DFS) (b), progression-free survival (PFS) (c) and event-free survival (EFS) (d) for the 112 patients evaluated in the study. Data were evaluated on an intention-to-treat basis. The estimated 4-year projections are: 76% (CI 68–85%) for OS, 93% (CI 88–98%) for DFS, 79% (CI 71–86%) for PFS and 73% (CI 64–81%) for EFS.

The outcome was evaluated according to main clinico-pathological parameters. As shown in Table 4, age was the only factor influencing the outcome, with a significantly higher OS and EFS for younger vs older patients (assuming as cut-off, the median age of 48 years). There was no difference between the vast group of 89 patients with the typical DLB-CL form compared to 23 patients with the other histologic variants. Among clinical parameters evaluated, it is of interest that BM involvement had no adverse influence in the outcome; indeed, among 35 patients presenting with BM positive, 23 are presently in continuous CR (data not shown). There was a trend towards a better outcome in aaIPI 2 vs 3, both for OS and EFS, as reported in Table 4 and illustrated in Figure 3a and b. However, the difference did not reach statistical significance. Finally, a trend towards better OS and EFS was observed in GCB vs ABC subgroups; however, again the difference did not reach statistical significance (see Table 4 and Figure 4a and b).

Table 4: Univariate analysis
Figure 3
Figure 3

Kaplan–Meyer estimate of probability of overall survival (OS) (a) and event-free survival (EFS) (b) according to aaIPI score. The estimated 4-year projections are: 82% and 67% for OS and 78% and 62% for EFS, for patients with low aaIPI score 2 (n=74) and patients with aaIPI score 3 (n=38), respectively.

Figure 4
Figure 4

Kaplan–Meyer estimate of probability of overall survival (OS) (a) and event-free survival (EFS) (b) in subgroups with germinal center B-cell (GCB) and activated B-cell (ABC) phenotype. The estimated 4-year projections are: 87% and 77% for OS and 80% and 77% for EFS, for GCB (n=31) and ABC (n=39) subgroups, respectively.

Treatment feasibility and early and late toxicity

The regimen was feasible at the multicenter level. As detailed in Table 5, 93 patients (83%) completed the program. The main cause of interruption was disease progression, documented in 12 patients (11%); one more patient was switched to allogeneic transplantation while in PR after hd-CY; follow-up for this patient was discontinued at that time. Six patients (5%) were unable to complete the program due to severe toxicities, including: (i) fatal infectious complications in two patients; (ii) cardiac complications in two patients (one acute myocardial infarction and one markedly reduced left ventricular ejection fraction); (iii) one deep vein thrombosis; (iv) one severe peripheral neurotoxicity following hd-Ara-C.

Table 5: Feasibility of the R-HDS-maps regimen by treatment course

All responsive patients displayed high levels of progenitor cell mobilization and adequate quantities of CD34+ cells could be collected following either hd-CY or hd-Ara-C or both, in line with a previous observation.29 In fact, with the exception of one single patient who received 4.4 × 106 CD34+/kg, the remaining 92 patients received >5 × 106 CD34+/kg (median 7.8 × 106) for the final autografting phase following hd-Mito/L-PAM. This allowed a rapid hematological recovery, with a short period of neutropenia (days with ANC<500/mmc: median=9, range 5–15) and of thrombocytopenia (days with Plts<50.000 median=7, range 5–15). These numbers are quite similar to those recorded following the two most intense hd-courses, that is, hd-CY (days with ANC<500/mmc: median=4, range 1–10; days with Plts<50.000: median=3, range 2–16) and hd-Ara-C (days with ANC<500/mmc: median=8, range 4–17; days with Plts<50.000 median=9, range 3–21). Hematopoietic recovery and transfusion requirements following hd-CY, hd-Ara-C and following Mito/L-PAM were not significantly different from data reported in previous experiences with the Ara-C-containing HD-schedule.10, 25, 29 The adequate hematopoietic reconstitution allowed the delivery of consolidation radiotherapy (25–30 Gy) on sites of bulky disease in 38 patients, without major toxic complications.

Infectious complications were the most relevant side effects of the program: infection was the cause of the five early fatal toxicities, occurring either in the hd-phase (two cases) or in the recovery following autograft (three cases), as detailed in Table 6. In addition, there was one fatal event due to rapidly deteriorating pneumonia in a patient in CR at 1 year after autograft. Lastly, one more patient died for the occurrence of secondary myelodysplasia at 2.5 years since autograft. As detailed in Table 7, Grade III-IV extrahematological toxicity (other than oral and gastrointestinal mucositis during the myeloablative phase) included the following: (i) four patients with congestive heart failure and one AMI: three of these patients, including that with AMI, fully recovered within a few months; one patient is stable without symptoms, following appropriate medical therapy; the fifth patient was a young girl (29-year-old), with a family history of congestive heart failure; she had progressively worsening symptoms a few months after autograft, and an orthotopic heart transplant was required; the patient is presently alive and well, in CCR of her lymphoma, without cardiac symptoms and with no signs of transplanted organ rejection, at 4 years since heart transplantation; it should be mentioned that her father is also presently on the waiting-list for heart transplantation; (ii) seven cases of pneumonia, in one case with fatal outcome; (iii) six sepsis, three of them fatal; (iv) two enterocolitis, both of micotic origin, which resolved within 1–2 weeks of antimicotic therapy; (v) three DVT, one leading to treatment discontinuation; (vi) one transient pancreatitis; (vi) two cases of peripheral neuropathy – in one case the patient was switched to allograft, the other patient recovered fully from the complication.

Table 6: Early and late fatal toxicity
Table 7: Extrahematological toxicity in patients receiving R-HDS-maps

With a median follow-up of 48 months, the following late toxic episodes were recorded: (i) the case of pneumonia occurring at 10 months, and the case of sMDS at 2.5 years after autograft, both of which had a fatal outcome; (ii) one case of severe marrow aplasia developed at 14 months since autograft; the re-infusion of back-up PBPC did not improve the hematological parameters and the patient is still requiring supportive therapy, including periodic transfusions.

Discussion

This paper illustrates the results of a multicenter prospective study using R-HDS-maps, a rituximab-supplemented, early-intensified hd-chemotherapy regimen, delivered with multiple autologous support using in vivo purged PBPC, in a series of 112 previously untreated patients with DLB-CL and aaIPI 2 or 3. The results have been obtained from a prospective, multicenter study, on a considerable group of patients, after around four years of median follow-up. They show that R-HDS-maps is feasible at the multicenter level, although the marked immunodeficiency is associated with a non-negligible incidence of infectious complications. Indeed, careful clinical monitoring and prompt therapeutic intervention are essential to lessen the risk of severe toxic complications of this intensive program. Nevertheless, response and outcome were definitely promising, and compare favorably with the dismal outcome, commonly observed in poor-risk DLB-CL treated with conventional chemotherapy regimens.30, 31 The observation of a high proportion of patients in prolonged CR makes R-HDS-maps an effective treatment option for young patients with unfavorable DLB-CL, worthy of further comparative analysis with the recently-developed intensified day-14 CHOP, which is now considered the best option among chemotherapy schedules not requiring PBPC support.32

It is widely accepted that high-risk DLB-CL patients are those who might benefit from front-line intensive programs with autograft.33, 34, 35, 36 Therefore, the R-HDS-maps program was evaluated in a series of consecutive patients with definitely unfavorable presentation, identified as an aaIPI score of 2 or 3. All patients were aged below 60, with the exception of eight patients aged between 60 and 65 years, who were included due to the absence of concomitant severe organ failure. The strict selection of poor-risk patients is confirmed by the 75% of patients with high LDH and 30% of patients with over 2 extranodal sites involved. In addition, the unusually high proportion of patients with BM involvement, 31% of the whole series, indicates that the study addressed a patient population that was selected for adverse clinical presentation. Also, the higher frequency of ABC compared to GCB subtypes may be related to the very poor-risk presentation of patients accrued in the program. Thus, unique aspects make the present study quite different from previous experiences with the HDS approach, namely: (i) the development of a more intensive regimen (R-HDS-maps) as compared to the original HDS schedule; (ii) its use in a multicenter setting; (iii) the inclusion in the program of unselected, consecutive younger DLB-CL patients presenting with poor prognostic features, and thus minimizing any selection bias possibly occurring in previous studies.

Feasibility is a major issue in the setting of intensified regimens with autograft. Indeed, an advantage of autograft-based programs over conventional chemotherapy has been observed only in those studies where the drop-out rate of patients in the intensive arm was below 25%, suggesting the need to reduce treatment toxicity, to exploit the potential efficacy of dose intensification.5, 36 In the present study, 19 (17%) out of 112 patients were prematurely withdrawn from the study protocol and did not complete the program. However, the major cause of treatment interruption was disease progression, documented in 12 (11%) patients. This is consistent with the selection of a true poor-risk patient population, with some cases displaying a highly refractory disease, unresponsive to repeated courses of hd cytotoxic drugs given at short intervals.

Although disease progression was the major cause of treatment interruption, toxicity was the second major cause of treatment failure. Early TRM was 4.5%, which is slightly higher than that expected with the use of intensive chemotherapy with autograft.37, 38, 39, 40 Severe and fatal toxic events occurred both in the sequential hd phase and following autograft. This is in line with other reports showing that the degree of intensity of the induction treatment is chiefly responsible for the overall toxicity of intensive programs with autograft.25, 34, 39, 40, 41 In our schedule, rituximab administration may have favored the onset of infections. Severe, often fatal viral reactivations have been reported after rituximab treatment.42, 43, 44, 45, 46, 47, 48, 49 Also in our series, incidence of viral reactivations was unusually high. In addition, there were a number of bacterial infections, sometimes leading to life-threatening sepsis. It is quite likely that the concurrent administration of tightly scheduled hd-courses along with rituximab generated marked immunosuppression and consequently an increased risk of severe infectious complications. In addition, the poor clinical condition of most patients who entered the study program might have enhanced the risk of severe treatment-related toxicity. Thus, careful clinical monitoring and prompt and vigorous treatment of any signs of infection are mandatory while delivering R-HDS-maps to patients with poor-risk DLB-CL. Since this policy was uniformly followed in our multicenter group, we have achieved a marked reduction in severe complications and there have been no fatal complications among the last 20 patients enrolled.

Despite toxicity, the overall results were distinctly good, with 80.4% of patients alive and in CR at program conclusion. At least, in terms of CR rate, our results compare favorably with historical results in conventionally treated poor-risk patients, whose CR rates have ranged between 46 and 57%.30, 31 Response was also durable, and among the 90 patients reaching CR, only 6 disease recurrences have been recorded so far, all occurring within approximately the first year following HDS. In other words, the main problem with poor-risk DLB-CL remains that of refractory disease, that is, that group of patients fully unresponsive even to very intensive debulking programs, while the risk of disease recurrence appears to be a lesser problem once CR is achieved. At present, after a median follow-up close to 4 years, the high rate of durable CR has led to overall and EFS projections (76% for aaIPI 2 and 65% for aaPIP 3 patients, respectively) that are definitely good for a patient series with such an unfavorable clinical presentation. Of note, in the recently published paper by Milpied et al.,35 the 5-year EFS rate for 56 aggressive lymphoma patients with aaIPI 2, treated with hd-chemotherapy, was 56%, which was significantly superior to the 28% EFS rate observed in the randomized control group, receiving conventional CHOP chemotherapy. Both the inclusion of rituximab and possibly the early dose intensification may explain the improved outcome, compared to the Milpied et al.'s35 study, in our series of prognostically analogous patients.

Among poor-risk DLB-CL patients, a remarkably poor outcome is associated with aaIPI score 3 at presentation. In a previous study, we observed a significantly better long-term outcome for aaIPI score 2 patients compared to those with score 3, following HDS devoid of rituximab.50 Indeed, the recent randomized study by Milpied et al.,35 comparing intensive treatment with autograft vs conventional chemotherapy in DLB-CL, excluded patients with aaIPI 3 – their exceedingly unfavorable prognosis induced the trial coordinators to consider unacceptable and unethical the randomization of this patient subgroup into a conventional treatment arm. We thus evaluated outcome following R-HDS-maps by aaIPI scores. Although a trend towards better overall and EFS was noted in aaIPI score 2 vs score 3, the difference in outcome between the two prognostic subgroups was less pronounced than in our previous experience with rituximab-free HDS. It would appear that the addition of rituximab to HDS was responsible for this difference, definitely improving response and long-term outcome in aaIPI score 3 patients. BM involvement has also been reported as an adverse prognostic feature in DLCL, especially if associated with intermediate/high IPI scores.51, 52, 53 In our series, 23 out of 35 patients with BM involvement are now in continuous CR and it is quite likely that, here too, rituximab played a major role in this particular setting. Finally, a favorable outcome was also obtained in the subgroup of patients with DLB-CL and ABC phenotype, a phenotypic subgroup characterized by a reduced response to both conventional and intensified approaches.54, 55 Thus, our study further strengthens the evidence for the benefit of adding rituximab to intensive programs with autograft for DLB-CL patients, exploiting not only its antitumor activity, but also its in vivo purging effect on PBSC harvests.10, 11, 12, 13, 56, 57

In conclusion, the efficacy of combining early hd-chemotherapy, multiple PBPC support and rituximab in high-risk DLB-CL is shown in this prospective multicenter study, confirming the recent promising observations with early dose intensity and autograft in poor prognosis aggressive lymphoma.5, 7, 8 Thus, in spite of a number of novel treatment approaches that are under development and are expected to improve our lymphoma management strategies, intensified treatments with autograft should still be considered as effective therapeutic weapons, worthy of being evaluated in comparison with other intensified chemoimmunotherapy schedules not requiring autologous progenitor cell support.

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Acknowledgements

Investigators from the following Institutions in Italy contributed to the trial: Divisione Universitaria di Ematologia, A.S.O. S. Giovanni B., Torino: C Tarella, D Caracciolo, ML, I Ricca, MZ, MB; Divisione di Oncologia Medica and Divisione di Ematologia, Istituto Nazionale Tumori, Milano: AMG, PC, MDiN, MM, LD, F Zallio; Divisione di Ematologia, A.S.O. V.Cervello (Palermo): SM, CP, R Scimé, AC; Divisione di Ematologia, A.S.O. S. Croce, Cuneo: AG, RC, C Castellino; Bone Marrow Trasplantation Unit, Istituto Scientifico H. S. Raffaele (Milano): AP, MB; Divisione di Ematologia, A.S.O. S. Camillo-Forlanini, Roma: IM, VZ; Istituti di Anatomia Patologica di, Università di Torino: G Inghirami, DN, AF; Istituto Nazionale Tumori, Milano: A Carbone, AC; A.S.O. V. Cervello, Palermo: A Rizzo, MS; A.S.O. S. Croce, Cuneo: AC; A.S.O. S. Camillo-Forlanini, Roma: RP, DR; Istituto Scientifico H. S. Raffaele, Milano: C Doglioni, M Ponzoni. This work was supported in part by grants from: Ministero dell’Istruzione, dell’Università e della Ricerca (MIUR); the Michelangelo Foundation for Advances in Cancer Research and Treatment; the Piedmont Regional Government (Regione Piemonte). We thank Professor Giorgio Inghirami for helpful suggestions and assistance in the pathological review and immunohistochemical reassessment.

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Affiliations

  1. Dip Medicina-Oncologia Sperimentale, Divisione Universitaria di Ematologia, Torino, Italy

    • C Tarella
    • , M Zanni
    • , D Caracciolo
    • , M Ladetto
    •  & M Boccadoro
  2. Divisione di Oncologia Medica, I.N.T. and Università di Milano, Milano, Italy

    • M Di Nicola
    • , M Magni
    • , L Devizzi
    •  & A M Gianni
  3. Divisione di Ematologia, Azienda Ospedaliera V. Cervello, Palermo, Italy

    • C Patti
    •  & S Mirto
  4. Divisione di Ematologia, Azienda Ospedaliera S. Croce, Cuneo, Italy

    • R Calvi
    •  & A Gallamini
  5. Bone Marrow Transplantation Unit, IRCCS H. S. Raffaele, Milano, Italy

    • A Pescarollo
    •  & M Bregni
  6. Divisione di Ematologia, Ospedale S. Camillo-Forlanini, Roma, Italy

    • V Zoli
    •  & I Majolino
  7. Center for Experimental Research and Medical Studies (CERMS), Ist. Univ. Anatomia Patologica, Torino, Italy

    • A Fornari
    •  & D Novero
  8. Ist. Anatomia Patologica, Istituto Nazionale Tumori, Milano, Italy

    • A Cabras
  9. Ist. Anatomia Patologica, Azienda Ospedaliera V. Cervello, Palermo, Italy

    • M Stella
  10. Ist. Anatomia Patologica, Azienda Ospedaliera S. Croce, Cuneo, Italy

    • A Comino
  11. Ist. Anatomia Patologica, Ospedale S. Camillo-Forlanini, Roma, Italy

    • D Remotti
  12. Ist. Anatomia Patologica, IRCCS H. S. Raffaele, Milano, Italy

    • M Ponzoni
  13. Servizio di Epidemiologia dei Tumori, Università di Torino, Torino, Italy

    • R Rosato
  14. Divisione di Ematologia, I.N.T. and Università di Milano, Milano, Italy

    • P Corradini

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DOI

https://doi.org/10.1038/sj.leu.2404781

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