Alternating Courses of CHOP and DHAP Plus Rituximab (R) Followed by a High-Dose Cytarabine Regimen and ASCT is Superior to Six Courses of CHOP Plus R Followed.

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Alternating Courses of CHOP and DHAP Plus Rituximab (R) Followed by a High-Dose Cytarabine Regimen and ASCT is Superior to Six Courses of CHOP Plus R Followed by Myeloablative Radiochemotherapy and ASCT in Mantle Cell Lymphoma Hermine O et al. Proc ASH 2010;Abstract 110.

Background Although the outcomes of patients with MCL have improved over the last decades, the disease has been characterized by poor long-term prognosis. A Phase II trial of myeloablative consolidation followed by ASCT demonstrated significant prolonged progression-free survival in advanced stage MCL (Blood 2005;105:2677). Sequential R-CHOP/R-DHAP followed by ASCT demonstrated an overall response rate of 95% and a 75% survival rate at five years in a Phase II study of patients with MCL (Proc ASH 2008;Abstract 581). Hermine O et al. Proc ASH 2010;Abstract 110.

Study Schema Primary endpoint: Time to treatment failure (TTF), monitored continuously. Control arm: R-CHOP x 6 → myeloablative radiochemotherapy 1 and ASCT Experimental arm: Alternating CHOP x 3 and DHAP x 3 + R → high-dose ARA-C containing myeloablative radiochemotherapy 2 and ASCT Hermine O et al. Proc ASH 2010;Abstract 110. Eligibility Untreated mantle- cell lymphoma (MCL) Stage II to IV Age ≤ 65 years Accrual: 497 (Closed) 1 12 Gray total body irradiation (TBI), cyclophosphamide 60 mg/kg x 2; 2 10 Gray TBI, ARA-C 1.5 g/m 2 x 4, melphalan 140 mg/m 2 R

Patient Characteristics Control armExperimental arm Age, median55 years56 years Male gender78%79% Stage IV85%79% B symptoms43%33% ECOG >25% Elevated LDH37%38% MIPI risk level (low/intermediate/high) 61%/25%/14%62%/23%/15% Hermine O et al. Proc ASH 2010;Abstract 110.

Efficacy Results (from Abstract) Control armExperimental armp-value Time to treatment failure49 monthsNot reached0.0384* 3-year overall survival79%80%0.74 *Mainly due to a lower number of relapses in the experimental arm after complete or partial response (control arm, 20%; experimental arm, 10%) as the rate of ASCT-related deaths during remission was similar in both arms (control arm, 3%; experimental arm, 4%). Hermine O et al. Proc ASH 2010;Abstract 110.

Efficacy Results (from Abstract) Control armExperimental armp-value Response following induction Overall response90%94%0.19 Complete response (CR)26%39%0.012 CR/unconfirmed CR41%60% Hermine O et al. Proc ASH 2010;Abstract 110.

Efficacy Results (from Abstract) Control armExperimental armp-value Patients transplanted 72%73%— Response following transplant Overall response97% Not reported Complete response (CR)63%65%Not reported Remission duration (All patients) 48 monthsNot reached0.047 Remission duration (Patients achieving CR) 51 monthsNot reached0.077 Hermine O et al. Proc ASH 2010;Abstract 110.

Grade 3 or 4 Adverse Events (from Abstract) Control armExperimental arm Induction regimen Anemia8%28% Leucopenia48%75% Thrombocytopenia9%74% Renal toxicity0%2% Conditioning regimen Mucositis43%61% Hermine O et al. Proc ASH 2010;Abstract 110.

Author Conclusions The use of high-dose ARA-C in addition to R-CHOP and ASCT significantly increases complete response rates and TTF compared to standard therapy. –CR: 26% vs 39% (p = 0.012) –CR/CRu: 41% vs 60% (p = ) –TTF: 49 months vs not reached (p = ; HR, 0.68) High-dose ARA-C plus R-CHOP followed by ASCT does not cause clinically relevant increases in toxicity. Based on these data, the new standard regimen for patients up to 65 years of age with MCL should contain high-dose ARA-C followed by ASCT. Hermine O et al. Proc ASH 2010;Abstract 110.

Investigator comment on alternating courses of 3x CHOP and 3x DHAP and rituximab followed by a high-dose Ara-C-containing myeloablative regimen as part of ASCT Though the pretransplant OR rates are equal, the CR is significantly higher in the experimental arm with R-CHOP/R-DHAP induction. It is also interesting that even though both arms were equal in terms of OR and CR rates after transplantation, the time to treatment failure was improved in the arm with a high-dose Ara-C-containing myeloablative regimen. It tells us that all complete responses are not created equal. I believe this trial provides additional information that a more aggressive therapy that includes high-dose Ara-C, in a younger patient, will get to the goal of a longer disease-free survival. Until we learn more about how to treat mantle-cell lymphoma with a curative intent, I believe this is an appropriate mode of approaching younger patients with MCL. Interview with Lauren C Pinter-Brown, MD, January 7, 2011