Dose-Adjusted EPOCH plus Rituximab in Untreated Patients with Poor Prognosis Large B-Cell Lymphoma, with Analysis of Germinal Center and Activated B-Cell.

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Presentation transcript:

Dose-Adjusted EPOCH plus Rituximab in Untreated Patients with Poor Prognosis Large B-Cell Lymphoma, with Analysis of Germinal Center and Activated B-Cell Biomarkers Purroy N et al. Proc ASH 2011;Abstract 593.

Background Patients with large B-cell lymphomas treated with frontline, dose-adjusted EPOCH (DA-EPOCH) have a complete response (CR) rate of 92% and 5-year progression-free survival (PFS) of 70% (Blood 2002;99:2685). Combination of rituximab (R) with DA-EPOCH (DA-EPOCH-R) showed promising results in patients with untreated diffuse large B-cell lymphomas (DLBCL) (J Clin Oncol 2008;26:2717; Br J Haematol 2007;136:276). Current study objective: Assess the efficacy and safety of DA-EPOCH-R in patients with untreated large B-cell lymphomas with poor prognosis in a Phase IV study. Purroy N et al. Proc ASH 2011;Abstract 593.

Phase IV Study Design Eligibility criteria (N = 81) Biopsy-proven DLBCL, PMBCL and Grade III FL (WHO) IPI ≥2 or aaIPI ≥1 Stage II-IV (Stage I if bulky) Primary endpoint: PFS DA-EPOCH-R (x 3) DA-EPOCH-R (x 3) CR, PR SD, PD Out of study Purroy N et al. Proc ASH 2011;Abstract 593. Tumor samples analyzed by IHC for biomarkers of proliferation (Ki-67) and markers of cellular differentiation. IHC to determine the histological origin of patients according to the Choi and Hans algorithms was performed retrospectively. Follow-up: Evaluation every 3 mo for 2 y, then every 6 mo for 3 y

DA-EPOCH-R Dosing Schedule  Radiation therapy (30 Gy): For bulky/residual disease  Cycles administered q3wk if ANC ≥1 x 10 9 /L and platelet ≥100 x 10 9 /L  After every cycle, doses were adjusted according to known hematological parameters  For neutropenic fever, dose reduced 20% below the last cycle DrugDoseTreatment days Etoposide (CIV)50 mg/m 2 /day1,2,3,4 Doxorubicin (CIV)10 mg/m 2 /day1,2,3,4 Vincristine (CIV)0.4 mg/m 2 /day1,2,3,4 Rituximab (IV)375 mg/m 2 /day1 Cyclophosphamide (IV)750 mg/m 2 /day5 Prednisone (PO)60 mg/m 2 /day1,2,3,4,5 Purroy N et al. Proc ASH 2011;Abstract 593.

PFS and OS With permission from Purroy N et al. Proc ASH 2011;Abstract 593. PFS (5 years): 62% OS (5 years): 67% Median follow-up: 55 months Overall survival (%) Progression-free survival (%) Time (months)

Complete Response Rates in Patient Subgroups CharacteristicCR ratep-value IPI 0-2 (n = 13) 3-5 (n = 68) 100% 75% 0.06 Choi algorithm GCB (n = 22) ABC (n = 17) 86.3% 88.2% 1.0 Hans algorithm GCB (n = 16) Non-GCB (n = 23) 81.2% 91.3% Ki-67 <80% (n = 29) ≥80% (n = 29) 82.7% 86.7% 1.0 Overall (N = 81) CR/uCR: 80.2%, PR: 9.9%, failure rate: 9.9% Purroy N et al. Proc ASH 2011;Abstract 593. GCB = germinal center B cell; ABC = activated B cell

Adverse Events Adverse event (N = 81) Incidence (%) Anemia (Grade 3/4)84.0% Thrombocytopenia (Grade 3/4)71.6% Neutropenic fever45.7% Mucositis (Grade 3/4)11.1% Neurotoxicity (Grade 3/4)2.5% Discontinuation: 6 patients, 2 due to disease progression Deaths: 4 (pneumonia: 2, septic shock: 2) Purroy N et al. Proc ASH 2011;Abstract 593.

Author Conclusions Patients with DLBCL who had adverse prognostic features showed a high response rate to DA-EPOCH-R. PFS was 62% at 5 years and was comparable to dose- dense or other high-dose regimens. DA-EPOCH-R seems to diminish the impact of adverse clinical variables and the value of histological origin and tumor proliferation (data not shown). Randomized studies comparing R-CHOP to DA-EPOCH-R in patients with high-risk DLBCL are warranted. Purroy N et al. Proc ASH 2011;Abstract 593.

Investigator Commentary: Dose-Adjusted EPOCH with Rituximab in Patients with Untreated Poor-Prognosis Large B-Cell Lymphoma This is an interesting, large, single-arm study evaluating dose-adjusted EPOCH in a patient population with an age-adjusted IPI of 1 or higher. They reported an overall response rate of about 90%, with 80% of patients having a CR and an overall survival of 67%. In the absence of a randomized trial it is hard to determine whether this regimen is better than R-CHOP-21. When the Intergroup study comparing R-CHOP to EPOCH-R is completed, we should have good evidence indicating whether we can improve on the standard R-CHOP regimen. Interview with Owen A O’Connor, MD, PhD, February 3, 2012 In comparison to these data, the study by Pfreundschuh and colleagues (Proc ASH 2011;Abstract 592) showed better efficacy. Because the dose of EPOCH-R is adjusted based on blood counts, it requires a costly double-lumen catheter procedure in which patients are admitted for 5 days every 3 weeks. Hence, for the EPOCH-R regimen to be used, especially in the United States, it will have to be superior to R-CHOP-21 in an Intergroup study. Interview with Craig Moskowitz, MD, January 11, 2012