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Originally published as JCO Early Release 10.1200/JCO.2007.13.5533 on April 14 2008 © 2008 American Society of Clinical Oncology. Intensive Chemotherapy Followed by Hematopoietic Stem-Cell Rescue for Refractory and Recurrent Primary CNS and Intraocular Lymphoma: Société Française de Greffe de Moëlle Osseuse-Thérapie Cellulaire
From the Department of Hematology; Biostatistics Unit, Centre René Huguenin, Saint-Cloud; Departments of Neurology and Hematology, Hôpital Pitié-Salpétrière; Department of Hematology, Hôpital Lariboisière, Paris; Departments of Neurology and Hematology, Centre Hospitalier Universitaire (CHU), Nancy; Department of Hematology, CHU Dijon; Department of Hematology, CH Lens; Department of Hematology, Hôpital Militaire, Percy; Department of Hematology, Hôpital de Versailles, Versailles; Department of Hematology, Hôpital Saint-Louis, Paris; Department of Hematology, CHU, Limoges; and the Department of Hematology, CHU Reims, France Corresponding author: Carole Soussain, MD, Centre René Huguenin, Service d'Hématologie, 35 rue Dailly, 92210 Saint-Cloud, France; e-mail: soussain{at}crh1.org
Purpose: The prognosis of relapsing primary CNS lymphoma (PCNSL) is poor. We report the results of a prospective multicenter trial of intensive chemotherapy followed by autologous hematopoietic stem-cell rescue (IC + HCR) in immunocompetent adult patients with PCNSL or intraocular lymphoma (IOL) after failure of high-dose methotrexate-based treatment. Patients and Methods: Salvage treatment consisted of two cycles of high-dose cytarabine and etoposide (CYVE). Intensive chemotherapy combined thiotepa, busulfan, and cyclophosphamide. Forty-three patients (median age, 52 years; range, 23 to 65 years) were included, with relapse (n = 22), refractory disease (n = 17), or a partial response to first-line treatment (n = 4). The response to CYVE was not assessable in three cases because of treatment-related death. Twenty patients (47%) were chemosensitive to CYVE: 15 of them proceeded to IC + HCR. IC + HCR was also administered to 12 patients who did not respond to CYVE. All but one of the 27 patients who underwent IC + HCR entered complete remission. Results: With a median follow-up of 36 months, the median overall survival was 18.3 months in the overall population, and 58.6 months among patients who completed IC + HCR. The respective median progression-free survival (PFS) times after IC + HCR were 11.6 and 41.1 months. The 2-year overall survival probability was 45% in the whole population and 69% among the 27 patients who received IC + HCR. The 2-year PFS probability was 43% among all the patients and 58% in the IC + HCR subpopulation. Conclusion: IC + HCR is an effective treatment for refractory and recurrent PCNSL.
Combined-modality therapies have significantly improved the prognosis of primary CNS lymphoma (PCNSL), but first-line treatments fail in approximately 35% to 60% of cases.1 Without treatment, patients with recurrent PCNSL have a median overall survival (OS) of up to 5 months.2 Salvage radiotherapy, which is restricted to patients who do not receive radiation as part of their first-line treatment, increases the median OS to approximately 11 months.3 There is no consensus treatment for relapsed PCNSL. Various second-line chemotherapies have been tried,4-10 yielding median OS ranging from 7 to 14 months. The use of intensive chemotherapy followed by hematopoietic stem-cell rescue (IC + HCR) in PCNSL is based on its efficacy in recurrent systemic non-Hodgkin's lymphoma (NHL).11 In the specific setting of PCNSL, the aim of intensive chemotherapy is also to overwhelm the blood-brain barrier, which otherwise restricts drug delivery to the brain.12 A pilot study involving 22 patients with relapsing or refractory PCNSL and/or intraocular lymphoma (IOL) showed that this procedure was feasible and gave promising results.13 However, half of the patients had IOL, and the slower progression of this form might partly explain these good results. We present here the results of a prospective phase II multicenter study of IC + HCR as second-line treatment for patients with recurrent or primary refractory PCNSL or IOL. The primary end point was the median OS from inclusion in the study. Secondary end points were the rates of complete remission (CR) before and after intensive chemotherapy, median progression-free survival (PFS), and the tolerability of the entire procedure.
Patients This prospective trial took place from January 2000 through December 2005. It was sponsored by the Société Française de Greffe de Moëlle Osseuse-Thérapie Cellulaire. Patients with refractory or primary-relapsed PCNSL or IOL were included in the study if they tested negative for HIV, were younger than 65 years, and had previously received high-dose methotrexate (  3 g/m2). The study was approved by a local human investigation committee and was covered by an appropriate insurance policy. The patients gave their written informed consent.
Treatment Intensive chemotherapy consisted of high-dose thiotepa (250 mg/m2/d days 9 through 7) plus busulfan (total dose 10 mg/kg orally [PO] or 8 mg/kg intravenously [IV], days 6 through 4) and cyclophosphamide (60 mg/kg/d days 3 and 2). The busulfan dose was reduced by 40% in patients 60 years of age and older. Clonazepam (2 mg/d IV) was used to prevent seizures from the first day of busulfan therapy to the day after completion of busulfan therapy. Hematopoietic stem cells were reinfused on day 0.
Staging Before Inclusion on the Study
Evaluation of Disease Status Before Inclusion
Evaluation of Responses
Evaluation of Toxicity
Survival
Patient Characteristics Forty-three patients (22 men and 21 women) were enrolled in the study (Table 1). Their median age was 52 years (range, 23 to 65 years). Five patients were older than 60 years.
Diffuse large B-cell lymphoma was the main histologic type (39 cases). Three patients had diffuse large-cell lymphoma of unspecified immunophenotype. One patient had features of small non–cleaved-cell lymphoma, but no cytogenetic or molecular biology studies were performed, and the diagnosis of Burkitt's lymphoma could not be confirmed. At inclusion on the study, 36 patients had brain parenchyma involvement, associated with IOL in four cases and with CSF infiltration in three cases. Five patients had isolated IOL, one patient had isolated CSF infiltration, and one patient had concomitant IOL and CSF infiltration. WHO performance status was less than 2 in 30 patients, 2 or higher in 12 patients, and not recorded in one patient. The serum LDH level was elevated in 10 of the 30 patients in whom it was measured. All of the patients had received high-dose methotrexate, combined with either lomustine or procarbazine, or with anthracycline, cyclophosphamide, vincristine, and prednisone, depending on the referring center. Twenty-nine patients received chemotherapy alone, whereas the other 14 patients received cranial irradiation (40 Gy to the whole brain, n = 1; 20 Gy to the whole brain + boost of 30 Gy, n = 12; 40 Gy to the whole brain + boost of 14 Gy, n = 1) as part of their first-line treatment. Twenty-two patients were enrolled onto the study for relapse, which occurred a median of 27 months after initial diagnosis (range, 5 to 126 months). Four patients entered onto the study with partial responses and 17 patients with primary refractory disease after first-line treatment.
Survival
Salvage Treatment During the salvage phase of the CYVE regimen, three patients died as a result of treatment-related toxicity (septic shock in two cases, mesenteric necrosis in one case) and were not assessable for the response. Another patient died as a result of hemorrhage after brain biopsy performed after the second course of CYVE, but was assessable for response because pathologic examination showed persistent lymphoma infiltration. Twenty patients were chemosensitive to CYVE, of whom 15 entered CR and five PR. Second-line chemotherapy failed in 20 patients (Fig 3).
Among CYVE-responsive patients, five were withdrawn from the intensive chemotherapy program because of failed stem-cell collection in two cases and treatment-related toxicity in three cases. Four patients started a third-line treatment consisting of radiotherapy (n = 1), chemotherapy (n = 2), or chemotherapy plus radiotherapy (n = 1). Among CYVE-nonresponsive patients, one patient died as a result of hemorrhage after brain biopsy, 12 patients (SD, n = 1; PD, n = 11) received IC + HCR, and seven patients were withdrawn from the intensive chemotherapy program on the basis of a staff consensus, reflecting the uncertain utility of the procedure in this situation. Two of them started a third-line treatment consisting of chemotherapy alone.
IC + HCR Two patients who had PD before intensive chemotherapy received whole-brain irradiation (30 and 40 Gy, respectively) 3 months after intensive chemotherapy, during CR. One of them died 10 months after inclusion as a result of PD, whereas the other one was alive at 81 months. Twelve patients received IC + HCR despite failure of the CYVE regimen. The median OS and PFS in this subgroup of patients were 18.5 and 9 months, respectively. Eleven patients entered CR. Eight patients relapsed, a median of 5.4 months after IC + HCR (range, 2.5 to 42 months). CR lasted longer after IC + HCR than after first-line treatment in eight patients. One patient died in CR 5 months after IC + HCR as a result of treatment-related neurotoxicity. Six patients died as a result of PD. Five patients were alive at last follow-up, respectively 20, 23, 36, 68, and 81 months.
Relapse After IC + HCR
Toxicity of the Overall Procedure Prospective neurocognitive testing was not performed. All reported signs of neurotoxicity were analyzed. One patient had acute transient encephalopathy after the first CYVE cycle but not after the following cycle. Five patients had late neurologic toxicity after IC + HCR, primarily manifesting as leukoencephalopathy and characterized by new-onset cognitive dysfunction (severe in three cases, moderate in two). All of these patients were younger than 60 years. Onset occurred from 10 days to 5 years after IC + HCR. Two of these patients had received first-line cranial radiotherapy before IC + HCR. One patient died, probably as a result of late neurotoxicity, with no signs of malignant disease progression; this 48-year-old patient had received cranial radiotherapy 10 years previously as part of the first-line treatment. Acute cerebellar toxicity after high-dose cytarabine for acute leukemia has been linked to renal status.15 In our study, no cerebellar toxicity occurred, and patients who experienced late neurotoxicity had normal renal function.
Prognostic Factors
Patients who were chemosensitive to CYVE had significantly better OS and PFS rates than those who had no objective response to CYVE: The respective median OS was 64 and 8.7 months (log-rank P = .0022) and the respective median PFS was 41 and 6 months (log-rank P = .0016). Regardless of their status before intensive chemotherapy, patients who received IC + HCR had far better OS and PFS than patients who did not complete the procedure. The respective median OS times were 58.6 and 4.6 months (P < .0001) and the respective median PFS times were 41.1 and 4.8 months (P = .0001). None of the patients who did not receive IC + HCR survived. Not surprisingly, patients who had an objective response to CYVE and who subsequently received IC + HCR are doing better than the other patients. Their median OS and PFS times have not yet been reached. Patients who neither responded to CYVE nor received IC + HCR had the worst outcome, with a median OS of only 3 months. Responders to CYVE who did not receive IC + HCR and nonresponders to CYVE who still received IC + HCR had intermediate survival rates, with a median OS of approximately 18 months in both cases (Fig 4). PFS was also independently influenced by the chemosensitivity to the CYVE regimen and the use of IC + HCR.
The following factors were not predictive of survival: age (< 50 v 50 years), LDH (normal v abnormal), the disease site (parenchymal v nonparenchymal), isolated IOL versus other forms, disease status at inclusion (relapse or primary refractory), and first-line treatment (chemotherapy alone or chemotherapy + cranial radiotherapy).
The aim of this study was to validate, in a prospective multicenter trial, the results we had previously obtained with IC + HCR as salvage treatment for PCNSL. Forty-three patients were enrolled and analyzed. The rationale for using CYVE and the thiotepa-busulfan-cyclophosphamide combination is discussed extensively in the report of our pilot study.13 Briefly, this combination was chosen for IC because of the good CSF and brain diffusion of thiotepa and busulfan.16-19 The use of cyclophosphamide is debatable because data on its CNS penetration are controversial as a result of to the difficulty of measuring its active metabolite.12 Nevertheless, cyclophosphamide is effective on systemic lymphoma and could thus be of value for treating subclinical systemic lymphomatous infiltration, which is found at autopsy in approximately 7% of patients with PCNSL.20 The CYVE regimen was used because of the lack of cross-resistance between cytarabine, etoposide, and methotrexate and for its known efficacy in adults and children with Burkitt's lymphoma and initial CNS disease.21,22 Intensive chemotherapy has also been used as first-line treatment for PCNSL. The BEAM (carmustine, etoposide, cytarabine, melphalan) conditioning regimen gave disappointing results,23 with event-free survival of only 9.3 months and early relapses in nearly every case. Encouraging results have been reported with conditioning regimens combining thiotepa and carmustine24 or thiotepa and busulfan,25 although whole-brain irradiation was administered to all the patients in one study24 and in the other study, to patients who did not respond to induction chemotherapy or who did not enter CR after IC.25 Our population comprised patients in relapse, patients with partial responses, and patients refractory to high-dose methotrexate-based first-line chemotherapy. The median time to recurrence after first-line treatment was 22 months, in keeping with other reports.2-10 With conventional salvage treatments, the median OS and PFS range from 6 to 14 months and from 2 to 6 months, respectively4,5,8,10; with whole-brain irradiation at relapse,3 median OS is 10.9 months. Most of these latter studies reported small single center or retrospective experiences. We obtained a 2-year OS probability of 45% and a similar PFS. The intention-to-treat median OS was 18.3 months. Patients who had an objective response to CYVE and who then received IC + HCR had significantly longer responses given that their median OS and PFS have not yet been reached. These results compare favorably with those of other salvage treatments, but also underline the need to achieve a higher response rate to second-line treatment (before IC + HCR) while also minimizing toxicity. Five patients (11%) had late neurotoxicity in this phase II trial, including three patients with severe cognitive impairment, which was fatal in one case. In the absence of prospective neuropsychometric testing, the frequency of neurotoxicity might have been underestimated. Formal prospective cognitive testing is now recommended by the international group for PCNSL.14,26 Our ongoing first-line trials in PCNSL now include such studies. In contrast, no significant treatment-related neurotoxicity was noted in several studies of IC + HCR as first-line treatment for PCNSL.23, 24, 27 This difference could be a result of the fact that our patients had all previously received first-line high-dose methotrexate-based chemotherapy, plus cranial radiotherapy in some cases. These latter treatments, and their combination, are known to cause late neurotoxicity, especially in elderly patients. Hence, the specific role of IC + HCR in our patients' delayed neurotoxicity is difficult to assess. Although the frequency of severe cognitive disorders was acceptable, given the poor prognosis of the disease at relapse, this salvage treatment should likely be reserved for patients younger than 60 years. The impact of IC + HCR on survival, whatever the disease status before IC, and the lengthy survival of some patients who entered CR after IC + HCR despite complete failure of CYVE, suggest that IC + HCR might overcome resistance mediated by the blood-brain barrier. However, this is only speculative. IC + HCR is thus an attractive alternative for the treatment of PCNSL, and warrants comparative studies with conventional combined chemoradiotherapy in newly diagnosed patients.
The author(s) indicated no potential conflicts of interest.
Conception and design: Carole Soussain, Khe Hoang-Xuan, Véronique Leblond Financial support: Carole Soussain Administrative support: Carole Soussain Provision of study materials or patients: Carole Soussain, Khe Hoang-Xuan, Luc Taillandier, Sylvain Choquet, Francis Witz, Olivier Casasnovas, Brigitte Dupriez, Bertrand Souleau, Anne-Laure Taksin, Christian Gisselbrecht, Arnaud Jaccard, Antonio Omuro, Marc Sanson, Maud Janvier, Brigitte Kolb, Jean-Marc Zini, Véronique Leblond Collection and assembly of data: Carole Soussain, Luc Taillandier, Olivier Casasnovas, Brigitte Dupriez, Bertrand Souleau, Anne-Laure Taksin, Christian Gisselbrecht, Arnaud Jaccard, Maud Janvier, Brigitte Kolb, Jean-Marc Zini Data analysis and interpretation: Carole Soussain, Khe Hoang-Xuan, Emmanuelle Fourme Manuscript writing: Carole Soussain, Khe Hoang-Xuan Final approval of manuscript: Carole Soussain, Khe Hoang-Xuan, Luc Taillandier, Emmanuelle Fourme, Sylvain Choquet, Francis Witz, Olivier Casasnovas, Brigitte Dupriez, Bertrand Souleau, Anne-Laure Taksin, Christian Gisselbrecht, Arnaud Jaccard, Antonio Omuro, Marc Sanson, Maud Janvier, Brigitte Kolb, Jean-Marc Zini, Véronique Leblond
published online ahead of print at www.jco.org on April 14, 2008 Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
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Wong ET, Tishler R, Barron L, et al: Immunochemotherapy with rituximab and temozolomide for central nervous system lymphoma. Cancer 101:139-145, 2004[CrossRef][Medline] 7. Enting RH, Demopoulos A, DeAngelis LM, et al: Salvage therapy for primary CNS lymphoma with a combination of rituximab and temozolomide. Neurology 63:901-903, 2004 8. Tyson RM, Siegal T, Doolittle ND, et al: Current status and future of relapsed primary central nervous system lymphoma (PCNSL). Leuk Lymphoma 44:627-633, 2003[CrossRef][Medline] 9. Plotkin SR, Betensky RA, Hochberg FH, et al: Treatment of relapsed central nervous system lymphoma with high-dose methotrexate. Clin Cancer Res 10:5643-5646, 2004 10. Arellano-Rodrigo E, Lòpez-Guillermo A, Bessel EM, et al: Salvage treatment with etoposide (VP-16), ifosfamide and cytarabine (cytarabine) for patients with recurrent primary central nervous system lymphoma. Eur J Hematol 70:219-224, 2003[CrossRef][Medline] 11. Philip T, Guglielmi C, Hagenbeek A, et al: Autologous bone marrow transplantation as compared with salvage chemotherapy in relapses of chemotherapy-sensitive non-Hodgkin's lymphoma. N Engl J Med 333:1540-1545, 1995 12. Muldoon LL, Soussain C, Jahnke K, et al: Chemotherapy delivery issues in CNS malignancy: A reality check? J Clin Oncol 25:2295-2305, 2007 13. Soussain C, Suzan F, Hoang-Xuan K, et al: Results of intensive chemotherapy followed by hematopoietic stem-cell rescue in 22 patients with refractory or recurrent primary CNS lymphoma or intraocular lymphoma. J Clin Oncol 19:742-749, 2001 14. Abrey LE, Batchelor TT, Ferreri AJM, et al: Report of an international workshop to standardize baseline evaluation and response criteria for primary CNS lymphoma. J Clin Oncol 23:5034-5043, 2005 15. Smith GA, Damon LE, Rugo HS, et al: High-dose cytarabine dose modification reduces the incidence of neurotoxicity in patients with renal insufficiency. J Clin Oncol 15:833-839, 1997 16. 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Patte C, Leverger G, Perel Y, et al: Updated results of the LMB86 protocol of the French Pediatric Oncology Society (SFOP) for B-cell non-Hodgkin's lymphoma (B-NHL) with CNS involvement (CNS+) and B-ALL. Med Pediatr Oncol 18:406, 1990 (abstr) 22. Soussain C, Patte C, Ostronoff M, et al: Small noncleaved cell lymphoma and leukemia in adults: A retrospective study of 65 adults treated with the LMB pediatric protocols. Blood 85:664-674, 1995 23. Abrey LE, Moskowitz CH, Mason WP, et al: Intensive methotrexate and cytarabine followed by high-dose chemotherapy with autologous stem-cell rescue in patients with newly diagnosed primary CNS lymphoma: An intent-to-treat analysis. J Clin Oncol 21:4151-4156, 2003 24. Illerhaus G, Marks R, Ihorst G, et al: High-dose chemotherapy with autologous stem-cell transplantation and hyperfractionated radiotherapy as first-line treatment of primary CNS lymphoma. J Clin Oncol 24:3865-3870, 2006 25. Montemurro M, Kiefer T, Schüler F, et al: Primary central nervous system lymphoma treated with high-dose methotrexate, high-dose busulfan/thiotepa, autologous stem-cell transplantation and response-adapted whole-brain radiotherapy: Results of the multicenter Osteutsche Studiengruppe Hämato-Onkologie OSHO-53 phase II study. Ann Oncol 18:665-671, 2007 26. Colombat P, Lemevel A, Bertrand P, et al: High-dose chemotherapy with autologous stem cell transplantation as first-line therapy for primary CNS lymphoma in patients younger than 60 years: A multicenter phase II study of the GOELAMS group. Bone Marrow Transplant 38:417-420, 2006[CrossRef][Medline] 27. Correa DD, Maron L, Harder H, et al: Cognitive functions in primary central nervous system lymphoma: Literature review and assessment guidelines. Ann Oncol 18:1145-1151, 2007 Submitted August 17, 2007; accepted January 25, 2008.
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Copyright © 2008 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
