new effective treatment of primary mediastinal b cell
TRANSCRIPT
New Effective Treatment of Primary Mediastinal B cell Lymphoma in
Taiwan: A Single Institution Experience
Miao-Erh Chang, Jyh-Pyng Gau, Hao-Yuan Wang, Po-Shen Ko, Yao-Chung Liu, Liang-Tsai Hsiao, Tzeon-Jye Chiou, Po-Min Chen, Jin-Hwang Liu
Taipei Veterans General Hospital
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INTRODUCTION
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• Primary mediastinal B cell lymphoma (PMBCL)
– derives from putative thymic B cells
– about 10% of diffuse large B cell lymphomas (DLBCL)
– women in 30s~40s
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Blood 2015 125:33-39
• Clinical features
– a bulky tumor in the anterior mediastinum
– local compressive symptoms (50%): dyspnea, cough, dysphagia, a superior vena cava syndrome
– pleural or pericardial effusions, often present
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The Oncologist May 1, 2006 vol. 11 no. 5 488-495
• PMBCL, an aggressive lymphoma, favorable outcomes compared to other subgroups of DLBCL (activated B cell subtype)
• NO large prospective randomized studies for therapy of PMBCL, a lack of treatment standards
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• Standard-dose chemoimmunotherapy needs consolidative mediastinal radiotherapy to cure the disease
• Aggressive chemoimmunotherapy, greatly improve outcomes, obviate radiotherapy, infusional dose-adjusted etoposide, prednisone, vincristine, cyclophosphamide, doxorubicin, rituximab (DA-EPOCH-R)
• Caucasian population Asian population
Dunleavy K, et al. Dose-adjusted EPOCH-rituximab therapy in primary
mediastinal B-cell lymphoma. NEJM; 2013; 368:1408-1416
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METHODS
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Patients
• 2013/8 ~ 2016/10
• 12 patients, newly-diagnosed PMBCL, infusional DA-EPOCH-R, in Taipei Veterans General Hospital
• Primary study objectives: event-free survival (EFS) rate and overall survival (OS) rate
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Study Therapy• Infusional DA-EPOCH-R for 6-8 cycles
• Evaluation of diseases after cycle 3-4 and 6
• DA-EPOCH-R Regimen
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N Engl J Med 2013; 368:1408-1416
Study Therapy
• Revised Response Criteria for Malignant Lymphoma by International Working Group
• All patients, evaluated by FDG-PET-CT after therapy
• Tumor biopsy as clinically indicated
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RESULTS
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Baseline characteristics
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Clinical Outcomes• Median follow-up: 22.3 months (9.7~38.1)
• EFS rate: 92% (95% CI, 76-100%)
• OS rate: 100%
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Clinical Outcomes
• After treatment
– 1 patient, pathology-confirmed residual disease
• 3 cycles of R-ESHAP + mediastinal radiotherapy PD
• Auto-HSCT conditioned with BEAM CR
• Allo-HSCT with RIC (fludarabine + busulfan) CR
– 1 patient, a suspicious residual tumor
(no tumor biopsy)
• prophylactic mediastinal radiotherapy CR
• At the last follow-up, 2 patients remaineddisease-free
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FDG-PET-CT Findings
Scores of 1 and 2 “negative”Scores of 4 and 5 “positive”Score 3 according to the clinical condition
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Dose and Toxicity of DA-EPOCH-R
• Mean cumulative dose of doxorubicin: 297 mg/m2
(241-388) NO cardiac complication
• All patients, A dose escalation
• 58% to dose level 3
• 17% to dose level 4
16N Engl J Med 2013; 368:1408-1416
Dose and Toxicity of DA-EPOCH-R
• Absolute neutrophil count (ANC) nadirs
– 100~499/mm3 30% of cycles (74)
– <100/mm3 12% of cycles
• Platelet count < 30,000/mm3 0% of cycles
• Blood transfusion 0% of cycles
• Hospitalization for neutropenic fever 8% of cycles
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CONCLUSION
• Infusional DA-EPOCH-R in PMBCL offers excellent outcomes and obviates the need for radiotherapy in Asian population.
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