Риск-адаптированная интенсивная индукционная терапия, аутологичная трансплантация стволовых кроветворных клеток и поддерживающая терапия ритуксимабом позволяют достигнуть высоких показателей 7-летней выживаемости у больных лимфомой из клеток мантийной зон
Риск-адаптированная интенсивная индукционная терапия, аутологичная трансплантация стволовых кроветворных клеток и поддерживающая терапия ритуксимабом позволяют достигнуть высоких показателей 7-летней выживаемости у больных лимфомой из клеток мантийной зон
Воробьев В.И., Гемджян Э.Г., Дубровин Е.И. и др. Риск-адаптированная интенсивная индукционная терапия, аутологичная трансплантация стволовых кроветворных клеток и поддерживающая терапия ритуксимабом позволяют достигнуть высоких показателей 7-летней выживаемости у больных лимфомой из клеток мантийной зоны. Терапевтический архив. 2019; 91 (7): 41–51. DOI: 10.26442/00403660.2019.07.000322
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Vorobyev V.I., Gemdzhian E.G., Dubrovin E.I., et al. Risk-adapted intensive induction therapy, autologous stem cell transplantation, and rituximab maintenance allow to reach a high 7-year survival rate in patients with mantle cell lymphoma. Therapeutic Archive. 2019; 91 (7): 41–51. DOI: 10.26442/00403660.2019.07.000322
Риск-адаптированная интенсивная индукционная терапия, аутологичная трансплантация стволовых кроветворных клеток и поддерживающая терапия ритуксимабом позволяют достигнуть высоких показателей 7-летней выживаемости у больных лимфомой из клеток мантийной зон
Воробьев В.И., Гемджян Э.Г., Дубровин Е.И. и др. Риск-адаптированная интенсивная индукционная терапия, аутологичная трансплантация стволовых кроветворных клеток и поддерживающая терапия ритуксимабом позволяют достигнуть высоких показателей 7-летней выживаемости у больных лимфомой из клеток мантийной зоны. Терапевтический архив. 2019; 91 (7): 41–51. DOI: 10.26442/00403660.2019.07.000322
________________________________________________
Vorobyev V.I., Gemdzhian E.G., Dubrovin E.I., et al. Risk-adapted intensive induction therapy, autologous stem cell transplantation, and rituximab maintenance allow to reach a high 7-year survival rate in patients with mantle cell lymphoma. Therapeutic Archive. 2019; 91 (7): 41–51. DOI: 10.26442/00403660.2019.07.000322
Лимфома из клеток мантийной зоны (ЛКМЗ) является агрессивной В-клеточной лимфомой, диагностируемой преимущественно у мужчин старшей возрастной группы. Применение R-CHOP-подобных схем позволяет у большинства больных достигнуть общий ответ (ОО), но медиана общей выживаемости (ОВ) составляет всего 3–4 года. Добавление к терапии высоких доз цитарабина и аутологичной трансплантации стволовых кроветворных клеток (аутоТСКК) увеличивают частоту достижения полных ремиссий (ПР) и продолжительность жизни, но только у соматически сохранных пациентов. Основываясь на высокой эффективности и безопасности гемцитабин- и оксалиплатинсодержащих схем в терапии рецидивов ЛКМЗ, мы предложили альтернативный курс терапии первой линии R-GIDIOX для пациентов, не являющихся кандидатами для применения высоких доз цитарабина и метотрексата (R-HD-MTX-AraC). Цель. Оценка эффективности и токсичности схем альтернирующей терапии R-DA-EPOCH/R-HD-MTX-AraC или R-DA-EPOCH/ R-GIDIOX, аутоТСКК и поддерживающей терапии ритуксимабом у вновь заболевших больных ЛКМЗ. Материалы и методы. В проспективное исследование с апреля 2008 по сентябрь 2013 г. включено 47 пациентов из 6 центров. Медиана возраста – 55 (29–64) лет, отношение мужчины/женщины – 76%/24%. Во всех случаях диагноз подтвержден выявлением t(11;14)(q13;q32); ECOG 0–3; распределение по MIPIb: 28% – низкий, 33% – промежуточный и 39% – высокий риск. В зависимости от переносимости первого курса терапии R-EPOCH пациенты рекрутировались в ветвь более интенсивной терапии R-DA-EPOCH/ R-HD-MTX-AraC или менее интенсивной терапии R-DA-EPOCH/R-GIDIOX. При отсутствии гематологической токсичности 4-й степени более 3 сут, серьезных инфекционных осложнений и признаков почечной недостаточности пациентам проводился курс R-HD-Met-AraC (R 375 мг/м2 в день 0, метотрексат 1000 мг/м2/24 ч в день 1, цитарабин 3000 мг/м2 2 раза в день в дни 2–3). При развитии одного из вышеперечисленных осложнений за первым курсом R-EPOCH следовал курс R-GIDIOX (R 375 мг/м2 в день 0, гемцитабин 800 мг/м2 в дни 1 и 4, ифосфамид 1000 мг/м2 в дни 1–5, дексаметазон 10 мг/м2 внутривенно в дни 1–5, иринотекан 100 мг/м2 в день 3, оксалиплатин 120 мг/м2 в день 2). Далее курсы полихимиотерапии (ПХТ) чередовались в каждом рукаве протокола. В зависимости от времени достижения ПР проводилось от 6 до 8 курсов терапии. При достижении частичной ремиссии (ЧР) и более выполнялась аутоТСКК (BEAM-R). Затем проводилась поддерживающая терапия ритуксимабом в дозе 375 мг/м2 1 раз в 3 мес в течение 3 лет. Результаты. Включено 29 из 47 пациентов в группу R-HD-MTX-AraC (медиана возраста 50 лет; MIPIb: 35,7% – низкий, 28,6% – промежуточный, 35,7% – высокий риск) и 18 из 47 – в группу R-GIDIOX (медиана возраста 60 лет; MIPIb: 16,7% – низкий, 38,9% – промежуточный, 44,4% – высокий риск). ПР в группе R-HD-MTX-AraC достигнута у 96,5%. Общий ответ и ПР в рукаве R-GIDIOX достигнуты в 94,4 и 77,7% соответственно. Лейкопения 4-й степени развилась после 74,1% курсов R-GIDIOX. Семилетняя ОВ и бессобытийная выживаемость (БСВ) в группе R-HD-MTX-AraC составили 76 и 57% соответственно, а в группе R-GIDIOX – 59 и 44% (при медиане наблюдения 76 мес). Сравниваемые группы статистически значимо не различались как по БСВ (p=0,47), так и по ОВ (p=0,36). Заключение. Применение риск-адаптированной стратегии позволило в 95,7% случаев достигнуть ответа на терапию, выполнить аутоТСКК и начать поддерживающую терапию ритуксимабом. Никому из больных не потребовалось преждевременного прекращения терапии из-за неприемлемой токсичности. Выполнение аутоТСКК и поддерживающей терапии ритуксимабом позволило частично нивелировать различия в интенсивности индукционной ПХТ и получить сопоставимые результаты лечения в обеих ветвях терапии.
Ключевые слова: лимфома из клеток мантийной зоны, высокие дозы цитарабина, аутологичная трансплантация, поддерживающая терапия ритуксимабом, гемцитабин и оксалиплатин.
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Mantle cell lymphoma (MCL) is aggressive B-cell neoplasm diagnosed predominantly among older men. R-CHOP-like regimens allow to achieve high response rate, but the overall survival (OS) are disappointingly short – 3–4 years. An addition of high-dose cytarabine to the upfront therapy and autoSCT significantly improved outcomes but remain feasible largely for medically fit patients. Based on the activity and good tolerance of gemcitabine-oxaliplatin schemes in relapsed and refractory MCL patients, we developed an alternative first-line course for patients who are not eligible for R-HD-MTX-AraC. Aim. Assess toxicity and efficacy of R-DA-EPOCH/ R-HD-MTX-AraC and R-DA-EPOCH/R-GIDIOX schemes, autoSCT and R-maintenance in untreated MCL patients. Materials and methods. 47 untreated MCL patients from 6 centers were enrolled in prospective study between April 2008 and September 2013. All patients have stage II–V; ECOG 0–3; median age 55 years (29–64); Male/Female 76%/24%. MIPIb: 28% low, 33% intermediate and 39% high risk. Following 1st R-EPOCH patients were assigned to receive either R-DA-EPOCH/ R-HD-MTX-AraC or R-DA-EPOCH/ R-GIDIOX regimen. In the absence of renal failure, hematological toxicity grade 4 more than 3 days and severe infections patients received R-HD-MTX-AraC scheme (R 375 mg/m2 Day 0, Methotrexate 1000 mg/m2/24 hours Day 1, AraC 3000 mg/m2 q 12 hrs Days 2–3). Patients who had at least one of these complications received R-GIDIOX scheme (R 375 mg/m2 day 0, gemcitabine 800 mg/m2 days 1 and 4, ifosfamide 1000 mg/m2 days 1–5, dexamethasone 10 mg/m2 IV days 1–5, irinotecan 100 mg/m2 day 3, oxaliplatin 120 mg/m2 day 2). Subsequently these courses were alternating with R-DA-EPOCH in each arm of the protocol. Depending on the time of achieving CR patients received 6 or 8 courses, unless they progressed on therapy. Those patients who achieved PR/CR/CRu underwent autoSCT (BEAM-R). Post-transplant R-maintenance was administered for 3 years (R – 375 mg/m2 every 3 months). Results. 29/47 patients were treated on R-HD-MTX-AraC arm (median 50 years; MIPIb: 35.7% low, 28.6% intermediate, 35.7% high risk) and 18/47 patients were on R-GIDIOX arm (median 60 years; MIPIb: 16.7% low, 38.9% intermediate, 44.4% high risk). In R-HD-MTX-AraC arm CR rate was 96.5%. In R-GIDIOX arm OR and CR rates were 94.4% and 77.7% respectively. Main hematological toxicity of R-GIDIOX was leukopenia gr. 4 occurred in 74.1%. With median follow-up of 76 months, the estimated 7-years OS and EFS in R-HD-MTX-AraC arm are 76% and 57% respectively. In R-GIDIOX arm the estimated 7-years OS and EFS are 59% and 44%, respectively. There are no statistical differences in EFS (p=0.47) and OS (p=0.06) between two arms. Conclusions. The use of a risk-adapted strategy allowed 95.7% of patients achieve PR/CR/CRu, performed autoSCT and begun R-maintenance therapy with rituximab. None of the patients needed a premature discontinuation of therapy because of unacceptable toxicity. The performance of autoSCT and R-maintenance apparently allowed to partially offset differences in the intensity of induction therapy and to maintain comparable results of therapy in both induction arms.
Keywords: mantle cell lymphoma, high dose cytarabine, autoSCT, gemcitabine and oxaliplatin, R-maintenance.
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47. Wang M, Rule S, Zinzani PL, et al. Acalabrutinib in relapsed or refractory mantle cell lymphoma (ACE-LY-004): a single-arm, multicentre, phase 2 trial. Lancet. 2018 Feb 17;391(10121):659-67. doi: 10.1016/S0140-6736(17)33108-2
48. Tam CS, Anderson MA, Pott C, et al. Ibrutinib plus Venetoclax for the Treatment of Mantle-Cell Lymphoma. N Engl J Med. 2018 Mar 29;378(13):1211-23. doi: 10.1056/NEJMoa1715519.
________________________________________________
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1 ГБУЗ «Городская клиническая больница им. С.П. Боткина» Департамента здравоохранения г. Москвы, Москва, Россия;
2 ФГБУ «Национальный медицинский исследовательский центр гематологии» Минздрава России, Москва, Россия;
3 ГБУЗ «Волгоградский областной клинический онкологический диспансер», Волгоград, Россия;
4 ГУЗ ТО «Тульская областная клиническая больница», Тула, Россия
1 Botkin Moscow City Clinical Hospital, Moscow, Russia;
2 National Research Center for Hematology, Moscow, Russia;
3 Volgograd Regional Clinical Oncologic Dispensary, Volgograd, Russia;
4 Tula Region Hospital, Tula, Russia