an update on the treatment of lymphoma ted wun, m.d., f.a.c.p. professor of medicine and chief in...

An Update on the Treatment of Lymphoma

Ted Wun, M.D., F.A.C.P.Professor of Medicine and Chief

In consultation with Joseph Tuscano, M.D.Professor of Medcine

Division of Hematology Oncology, UC Davis SOM

Objectives

• To have a better understanding of the role of maintenance Rituximab after initial induction therapy for indolent lymphoma

• Elucidate the role of dose dense chemotherapy in the management of diffuse large cell lymphoma

• Examine the role of Lenalidomide in the management of lymphoma

• Have a better understanding of the up-front management strategies for indolent lymphoma-answer the question “is there a new standard of care?”

The Role of Rituxan for Induction and Maintenance of Indolent Lymphoma

Unresolved questions

• How does Rituximab maintenance compare with retreatment at progression?

• Will newer, more effective induction regimens eliminate the need for Rituximab maintenance?

• What are the best endpoints for Rituximab maintenance trials?

– ORR, PFS, OS, QOL ?

What is the Role of Rituxan for Purging Prior to Auto PSCT and Maintenance After

EBMT-Lym-1Conclusions

• Rituximab maintenance significantly prolongs PFS post AutoPSCT for relapsed indolent NHL

• Rituximab purging does not have a significant effect on PFS

•Consistent with prior studies, AutoPSCT produces durable remissions in patients with relapsed indolent NHL and may be curative in some patients

Maintenance rituximab for FL

Richard Fischer ASCO 2010

The role of Lenalidomide for the treatment of lymphoma

Relapsed/Refractory Diffuse Large B-Cell Lymphoma With Nongerminal Center B-Cell Phenotype Is Associated With a Higher Response to Lenalidomide Monotherapy or in Combination With Rituximab

Francisco Hernandez-Ilizaliturri, MD,1 George Deeb, MD,2 Pier Luigi Zinzani, MD,3 Stefano A. Pileri, MD,3 Farhana Malik, MD,4

William R. Macon, MD,5 Andre Goy, MD,6 Thomas E Witzig, MD,5 and Myron S. Czuczman, MD1

American Society of Clinical Oncology June 2010

1. Medical Oncology and Immunology, Roswell Park Cancer Institute, Buffalo, NY; 2. Pathology, Roswell Park Cancer Institute, Buffalo, NY; 3. Department of Haematology and Oncological Sciences Lorenzo and Ariosto Seràgnoli (DHOS-S), University of Bologna, Bologna, Italy; 4. Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY; 5. College of Medicine, Mayo Clinic, Rochester, MN; 6. The John Theurer Cancer Center at the Hackensack University Medical Center, Hackensack, NJ.

1. Medical Oncology and Immunology, Roswell Park Cancer Institute, Buffalo, NY; 2. Pathology, Roswell Park Cancer Institute, Buffalo, NY; 3. Department of Haematology and Oncological Sciences Lorenzo and Ariosto Seràgnoli (DHOS-S), University of Bologna, Bologna, Italy; 4. Medical Oncology, Roswell Park Cancer Institute, Buffalo, NY; 5. College of Medicine, Mayo Clinic, Rochester, MN; 6. The John Theurer Cancer Center at the Hackensack University Medical Center, Hackensack, NJ.

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Lenalidomide Response in Rel/Ref DLBCL: NFκB Target Genes Are Highly Expressed in Activated B-Cell–Like DLBCL

Rel/Ref=relapsed/refractory; DLBCL=diffuse large B-cell lymphoma; NFKB=nuclear factor kappa B; ABC=activated B-cell–like; GCB=germinal center B-cell–like. Courtesy of L. Staudt. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

Rel/Ref=relapsed/refractory; DLBCL=diffuse large B-cell lymphoma; NFKB=nuclear factor kappa B; ABC=activated B-cell–like; GCB=germinal center B-cell–like. Courtesy of L. Staudt. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

NFκB Target Gene P ValueIRF-4 6.23 E-29Cyclin D2 1.28 E-16Pim-1 2.69 E-19Lyn 5.34 E-19BIC 6.49 E-18CD44 2.35 E-13FLICE 3.30 E-14IM684838 8.74 E-14IκB 7.64 E-09EBI2 2.77 E-07NCF2 6.67 E-07DIFF48 2.86 E-06CCR7 1.55 E-05SNF2L2 1.16 E-05NFκB1 6.68 E-05IL-6 4.01 E-04

Lenalidomide Response in Rel/Ref DLBCL: The Stromal-2 Signature Encodes Regulators and Components of Angiogenesis (unfavorable)

Courtesy of L. Staudt. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

Courtesy of L. Staudt. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

Lenalidomide Response in Rel/Ref DLBCL: Can We Predict Clinical Response to Lenalidomide in DLBCL Patients?• Retrospective study of patients with DLBCL treated with lenalidomide

alone or in combination with rituximab or dexamethasone at 4 academic institutions (N=56)

– RPCI (N=19)– Mayo Clinic (N=20)– University of Bologna (N=11)– John Theurer Cancer Center at the Hackensack University (N=6)

• Patients divided into GCB and non-GCB cohorts using the criteria proposed by Hans et al

• Tumor biopsies are routinely stained for MUM1, CD10, Bcl-6, and Ki67 by the Pathology Department at RPCI or the Mayo Clinic

• Responses to lenalidomide assessed by standard and/or revised Cheson criteria1,2

• Differences in RR, response duration to lenalidomide and OS were analyzed using the software program SPSS 14

RPCI=Roswell Park Cancer Institute; RR=response rate; OS=overall survival.Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.1. Cheson et al. J Clin Oncol. 2007 Feb 10;25(5):579-86; 2. Cheson et al. J Clin Oncol. 1999;17:1244-1253.

RPCI=Roswell Park Cancer Institute; RR=response rate; OS=overall survival.Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.1. Cheson et al. J Clin Oncol. 2007 Feb 10;25(5):579-86; 2. Cheson et al. J Clin Oncol. 1999;17:1244-1253.

Lenalidomide Response in Rel/Ref DLBCL: Can We Predict Clinical Response to Lenalidomide in DLBCL Patients?

• Rel/Ref DLBCL: N=56• Histological diagnosis

– DLBCL=49

– FL and DLBCL (composite)=5

– Transformed NHL=2

• IHC classification of the patients– Non-GCB=28

– GCB=25

– Undetermined=3

• Median age=66 years (range 43-80)• Median number of prior therapies=4 (range 2-13)• Median cycles of lenalidomide=2 (range 1-35)

FL=follicular lymphoma; IHC=immunohistochemistry.Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

FL=follicular lymphoma; IHC=immunohistochemistry.Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

Lenalidomide Response in Rel/Ref DLBCL: Differences in Responses to Lenalidomide Monotherapy in Rel/Ref GCB vs Non-GCB DLBCL (N=40)

• The ORR rate for patients with GCB DLBCL was 8.7% vs 53% for patients with non-GCB DLBCL treated with lenalidomide monotherapy

• No differences in the median number of treatments, IPI score, histology, stage, or other demographic characteristics were seen at time of lenalidomide Rx between the 2 groups

PR=partial response; CR=complete response; ORR=overall response rate. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

PR=partial response; CR=complete response; ORR=overall response rate. Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

DLBCL Subtype

Median

Estimate SE

95% Confidence

Interval

N=40 Lower Bound

Upper Bound

Non-GCB 187 51.4 86.16 287.84

GCB 51 22.1 7.57 94.43

Lenalidomide Response in Rel/Ref DLBCL: PFS Following Lenalidomide Monotherapy in DLBCL According to Histological Subtype

Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.Hernandez-Illizaliturri et al. Abstract and poster presented at: 2010 Annual ASCO Meeting; June 4-8, 2010; Chicago, IL. Abstract 8038.

Lenalidomide Response in Rel/Ref DLBCL: CC-5013-DLC-001 Study Schema


Lenalidomide Response in Rel/Ref DLBCL: Summary• Lenalidomide monotherapy or in combination with rituximab are active

salvage therapies in rel/ref DLBCL• These data strongly suggest that 2 previously identified groups of

patients with DLBCL (GCB vs non-GCB) appear to have significantly different degrees of responsiveness to lenalidomide in the rel/ref setting

• A prospective phase 2/3 randomized clinical trial comparing lenalidomide vs investigator choice of “salvage monotherapy” in patients with rel/ref DLBCL is underway; patients will be stratified according to the Hans algorithm as GCB or non-GCB DLBCL prior to treatment


R2: Preliminary Results of a Phase 2 Study of Lenalidomide and Rituximab in Relapsed/Refractory Indolent NHL

Mrinal Dutia,1 Ian DeRoock,2 Karen Chee,3 Robert O’Donnell,2 Christine Quirch,2

Christine Reed-Pease,2 Joseph M. Tuscano2

1UC Davis Cancer Center, Sacramento, CA, 2UC Davis Medical Center, Sacramento, CA,

3California Cancer Care, San Mateo, CA

American Society of HematologyDecember 2009

Back to TOC Back to TOC

Lenalidomide and Rituximab in Rel/Ref Indolent NHL: Introduction and Objective

• Introduction– Lenalidomide is a potent immunomodulatory agent

with both antiproliferative and antiangiogenic activity– Lenalidomide monotherapy has clinical activity in patients with

rel/ref indolent and aggressive lymphomas– Synergistic activity between lenalidomide and

rituximab has been reported in both cellular and animal lymphoma models

• Objective– To evaluate the safety and efficacy of the combination of R2 in a

phase 2, single-arm study of patients with rel/ref indolent NHL

Rel/ref=relapsed/refractory. Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679. Back to TOC Back to TOC

Baseline Patient Characteristics

Median age, years (range) 60 (50-91)

Men/women, n (%) 8/8 (50/50)

Histology, n (%)

FL 13 (81)

MZL 2 (13)

SLL 1 (6)

Median time from dx to treatment, years (range) 7.3 (1.2-19)

Median lines of prior therapy (range) 3 (1-11)

Prior rituximab, n (%) 14 (88)

Refractory to prior rituximab, n (%)* 7 (44)

Lenalidomide and Rituximab in Rel/Ref Indolent NHL: Baseline Characteristics (N=16)

MZL=marginal zone lymphoma; dx=diagnosis.* Rituximab resistance was defined as no response, or relapse ≤6 months after initiating rituximab.Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679.


Lenalidomide and Rituximab in Rel/Ref Indolent NHL: Grade 3/4 AEs (N=16)

After prophylaxis was initiated, TLS was not observed at the 20-mg dose level

After prophylaxis was initiated, TLS was not observed at the 20-mg dose level

AE=adverse event.Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679.

Grade 3/4 AEs (occurring in 10% of patients ) n (%)

Lymphopenia 4 (25)

Neutropenia 3 (18)

Fatigue 2 (12)

Hyponatremia 3 (18)


Lenalidomide and Rituximab in Rel/Ref Indolent NHL: Response Based on Histology and Prior Therapy

nn ORR, %ORR, % CR/CRu, nCR/CRu, n PR, nPR, n SD, nSD, n PD, nPD, n

Indolent NHL 16 75 5 7 2 2

FL 13 85 5 6 1 1

MZL 2 50 0 1 0 1

SLL 1 0 0 0 1 0

Responses based on prior therapy

Rituximab-refractory 77 5757 11 33 11 22

Heavily pretreated* 1010 7070 33 44 11 22

* Heavily pretreated, 3 prior therapies; CRu=unconfirmed complete response; PD=progressive disease.Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679. Back to TOC Back to TOC

Lenalidomide and Rituximab in Rel/Ref Indolent NHL: Summary and Conclusions

• 75% ORR (31% CR) in all patients with indolent NHL• Particular activity noted among patients with rel/ref FL

– 85% ORR in (11 of 13) patients with FL

– 38% CR/CRu

• Responses appeared to correlate with number of cycles of lenalidomide received

– 5 patients with a CR/CRu received a median of 13 cycles

– 7 patients with a PR received a median of only 7 cycles

• TLS prophylaxis and monitoring are recommended, particularly during the initial cycles of treatment

• Further evaluation of this combination is underway– In larger studies of indolent NHL, and particularly in patients with FL

– In earlier lines of therapy

Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679.

A Biologic Combination of Lenalidomide and Rituximab for Frontline Therapy of Indolent B-Cell Non-Hodgkin’s Lymphoma

Nathan Fowler, Peter McLaughlin, Fredrick Hagemeister, Larry W. Kwak, Michelle Fanale, Sattva Neelapu, Louis Fayad, Barbara Pro, Crystal Sergent, Shana White, Felipe Samaniego

Department of Lymphoma/Melanoma, MD Anderson Cancer Center, Houston, Texas

American Society of HematologyDecember 2009

Phase II Study of Lenalidomide + Rituximab in Indolent NHL: Rationale and Objective • Despite advances, optimal treatment for patients with newly-

diagnosed indolent NHL has not been determined• In the rel/ref setting, treatment with lenalidomide has resulted in a

response duration 16.5 months• Rituximab has been shown to have clinical activity

in indolent NHL• This phase II study evaluates the efficacy and safety of the

lenalidomide and rituximab as frontline treatment of indolent NHL– Patients with untreated stage III or IV indolent NHL

– Rituximab 375 mg/m2 IV on Day 1 and lenalidomide 20 mg/day on Days 1-21 of a 28-day cycle

– A total of 6 cycles administered

Rel/ref=relapsed/refractory; IV=intravenous.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714.

Phase II Study of Lenalidomide + Rituximab in Indolent NHL: Patient Demographics (N=30)

Characteristic

Median Age (range), years56 (33-

77)

Sex, n (%)Women 13 (43)

Men 17 (57)

Histology, n (%)

MZL 9 (30)

SLL 3 (10)

FL 18 (60)

FLIPI score, n (%)(n=18)

Low 3 (17)

Intermediate 12 (66)

High 3 (17)

BM involvement, n (%)Positive 7 (23)

Negative 23 (77)FLIPI=Follicular Lymphoma International Prognostic Index; BM=bone marrow; MZL=marginal zone lymphoma.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714.

Phase II Study of Lenalidomide + Rituximab in Indolent NHL: Most Common Grade 3 or 4 AEs Were Rash, Neutropenia, and Myalgia (N=30)

AEsGrade 3

n (%)Grade 4

n (%)

Rash 6 (20) 0

Neutropenia 4 (13) 3 (10)

Myalgia 4 (13) 0

Infection 1 (3) 0

Neuropathy 1 (3) 0

Fatigue 1 (3) 0

Thrombosis 0 1 (3)

AEs=adverse events.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714. Back to TOC Back to TOC

Phase II Study of Lenalidomide + Rituximab in Indolent NHL: Therapy Was Generally Well Tolerated (N=30)

• 50% of patients developed rashes (all grades)– Rash was self-limited – Usually did not occur on re-exposure to drug– 1 patient discontinued during cycle 1 due to leukocytoclastic

vasculitis

• 4 patients required dose reductions due to neutropenia

• No patients developed TLS

• 1 patient experienced neuropathy (Grade 2)

• Most common AEs were myalgia and fatigue (Grade 1/2)

TLS=tumor lysis syndrome.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714. Back to TOC Back to TOC

Frontline Therapy With Lenalidomide + Rituximab is Clinically Active in Patients With Indolent NHL

• 28 patients received at least 1 post-baseline tumor assessment and were evaluable for response

Tumor subtype n SD PR CR/CRu ORR (CR/CRu)

FL 17 1 0 16 94% (94%)

SLL 3 0 2 1 100% (33%)

MZL 8 3 1 4 63% (50%)

Total 28 4 3 21 86% (75%)

CRu=unconfirmed complete response.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714.

Lenalidomide Plus Rituximab Is Clinically Active as Frontline Therapy in Indolent NHL• 86% ORR (75% CR/CRu) in patients with indolent B-cell NHL

treated with lenalidomide + rituximab– 94% ORR (94% CR/CRu) in patients with follicular lymphoma – Treatment was well tolerated with a manageable toxicity profile

• Tolerability profile comparable to that observed with studies of lenalidomide monotherapy

• The lenalidomide and rituximab combination appears to be clinically relevant for first-line therapy of indolent B-cell NHL

• Additional studies are underway to explore the role for lenalidomide + rituximab in the treatment of indolent NHL1,2

1. Ahmadi et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1700; 2. Dutia et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009. Abstract 1679.Fowler et al. Abstract and poster presented at: 51st Annual ASH Meeting and Exhibition; December 5-8, 2009; New Orleans, LA. Abstract 1714.

Does dose dense CHOP-R improve outcomes in patients with DLCL

R-CHOP14 VS R-CHOP21 in Elderly DLBCL Patients: LNH03-6B GELA Trial

• In 2000, GELA trial showed superiority of R-CHOP21 over CHOP21 in elderly patients with DLBCL[1]

• Other trials in elderly patients with DLBCL show superiority for – CHOP14 vs CHOP21 – R-CHOP14 vs CHOP14 – LNH03 designed to compare R-CHOP14 vs R-CHOP21 in this

setting[2]

1. Coffier B, et al. N Engl J Med. 2002;346:235-242. 2. Delarue R, et al. ASH 2009. Abstract 406.

• Primary endpoint: EFS• Secondary endpoints: CR or CRu , ORR, PFS , DFS, OS, dose

intensity, toxicity

LNH03-6B GELA Trial: Study Design

Delarue R, et al. ASH 2009. Abstract 406.

R-CHOP every 14 days for 8 cycles +

IT MTX for 4 cycles (n = 103)

R-CHOP every 21 days for 8 cycles +

IT MTX for 4 cycles (n = 99)

DLBCL patients60-80 yrs of age

(N = 202)

ProphylacticDarbepoetin alfa

Conventional treatmentfor chemotherapy-

induced anemia

ProphylacticDarbepoetin alfa

Conventional treatmentfor chemotherapy-

induced anemia

LNH03-6B GELA Trial: Pt Characteristics

Characteristic R-CHOP21 (n = 99)

R-CHOP14 (n = 103)

Median age, yrs 72 71

Elevated LDH, % 68 68

Mass > 10 cm, % 17 18

B symptoms, % 43 37

Status

Ann Arbor 111-IV, % 85 92

IPI > 3, % 36 42

Age-adjusted IPI 2-3, % 59 67


LNH03-6B GELA Trial: Results


Outcome R-CHOP21(n = 99)

R-CHOP14(n = 103)

P Value

2-yr EFS, % 61 48 .11

Median EFS, mos Not reached 22 --

2-yr PFS, % 63 49 .12

Median PFS, mos Not reached 23 --

2-yr DFS, % 70 57 .40

Median 2-yr OS, % 70 67 .37

End-of-treatment response rates

CR + CRu 75 67 NS PR 9 14 NS ORR 84 81 NS

• Hematologic toxicities greater for R-CHOP14

• Patients on R-CHOP14 had higher rates of febrile neutropenia, hospitalization, and death due to toxicity

LNH03-6B GELA Trial: Toxicities


R-CHOP14R-CHOP21

11152221

36

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69

8373

83

Pat

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ts (

%)

100908070605040302010

0Grade 3/4

LeukocytesGrade 3/4

NeutrophilesGrade 3/4

HemoglobinRBC

TransfusionGrade 3/4Platelets

PlateletTransfusion

LNH03-6B GELA Trial: Other Outcomes

• Patients randomized to receive every-21-day dosing more likely to receive scheduled dose intensity

– Median cyclophosphamide dose intensity 96% with R-CHOP21 vs 84% with R-CHOP14

– Median doxorubicin dose intensity 95% with R-CHOP21 vs 83% with R-CHOP14

• 90% of patients in R-CHOP14 group administered filgrastim or pegfilgrastim vs 68% for R-CHOP21


The role of Bendamustine in the initial management of patients with indolent

lymphoma

STiL: First-line Bendamustine + Rituximab in Patients With FL, Indolent, and MCL

• Primary endpoint: noninferiority of bendamustine-rituximab when compared with R-CHOP for first-line treatment of advanced lymphomas

• Secondary endpoints: response rates, time to next treatment, EFS, OS, adverse events, infectious complications

Rummel MJ, et al. ASH 2009. Abstract 405.

Bendamustine-RituximabBendamustine 90 mg/m2 on Days 1, 2

+ Rituximab 375 mg/m2 on Day 1max 6 cycles, q 4 wks

(n = 260)

R-CHOP Max 6 cycles, q 3 wks

(n = 253)

Stage III or IV CD20+ lymphoma

(N = 549)

STiL: Results

• Primary endpoint: bendamustine-rituximab superior to R-CHOP for PFS in overall population

– PFS: 54.9 vs 34.8 mos (P = .00012)

• In subanalysis, bendamustine-rituximab superior to R-CHOP in FL (P = .0281), mantle cell lymphoma (P = .0146), and Waldenström’s macroglobulinemia (P = .0024)

• Secondary endpoints: bendamustine-rituximab at least comparable to R-CHOP in all measurements

– bendamustine-rituximab better to R-CHOP for CR (39.6% vs 30.0%, respectively: P = 0.26) and time to next treatment (not reached vs 37.5 mos, respectively; P = .001)


STiL: Toxicities

• Myelosuppression grade 3/4; B-R vs R-CHOP (% of cycles), respectively; P < .0001

– Neutropenia: 10.7% vs 46.5% – Leukocytopenia: 12.1% vs 38.2%– G-CSF administered: 4.0% vs

20.0%

• Other adverse events for BR– Less alopecia (P < .001) – Paresthesias (P < .001) – Infectious complications

(P = .0025)


B-R (n = 260)R-CHOP (n = 253)

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Conclusions

• Rituxan maintenance is appropriate for selected patients after R-containing induction chemotherapy. However the optimal maintenance remains undefined

• Lenalidomide with or without Rituximab is highly active in patients with both indolent and DLCL-consider enrolling patients of UCD clinical trials #197 (relapsed/refractory) and #224 (initial therapy)

• CHOP-R 21 (for 8 cycles) remains the standard of care for the initial management of DLCL-consider enrolling patients on CALBG 50303 (DA-EPOCH-R vs CHOP-R)

• BR can be considered a new standard induction regimen of the initial management of indolent NHL

an update on the treatment of lymphoma ted wun, m.d., f.a.c.p. professor of medicine and chief in...

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