ACVBP Versus ACVBP Plus Rituximab in Low Risk Localized Diffuse Large B-cell Lymphoma
Diffuse Large Cell Lymphoma
|Study Design:||Allocation: Randomized
Endpoint Classification: Safety/Efficacy Study
Intervention Model: Parallel Assignment
Masking: Open Label
Primary Purpose: Treatment
|Official Title:||Randomized Study of ACVBP Versus ACVBP Plus Rituximab in Previously Untreated Patients Aged From 18 to 65 Years With Low-risk Localized Diffuse Large B-cell Lymphoma (Age-adjusted IPI = 0)|
- Event-free survival (EFS), events defined as death from any cause, relapse for complete responders (CR) and unconfirmed complete responders (CRu), progression during and after treatment and change of therapy.
- Response rate at the end of the treatment, disease-free survival for complete responders, overall survival and additional toxicities with R-ACVBP.
|Study Start Date:||December 2003|
|Estimated Study Completion Date:||December 2008|
Approximately 30 to 40% of diffuse large B cell lymphomas are localized at diagnosis (stage I-II). Until the seventies, radiotherapy was used as the single modality to treat these localized stages but no more than half of the patients were cured. From the eighties, anthracycline-based regimens combined or not with radiotherapy gave superior results in term of relapse free survival compared with radiotherapy alone. Later on Miller et al. published a randomized study showing that 3 cycles of CHOP combined with radiotherapy gave superior results in term of overall survival as compared with 8 cycles of CHOP. This study was recently updated with a follow up of more than 8 years and shows no more difference between the two arms, due to an excess of late mortality after the combined treatment.
Recently, two trials were conducted by the GELA to compare chemotherapy alone to a combined chemo-radiotherapy approach in patients with low risk localized diffuse large cell lymphoma (age-adjusted IPI = 0).
- The objective of the LNH 93-1 study was to compare, in patients aged from 18 to 60 years 3 cycles of CHOP followed by radiotherapy with chemotherapy alone consisting in 3 cycles of ACVBP. The ACVBP regimen includes a more intensive induction followed by a sequential consolidation. With a median follow up of 55 months, the results have shown a superiority of the ACVBP arm for both the 5 year event free (83% vs. 74%, p = 0.004) and overall survival (89% vs. 80%, p = 0.02).
- The LNH 93-4 study compared in patients >60 years the association of 4 cycles of CHOP + radiotherapy to the same regimen without irradiation. This study fails to demonstrate any benefit of the combined chemo-radiotherapy in term of survival, but indicates that chemotherapy alone is probably less toxic in patients older than 69 years.
Considering these two trials, we concluded that radiotherapy given after chemotherapy did not give any benefit to elderly patients treated for a low risk localized diffuse large cell lymphoma, and that ACVBP regimen was superior to 3 CHOP + radiotherapy in patients <60 years, and has to be considered as the treatment of reference in these patients.
Two other GELA trials contributed recently to improve the treatment of diffuse large B cell lymphoma and have to be considered for the elaboration of future studies:
- The objective of the LNH 98-5 study was to compare the association of CHOP + rituximab (R-CHOP) to the CHOP regimen alone in elderly patients with previously untreated large B-cell lymphoma. The analysis showed a significant superiority of the association CHOP + rituximab.
- The LNH 93-5 study compared the ACVBP regimen to the CHOP in patients aged from 61 to 69 years with aggressive lymphoma and at least one adverse prognostic factor according to the International Prognostic Index. Out of 703 patients included in this study, the results have shown the same complete response rate in the two arms, but a significantly better 3-year event free survival and overall survival in the ACVBP arm than in the CHOP arm. However, the benefit seems to be greater in patients <66 years, due to higher toxicity with the ACVBP regimen in elderly patients.
All the above-mentioned results led us to propose a randomized trial comparing ACVBP to ACVBP + rituximab (R-ACVBP) in previously untreated patients with low risk localized diffuse large B-cell lymphoma (age-adjusted IPI = 0), and to extend the upper age limit from 60 to 65 years.
Please refer to this study by its ClinicalTrials.gov identifier: NCT00140660
|Groupe d'Etude des Lymphomes de l'adulte|
|Hôpital Henri Mondor|
|Créteil, France, 94010|
|Hématologie CHU de Lille|
|Lille, France, 59000|
|Hôpital Saint Louis|
|Paris, France, 75010|
|Hématologie Adultes - Hôpital Necker|
|Paris, France, 75743|
|Service d'Hématologie - Centre Hospitalier Lyon-Sud|
|Pierre-Bénite cedex, France, 69495|
|Centre Hospitalier Robert Debré|
|Reims, France, 51092|
|Centre Henri Becquerel|
|Rouen, France, 76038|
|Hématologie CHU Purpan|
|Toulouse, France, 31059|
|Institut Gustave Roussy|
|Centre Pluridisciplinaire d'Oncologie, CHUV|
|Lausanne, Switzerland, 1011|
|Principal Investigator:||Nicolas Ketterer, MD||Lymphoma Study Association|
|Study Director:||Felix Reyes, MD||Lymphoma Study Association|
|Study Chair:||Hervé Tilly, MD||Lymphoma Study Association|
|Study Chair:||Corinne Haioun, MD||Lymphoma Study Association|