Management of Relapse

Chemo Secrets From a Breast Cancer Survivor

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A relapse indicates a poor prognosis, regardless of the site of relapse, tumor histology, other original prognostic factors, prior therapy, or time from diagnosis to relapse. For this reason, the selection of the most effective front-line treatment is critical. Relapsed patients are first treated to induce remission. For lymphoblastic lymphoma and B-cell lymphomas, see Table 16-11. Chemotherapy with ifosfamide, carboplatin, and etoposide (VP-16) is a useful salvage regimen following which autologous stem cell harvest is generally easily achieved. After induction of complete or very good partial remission, consolidation with stem cell transplantation is indicated. Patients who are chemotherapy resistant are unlikely to be cured using autologous stem cell transplantation. Patients with B-lineage lymphomas that are CD20+ may benefit from the addition of rituximab to help induce remission. ALCL may require less aggressive salvage (see Table 16-12). Autologous transplant does not provide added benefit. Patients who have a second relapse may benefit from therapy with vinblastine 6 mg/m2/week for 12-18 months. Cis-retinoic acid, with or without interferon-a, has maintained prolonged remissions in some patients.

Adoptive immunotherapy using allogeneic stem cell transplantation is theoretically preferable because numerous studies demonstrate a substantially lower relapse rate as a result of graft versus lymphoma effects. There is a tendency toward improved survival with allogeneic compared to autologous transplantation; however, the increased risk of allogeneic transplant-related mortality reduces this advantage somewhat. As transplantation techniques improve, it is likely that these differences will become statistically significant. Disease-free survival for allogeneic

Table 16-11. Treatment for Relapsed NHL

• Ifosfamide 1800 mg/m2/day IV over 1 hour with Mesna 1800 mg/m2/day IV (in 5 divided doses of 360 mg/m2 given as a bolus: immediately before, as a 3-hour infusion immediately after ifosfamide, and as a bolus at hours 3, 6, and 9 post-ifosfamide) on days 1-5.

• Carboplatin 300 mg/m2/day IV over 1 hour on days 1-3.

• Etoposide, 100 mg/m2/day IV over 1 hour on days 1-5.

• Repeat second cycle 3 weeks from the first cycle, then reevaluate radiographically. If in complete remission or very good partial remission, proceed to consolidation with transplantation. If responsive, may give 3rd cycle prior to consolidation with transplantation.

If resistant, alternate therapies such as rituximab or phase I/II therapy are indicated.

Table 16-12. Treatment of Relapsed Anaplastic Large Cell Lymphoma

Six-week cycles repeated for 12 months:

transplants range from 24% to 68%, and in autologous transplants from 22% to 46%. Although these numbers are encouraging, they represent patients transplanted, excluding those who could not be transplanted because of prior toxicity or lack of response.

Myeloablative chemotherapy regimens, including CBV (Table 16-13) or BEAM (Table 16-14), have been utilized followed by stem cell transplantation. Other mye-

Table 16-13. CBV Regimen for Stem Cell Transplantation in Non-Hodgkin

Lymphoma

Table 16-13. CBV Regimen for Stem Cell Transplantation in Non-Hodgkin

Lymphoma

Days

Chemotherapy

-8, -7, -6

BCNU: 100 mg/m2/day IV over 3 hours (total dose = 300 mg/m2)

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