how i treat the peripheral t-cell lymphomas - portal.ebmt.org · d'amore f et al. jco...
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How I treat the peripheral T-cell
lymphomas
Heidelberg, 25.09.2015
Norbert Schmitz
Hematology, Oncology and Stem Cell Transplantation
Asklepios Hospital St. Georg, Hamburg
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Mature T- and NK-cell disorders Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW (Eds.):
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC: Lyon 2008
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphome (ALCL), ALK negative
Anaplastic large cell lymphome (ALCL), ALK positive
Extranodal NK-/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
T-cell prolymphocytic leukaemia
T-cell large granular lymphocytic leukaemia
Chronic lymphoproliferative disorders of NK-cells
Aggressive NK-cell leukaemia
EBV-positive T-cell lymphoproliferative disorders of childhood
Adult T-cell leukaemia/lymphoma
Mucosis fungoides
Sézary syndrome
Primary cutaneous CD30-positive T-cell lymphoproliferative disorders
Primary cutaneous gamma-delta T-cell lymphomas
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Mature T- and NK-cell disorders Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW (Eds.):
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC: Lyon 2008
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphome (ALCL), ALK negative
Anaplastic large cell lymphome (ALCL), ALK positive
Extranodal NK-/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
T-cell prolymphocytic leukaemia
T-cell large granular lymphocytic leukaemia
Chronic lymphoproliferative disorders of NK-cells
Aggressive NK-cell leukaemia
EBV-positive T-cell lymphoproliferative disorders of childhood
Adult T-cell leukaemia/lymphoma
Mucosis fungoides
Sézary syndrome
Primary cutaneous CD30-positive T-cell lymphoproliferative disorders
Primary cutaneous gamma-delta T-cell lymphomas
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Mature T- and NK-cell disorders Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW (Eds.):
WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. IARC: Lyon 2008
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphome (ALCL), ALK negative
Anaplastic large cell lymphome (ALCL), ALK positive
Extranodal NK-/T-cell lymphoma, nasal type
Enteropathy-associated T-cell lymphoma
Hepatosplenic T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
T-cell prolymphocytic leukaemia
T-cell large granular lymphocytic leukaemia
Chronic lymphoproliferative disorders of NK-cells
Aggressive NK-cell leukaemia
EBV-positive T-cell lymphoproliferative disorders of childhood
Adult T-cell leukaemia/lymphoma
Mucosis fungoides
Sézary syndrome
Primary cutaneous CD30-positive T-cell lymphoproliferative disorders
Primary cutaneous gamma-delta T-cell lymphomas
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T-cell lymphomas in DSHNHL trials
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Pro
po
rtio
n
0 10 20 30 40 50 60 70 80 90 100 110
Months
1: ALK+ (n= 73)
2: ALK- (n= 108)
3: PTCL (n= 68)
4: AILT (n= 28)
5: T/NK (n= 18)
p-values:
2 3 4 5
1 <0.001 <0.001 0.001 <0.001
2 0.350 0.958 0.339
3 0.537 0.700
4 0.472
Schmitz et al., Blood 2010;116(18):3418
ALK+ 88.8% (95% CI: 80.8%-96.8%)
ALK- 63.3% (95% CI: 53.9%-72.7%)
3-years OS-rate:
PTCL 52.9% (95% CI: 40.2%-65.6%)
AILT 65.9% (95% CI: 47.7%-84.1%)
T/NK 48.9% (95% CI: 25.4%-72.4%)
OS - histological subtypes (n=295)
DSHNHL
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T-cell lymphomas in the Swedish Lymphoma Registry
OS - histological subtypes
ALK+ ALCL
ALK- ALCL
ALKu ALCL
PTCL NOS AITL
TCLu
Ellin et al., Blood 2014; 124:1570-77
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T-cell lymphomas in DSHNHL trials
DSHNHL
OS - International Prognostic Index (IPI) for all patients
(n=320)
IPI 0
(n=93)
IPI 1
(n=70)
IPI 2
(n=80)
IPI 3
(n=48)
IPI 4
(n=25)
IPI 5
(n=4)
0 10 20 30 40 50 60 70 80 90 100 110
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Pro
po
rtio
n
3-years OS-rate:
IPI 0: 82.0% (95% CI: 74.0-90.0%)
IPI 1: 72.7% (95% CI: 61.3-84.1%)
IPI 2: 60.7% (95% CI: 49.5-71.9%)
IPI 3: 49.8% (95% CI: 35.1-64.5%)
IPI 4: 26.7% (95% CI: 8.9-44.5%)
IPI 5: 25.0% (95% CI: 0.0-67.5%)
Months
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Treatment Strategies in
Peripheral T-cell Lymphoma First-Line Therapy
CHO(E)P
High-dose therapy/autologous Tx
HDT
A
S
C
T
CHO(E)P
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%
0
10
20
30
40
50
60
70
80
90
100
Months
0 10 20 30 40 50 60 70 80 90 100 110
p=0.057
without Etoposide (n=29)
with Etoposide (n=69)
Patients with other major subtypes GERMAN HIGH-GRADE NHL
STUDY GROUP (DSHNHL) www.lymphome.de/en/Groups/DSHNHL
Schmitz et al., Blood 2010;116(18):3418
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Gemcitabine in PTCL
Study Regimen N ORR
Sallah et al
Br J Haematol. 2001 Gemcitabine monotherapy 10 60%
Zinzani et al
Phase II
Ann Oncol. 2010
Gemcitabine monotherapy 39 69%
Royal Marsden
Phase II
Arkenau. Haematologica
2007
GEM-P 16 69%
Spencer et al
Pilot study
Intern Med J. 2007
VGF 10 70%
Kim et al
Pilot study
Cancer Chemother
Pharmacol. 2006
CHOP-EG 26 77%
CHOP-EG=CHOP-etoposide, gemcitabine; GEM-P=gemcitabine, cisplatin, methylprednisolone;
VGF=vinorelbine, gemcitabine, filgrastim.
Courtesy Dr. Advani
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Autologous transplantation
for consolidation after 1st-line therapy
No randomized study done!
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HDT / autoSCT as part of 1st-line therapy in
PTCL:Prospective trials
Patients (n)
Age (years)
Regimen
Tx-rate (%)
ORR (%)
TRM (%)
OS F/U
Corradini Leukemia 2006
62 43
1. APO → DHAP →
HD Mito./Mel
2. MACOP-B →
HD AraC/Mito →
BEAM
74 72 4.8 34% (12 y) 76 mo
Rodriguez Eur J Haematol 2006
26 44
MegaCHOP/IFE
→ BEAM
73 81 0 73% (3y) 35 mo
Mercadal Ann Oncol 2008
41
47
HighCHOP/
ESHAP altern. →
BEAM/BEAC
41 59 n.d. 39% (4 y) 3.2 y
Reimer J Clin Oncol 2009
83 47
CHOP →
DexaBEAM/ESHAP
→ HD Cy + TBI
66 71 3.6 48% (3 y) 33 mo
D`Amore J Clin Oncol 2012
160 57
CHOEP-14
→ BEAM
72 82 4 51% (5 y) 61mo
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Wilhelm et al. (submitted)
OS
HDT / autoSCT for consolidation after CHOP-
therapy in peripheral T-cell lymphoma
Overall Survival
(n=111)
++
++++
++++++ +++++++
++++ +
+++++++++++ ++++++++++++ ++++++ + ++
0 20 40 60 80 100 120
Time (months)
0,0
0,1
0,2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
1,0
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CHOEP-14 x 3
CR, PR NC,PD
CHOEP-14 x 3
stem cell collection
NLG-T-01: Design
CR, PR NC,PD
BEAM
Follow-up
Excluded:
1) alk-1 pos
ALCL T/0
2) CTCL
3) Leukemic T-
NHL
Nordic
Lymphoma
Group
d'Amore F et al. JCO 2012;30:3093-3099
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Kaplan-Meier estimates of (A) overall (OS) and (B) progression-free survival (PFS) for the entire NLG-T-01 cohort and (C) OS and (D) PFS for the four largest histologic subtypes.
d'Amore F et al. JCO 2012;30:3093-3099
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Allogeneic transplantation
as part of first-line therapy
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AlloSCT in newly diagnosed patients with p-TCL
Corradini et al. Leukemia 2014; 28: 1885-91
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AlloSCT in newly diagnosed patients with p-TCL
Corradini et al. Leukemia 2014; 28: 1885-91
PD (n=5)
PD (n=6)
PD (n=7)
Only 61% of patients were transplanted!
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Allogeneic or Autologous Transplantation
as First-Line Therapy for Younger Patients with
Peripheral T-Cell Lymphoma
Results of the Interim Analysis of the AATT Trial
Norbert Schmitz, Maike Nickelsen, Bettina Altmann, Marita Ziepert, Kamal
Bouabdallah, Christian Gisselbrecht, Sébastien Maury, Guillaume Cartron,
Emmanuel Gyan, Arnaud Jaccard, Laurence Sanhes, Philippe Gaulard,
Andreas Rosenwald, Lorenz Truemper, Bertram Glass, Peter Reimer,
Wolfgang Herr, Martin Wilhelm and Olivier Tournilhac
GERMAN HIGH-GRADE
LYMPHOMA STUDY GROUP
(DSHNHL)
THE LYMPHOMA
STUDY ASSOCIATION
(LYSA Lymphomes T)
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C H O E P
C H O E P
C H O E P
C H O E P
D H A P
B E A M
A S C T
PBSC harvest
C H O E P
C H O E P
C H O E P
C H O E P
D H A P
F B C
S C T
CR, PR, NC
No donor available
R
Days 1 15 29 43 64 4–6 weeks
CR, PR, NC
THE LYMPHOMA
STUDY ASSOCIATION
(LYSA Lymphomes T)
Inclusion criteria
• Patients 18-60 years
• ECOG 0-3
with
• Peripheral T-cell lymphoma, NOS
• Angioimmunoblastic T-cell lymphoma
• Anaplastic large cell lyphoma, ALK negative
• Extranodal NK/T-cell lymphoma, nasal type
• Enteropathy type T-cell lymphoma
• Hepatosplenic T-cell lymphoma
• Subcutaneous panniculitis-type
T-cell lymphoma
• All stages and IPI except stage I and aalPI 0
GERMAN HIGH-GRADE
LYMPHOMA STUDY GROUP
(DSHNHL)
BEAM: BCNU 300 mg/m2, Ara-C 800 mg/m2, VP-16 800 mg/m2, Mel 140 mg/m2
FBC: Fludara 125 mg/m2, Busulfan 12 mg/kg, Cyclo 120 mg/kg
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autoSCT (n=30)
alloSCT (n=28)
total (n=58)
Male 17 (57%) 20 (71%) 37 (64%)
Age, median (range) 49 (28, 60) 50 (24, 60) 50 (24, 60)
LDH > UNV 20 (67%) 19 (68%) 39 (67%)
ECOG > 1 7 (23%) 5 (18%) 12 (21%)
Stage III/ IV 26 (87%) 26 (93%) 52 (90%)
Extranod. involvement > 1 11 (37%) 7 (25%) 18 (31%)
aaIPI 0
1
2
3
1 (3%)
10 (33%)
14 (47%)
5 (17%)
1 (4%)
8 (29%)
15 (54%)
4 (14%)
2 (3%)
18 (31%)
29 (50%)
9 (16%)
Peripheral T-cell lymphoma, NOS 11 (36%) 14 (50%) 25 (43%)
Angioimmunoblastic T-cell lymphoma 7 (23%) 9 (32%) 16 (28%)
Anaplastic large cell lymphoma, ALK-neg
6 (20%) 1 ( 4%) 7 (12%)
Other1 6 (20%) 2 ( 8%) 8 (28%)
AATT study: patient characteristics
1 NK/T-cell lymphoma (1), Intestinal T-/NK-cell lymphoma (3), Hepatosplenic gamma-delta lymphoma (3), Subcutaneous panniculitis-like PTCL (1)
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THE LYMPHOMA
STUDY ASSOCIATION
(LYSA Lymphomes T)
GERMAN HIGH-GRADE
LYMPHOMA STUDY GROUP
(DSHNHL)
R
30 pts
28 pts
C H O E P
C H O E P
30 → 28 pts
28 → 27 pts
change of histology (2)
PD (1)
C H O E P
C H O E P
28 → 25 pts
27 → 26 pts
PD(1)
toxicity (1)
other (1)
PD (1)
C H O E P
C H O E P
25 → 23 pts
26 → 25 pts
PD(2)
PD (1)
C H O E P
C H O E P
23 → 21 pts
PD(2)
PD (3)
CR, PR, NC
D H A P
D H A P
CR, PR, NC
21 → 19 pts
22 → 13 pts
PD(2)
PD (4)
no donor (5)
25 → 22 pts
PBSC harvest
B E A M
A S C T
mobil. fail (1)
no donor (n=5)
F B C
S C T
23 pts
13 pts
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AATT study: course of therapy
autoSCT
(n=30)
alloSCT
(n=28)
Total
(n=58)
Complete as per protocol
19 (63%) 17 (61%) 36 (62%)
Off study 11 (37%) 11 (39%) 22 (38%)
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AATT study: cause of death according to treatment arm (ITT)
autoSCT
(n=30)
alloSCT
(n=28)
Total
(n=58)
Lymphoma 10 6 16
Salvage treatment 1 1 2
Hemorrhage after salvage
0 1 1
Study treatment 0 6 (4 early, 2 late)
6
PTLD 0 1 1
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AATT study: cause of death after SCT
autoSCT
(n=30)
alloSCT
(n=28)
Total
(n=58)
Lymphoma 6 0 6
Salvage treatment 1 0 1
NRM 0 7* 7*
* includes one patient with PTLD
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AATT study: updated results of the interim analysis
OS according to treatment arm
time (months)
0 10 20 30 40 50
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
autoSCT (n=30)
p=0.362
median observation time: 26 months
alloSCT (n=28)
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Salvage therapy including
autologous transplantation
in relapsed / refractory
T-cell lymphoma
No randomized study done!
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(A) Second progression-free survival (median, 3.7 months) of patients treated with
chemotherapy (n = 89) with relapsed or progressive peripheral T-cell lymphoma (PTCL) and
(B) overall survival (median, 6.5 months) after first relapse or progression of PTCL.
Mak V et al. JCO 2013;31:1970-1976
©2013 by American Society of Clinical Oncology
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Treatment Strategies in Peripheral T-cell
Lymphoma Relapsed/Refractory Disease
High-dose therapy/autologous Tx
BEAM
A
S
C
T
Chemotherapy
DHAP
Allogeneic Tx DHAP
FBC
S
C
T
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HDT/ autoSCT in pTCL
36%
50%
0,00
0,20
0,40
0,60
0,80
1,00
0 12 24 36 48 60 72 84 96 108
Months after SCT
OS
0,00
0,20
0,40
0,60
0,80
1,00
0 12 24 36 48 60 72 84 96 108
Months after SCT
PFS
Retrospective analysis of T – cell lymphoma patients
at all stages treated with different preparatory regimens
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Allogeneic transplantation
In relapsed/refractory T-NHL
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AlloSCT in pTCL: The CIBMTR Experience
Smith S M et al. JCO 2013;31:3100-3109
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Wulf et al., BMT(in press)
n=95
patients at risk
(OS)
OS
PFS
95 58 40 30 22 14 9 5 4 3
OS: 46% + 6%
PFS: 43% + 5%
AlloSCT in pTCL: The German Experience
(n=95)
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Results in Allogeneic Transplantation for
Relapsed / Refractory T-Cell Lymphoma
French Study EFS 53% at 5 yrs
EBMT Study (AILT only) PFS 53% at 3 yrs
CIBMTR Study PFS 37% at 3 yrs
German Study PFS 43% at 3 yrs
40-50% of patients with relapsed / refractory disease survive long-term
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Treatment of PTCL: new drugs
Peripheral T-cell lymphoma, NOS
Angioimmunoblastic T-cell lymphoma
•Alemtuzumab
•Romidepsin
•Pralatrexate
•HDAC inhibitors
•Antiangiogenic drugs
•mTOR inhibitors
•Aurora A kinase inhibitors
Anaplastic large cell lymphome (ALCL), ALK-negative or positive
•Brentuximab Vedotin
•Crisotinib
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Fig 2: TCR signalling in nodal TFH derived lymphomas. Several genes associated with the TCR
signalling are mutated in AITL and TFH-like PTCL-NOS. Pathways were reconstructed using the Ingenuity
pathway analysis (IPA) tools and the KEGG database, and were subsequently used to group define mutant
variants in survival and gene set enrichment analysis.
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Fig 4: Enriched gene signatures in patients with or without mutations in TCR-related signalling genes.
Gene sets enriched in patients with mutated or non-mutated TCR-related signalling (irrespective of RHOA status)
genes indicate that pathway mutants have more proliferative activity, and express genes associated with TCR
activation. Genes tested in the enrichment analysis were selected from signatures relevant in T and B cell
differentiation and activation.
JAK-STAT
target genes
PIK3
target genes
NF-kB related
Ca2+ signalling
target genes
IRF4
target genes
Proliferation
Glycolysis
Proximal TCR
components
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How I treat the peripheral T-cell
lymphomas
The American View
Moskowitz AJ et al.
Blood 2014; 123: 2636-2644
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BACKUP
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Treatment Strategies in
Peripheral T-cell Lymphoma First-Line Therapy
CHO(E)P
High-dose therapy/autologous Tx
HDT
A
S
C
T
CHO(E)P
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Treatment Strategies in Peripheral T-cell
Lymphoma Relapsed/Refractory Disease
High-dose therapy/autologous Tx
BEAM
A
S
C
T
Chemotherapy
DHAP
Allogeneic Tx DHAP
FBC
S
C
T
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Response autoSCT
(n=30)
alloSCT
(n=28)
Total
(n=58)
CR/CRu 10 (33%) 11 (39%) 21 (36%)
CR/CRu and PD within 2
months 1 ( 3%) 1 ( 4%) 2 ( 3%)
PR 5 (17%) 2 ( 7%) 7 (12%)
NC 2 ( 7%) 0 ( 0%) 2 ( 3%)
PD 10 (33%) 10 (36%) 20 (35%)
Unknown 2 ( 7%) 0 ( 0%) 2 ( 3%)
Treatment - related death 0 ( 0%) 4 (14%) 4 ( 7%)
AATT study: response according to treatment arm
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Conclusions
• Interim analysis of 58 patients led to termination of the study because
conditional power analysis showed low probability to confirm hypothesis
• 38 % of pts could not proceed to auto- or alloSCT as per protocol
• AutoSCT gave results comparable to other studies
• GvL-effect of alloSCT counterbalanced by high TRM
• No significant difference between treatment arms (low patient numbers!)
• Final analysis on 104 patients expected 2017
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Treatment of PTCL: Summary
Improve induction Consolidate/maintain response
100% 65% 50% 48%
Improve induction
• C+ Alemtuzumab
• C+ Brentuximab Vedotin
• C+ Romidepsin
• C+ Pralatrexate
Consolidate response
• Auto SCT
• Allo SCT
• MoAb
• Pralatrexate
• HDAC inhibitors
Maintain response
• MoAb
• Antiangiogenic drug
• mTOR inhibitor
• Aurora A kinase inhibitors
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1st line treatment of PTCL
Improve
induction Consolidate/maintain response
100% 65% 50% 48%
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46
Study Design and Key Eligibility Criteria
• 329 patients were randomized at 78 sites in North America and Europe
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47
Progression-Free Survival in ITT population
PFS per IRF PFS per Investigator†
HR=0.57, P=0.001 HR=0.50
* Regularly scheduled CT scans † Includes information from both radiographic assessments and clinical lymphoma assessments
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Survival of relapsed patients after first-line therapy with
MegaCHOEP or CHOEP-14 (n=25)
DSHNHL
Allo SCT
0 10 20 30 40 50 60 70 80 90 100
Time after progression (months)
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
OS
(p
rop
ort
ion
)
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Survival of relapsed patients after first-line therapy with
MegaCHOEP or CHOEP-14 (n=25)
DSHNHL
Log-Rank-test p = .01209
0 10 20 30 40 50 60 70 80 90 100
time after progression (months)
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
Overa
ll s
urv
ival
(pro
po
rtio
n)
no allogeneic Tx. n=17
allogeneic Tx. n=8
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Survival of relapsed patients after first-line therapy with
MegaCHOEP or CHOEP-14
DSHNHL
0 10 20 30 40 50 60 70 80 90 100
Time after progression (months)
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
OS
(p
rop
ort
ion
) n=25
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Recommended approach to patients with relapsed peripheral T-cell lymphomas (PTCLs) regarding additional therapies and goals of care.
Lunning M A et al. JCO 2013;31:1922-1927
©2013 by American Society of Clinical Oncology
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Allo SCT in aggressive lymphoma : DSHNHL Study
Tacrolimus
MMF
Salvage
Therapy Allo SCT
F
25
F
25
F
25
F
25
F
25
B
4
B
4
B
4
C
60
C
60
R R R R R R
MMF
Tacrolimus
R CR
PR
SD
no
ATG optional ATG
F=fludarabine, B=busulfan, C=cyclophosphamide, R=rituximab, ATG=anti-thymoglobulin
18 - 65 years
Relapse < 12m
Refractory disease
Post auto SCT
off study
3 4 5 6 25 26 27 28 week -8 -5 week -9 -8 -7 -6 -5 -4 -3
R R
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RIC-allo in pTCL. The French Experience
Le Gouill et al., JCO 2008
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(A) Second progression-free survival (PFS) of patients treated with chemotherapy (n = 89) with relapsed or progressive peripheral T-cell lymphoma (PTCL) by performance status (PS;
median second PFS: PS 0 or 1, 5.0 months; PS ≥ 2, 1.8 months) and (B) overall...
Mak V et al. JCO 2013;31:1970-1976
©2013 by American Society of Clinical Oncology
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mCHOEP 1
CYC 1500
ADR 70
VCR 2
ETO 600
PRD 500
mCHOEP 2
CYC 4500
ADR 70
VCR 2
ETO 600 (960)
PRD 500
mCHOEP 3
CYC 4500
ADR 70
VCR 2
ETO 600 (960)
PRD 500
mCHOEP 4
CYC 6000
ADR 70
VCR 2
ETO 1480
PRD 500
PBPC
PBPC
PBPC
Mega-CHOEP Protocol
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OS in PTCL-NOS
International T-cell Lymphoma Project. J Clin Oncol 2008. 26; 25: 4124-4130
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OS in the common subtypes
of T-cell lymphoma
International T-cell Lymphoma Project. J Clin Oncol 2008. 26; 25: 4124-4130
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The European Group for Blood and Marrow Transplantation The European Group for Blood and Marrow Transplantation The European Group for Blood and Marrow Transplantation
Allo SCT in pTCL :
histologic subtypes n = 91
Peripheral T-cell lymphoma 54 (59.3%)
Anaplastic large cell lymphoma 26 (28.6%)
ALK pos 5 (5.4%)
ALK neg 6 (6.5%)
ALK unknown 15 (16.4%)
T-NHL unspecified 11 (12%)
(preliminary)
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The European Group for Blood and Marrow Transplantation The European Group for Blood and Marrow Transplantation The European Group for Blood and Marrow Transplantation
Allo SCT in pTCL:
patient characteristics (n = 91)
of eligible pts % of missing data
Male (%) 57.1
Age at diagn. (years) 39.9 (15-64)
SDaye III/IV (%) 90.4 19.8
Elevated LDH at diagnosis 54.3 49.5
aaIPI high / high int. (%) 63.8 48.4
Median time to SCT (months) 18 (3 – 233)
> 2 prev. treatment lines (%) 66.1 35.2
Previous auto SCT (%) 35.2
Stem cell source PB / BM (%) 73.6 / 23.1
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variable univariate p multvariate p RR 95% CI
lower limit
upper limit
age </> 50 0.39492 n.s.
m/f 0.86717 n.s.
diag. to tx </> 1y 0.5494 n.s.
lines ctx </>2 0.02816 0.013 2.368 1.201 4.667
prior auto y/n 0.61816 n.s.
PD / CR, PR, SD 0.00128 0.243 1.686 0.702 4.049
IPI 0,1,2 / 3,4 0.0079 0.241 1.821 0.669 4.956
LDH nl./elev. 0.00260 0.615 1.187 0.619 2.316
ECOG 0,1 / >2 0.01126 0.706 1.209 0.451 3.242
stage 1/2 vs 3/4 0.32942 n.s.
EN 0/1 vs >1 0.53926 n.s.
MRD / MUD,MMD 0.50185 n.s.
ATG / no ATG 0.17102 n.s.
aGvHD 0 / 1-4 0.01396 0.678 0.361 1.306
cGvHD lim. vs ext. 0.05266 n.s.
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61
61
DSHNHL
Wulf et al., submitted
n=95 B A n=95
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OS
n=97 n=97
PFS
n=97
OS OS n.s.
OS n.s.
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T-cell lymphomas in DSHNHL trials
OS - IPI score for all patients (n=320)
IPI 0
(n=93)
IPI 1
(n=70)
IPI 2
(n=80)
IPI 3
(n=48)
IPI 4
(n=25)
IPI 5
(n=4)
0 10 20 30 40 50 60 70 80 90 100 110
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Pro
po
rtio
n
Months
Schmitz et al., Blood 2010;116(18):3418
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Autologous Tx
in T-cell lymphoma
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C
H
O
P
C
H
O
P
C
H
O
P
C
H
O
P
C
H
O
P
C10 C10 C10 C10 C10 C10
C 3
PD
CR,PR
A)
B)
C
H
O
P
C
H
O
P
C 3
C10
C20
C30
HyperCHidam
HyperCHidam
CR,PR
PD
autoSCT
alloSCT
C
H
O
P
Corradini et al. (submitted)
Up-front chemo-immunotherapy with or without stem cell
transplantation in patients with peripheral T-cell lymphomas
results of a prospective multicenter phase II study
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66
66
DSHNHL
Wulf et al., submitted
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Reimer et al., JCO 2009; 27:106
PFS
HDT / autoSCT as part of 1st-line therapy in
peripheral T-cell lymphoma
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DSHNHL 2006-1A: study design
First-line treatment of mature (peripheral)
T-cell lymphoma (PTCL) for patients ≤ 60 years
Inclusion criteria • Peripheral T-cell lymphoma,
unspecified
• Angioimmunoblastic T-cell lymphoma
• Anaplastic large cell lyphoma, ALK negative
• Extranodal NK/T-cell lymphoma, nasal type
• Enteropathy type T-cell lymphoma
• Hepatosplenic T-cell lymphoma
• Subcutaneous panniculitis type T-cell lymphoma
• All stages and IPI except stage I with aalP10
C H O E P
C H O E P
C H O E P
C H O E P
D H A P
B E A M
A S C T
PBSC harvest
CR, PR, NC
C H O E P
C H O E P
C H O E P
C H O E P
D H A P
F B C
S C T
CR, PR, NC
No donor available
R
Days 1 15 29 43 64 4–6 weeks
March 2014: 90/ 146 patients randomized
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Treatment Strategies for patients with relapsed T-Cell lymphoma
chemotherapy :
platinum-based regimens, gemcitabine, methotrexate……..
new drugs:
alemtuzumab, pralatrexate, romidepsin, brentuximab, vedotin…….
high-dose therapy / autologous transplantation
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T-cell lymphomas in DSHNHL trials
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Pro
po
rtio
n
0 10 20 30 40 50 60 70 80 90 100 110
Months
1: ALK+ (n= 73)
2: ALK- (n= 108)
3: PTCL (n= 68)
4: AILT (n= 28)
5: T/NK (n= 18)
p-values:
2 3 4 5
1 <0.001 <0.001 0.001 <0.001
2 0.350 0.958 0.339
3 0.537 0.700
4 0.472
Schmitz et al., Blood 2010;116(18):3418
ALK+ 88.8% (95% CI: 80.8%-96.8%)
ALK- 63.3% (95% CI: 53.9%-72.7%)
3-years OS-rate:
PTCL 52.9% (95% CI: 40.2%-65.6%)
AILT 65.9% (95% CI: 47.7%-84.1%)
T/NK 48.9% (95% CI: 25.4%-72.4%)
OS - histological subtypes (n=295)
DSHNHL
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Gemcitabine in PTCL
Study Regimen N ORR
Sallah et al
Br J Haematol. 2001 Gemcitabine monotherapy 10 60%
Zinzani et al
Phase II
Ann Oncol. 2010
Gemcitabine monotherapy 39 69%
Royal Marsden
Phase II
Arkenau. Haematologica
2007
GEM-P 16 69%
Spencer et al
Pilot study
Intern Med J. 2007
VGF 10 70%
Kim et al
Pilot study
Cancer Chemother
Pharmacol. 2006
CHOP-EG 26 77%
CHOP-EG=CHOP-etoposide, gemcitabine; GEM-P=gemcitabine, cisplatin, methylprednisolone;
VGF=vinorelbine, gemcitabine, filgrastim.
Courtesy Dr. Advani
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AlloSCT in newly diagnosed patients with p-TCL
Corradini et al. Leukemia 2014; 28: 1885-91
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-6 -4 -3 -2 -1 0 +1 +3 +6 +30 +60 +70 +90 +120 +150 +180
Thiotepa 10 mg/kg
Fludarabine 30 mg/mq
Cyclophosphamide 30 mg/kg
Allo-HSCT
Cyclosporine (+ ATG 7.5 mg/kg for alternative donors)
MTX
MTX MTX
RIC treatment plan
Corradini et al. JCO 2004
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Graft-Versus-Lymphoma Effect in Relapsed Peripheral
T-Cell Non-Hodgkin’s Lymphomas After Reduced-
Intensity Conditioning Followed by Allogeneic
Transplantation of Hematopoietic Cells
Corradini et al. JCO 2004
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T-cell lymphomas in the Swedish Lymphoma Registry
OS - extranodal subtypes
SPTCL
HSTCL
EATL
NK/T
Ellin et al., Blood 2014; 124:1570-77