Non Hodgkin Lymphoma Clinical Trial
SWOG-9704 Chemoradiotherapy and Peripheral Stem Cell Transplantation Compared With Combination Chemotherapy in Treating Patients With Non-Hodgkin’s Lymphoma
Summary
RATIONALE: Drugs used in chemotherapy use different ways to stop cancer cells from dividing so they stop growing or die. Radiation therapy uses high-energy x-rays to damage cancer cells. Peripheral stem cell transplantation may allow the doctor to give higher doses of chemotherapy and radiation and kill more cancer cells. It is not yet known whether chemoradiotherapy plus peripheral stem cell transplantation is more effective than combination chemotherapy alone in treating non-Hodgkin's lymphoma.
PURPOSE: This randomized phase III trial is studying chemoradiotherapy and peripheral stem cell transplantation to see how well they work compared to combination chemotherapy in treating patients with stage II, stage III, or stage IV non-Hodgkin's lymphoma.
Full Description
OBJECTIVES:
Compare the overall survival and progression-free survival of patients with intermediate- or high-grade non-Hodgkin's lymphoma treated with high-dose chemoradiotherapy and autologous peripheral blood stem cell transplantation (APBSCT) vs conventional dose cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (or CHOP plus rituximab for CD20+ disease) with possible late APBSCT.
Compare the toxic effects of these regimens in this patient population.
OUTLINE: This is a randomized study. Patients are stratified according to disease risk (intermediate-high vs high).
Patients receive CHOP chemotherapy comprising cyclophosphamide IV over 15 minutes, doxorubicin IV, and vincristine IV on day 1 and oral prednisone on days 1-5. Patients with CD20-positive disease also receive rituximab IV on day 1 (or day 0 during course 1 only). Treatment repeats every 3 weeks for 5 courses in the absence of disease progression or unacceptable toxicity.
Within 35 days of completing the fifth course, patients with partial or complete response are randomized to one of two treatment arms.
Arm I: Patients receive CHOP (or CHOP plus rituximab [CHOP-R]) as above. Treatment repeats every 3 weeks for 3 additional courses. After completion of chemotherapy, patients are encouraged to undergo harvest of peripheral blood stem cells (PBSC) for possible use at time of relapse. After completion of 8 courses, patients receive no additional therapy until disease progression or biopsy-proven disease.
Arm II: Patients receive one additional course of CHOP/CHOP-R followed by filgrastim (G-CSF), sargramostim (GM-CSF), or other colony-stimulating factors used singly or in combination according to center preference. PBSC are harvested and selected for CD34+ cells. Patients under age 61 receive one of two preparative regimens: a total body irradiation (TBI)-based regimen comprising irradiation administered twice daily on days -8 to -5, etoposide IV over 4 hours on day -4, and cyclophosphamide IV over 1 hour on day -2 OR carmustine IV over 2 hours on days -6 to -4 and etoposide and cyclophosphamide as in the TBI-based regimen. Patients age 61 to 65 receive the augmented regimen comprising carmustine, etoposide, and cyclophosphamide as above. Patients receive involved field radiotherapy prior to the preparative regimen only if there is biopsy-proven residual bulk disease and at the discretion of the center. PBSC are reinfused 36-48 hours after completion of cyclophosphamide. If both bone marrow and PBSC are harvested, bone marrow is reinfused on day 0 and then PBSC are reinfused either the same day or the following day.
Patients are followed every 6 months for 2 years and then annually thereafter.
PROJECTED ACCRUAL: Approximately 360 patients (at least 135 per treatment arm) will be accrued for this study within 5 years.
Eligibility Criteria
DISEASE CHARACTERISTICS:
Histologically proven intermediate- or high-grade non-Hodgkin's lymphoma
Ann Arbor classification of "bulky" stage II, III, or IV
Must be classified as high-intermediate or high-risk according to International Age Adjusted Index
Bidimensionally measurable disease
No lymphoblastic, transformed, or mantle cell lymphomas
No CNS involvement by lymphoma
CD20 status confirmed by immunocytochemistry or flow cytometry
Must have either bilateral or unilateral bone marrow aspiration and biopsy ≥ 42 days before first course of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) therapy (or CHOP plus rituximab [CHOP-R] for CD20+ disease) OR within 42 days prior to registration if CHOP/CHOP-R therapy has not begun
Must have bilateral bone marrow aspiration and biopsy within 28 days of randomization
Bone marrow involvement with lymphoma is allowed, provided there is an improvement of at least 50% if used as an evaluable site of disease
No prior lymphoma, Hodgkin's lymphoma, myelodysplastic syndromes, or leukemia NOTE: A new classification scheme for adult non-Hodgkin's lymphoma has been adopted by PDQ. The terminology of "indolent" or "aggressive" lymphoma will replace the former terminology of "low", "intermediate", or "high" grade lymphoma. However, this protocol uses the former terminology.
PATIENT CHARACTERISTICS:
Age:
15 to 65
Performance status:
Not specified
Life expectancy:
Not specified
Hematopoietic:
Not specified
Hepatic:
Bilirubin no greater than 1.5 times upper limit of normal (ULN)
No nonlymphoma-related hepatic dysfunction
Renal:
Creatinine no greater than 2 times ULN
Creatinine clearance at least 60 mL/min
No nonlymphoma-related renal dysfunction
No history of grade 3 hemorrhagic cystitis due to cyclophosphamide
Cardiovascular:
No coronary artery disease, cardiomyopathy, congestive heart failure, or dysrhythmia requiring therapy
MUGA scan or 2-D echocardiogram required if patient's history is questionable
Ejection fraction normal
Pulmonary:
DLCO or FEV_1 at least 60% of predicted
Other:
Not pregnant or nursing
Fertile patients must use effective contraception
HIV negative
No other malignancy within the past 5 years except basal cell or squamous cell skin cancer or carcinoma in situ of the cervix
No allergy to etoposide
No active bacterial, fungal, or viral infection
PRIOR CONCURRENT THERAPY:
Biologic therapy:
No prior monoclonal antibody therapy for lymphoma except if included in a single course of CHOP/CHOP-R
Chemotherapy:
No prior chemotherapy for lymphoma except for a single course of CHOP/CHOP-R* NOTE: *Prednisone or other corticosteroids not considered prior chemotherapy
Endocrine therapy:
See Chemotherapy
Prior corticosteroids allowed
Radiotherapy:
No prior radiotherapy for lymphoma
No prior thoracic radiotherapy or radiotherapy greater than 2,000 cGy to any other site
Surgery:
Not specified
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There are 15 Locations for this study
Portland Oregon, 97201, United States
Calgary Alberta, T2N 4, Canada
Edmonton Alberta, T6G 1, Canada
Winnipeg Manitoba, R3E 0, Canada
Moncton New Brunswick, E1C 6, Canada
St. John's Newfoundland and Labrador, AIB 3, Canada
Halifax Nova Scotia, B3H 1, Canada
Hamilton Ontario, L8V 5, Canada
London Ontario, N6A 4, Canada
Toronto Ontario, M4N 3, Canada
Montreal Quebec, H2L 4, Canada
Montreal Quebec, H4J 1, Canada
Quebec City Quebec, G1R 2, Canada
Quebec City Quebec, G1S 4, Canada
Saskatoon Saskatchewan, S7N 4, Canada
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