Dipartimento di Medicina e Oncologia Sperimentale, Divisione Universitaria di Ematologia; Serv. 3 Univ. e 4 Osped di Medicina Nucleare; 5

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1 (2001) 15, Nture Publishing Group All rights reserved /01 $ High-dose mitoxntrone + melphln (MITO/L-PAM) s conditioning regimen supported by peripherl blood progenitor cell (PBPC) utogrft in 113 lymphom ptients: high tolerbility with reversible crdiotoxicity C Trell 1, F Zllio 1, D Crcciolo 1, A Cuttic 1, P Corrdini 1,2, P Gvrotti 1, M Ldetto 1, V Podio 3, A Srgiotto 4, G Rossi 5, AM Ginni 6 nd A Pileri 1 1 Diprtimento di Medicin e Oncologi Sperimentle, Divisione Universitri di Emtologi; Serv. 3 Univ. e 4 Osped di Medicin Nuclere; 5 Divisione Universitri di Rdioterpi-Aziend Ospedlier S Giovnni Bttist di Torino, Torino; nd 6 Unità Trpinto Midollo, Ist Nz. Tumori, Milno, Itly Hemtologicl nd extrhemtologicl toxicity of high-dose (hd) mitoxntrone (MITO) nd melphln (L-PAM) s conditioning regimen prior to peripherl blood progenitor cell (PBPC) utogrft ws evluted in 113 lymphom ptients (87 t disese onset). Autogrft ws the finl prt of hd-sequentil (HDS) chemotherpy progrm, including debulkying phse (1 2 APO ± 2 DHAP courses) nd then sequentil dministrtion of hd-cyclophosphmide, methotrexte (or Ar-C) nd etoposide, t 10 to 30 dy intervls. Autogrft phse included: (1) hd-mito, given t 60 mg/m 2 on dy 5; (2) hd-l-pam, given t 180 mg/m 2 on dy 2; (3) PBPC utogrft, with medin of CD34 /kg, or CFU-GM/kg, on dy 0. A rpid hemtologicl recovery ws observed in most ptients, with ANC 500/ L nd Plt / l vlues reched t medin of 11 nd 10 dys since utogrft, respectively. The good hemopoietic reconstitution llowed the delivery of consolidtion rdiotherpy (RT) to bulky sites in 53 out of 57 cndidte ptients, within 1 to 3 months following utogrft; five of these ptients required bck-up PBPC re-infusion due to severe post- RT pncytopeni. Few severe infectious complictions were recorded. There ws one single ftl event due to severe pncytopeni following whole bdomen RT. Crdic toxicity ws evluted s left ventriculr ejection frction (LVEF), monitored by crdic rdionuclide scn. LVEF prior to nd fter utogrft ws significntly reduced (medin vlues: 55% vs 46%) in 58 evluted ptients; however, significnt increse to medin vlue of 50% ws observed in 45 ptients evluted t 1 to 3 yers since utogrft. At medin follow-up of 3.6 yers, 92 ptients re live, with 7-yer overll survivl projection nd 6.7-yer filure-free survivl projection of 77% nd 69%, respectively. We conclude tht conditioning regimen with hd- MITO/L-PAM fits well within the HDS progrm. It implies good tolerbility nd reversible crdiotoxicity nd it my hve contributed to the good long-term outcome observed in this series of ptients. (2001) 15, Keywords: mitoxntrone; conditioning regimen; utogrft; crdiotoxicity; HDS; lymphom Introduction In the lst decde high-dose chemotherpy nd utogrft hve significntly improved the outcome of lymphom ptients. This pproch is presently the first choice for relpsed high grde non-hodgkin s nd Hodgkin s lymphom. 1 4 Moreover, in the lst few yers evidence hs been produced pointing towrds role for utogrft s first-line tretment for both low nd high grde poor prognosis non-hodgkin s lymphom The wide pplicbility of this procedure hs been possible due to the dvntges offered by peripherl blood progenitor cells (PBPC) in reducing hemtologicl toxicity Correspondence: C Trell, Cttedr di Emtologi, Vi Genov 3, Torino, Itly; Fx: Present ddress: Unità Trpinto, Ist Sc. S. Rffele, Milno, Itly Received 8 June 2000; ccepted 13 October 2000 The ese deriving from the excellent tolerbility of PBPC procedures probbly slowed down the efforts imed to look for innovtive nd possibly more effective conditioning regimens. In fct, most utogrft progrms employed nowdys re bsed on conditioning regimens designed severl yers go, such s TBI + cyclophosphmide (CY), or regimens contining nitrosure or melphln (L-PAM), such s BEAM, CBV or BEAC Looking for better conditioning regimen, one should not only consider the ntitumor ctivity of given drug combintion, but should be concerned with its toxicity s well. Tody, hemtologicl toxicity is not s severe s it used to be, due to the vilbility of mobilized PBPC. Thus, efforts should rther be ddressed to reduce extr-hemtologicl toxicity of intensive progrms. Lymphom ptients seem to benefit from nthrcyclinecontining conditioning regimens. Unfortuntely, their use t high dosge hs been hmpered by the risk of crdic toxicity Mitoxntrone (MITO), molecule derived from nthrcenedione, hs been proposed s n lterntive. Severl studies hve shown tht this drug cn be sfely used lone or in combintion, t doses significntly higher thn those commonly employed in conventionl protocols In spite of consistently reported good tolerbility, there is presently lck of studies conducted on wide nd homogeneous groups of ptients nd with n ppropritely long follow-up. Moreover, few studies hve been specificlly ddressed to nlyze crdic function prior nd following high-dose MITO. In this study we investigted the tolerbility of combintion of high-dose MITO nd L-PAM in 113 lymphom ptients. Autogrft ws the finl prt of high-dose (hd) sequentil chemotherpy progrm. 9,10,15 The study ws imed to evlute t short, medium nd long term: (1) hemtologicl toxicity; (2) extr-hemtologicl toxicity nd in prticulr crdic function evolution; (3) life expectncy, of ptients completing the whole progrm including utogrft. The results indicte tht MITO cn be sfely employed in conditioning regimens before PBPC utogrft, with n cceptble hemtologicl nd extr-hemtologicl toxicity; there ws certin crdic toxicity but this ws unexpectedly reversible, t lest in prt. Finlly, the prolonged long-term survivl indictes tht the combintion MITO/L-PAM my contribute to the effectiveness of hd-sequentil chemotherpy progrms. Ptients nd methods Ptients A retrospective nlysis on overll tolerbility nd crdic toxicity of the combintion of hd-mito + L-PAM ws crried out by collecting dt from 113 lymphom ptients treted t the

2 University Division of Hemtology of Turin, Itly between 1991 nd All ptients were prt of study protocols bsed on the use of the originl or modified high-dose sequentil (HDS) chemotherpy regimens. They received hd-mito/l- PAM followed by PBPC utogrft s the conclusive phse of the progrm. The protocols, including the finl PBPC utogrft, were pproved by the locl Ethicl Committee nd ll ptients gve written informed consent to both chemotherpy progrm nd utogrft. All enrolled ptients hd biopsyproven dignosis of lymphom. They received the HDS progrm either t disese onset, if they presented with dvncedstge nd poor prognostic fetures, or t disese relpse. Eligibility criteri included norml hert, renl nd liver functions s well s negtive tests for HIV, HBsAg nd HCV. All ptients underwent routine stging procedure before strting the chemotherpy progrm; their min clinicl fetures re shown in Tble 1. HDS tretment schedules All ptients received either the originl (64 ptients) HDS chemotherpy regimen or one of the two second-genertion schedules, nmed i-hds nd C-HDS. 9,10,15 The originl HDS regimen included the sequentil dministrtion of: (1) hd-cy given t 7 g/m 2 i.v., with PBPC hrvest t hemopoietic recovery; (2) methotrexte (8 g/m 2 ) plus vincristine (2 mg i.v.) pproximtely t dy 16; (3) hd-etoposide (VP16) t 2 g/m 2, pproximtely t dy 23; (4) myelobltive tretment with PBPC utogrft pproximtely between dys 48 nd 52. In 21 high-risk ptients, hd-ar-c replced hd-methotrexte (C- HDS). To minimize hemtologicl toxicity, smll mount of PBPC ( CD34 + cells/kg) were re-infused following hd-ar-c. In ddition, debulkying phse including three APO courses (A = doxorubicin 75 mg/m 2 ; O = Vincristine 1.2 mg/m 2, both drugs given t dy intervls; P = prednisone t 50 mg/m 2 /dy for dys), ws lso dded. The i-hds ws specificlly designed for ptients presenting with bone mrrow involvement nd it ws delivered to 49 ptients with low-intermedite grde lymphom. This ltter regimen includes n even more intensive debulky- ing prior to the hd-phse with four APO + two DHAP (dexmetsone/hd-ar-c/cispltin) courses. In the subsequent hd-phse, the CY/VP16 sequence ws inverted, in order to schedule PBPC hrvest t the end of the hd-scheme. In ddition, chemotherpy-free intervl of 30 dys ws included prior to hd-cy in order to llow dequte mrrow repopultion nd optiml progenitor cell mobiliztion. 31 In the chemotherpy-free intervl, totl of three hd-dexmethsone courses (dexmethsone t 40 mg/dy for 4 consecutive dys) were dministered every 10 dys. G-CSF (Filgrstim) ws given t 5 g/kg/ dy following CY, VP16, Ar-C nd utogrft, until myelopoietic recovery or completion of hrvesting procedures. The HDS chemotherpy schedules, ie originl HDS, i-hds nd C-HDS, re detiled in Figure 1. All ptients presenting with bulky disese received dditionl rdiotherpy (RT) to bulky sites 1 to 2 months fter utogrft. Twenty-six ptients received the HDS progrm s slvge fter disese recurrence. Their previous tretments consisted of MACOP-B (four ptients), CHOP (seven ptients), MINE (one ptient), chlormbucil (two ptients) nd ABVD or MAMA hybrid schemes (12 ptients). Only six ptients hd lso received involved field rdiotherpy. Collection nd evlution of hemopoietic progenitors PBPC were mobilized nd collected following hd-cy or, in few ptients, following hd-ar-c or hd-vp16. A BM hrvest 257 Tble 1 Min clinicl fetures of 113 lymphom ptients treted with hd-mito/l-pam nd utogrft Prmeter n % Age, medin (rnge) yers 44 (16 61) Sex M/F 64/49 57/43 Dignosis/Relpse 87/26 77/23 Histology smll lymphocytic 10 9 follicle-center mntle cell 7 6 diffuse lrge cell b peripherl T cell 9 8 CD Hodgkin Stge III/IV BM involvement LDH IPI c Twenty-two ptients received HDS s slvge therpy for refrctory or recurrent disese following first-line conventionl tretment. b Five of them hd trnsformed histology. c Age-djusted Interntionl Prognostic Index score. Figure 1 Scheme of the originl nd modified HDS regimens. i-hds, intensified HDS; C-HDS, hd-ar-c-hds; CY, cyclophosphmide; MTX, methotrexte; VP16, etoposide; MITO, mitoxntrone; L-PAM, melphln; APO, drimycin prednisone vincristine; DHAP, dexmethsone hd-ar-c cispltin; CDDP, cispltin; PBPC, peripherl blood progenitor cells.

3 258 ws performed t the end of the hd-phse in those ptients with low mounts of hrvested PBPC (see below). To predict number nd timing of leukphereses, circulting CD34 + cells long with cell blood counts were evluted dily strting from dy +9 following chemotherpy dministrtion to hrvesting procedure completion. CD34 + cell evlution ws crried out ccording to published procedures. 31 Peripherl blood buffy-cot cells were collected when the WBC count ws t lest 1000/ l nd PB CD34 + cells 10/ l. Leukphereses were performed using continuous-flow blood cell seprtors (Cobe-Spectr, Lkewood, CO, USA or Fresenius, Schweinfurt, Germny) nd 7 13 blood liters (medin 8.9 l) were processed for ech procedure. Progenitor estimtion in leukpheresis products ws crried out by evluting both CD34 + cells nd CFU-GM. The in vitro colony-forming ssy ws performed s previously described. 31 Vlues of CFU-GM/kg nd CD34 + cells/kg were tken s the miniml required dose of hrvested progenitors for ptients to be enrolled in the utogrfting progrm with PBPC only. In 12 ptients where lower mounts of progenitors were hrvested, dditionl BM hrvest ws combined with leukpheresis collection. MITO/L-PAM dministrtion nd post-utogrft supportive cre The combined dministrtion of hd-mito nd hd-l-pam ws used s conditioning regimen in ll ptients. 25 MITO ws given i.v. t 60 mg/m 2 in three divided doses of 1 h ech every 2 h on dy 5: this schedule llowed n dequte intervl for mitoxntrone clernce from plsm prior to PBPC reinfusion, in ccordnce with reported phrmcokinetic dt. 25,27,28 L- PAM ws given i.v. t 180 mg/m 2 in three divided doses of 30 min ech every 2 h on dy 2; PBPC were reinfused 2 dys lter. Since 1996, G-CSF ws dded following utogrft in order to ccelerte hemopoietic recovery. 32 G-CSF ws given i.v. over 1 h t 5 g/kg/dy strting on dy +1 until neutrophil count reched 500/ l on 2 consecutive dys. The entire pretrnsplnt progrm ws crried out in ordinry, non-protected rooms, wheres for the utogrft phse ptients were generlly dmitted to dedicted inptient bone mrrow trnsplnt unit. During the recovery phse following utogrft ptients were mnged with common protocol for prophylxis nd therpy of pncytopeni-relted complictions. Briefly, ntibiotic prophylxis included orl ciprofloxcin (500 mg twice dy) + fluconzole (150 mg) + i.v. cyclovir (250 mg three times dy); in the cse of fever 38 C, blood culture nd chest X-ry were performed, then ptients were empiriclly treted with i.v. mezlocillin + mikcin + vncomycin; this ltter is now dded only in the cse of positive surveillnce culture for grm+ cocci; if the fever ws of undetermined origin nd persisted fter h, mezlocillin ws replced by imipenem; i.v. mphotericin ws dded in few cses with fever persisting for more hours. Antibiotics were continued until the temperture reverted to norml vlues for t lest 2 consecutive dys long with the return of the ANC to 500/ l. Prenterl ntibiotics were lso strted in the bsence of fever whenever ptients were unble to continue orl prophylctic ntibiotics, due to mucositis. Irrdited, leukocyte-filtered, single-donor pltelet concentrtes or, less frequently, multiple-donor irrdited pltelet concentrtes were given when pltelet count ws less thn / l; irrdited, leukocyte-filtered pcked RBCs were given if hemoglobin ws less thn 8.0 g/dl. Outcome prmeters Physicl exmintion + cell blood count (CBC) nd common biochemicl blood tests were performed dily during recovery following utogrft. Therefter, ll ptients hd complete restging ssessment every 3 months during the first yer, nd every 6 months fterwrds. A thorough ressessment of renl, heptic nd crdic functions were scheduled prior to utogrft nd t given intervls therefter. In prticulr, crdic function ws monitored by creful clinicl exmintion, EKG nd chest X-ry. No ptients hd to be excluded from utogrft due to crdic dysfunction. A crdic rdionuclide scn ws performed t the strt of tretment nd prior to utogrft in ll ptients; in ddition, 58 ptients hd their crdic function evluted prior to utogrft nd within 6 months fter utogrft; 45 of these 58 ptients were subsequently studied t 1 to 3 yers since utogrft. Their clinicl chrcteristics did not differ from those of the other ptients. Thus, this group ws highly representtive of the whole series of 113 ptients. Long-term outcome of ptients completing the whole progrm ws evluted s overll survivl nd filure-free survivl. Survivl durtion ws mesured from tretment strt to the dy of deth or lst follow-up evlution. Filure-free survivl durtion ws clculted from utogrft up to the first dverse event, ie filure to rech complete remission (CR), relpse, tretment-relted or disese-relted deths or the dte the ptient ws lst known to be in remission. The cturil durtion of overll survivl (OS) nd filure-free survivl (FFS) were plotted s curves ccording to Kpln nd Meier product-limit method. 33 The closing dte for nlysis ws 30 June Results Hemtologicl toxicity Medin number of grfted progenitors nd time to post-grft hemopoietic recovery re reported in Tble 2. There were six ptients with delyed recovery; three of them hd prolonged requirement of trnsfusion support; rpid hemtologicl recovery ws the rule in ll remining ptients nd vlues of ANC 500/ L nd Plts / l were reched t medin of 11 (rnge 8 31) nd 10 (rnge 7 60) dys since utogrft, respectively. No sttisticlly significnt differences were observed in short-term hemopoietic recovery between originl nd modified HDS regimens. Indeed, pltelet nd RBC trns- Tble 2 Medin number of grfted progenitors nd time to postgrft hemopoietic recovery Medin Rnge Grfted progenitors CD34 + cells 10 6 /kg CFU-GM 10 4 /kg Dys to rech WBC 1000/ l 11 (8 40) ANC 1000/ l 12 (8 60) Plts / l 14 (9 100) Trnsfusion requirement No. of RBC trnsfusions (U) 3 (0 120) b No. of Plt trnsfusions (U) 2 (1 120) b Six ptients hd delyed plt recovery. b Three ptients hd prolonged trnsfusion requirement.

4 Tble 3 Medin cell blood counts recorded t 1, 3 nd 6 months since utogrft Prmeter Time since utogrft 1 month 3 months 6 months Hb g/dl medin rnge ( ) ( ) ( ) WBC 10 3 / l medin rnge ( ) ( ) ( ) ANC 10 3 / l medin rnge ( ) ( ) ( ) Plts 10 3 l medin rnge (7 494) (9 342) b (15 305) c ANC were / l in one ptient. b Plts were / l in six ptients. c One ptient showed vlues of Plts / l. fusion requirement ws similr for the three regimens employed. Hemopoietic reconstitution ws stble in most ptients. This is shown by medin CBCs recorded t 1, 3 nd 6 months fter utogrft (see Tble 3). The stble hemopoietic reconstitution is further proved by RT fesibility t 1 to 3 months following utogrft. In fct, RT could be delivered to bulky sites in 53 out of 57 cndidte ptients. Five more ptients required reinfusion of bck-up PBPC due to severe pncytopeni following RT. These ptients hd been trnsplnted with number of progenitor cells tht ws not out of the rnge of the whole ptient popultion. Unfortuntely, there ws toxic deth in ptient with persistent, severe pncytopeni following whole bdomen RT. The pncytopeni persisted fter reinfusion of bck-up PBPC. This ws the single toxic event occurring in this series of ptients. Long-term engrftment ws durble in ll evluble ptients, s shown by CBCs recorded t 1, 3 nd 6 yers fter utogrft (Tble 4). Tble 4 Medin cell blood counts recorded t 1, 3 nd 6 yers since utogrft Prmeter Time since utogrft Extrhemtologicl toxicity nd crdic function evlution Autogrft ws reltively well tolerted, with few severe infectious complictions, s shown in Tble 5. Mucositis of grdes III IV ws the most frequent compliction, occurring in 35 ptients. Fever ws lso quite common, occurring in the mjority of ptients. Mild nd reversible elevtion of liver enzymes ws observed in 10 ptients, nd bilirubin elevtion up to five-fold norml vlue occurred in 36 ptients. However, no long-term irreversible liver dmge ever occurred. No evidence of heptic venous occlusive disese ws ever observed nor severe toxicities of the kidney nd the urinry trct. There were no severe cute crdic toxicities during erly recovery following utogrft, with the exception of trnsient recurrence of tril fibrilltion. During the first 100 dys postutogrft, four ptients complined of plpittion, ssocited with sinus tchycrdi, requiring medicl therpy in three of them (propnolol in two, digoxin in one). Two of these ptients hd disese recurrence nd required further chemotherpy; the other two ptients re long-term, disese-free survivors nd re no longer symptomtic. One more ptient hd n overt hert filure occurring immeditely fter medistinl RT delivered t 2 months post-utogrft. She ws n obese ptient who hd n erly disese recurrence, with rpid nd ftl progression. In the long term, two ptients developed symptomtic hert filure: one is 55-yer-old mn treted with HDS for disese recurrence fter CHOP-bsed first-line therpy; the other is 32-yer-old obese subject who is now in continuous remission of high-grde lymphom 5 yers fter HDS + medistinl RT. In both ptients, symptoms subsided fter medicl therpy. These two ptients hd mrked left ventriculr ejection frction (LVEF) reduction, s detected by rdionuclide crdic-scn fter utogrft. However, both ptients improved their LVEF few months lter, similrly to tht observed in the whole ptient popultion (see below). One more ptient hd trnsient tril fibrilltion occurring t 4 yers fter utogrft + medistinl RT which spontneously subsided. No other symptomtic crdic disfunctions hve been recorded mong 92 survivors. Thirteen ptients hd to be rescued due to disese recurrence following HDS. Slvge therpy consisted of hd-chemotherpy nd second utogrft in five ptients nd llogeneic trnsplnt in four ptients. All were ble to receive retretment without mjor crdic dysfunctions. Crdic function ws investigted by rdionuclide crdic yer 3 yers 6 yers Tble 5 Extr-hemtologicl toxicity in 113 ptients Hb g/dl medin rnge ( ) ( ) ( ) WBC 10 3 / l medin rnge ( ) ( ) ( ) ANC 10 3 / l medin rnge ( ) ( ) ( ) Plts 10 3 / l medin rnge (12 352) (57 337) ( ) Plts / l in one ptient with secondry myelodysplsi, nd in one with bone mrrow relpse of NHL. Prmeter n % Fever Severe infections 8 7 Grdes 3 4 orl mucositis Liver enzyme increse b 10 9 Hyperbilirubinemi b Toxic deth c Dys under i.v. morphine medin (rnge) 6 (0 27) Five pneumoni, three CMV rectivtions. b Liver enzyme increse ws trnsient nd never exceeded three times norml vlue. c Persistent pncytopeni following post-grft bdominl RT.

5 260 Figure 2 LVEF evluted in 58 ptients by crdic rdionuclide scn immeditely prior to nd within 6 months fter hd-mito/l-pam nd PBPC utogrft. Vlues re expressed s box plot. scn. Virtully ll ptients were evluted t the strt of tretment nd before utogrft. LVEF vlue decresed following the hd-phse, lthough the difference ws not sttisticlly significnt (dt not shown). Three ptients underwent utogrft with LVEF vlues slightly below 40%. LVEF vlues prior to utogrft nd within 6 months fter utogrft could be compred in 58 ptients. Ten of them received medistinl RT fter utogrft. A LVEF decrese ws recorded in 51 ptients nd medin vlues recorded prior to nd fter utogrft were significntly different, s shown in Figure 2. A mrked reduction of LVEF ws seen in four out of the 10 evluble ptients who received medistinl RT. Finlly, 45 out of 58 ptients could be subsequently ssessed t 1 to 3 yers therefter. Thirty-four ptients displyed spontneous improvement of their LVEF nd medin LVEF vlue recorded t longterm ws significntly higher compred to the post-grft evlution (Figure 3). LVEF improvement ws not confined to ptients with mild or moderte crdic function impirment; in fct, ptients with post-grft LVEF lower thn 50% lso dis- Figure 4 LVEF evluted by crdic rdionuclide scn within 6 months nd t 1 to 3 yers fter hd-mito/l-pam nd PBPC utogrft in 32 ptients with mrked post-grft LVEF reduction ( 40%). Vlues re expressed s box plot. plyed significnt improvement t 1 yer following utogrft (Figure 4). As shown in Tble 6, the rte of post-grft LVEF reduction ws similr between ptients receiving the originl or the modified HDS schemes s well s between ptients receiving totl nthrcyclin dose lower or higher thn 200 mg/m 2.A significnt LVEF improvement ws recorded in ll these subgroups t 1 yer following utogrft. In ddition, other prmeters, including sex, ge (less or more thn 45 yers old), medistinl RT, previous tretments, did not significntly influence post-grft LVEF reduction nd its subsequent improvement. Overll outcome To dte, 92 ptients re live t 1 to 7 yers since disese onset. At medin follow-up of 3.8 yers, the 7-yer OS curve Tble 6 Chnges of LVEF t 3 6 months nd t 1 yer fter utogrft ccording to tretment schedule nd previous nthrcyclin dose Prmeter LVEF % Time since utogrft 3 6 months 1 3 yers medin (rnge) medin (rnge) HDS scheme originl HDS (n = 14) 45 (38 63) P = (45 57) i-hds nd C-HDS (n = 32) 46 (30 59) P = (35 64) Previous nthrcyclin dose 200 mg/m 2 (n = 11) 47 (35 66) P = (39 56) 200 mg/m 2 (n = 35) 46 (30 56) P = (35 64) Figure 3 LVEF evluted in 45 ptients by crdic rdionuclide scn within 6 months nd t 1 to 3 yers fter hd-mito/l-pam nd PBPC utogrft. Vlues re expressed s box plot. Significnt differences were lwys found between LVEF vlues obtined t 3 6 months nd those t 1 yer. No significnt differences were found between ptients receiving the originl or the modified HDS schedules s well s between ptients who hd received less or more thn 200 mg/m 2 nthrcyclines. i-hds, intensified HDS; C-HDS, HDS with hd-ar-c.

6 is projected to 77%. Eighty-two ptients re surviving in continuous complete remission, t 0.5 up to 6.7 yers fter utogrft. At medin follow-up of 3 yers, the 6.5-yer FFS curve is projected to 69%. Besides the single toxic deth, 17 ptients hd short-lsting PR or disese progression following HDS; 13 more ptients reched CR nd subsequently relpsed. All these ltter ptients were ble to receive slvge therpy, consisting of conventionl therpy (one ptient), RT (three ptients), second high-dose chemordiotherpy with PBPC or BM utogrft (five ptients) or llogeneic trnsplnttion (four ptients). Slvge therpy ws sfely delivered without ny ftl toxicity nd 11 out of 13 ptients were ble to rech prolonged second remission. Discussion The ssocition MITO/L-PAM ws first described in Severl spects mke this drug combintion prticulrly suitble for lymphom ptients: it includes high-dose nthrcenedione derivtive, closely relted to the nthrcycline fmily, keystone in the tretment of lymphom; L-PAM is n lkylting-gent prticulrly effective in lymphoid mlignncies s well; finlly, the bsence of TBI mkes the scheme very prcticl nd esy to use. In spite of these considertions, MITO/L-PAM hs not been pid prticulr ttention to dte nd, following the originl observtion, only one other study hs evluted the toxicity nd efficcy of this regimen, on reltively smll series of ptients, mostly ffected by solid tumor. 30 The present study ws ddressed to evlute shortnd long-term outcome in lrge series of 113 lymphom ptients receiving hd-mito/l-pam followed by PBPC utogrft. All ptients hve been followed for minimum of 1 yer nd up to 7 yers. Post-trnsplnt engrftment ws fst, s usully observed in utogrft with PBPC. The use of G-CSF following PBPC infusion my hve contributed to the rpid ANC recovery s lredy reported by others nd our group. 32,34,35 Blood counts were stisfying in the weeks immeditely following short-term engrftment. This is crucil issue, since it implies the possibility of delivering full-dose consolidtion rdiotherpy in most ptients requiring it. RT on bulky sites is very effective dditionl mesure in chemotherpy-treted high grde lymphom ptients. 36 RT constitutes n integrl prt of our HDS progrms, nd hs presumbly contributed to the very good results reported in poor-risk lymphom ptients. 10,37 Hence, mintinnce of good blood counts in the first months following utogrft is of definite importnce in every progrm including RT following hd-chemotherpy. Unfortuntely, one ptient hd prolonged pncytopeni following bdominl RT nd subsequently died of infection. This is the only toxic deth observed in this series of ptients. It is possible tht whole bdomen RT following HDS is poorly tolerted; for this reson we no longer use this pproch, nd rther, we prefer limited field RT in the cse of bdominl bulky msses. Four ptients could not undergo RT due to low CBC nd five more ptients experienced severe pncytopeni following consolidtion RT. In these ptients further bckup PBPC re-infusion ws necessry. Thus, following MITO/L- PAM, hemtologicl reconstitution is usully good, prt from few exceptions rising certin problem in delivering eventul consolidtion RT in smll though not negligible frction of ptients. This issue should not be disregrded nd we suggest collecting s mny PBPC s possible in order to hve extr PBPC if needed. The prolonged follow-up enbled us to monitor the longterm CBC pttern. This nlysis ws obviously crried out only in disese-free ptients, thus in the bsence of ny further cytotoxic tretment. There ws no grft filure ever, nd CBC vlues were constntly good; even those few ptients with vlues lower thn norml in the first months following trnsplnt showed progressive improvement of their CBCs. The long-term pttern of CBC is consistent with our previous observtions on PBPC stble nd durble engrftment, confirming those dt on wider number of cses nd with definitely longer follow-up. 38 It hs lwys been our policy to use lrge numbers of PBPC for utogrft. Also in this study most ptients received CD34 + /kg or CFU- GM/kg. These vlues re in line with those previously reported in study conducted on lrge number of ptients trnsplnted with PBPC. 39 Thus, grft filure is quite unlikely if such PBPC numbers re employed. On the other hnd, the long-term CBC outcome in subjects receiving fewer PBPC remins unpredictble. There were no severe extr-hemtologicl complictions. Advnced-grde oro-phryngel mucositis ws very common. This compliction ws probbly more pronounced with MITO/L-PAM compred to other schemes. Moreover, lowgrde liver toxicity ws lso commonly observed in bout 30% of cses, with liver function tests going bck to norml vlues within few dys. A severe toxic left over ws never observed nd MITO/L-PAM seems globlly to shre n overimposble toxicity pttern with other conditioning schemes commonly employed in ptients with lymphom. Due to the high MITO dose employed, the potentil crdic toxicity ws crefully evluted. From clinicl point of view there ws no prticulr dverse event with the exception of one cse of tril fibrilltion nd two episodes of hert filure, in ny cse promptly resolved following medicl tretment. Hert function ws evluted by crdic rdionuclide scn, commonly ccepted s the most relible test to ssess druginduced crdic toxicity. 40,41 In the present study, LVEF ws systemticlly evluted before nd fter trnsplnt in s mny s 58 ptients. This function ssessment ws significntly reduced from 55% to 46% medin vlues. Such reduction is in line with the one mentioned in previous study on hd-mito. 28 Only very few ptients showed post-grft LVEF vlues below 40%. Moreover, we should not forget tht in the present study the MITO/L-PAM conditioning ws preceded by severl other cytotoxic tretments, including preliminr debulkying with doxorubicin, nd sequence of hd drugs such s CY nd, in most ptients, followed by RT, often delivered to the thorcic region. Thus, in spite of other potentilly crdiotoxic tretments, LVEF reduction following hd-mito ws globlly cceptble nd not higher thn the one observed with other commonly employed regimens such s CY/TBI. 42 Post-grft LVEF reduction hd little clinicl impct. There were only two cses of limited-grde hert filure. In fct, crdic function ws shown to improve with the pssge of time. LVEF ws better in most cses 2 3 yers fter trnsplnt, s ssessed by crdic rdionuclide scn. Hert filure hs been reported s possible lte compliction in pproximtely 14% of long-term surviving lymphom ptients treted with conventionl-dose nthrcycline-contining regimens. 43 Anthrcycline-linked hert dmge drmticlly increses with cumultive doses over 550 mg/m 2 nd there is little evidence of its reversibility ,43 47 From this viewpoint our dt my be of interest. We re well wre tht hd-mito implies certin crdic toxicity, however, this toxicity hs little clinicl impct. In ddition, the use of conditioning 261

7 262 regimen such s MITO/L-PAM following n intensive highdose sequentil schedule does not preclude t lest prtil recovery of crdic function. A more prolonged follow-up is required to ssess if LVEF recovery cn be complete with time. Additionl studies might verify whether reversibility selectively pplies to MITO-induced crdiotoxicity or whether it lso concerns the dmge linked to the other potentilly crdiotoxic drugs included in the progrms. Besides tolerbility, ny conditioning regimen needs creful evlution of efficcy s well. Unfortuntely, this spect could not be dequtely ssessed in this study. Autogrft ws the finl prt of very intensive hd-progrm nd it is very difficult to distinguish between MITO/L-PAM ctivity nd the ctivity of the hd-phse itself. Moreover, most ptients undergoing utogrft were lredy in clinicl remission. Long-term outcome of grfted ptients ws very good nywy, in terms of both overll nd filure-free survivl. Thus we cn t lest conclude tht dvnced-stge lymphom ptients completing the whole hd-progrm including utogrft hve high chnce of prolonged disese-free survivl. The finl utogrft phse seems to fit well into the hd-sequentil progrm nd probbly contributes in non-mesurble wy to the good clinicl outcome observed in these ptients. In ddition, due to its good tolerbility, utogrft did not eventully prevent the dministrtion of rescue tretments in those ptients who subsequently relpsed. Most of these ptients were ble to undergo second-line high-dose regimen with utogrft or llogeneic trnsplnttion, often with chievement of second remission. Thus, fesibility of effective slvge therpies my hve further improved the overll life expectncy of this series of ptients. Dose size is of criticl importnce in the utogrft setting, since the whole ntitumor effect relies on the drugs delivered. 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