Asco-cim.linfoma.pptx

Chicago, USA
31 Mayo-4 Junio 2013
Lo mejor de ASCO-2013. Linfomas
11 de Julio de 2013. Hospital Hermanos Amejeiras.
Dr. Elías A. Gracia Medina.
Jefe Servicio Oncología Medica
Instituto Nacional de Oncología y Radiobiología
Lugano, Suiza
19-22 Junio 2013
12-ICML

Highlight from ASCO 2013 and 12-ICML:
Lymphoma
1.Resultados de ensayos clínicos fase III, sobre
todo aquellos que pueden cambiar estándares
2.¿Qué puede ser útil para mejorar el
tratamiento de mis pacientes en la
practica diaria?

3
Follicular lymphoma and other indolent
lymphomas?
1. Patterns of care and outcomes of front-line chemoimmunotherapy for
advance stage, Grade-3 follicular lymphoma: Data from the National
LYMPHOCARE study. Nastoupil LJ. 12-ICML, Abstract 187
2. Chlorambucil plus rituximab produces better EFS and PFS in comparison with
chlorambucil or rituximab alone in extranodal marginal zone lymphoma
(MALT lymphoma): 5-years results of the IELSG-19 Study. Zucca E. Bellinzona,
12-ICML. Abstract 007.
3. Bendamustine plus Rituximab in First Line Systemic Treatment for Extranodal
MALT Lymphoma: Final Results of Phase II Trial of the Spanish Lymphoma
Study Group (GELTAMO) Salar A, el al. Barcelona. Abstract 100
4. The BRIGHT Study: First-Line Bendamustine-Rituximab (BR) or R-CHOP/R-
CVP in Advanced Indolent Non-Hodgkin’s Lymphoma (NHL) or Mantle Cell
Lymphoma (MCL). Flinn I.Nashville. Abstrac 84

PFS for Stage III/IV Patients with Grade 3 Histology by First-line
Anthracycline Use (ITT Population) (n=210)
Time (Years)
0
0.0
1 2 3 4 5 6 7 8 9 10
Anthracycline (AC) Use
Non-Anthracycline (AC) Use
Survival
Probability
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
Nastoupil LJ et al. 12-ICML, Abstract 187
Outcome Anthracyc. Other HR (95%CI) P value
3 yrs PFS 70% 53% 0.49 (0.29, 0.84) .067
3 yrs TFS 87% 61% 0.40 (0.21, 0.77) .002
3 yrs OS 91% 73% 0.45 (0.22, 0.91) .015
Conclusions: In the USA, anthracycline-based R-chemo was the most commonly used
approach for stage III/IV G3 FL and was associated with significantly better TFS and OS
even after controlling for FLIPI

Trial Profile
N= 250 +200 → N= 450

Trial Profile
N= 250 → +200 → N= 450

Response to Treatment
Response
ORR 110 (85%) 124 (95%) 104 (79%)
CR* 80 (62%) 104 (80%) 73 (55%)
PR 30 (23%) 20 (15%) 31 (23%)
SD 11 (8%) 1 (<1%) 15 (11%)
PD 7 (5%) 4 (3%) 9 (7%)
NA 2 (1.5%) 2 (1.5%) 4 (3%)
* R-Chl vs. Chl, P=0.001 R-Chl vs. R, P<0.001; Chl vs. R, P= 0.372

Event-Free Survival
Log-rank HR 95% C.I.
R vs. Chl, P=0.957 0.99 (0.82-1.20)
R-Chl vs. Chl, P=0.0005 0.52 (0.35-0.75)
R-Chl vs. R, P= 0.0015 0.51 (0.33-0.78)
70%
52%
51%

Progression-Free Survival
Log-rank HR 95% C.I.
R vs. Chl, P=0.383 1.09 (0.89-1.35)
R-Chl vs. Chl, P=0.013 0.59 (0.39-0.90)
R-Chl vs. R, P= 0.006 0.53 (0.34-0.84)
72%
59%
58%

Overall Survival
5-year OS (95%CI):
Chlorambucil , 89% (82%-94%)
R-Chlorambucil, 89% (82%-94%)
Rituximab, 94% (86%-97%)

Variable Haz.Ratio P-value [95% C.I.]
combination arm 0.52 <0.001 0.36-0.74
IPI (lo/lo-int vs. int-hi/hi) 1.81 0.001 1.27-2.56
nodal involvement 1.53 0.009 1.11-2.11
non-gastric site 1.34 0.089 0.96-1.87
prior local treatment 0.91 0.737 0.52-1.58
EFS Multivariate Analysis

• “Synergism” between R and chemotherapy
confirmed in MALT lymphomas
• R-chlorambucil produced better CR rate
and longer EFS and PFS
• Differences in EFS PFS and CR rate,
however,
did not translate into improved OS
• All treatments were well tolerated and no
unexpected side effects were recorded
Conclusions

Study Design and Objectives
• Primary objective
─ Event-free-survival (EFS) (failure or death from any cause) for all patients
• Secondary objectives
─ Complete and partial remission rates for all patients
─ Response duration (time to relapse or progression) for responder patients
─ Progression-free-survival and overall survival for all patients
─ Early and late toxicity
• Sample size
─ 60 patients: 15% 2 years-EFS improvement (alpha 0.05; potency 80%)
 Nation-wide, multicenter, open-label, phase II study of
bendamustine and rituximab in first line extranodal MALT
lymphoma
Salar A, el al. 12-ICML. Abstract 100

Study Schema
EVALUATION
Rituximab: 375 mg/m2 i.v. day 1
Bendamustine: 90 mg/m2 i.v. day 1, 2
3 cycles
x 1 cycle
Withdrawal of
study
Stable diasease
Progression
Complete remission
(CR or uCR)
Parcial remission
(PR)
REGISTRY
x 3 cycles

Grade 3 or Higher AEs by cycle>1 Incidence
0 10 20 30 40 50 60 70 80 90 100
Leucopenia
Neutropenia
Lymphocytopenia
Grade 3
Grade 4
0 10 20 30 40 50 60 70 80 90 100
Hypotension
Neurologic disor
GI disorder
Pharyngeal edema
Asthenia
Fever
Infections
Febril neutropenia
Grade 3
Grade 4
Hematologic AE:
Non-Hematologic AE:

Final Response Evaluation (ITT Population)
Percent
Response
(CR+PR)
98 100 100
83
2
17
0
20
40
60
80
100
All patients Gastric Non-gastric Multifocal
PR
CR/uCR
%

Event Free Survival
Median follow-up: 27 months (6-40 months)
At risk: 59 57 56 54 36 13 1
 Events:
 1Toxicity
 2 Deaths (unrelated)
 2 Relapses

Conclusions
 Bendamustine plus Rituximab is well tolerated, including in elderly,
and very well accepted by patients
 Efficacy is excellent when compared to standard regimens, either in
gastric or non-gastric MALT lymphomas
 The large majority of patients require only 4 cycles of treatment, thus
reducing time under treatment and reducing treatment costs
 This response-adapted schedule with Bendamustine plus Rituximab
is a foremost therapeutic strategy for this type of lymphoma

The BRIGHT Study: First-Line
Bendamustine-Rituximab (BR) or
R-CHOP/R-CVP in Advanced Indolent
Non-Hodgkin’s Lymphoma (NHL) or Mantle
Cell Lymphoma (MCL)
Ian W. Flinn, MD, PhD1; Richard van der Jagt, MD, FRCPC2; Brad S. Kahl, MD3; Peter Wood, MRCP4;
Tim E. Hawkins, MBChB5; David MacDonald, MD6; Mark Hertzberg, MBBS, PhD7; Yiu-Lam Kwan, MBBS8;
David Simpson, MBChB9; Michael Craig, MD10; Kathryn S. Kolibaba, MD11; Samar Issa, MBChB12; Regina
A. Clementi, RN, MS13; Doreen M. Hallman, BS13; Mihaela C. Munteanu, MS13; Ling Chen, PhD13; and
John M. Burke, MD14
1Sarah Cannon Research Institute; 2University of Ottawa; 3University of Wisconsin Carbone Cancer Center; 4Princess Alexandra
Hospital; 5Auckland Hospital; 6Dalhousie University; 7Westmead Hospital; 8Concord Repatriation General Hospital; 9North Shore
Hospital; 10West Virginia University; 11McKesson Specialty Health/US Oncology Research and Compass Oncology; 12Middlemore
Hospital; 13Teva Branded Pharmaceutical Products R&D, Inc.; 14McKesson Specialty Health/US Oncology Research and Rocky
Mountain Cancer Centers
084

Treatments
• 6 cycles during the randomized treatment phase
– Up to 8 cycles at investigator’s discretion
Bendamustine
Rituximab
(28-day cycle)
• Bendamustine 90 mg/m2/day
(Day 1 and 2; 30-min infusion)
• Rituximab 375 mg/m2 (Day 1)
BR or R-CVP
(Randomization)
BR or R-CHOP
(Randomization)
Preassignment by investigator
R-CHOP
(21-day cycle)
• Standard dosing
Bendamustine
Rituximab
(28-day cycle)
• Bendamustine 90 mg/m2/day
(Day 1 and 2; 30-min infusion)
• Rituximab 375 mg/m2 (Day 1)
R-CVP
(21-day cycle)
• Standard dosing
5-Year Follow-up
21

Objective and Measures
Primary objective
• To determine whether BR is noninferior to standard treatment
(R-CHOP or R-CVP) in CR rate as first-line treatment of
indolent NHL or MCL
Primary measure
• Noninferiority of complete response (CR) rate
Secondary measures
• Overall response rate
• Safety and tolerability of BR and R-CHOP or R-CVP
• Quality of life as determined by QLQ-C30
• Time-to-event analyses (immature as of June 2012 data cutoff)
22
QLQ-C30, European Organisation for Research and Treatment of Cancer (EORTC) Core Quality-of-Life Questionnaire.

Demographics/Disease Characteristics
Characteristic
BR
(n = 224)
R-CHOP/R-CVP
(n = 223)
Age, years, median (range) 60 (28-84) 58 (25-86)
Male, % 61 59
ECOG, % 0
1
2
64
31
4
64
31
4
Lymphoma type, % Indolent NHL
MCL
Missing
83
16
<1
83
17
<1
Ann Arbor stage, % II
III
IV
9
21
69
9
22
68
Median time from diagnosis to
randomization, months, median (range) 1.55 (0.1-266.7) 0.80 (0.1-86.2)
FLIPI risk, %* Low
Intermediate
High
14
25
29
14
25
33
*BR (n = 154); R-CHOP/R-CVP (n = 160). 23

Preassigned to R-CHOP Preassigned to R-CVP
Adverse Event Category (%)
BR
(n = 103)
R-CHOP
(n = 98)
BR
(n = 118)
R-CVP
(n = 116)
Gastrointestinal
Nausea 63 58 63 39
Vomiting 29 13 25 13
Constipation 32 40 27 44
Immune Disorders
Drug hypersensitivity 14 5 8 3
Infections
Febrile neutropenia 3 6 3 4
Opportunistic infection 10 7 12 9
Nervous System Disorders
Peripheral neuropathy 4 20 4 26
Paresthesia <1 12 5 10
Peripheral sensory neuropathy <1 6 3 12
Skin Disorders
Rash 12 7 18 9
Alopecia 4 51 3 21
Adverse Events (all grades)
24
■ = Higher incidence.

NI, noninferior; Sup, superior.
Evaluable: IRC
BR
(n = 213)
R-CHOP/R-CVP
(n = 206)
BR vs
Standard
Therapy
CR Ratio
P Value
(NI)
P Value
(Sup)
CR
(95% CI)
31
(25.3-38.2)
25
(19.5-31.7)
1.26
(0.93-1.73) 0.0225 0.1269
PR 65 66
OR of CR + PR
(95% CI)
97
(93.3-98.7)
91
(86.0-94.4)
Primary Endpoint:
Complete Response Rate
25

Complete Response Rate Ratios
26
Ratio (95% CI)
Evaluable: IRC
Randomized: IRC
Evaluable: Investigator
Randomized: IRC
Indolent NHL
Randomized: IRC
Mantle Cell Lymphoma
P value P value
NI Sup
0.023 0.127
0.008 0.055
0.002 0.005
0.129 —
0.017 0.018
0 1 2 3 4
.
.
.
.
.
Rate Ratio
1.26
1.34
1.51
1.16
1.95
Favors R-CHOP/R-CVP ◄► Favors BR

Conclusions
• The CR rate of BR regimen is statistically
noninferior to R-CHOP/R-CVP in patients with
previously untreated indolent NHL and MCL
• OR rate was high for both treatment groups
• BR and R-CHOP/R-CVP have distinct toxicity
profiles
27

29
Aggressive Lymphoma
1. Rituximab maintenance treatment versus observation in patients with
aggressive B-cell lymphoma: results of the AGMT NHL13 trial. Jaeger U, et al.
12-ICML, Abstract 119
2. Gemcitabine, dexamethasone, cisplatin (GDP) compared with
dexamethasone, cytarabine, cisplatin (DHAP) salvage chemotherapy prior to
autologous stem cell transplantation for relapsed and refractory aggressive
lymphomas: Final result of the phase III NCIC CTG study LY12. Crump M. et al.
12-ICML Abstract 85
3. Treatment outcomes for older patients with relapsed/ refractory aggressive
lymphoma receiving salvage chemotherapy and autologous stem cell
transplantation (ASCT) are similar to younger patients: a subgroup analysis
from the phase III NCIC CTG LY12 trial. Davison K. et al; 12-ICML Abstract 22

8 x
rituximab
plus
4–8 x
CHOP-like
chemo
Not eligible
CR
CRu
R
E
G
I
S
T
R
A
T
I
O
N
Stratification*
12 x rituximab
375 mg/m2
q2mo for 2 years
Observation
Induction
Response
evaluation
R
A
N
D
O
M
I
S
E
D
2-year follow-up
Maintenance
* - Type of CHOP-like induction treatment (R-CHOP-14,21; R-CHOEP, etc.)
- Number of chemotherapy cycles in induction treatment (<6 vs. >6)
- Geographical region
Rituximab maintenance therapy
in DLBCL or follicular NHL grade 3
PR
SD
PD
NHL13
4–12 weeks
683 patients from 134
centers and 26 countries
Jaeger U, et al. 12-ICML, Abstract 119

Patient characteristics at diagnosis
Maintenance
N = 338
Observation
N = 345
Median age, years (range) 57 (19–87) 58 (19–88)
Sex (male) 163 (48.2%) 182 (52.8%)
Median BMI 25.9 25.6
At least one concomitant disease 231 (68.3%) 230 (66.7%)
DLBCL 329 (97.3%) 333 (96.5%)
FL grade 3 9 (2.7%) 12 (3.5%)
Ann Arbor I 59 (17.5%) 67 (19.5%)
Ann Arbor II 110 (32.5%) 116 (33.7%)
Ann Arbor III 83 (24.6%) 77 (22.4%)
Ann Arbor IV 86 (25.4%) 84 (24.4%)
Diameter of largest lymph node: > 5 cm 126 (37.3%) 124 (36%)
> 10 cm 33 (9.8%) 44 (12.8%)
Bone marrow involvement 41 (12.1%) 33 (9.6%)
LDH > upper limit of normal 154 (45.6%) 163 (47.2%)
IPI: 0,1 (low) 161 (47.6%) 165 (48.0%)
2 (low-intermediate) 96 (28.4%) 82 (23.8%)
3 (high-intermediate) 59 (17.5%) 67 (19.5%)
4,5 (high) 22 (6.5%) 30 (8.7%)

Event Free Survival by Treatment Arm
(ITT population; N=683)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Time [months]
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81
A: RITUXIMAB B: OBSERVATION
p = 0.067
80.1%
76.5%
HR: 0.78
95% CI: 0.57-1.08
Rituximab
maintenance
Observation
N at risk
Rituximab 338 302 283 269 261 249 242 204 23 13 12 12 1 0
Observation 342 308 283 275 261 245 234 198 34 20 18 17 3 0

Progression Free Survival by Treatment Arm
(ITT population)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Time [months]
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81
HR: 0.62
95%CI: 0.43-0.90
86.3%
79.0%
Rituximab
maintenance
Observation
N at risk
Rituximab 337 303 284 271 264 250 243 207 23 13 12 12 1 0
Observation 342 309 285 278 263 248 236 200 34 21 18 18 3 0

Overall Survival by Treatment Arm
(ITT population)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Time [months]
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99
HR: 0.78
95% CI: 0.49-1.34
92.0%
90.3%
Rituximab maintenance
Observation
N at risk
Rituximab 338 323 314 301 294 277 258 230 67 35 18 14 5 1 1
Observation 343 330 320 313 296 287 270 228 81 47 31 21 9 2 1

NHL13: Summary
• Rituximab maintenance treatment did not statistically
significantly prolong EFS in patients with DLBCL (or
FLG3).
• However:
• Trend in favour of R maintenance in EFS (p=0.06)
• Lymphoma relapses reduced by 44% (from 18.7
to 10.7%)
• These signals warrant further exploration of dosing and
scheduling (including maintenance) of Rituximab in
DLBCL.

Gemcitabine, Dexamethasone, Cisplatin (GDP)
compared to Dexamethasone, Cytarabine, Cisplatin
(DHAP) Salvage Chemotherapy Prior to Autologous
Stem Cell Transplantation for Relapsed and Refractory
Aggressive Lymphomas: Final Results of the
Randomized Phase III NCIC CTG Study LY12
Michael Crump, John Kuruvilla, Stephen Couban,
David Macdonald, Vishal Kukreti, Tom Kouroukis, Ralph Meyer,
Morel Rubinger, Rena Buckstein, Kevin Imrie, Massimo Federico,
Nicola Di Renzo, Kang Howson-Jan, Tara Baetz, Leonard Kaizer, Michael Voralia,
Harold Olney, Robert Turner, Jonathan Sussman, Annette Hay, Marina
Djurfeldt, Bingshu Chen, and Lois Shepherd

What is the optimum SALVAGE
therapy prior to ASCT?
What is the role of
rituximab MAINTENANCE
post-ASCT?
R1
(R)DHAP
(R)GDP
Non-inferiority design
SS: 630
R2
observation
rituximab q2m x6
SS: 240
NCIC CTG LY.12
Enrolment Aug 2003 – Oct 2011

Randomization stratified by:
- treating centre
- IPI score at relapse
- immunophenotype – B vs T/NK
- duration of response to primary therapy
- prior treatment with rituximab
gemcitabine 1000 mg/m2 d 1& 8
dexamethasone 40 mg po d 1-4
cisplatin 75 mg/m2 d 1
dexamethasone 40 mg po d 1-4
cytarabine 2 g/m2 q12h x 2 d2
cisplatin 100 mg/m2 /24h d1
2-3 cycles PBSC mobilization if CR, PR (or < PR as
per centre policy)
CD20+ :
rituximab
375 mg /m2 d1
Chemotherapy treatment
R

Random Assignment
N = 619
Allocated to GDP
N = 310
Allocated to DHAP
N = 309
4 Ineligible
3 Not treated
N = 303
ITT
population
3 Ineligible
4 Not treated
N = 302
CONSORT Diagram
Per protocol
population

Median age (y)
age >60 %
55 (19-71)
28
55 (23-74)
29
ECOG PS % 0,1
2,3
86
13
86
13
Stage % III
IV
26
44
25
43
Prior rituximab treatment, % 67 67
Relapse IPI, % 0,1
2
≥3
38
29
33
38
29
32
Immunophenotype % B
T/NK
89
11
90
10
Prior response NR/PD
to treatment, % CR < 1 y
CR ≥ 1 y
31
42
27
30
42
27
Patient Characteristics
GDP n=310 DHAP n = 309

Primary Endpoint – Response Rate
Intention to Treat Population
CR 4.5 5.2
CRu 9.0 9.1
PR 31.6 29.8
Response rate: 45.2 44.0
n 310 309
Upper boundary of 95.6% CI for difference in RR is
5.67%  GDP is non-inferior to DHAP (p = 0.005)
GDP (%) DHAP (%)

Overall Survival – Intent to Treat Population
4 year OS GDP 39%
DHAP 39%

Event-free Survival – Intent to Treat Population
4 year EFS GDP 26%
DHAP 26%

Adverse Events during Salvage Therapy
Any toxicity gr 3-4* 47 61 p = 0.0003
Febrile neutropenia 9 23 p < 0.0001
Platelet transfusion
(cycle 1 & 2) 18 32 p < 0.0001
Hospitalization for AE/illness 18 30 p = 0.0005
Any hospitalization 46 99 p < 0.0001
GDP % DHAP %
n=306 n=304
* CTC version 2.0

QoL Results: FACT-G Total - Means

NCIC-CTG LY.12 - Conclusions
• salvage chemotherapy with GDP (gemcitabine,
dexamethasone, cisplatin) is not inferior to standard
DHAP prior to ASCT
• GDP results in significantly less toxicity –
febrile neutropenia, plt transfusion, days in hospital
• better tolerated as shown by superior QoL
GDP represents a new standard for 2nd line chemotherapy
- could form the basis for design of regimens
incorporating novel agents into salvage therapy

Treatment outcomes for older patients with
relapsed/refractory aggressive lymphoma
receiving salvage chemotherapy and
autologous stem cell transplantation are
similar to younger patients: a subgroup
analysis from the Phase III NCIC CTG LY12
trial
K Davison, B Chen, V Kukreti, S Couban, A Benger, N Berinstein, L
Kaizer, P Desjardins, J Mangel, A Le, M Djurfeldt, L Shepherd and M
Crump, on behalf of the NCIC CTG

NCIC CTG LY12
• NCIC CTG LY12 is a prospective, randomized
phase III trial evaluating two questions:
– Optimal salvage chemotherapy pre-ASCT
– Value of rituximab maintenance post-ASCT
GDP +/- Rituximab
DHAP +/- Rituximab
R 2-3 cycles
PBSC mobilization
+ ASCT if CR, PR
(or < PR as per
centre policy)
*
* Stratified by treating centre, IPI, immunophenotype, response to
primary therapy and prior rituximab treatment

Random Assignment
N = 619
Age <60 (n = 442)
• Median age 51.2
• Range 19-59
Age > 60 (n = 177)
• Median age 63.7
• Range 60.2-74
GDP 222
DHAP 220
GDP 88
DHAP 89
Chemotherapy
Consort Diagram
ITT population

Histology (%) DLBCL
Transf IL
Other
68
14
18
73
15
11
ECOG PS (%) 0,1
2
86
14
88
12
Stage (%) I-II
III-IV
B
33
67
37
26
74
31
Prior rituximab treatment (%)
Prior radiation treatment (%)
66
24
72
27
LDH ↑ (%)
Extra-Nodal >1 (%)
42
27
42
23
Prior response NR/PD
to treatment (%) CR < 1 y
CR ≥ 1 y
34
42
24
26
42
32
< 60 (n=442)
> 60 (n=177)

ORR (%) 43 49 (p = 0.21)
ASCT rate (%) 50 50 (p = 0.87)
PBSC mob rate* (%) 86 84
Age < 60 Age > 60
(n= 442) (n = 177)
Primary endpoints: Response to
salvage and transplantation rates
*Success: >2.0 x 106 CD34+ cells/kg

Percentage
0
20
40
60
80
100
Timefromtransplantationcompletedate(months)
#At Risk(AGE </=60)
#At Risk(AGE >60)
0
442
177
12
220
84
24
161
61
36
127
50
48
104
36
60
78
21
72
41
12
NCICCTG LY.12
OS
AGE</=60 AGE>60
Overall Survival: Age < 60 vs
> 60 yrs
Percentage
Age <60
Age ≥ 60
Time from randomization (months)
median follow-up:
53 months
4 y OS:
40% for younger
vs 36% for older
pts (p = 0.42)

Percentage
0
20
40
60
80
100
Timefromtransplantationcompletedate(months)
#At Risk(AGE</=60)
#At Risk(AGE>60)
0
442
177
12
142
63
24
106
40
36
86
31
48
69
20
60
51
11
72
29
5
NCICCTG LY.12
EFS
AGE</=60 AGE>60
Event Free Survival: Age < 60
vs > 60 yrs
Percentage
Age <60
Age >60
Time from randomization (months)
median follow-up:
53 months
4yr EFS:
28% for younger
vs 20% for older
pts (p = 0.43)

Febrile neutropenia (%) 23 30 (p = 0.053)
GDP 17 18
DHAP 29 43
Hospitalization for AE/illness (%) 32 38 (p = 0.17)
GDP 26 30
DHAP 38 46
* CTC version 2.0
Toxicity during Salvage Therapy
Age < 60 Age ≥ 60
(n = 436) (n = 174)

Conclusions
• Outcomes for patients > 60 yrs of age with rel/ref
NHL are similar to those of younger patients with
respect to:
– Response rate, ASCT rate
– OS, EFS
– toxicity
• High-dose therapy and ASCT should be
considered for the management of older patients
with rel/ref aggressive NHL in the rituximab era
– Small number of pts > 65 years on LY12 make
generalizability of these findings to all patients >
60 yrs less certain

56
CNS and lymphomas
1. A new prognostic model to assess the risk of CNS disease in patients with
aggressive B-cell lymphoma. N. Schmitz et al 12-ICML, Abstract 47
2. Risk-tailored CNS prophylaxis in a mono institutional series of 194 patients
with diffuse large B-cell lymphoma treated in the rituximab era. Ventre MB,
et al. 12-ICML. Abstract 218
3. Phase II trial of temsirolimus for relapsed/refractory primary central nervous
system lymphoma (PCNSL) P. Kiewe, et al. 12-ICML, Abstract 46

CNS prophylaxis
CHOP MACOP-B ProMACE m-BACOD
none none BM + at dx– after
cycle 4
Cranial XRT 2,400
cGy
IT MTX (12mg)
AraC (30mg/m2)
2x week
x 6 doses
BM + at dx–
after > wk6
4.4% 2.2% 3.0% 1.4%
JCO 2008;27:114
P = 0.24

58
Does Including Rituximab In The Treatment
Regimen Decrease CNS Relapse?
Mayo Clinic Proc 2012;57:161
Incidence of CNS Relapse
Vancouver* UNMC
CHOP 5.8% 3.6%
R-CHOP 2.2% 2.2%
* Pacients who achieved CR

GERMAN HIGH-GRADE NHL
STUDY GROUP (DSHNHL)
www.lymphome.de/en/Groups/DSHNHL
Allocation of patients treated
with CHOP/CHOEP and Rituximab
Trial patient
number
with CNS
involvement
w/ o CNS
involvement
18 - 60 years:
MegaCHOEP Phase II
MegaCHOEP Phase III
MInT
Unfolder
All
76
262
413
443
1194
-
3
1
-
4
76
259
412
443
1190
60 - 80 years:
RICOVER
Pegfilgrastim
Escalated Rituximab
All
610
56
313
979
2
-
3
5
608
56
310
974
Total 2173 9 2164

Total
n=2164
With CNS event
n=64
No CNS event
n=2100
p-value
Male 1244 (57.5%) 30 (46.9%) 1214 (57.8%) 0.081
Age, median 58 63.5 57
Age > 60 years 974 (45.0%) 43 (67.2%) 931 (44.3%) <0.001
LDH > N 1147 (53.0%) 50 (78.1%) 1097 (52.2%) <0.001
ECOG > 1 247 (11.4%) 21 (32.8%) 226 (10.8%) <0.001
Stage III/ IV 1148 (53.1%) 49 (76.6%) 1099 (52.4%) <0.001
Extranodal involvement > 1 479 (22.1%) 23 (35.9%) 456 (21.7%) 0.007
IPI 0
1
2
3
4
5
237 (11.0%)
772 (35.7%)
523 (24.2%)
398 (18.0%)
178 ( 8.2%)
53 ( 2.5%)
1 ( 1.6%)
9 (14.1%)
14 (21.9%)
20 (31.3%)
11 (17.2%)
9 (14.1%)
236 (11.3%)
763 (36.4%)
509 (24.3%)
378 (18.0%)
167 ( 8.0%)
44 ( 2.1%)
<0.001
Bulky disease 1027 (47.5%) 32 (50.0%) 995 (47.4%) 0.679
B-symptoms 703 (32.5%) 32 (50.0%) 671 (32.0%) 0.002

Factor Relative risk p-value 95% CI
LDH > N 2.3 0.010 (1.2; 4.3)
Stage III/ IV 1.9 0.034 (1.1; 3.6)
ECOG > 1 2.3 0.005 (1.3; 4.0)
Age > 60 years 2.4 0.001 (1.4; 4.2)
Kidney or adrenal glands 3.1 0.002 (1.5; 6.2)
CNS - IPI
for patients treated with R – CHO(E)P
Immunoblastic /
plasmoblastic morphology
2.7 0.013 (1.2; 6.0)
Towards the CNS - IPI: Model III

Months
0 10 20 30 40 50 60 70 80 90 100
0.00
0.05
0.10
0.15
0.20
0.25
0.30
Proportion
CNS - IPI
for patients treated with R – CHO(E)P
82 patients without data on reference pathology
4-6 factors
n=141
3 factors
n=354
0-2 factors
n=1587
The CNS - IPI: Final Model

0-2 risk factors 4-6 risk factors
3 risk factors
1587/ 2082 pts. ( 76 % )
2-year-rate: 1.2%
[0.6; 1.8%]
354/ 2082 pts. ( 17 % )
2-year-rate: 6.1%
[3.4; 8.8%]
141/ 2082 pts. ( 7 % )
2-year-rate : 15.7 %
[9.0; 22.4%]
No prophylaxis ? CNS-protocol
No prophylaxis
Prophylaxis ?
Change to CNS-protocol?
None CSF analysis, MRI
The CNS-IPI in Aggressive B-cell Lymphoma:
Consequences for diagnostic and prophylactic measures
The final model
diagnostics

N= 194 DLBCL
Risk factors:
• testis, spine, base of skull,
kidney, breast,
• IPI≥2, (include LDH, stage III-IV,
Ext N >1)
Risk
Group
CNS Proph. CNS
Relapse
Low No/Yes 1%
High yes 0%
High No 12%
CNS Prophylaxis For DLBCL In The Rituximab Era (Milan, Italy)

Phase II trial of Temsirolimus for
relapsed/refractory primary CNS lymphoma
(#046)
P. Kiewe, E. Thiel, T. Grobosch, U. Schlegel, P. Martus, and A. Korfel
• 30 patients enrolled
• Median age: 69y, median ECOG: 2
• Median # of previous treatments: 2 (range, 1-5)
Treatment:
• 1st cohort (25mg): 6 patients, 2nd cohort (75mg)
24 pts.
• Median # of weekly infusions: 7 (range, 1-28)

Efficacy
IPCG criteria N %
CR 6 20
PR 10 33
SD/no change 6 20
PD 4 13
NE* 4 13
*early deterioration or death before imaging
53% ORR
• n= 30 patients documented
All but one responses seen in 75mg cohort (ORR in
75mg cohort: 62%)
Median PFS 2.7 months (range, 0.7-17.7)

C.E., female, 73 yrs, PD 2 mo after R/HDMTX/IFO
7.12.2012 14.1.2013
no
concomitant
steroids
PFS 4.2 mo

12.12.2011 20.2.2012
12.12.2011 13.1.2013
15.11.2011
R.A., female, 73 yrs, relapse 4 months after HDMTX/Ifo
TEM 16.11.2011-21.5.2012
Steroids week 1-3. PFS 17.7 months

Summary and Conclusions
• Single agent Temsirolimus at a weekly dose of 75mg shows surprisingly
high activity in relapsed/refractory PCNSL
• Toxicity is notable in this patient population, particularly thrombocytopenia
and lung toxicity
• Response duration is short (2.7 months) but 2 long term responses
(12.3+ and 17.7 months) have been observed
• Neither Temsirolimus nor its active metabolite Sirolimus penetrate into
CSF

70
The Place Of Radiotherapy In Treating Patients
With Lymphoma
1. Managing stage I-II follicular lymphoma with upfront definitive radiation
therapy: the forty-year experience of the Princess Margaret Cancer Centre.
Charpentier A. Toronto. 12-ICML. Abstract 062
2. The role of radiotherapy to bulky disease in elderly patients with aggressive B-
cell lymphoma. Results from 2 prospective trials of the DSHNHL. Zwick C.
Homburg. 12-ICML. Abstract 122
3. Role of radiation in patients with diffuse large B-cell lymphoma (DLBCL) in the
Rituximab era: a comprehensive analysis from the National Comprehensive
Cancer Network (NCCN) lymphoma outcomes project. Dabaja B. Houston. 12-
ICML. Abstract 121
4. Long-term experience with PET-guided consolidative radiation therapy (XRT)
in patients with advanced-stage diffuse large B-cell lymphoma (DLBCL) treated
with CHOP. Sehn LH, Vancouver. 12-ICML. Abstract 123

• 526 patients
• Median F/U 12.5 years
• Median dose 31 Gy
(range 20-47)
• CR 99%
All patients
N = 708
Radiation
alone
N = 526
Extra-nodal
disease
N = 170
Overall survival 65.3% 64.9% 59.5%
Cause-specific
survival
80.0% 80.6% 78.0%
Relapse rate 48.0% 51.3% 45.5%
• Radiation in the upfront management of localized
FL provides excellent local disease control
• Plateau in relapse rate after 10-15 years suggests a
significant proportion of cured patients
• Chemotherapy can be avoided for a substantial
number of patients initially treated with RT
40 Year Experience With Definitive Radiotherapy For Stage I/II
Follicular Lymphoma

Investigators Rituximab Ages Outcome
DSHNHL No  60 yrs
bulky disease
HR 4.4 for PFS (p=.001)
favoring radiotherapy
NCCN Yes 57 yrs (17-90) 5-yrs FFS 83% vs 75% (p 
.05) favoring radiotherapy
Does Radiotherapy Add To The Treatment Of Patients With
Diffuse Large B-Cell Lymphoma?

Outcome
PET status n 4 yrs TTP 4yrs OS
PET negative 167 74% 83%
PET positive, XRT 60 81% 85%
PET positive, no XRT 22 33% 30%
PET Guided Radiotherapy In High Stage DLBCL Treated
With CHOP-R
Sehn LH, et al. 12-ICML. Abstract 123

74
What is the value of survaillance imaging?
1. Utility of Post-Therapy Surveillance Scan in Difuse Large B-Cell Lymphoma.
Thompson C. Rochester, Lyon, Iowa. ASCO-2013 , abstract 8546. 12-ICML.
Abstract 226
2. Clinical or survival benefit to routine suveilance imaging for clasiccal Hodgkin
Lymphoma patients in first complete remission. Pingali SR. ASCO-2013
Abstract 8505
3. Patient-reported symptoms are still the single most important factor for
detecting lymphoma relapse. El-Galaly T. Aarhus. 12-ICML. Abstract 225.

Features Iowa/Mayo SPORE
n=644
Lyon
n=269
Post. treatment obs 538 230
Median Follow-up 59 months 35 months
Relapsed 108 (20%) 48 (21%)
Two independent DLBCL cohorts demonstrated similar patterns of relapse detection
occurring outside of planned follow-up visits, which are detectable via symptoms,
physical exam or laboratory abnormalities. Post-therapy surveillance scans added
little to detection of relapse.
Thompson C, ASCO 2013. Abstract 8546; Ghesquieres H. 12-ICML Abstract 226

Pingali SR.ASCO 2013 Abstract 8505
Clinical or survival benefit to routine suveilance imaging for
clasiccal Hodgkin Lymphoma

Patient Reported Symptoms As The Reason For Detecting
Relapse (Denmark)
• 309 pts. (52 HL and 257 NHL)
• Reason for detecting relapse:
• Relapse detected by imaging had a better survival in aggressive B-cell
NHL
• symptoms alone (41%)
• clinical findings (32%)
• routine imaging (27%)

Smith S. ASCO 2013. Annual Meeting

[TITLE]
Presented By Sonali M. Smith, MD at 2013 ASCO Annual Meeting

[TITLE]
Presented By Leo I. Gordon, MD at 2013 ASCO Annual Meeting

1. Impact of gender, body mass index and body surface area on outcomes of
diffuse large B-cell lymphoma patients treated with rituximab: Analysis of the
U.S. NCCN database. Z. Zhou et al. 12-ICML Abstract 208
2. Male sex evolves as a significant risk factor in diffuse large B-cell lymphoma
treated with rituximab only in elderly, but not in young patients: Correlation
with rituximab pharmacokinetics. M. Pfreundschuh et al. 12-ICML. Abstract
209
Rituximab dose and gender

Rituximab Clearance In Elderly (i.e. >60 years) Patients
(DSHNHL)
• Males had a significantly more rapid rituximab clearance (p=.003)
• Females had a superior 3-year PFS: 68% v 61% (p=.06)
• Males receiving rituximab over a longer period of time (8 months
rather than 3 months) had a superior 3 year PFS (71% v 53%, p=.05)
and OS (80% v 60%, p=.04)
ASCO 2012, Abstracts 8024, 8025
Differences In Outcome With Rituximab By Gender In
DLBCL And Follicular Lymphoma (ECOG)
• With CHOP-R in DLBCL
• FFS and OS favored women (p=.02)
• No difference by gender for CHOP alone
Men Women P
CR/PR 72% 83% =.04
ASH 2012, Abstract #3705

Impact of Gender, BMI and BSA On Outcome Of Patients With DLBCL
Treated With CHOP-R (NCCN)
N= 1420 pts
Male gender was associate with worse
outcome in DLBCL trated with R-
containing regimen. This was well
pronounced in the elderly subgroup
(>60)
PFS
PFS
PFS

Male sex evolves as a significant risk factor in diffuse large B-cell
lymphoma treated with rituximab only in elderly, but not in young
patients: Correlation with rituximab pharmacokinetics. (DSHNHL)
• 2320 pts.; R kinetics measured in 33 young and 49 elderly
• R clearance same in young, but shorter serum half life in
elderly males
• Young males and females benefitted equally from R
• Elderly males had a higher rate of progression (HR 1.6,
p=.004)
Questions?
• Increase dose of Rituximab?
• Prolong treatment with Rituximab?
• Intense dose of Rituximab?

86
New Drugs. Monoclonal Antibodies
1. Phase I study of the anti-CD22 antibody-drug conjugate (ADC) DCDT2980s
with or without rituximab in patients with relapsed or refractory B-cell non
Hodgkin’s lymphoma. Advani R. et al. 12-ICML, Abstract 39.
2. Phase I study of the anti-CD79b antibody-drug conjugate DCDS4501a in
relapsed or refractory b-cell non Hodgkin’s lymphoma. M. C. Palanca-
Wessels et al. 12-ICML, Abstract 40
3. The efficacy and safety of Mogamulizumab (KW-0761) in multicentre phase
II study for patients with relapsed peripheral or cutaneous T-cell lymphoma.
Ueda R. et al. 12-ICML, Abstract 41
4. A phase I study of bispecific CD30/CD16a tandab antibody AFM13 in
patients with relapsed or refractory Hodgkin lymphoma. A. Engert et al. 12-
ICML, Abstract 42

Monoclonal Antibodies
Author Drug Target Phase Comment
Advani R. ICML
12
DCDT2980s CD22 Con I B-cell
Palanca-Wessels.
ICML-12
DCDS4501a CD79 Con I B-Cell
Ueda R. 12-ICML Mogamulizumab
(KW-0761)
CCR-4 II T-cell
A. Engert AFM13 CD30/CD1
6
I HL.
BCR Pathway
Leonard J. ASCO
2013
Idelalisib (GA-
1101)
PI3K I NHL relapsed, Associated with R,
B or RB (n=79)
CR 26% PFS 24 mths ORR 69%
Idelalisib (GA-
1101)
PI3K I
Ibrutinib (PCI
32765)
BCR I
New Drugs. Monoclonal Antibodies

Author Drug Target Phase Comment
DCDT2980s CD22 I

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