Randomized Study of ACVBP Versus ACVBP Plus Rituximab in Previously Untreated Patients Aged From 18 to 65 Years With Low-risk Localized Diffuse Large B-cell Lymphoma (Age-adjusted IPI = 0)
Approximately 30 to 40% of diffuse large B cell lymphomas are localized at diagnosis (stage
I-II). Until the seventies, radiotherapy was used as the single modality to treat these
localized stages but no more than half of the patients were cured. From the eighties,
anthracycline-based regimens combined or not with radiotherapy gave superior results in term
of relapse free survival compared with radiotherapy alone. Later on Miller et al. published
a randomized study showing that 3 cycles of CHOP combined with radiotherapy gave superior
results in term of overall survival as compared with 8 cycles of CHOP. This study was
recently updated with a follow up of more than 8 years and shows no more difference between
the two arms, due to an excess of late mortality after the combined treatment.
Recently, two trials were conducted by the GELA to compare chemotherapy alone to a combined
chemo-radiotherapy approach in patients with low risk localized diffuse large cell lymphoma
(age-adjusted IPI = 0).
- The objective of the LNH 93-1 study was to compare, in patients aged from 18 to 60
years 3 cycles of CHOP followed by radiotherapy with chemotherapy alone consisting in 3
cycles of ACVBP. The ACVBP regimen includes a more intensive induction followed by a
sequential consolidation. With a median follow up of 55 months, the results have shown
a superiority of the ACVBP arm for both the 5 year event free (83% vs. 74%, p = 0.004)
and overall survival (89% vs. 80%, p = 0.02).
- The LNH 93-4 study compared in patients >60 years the association of 4 cycles of CHOP +
radiotherapy to the same regimen without irradiation. This study fails to demonstrate
any benefit of the combined chemo-radiotherapy in term of survival, but indicates that
chemotherapy alone is probably less toxic in patients older than 69 years.
Considering these two trials, we concluded that radiotherapy given after chemotherapy did
not give any benefit to elderly patients treated for a low risk localized diffuse large cell
lymphoma, and that ACVBP regimen was superior to 3 CHOP + radiotherapy in patients <60
years, and has to be considered as the treatment of reference in these patients.
Two other GELA trials contributed recently to improve the treatment of diffuse large B cell
lymphoma and have to be considered for the elaboration of future studies:
- The objective of the LNH 98-5 study was to compare the association of CHOP + rituximab
(R-CHOP) to the CHOP regimen alone in elderly patients with previously untreated large
B-cell lymphoma. The analysis showed a significant superiority of the association CHOP
- The LNH 93-5 study compared the ACVBP regimen to the CHOP in patients aged from 61 to
69 years with aggressive lymphoma and at least one adverse prognostic factor according
to the International Prognostic Index. Out of 703 patients included in this study, the
results have shown the same complete response rate in the two arms, but a significantly
better 3-year event free survival and overall survival in the ACVBP arm than in the
CHOP arm. However, the benefit seems to be greater in patients <66 years, due to higher
toxicity with the ACVBP regimen in elderly patients.
All the above-mentioned results led us to propose a randomized trial comparing ACVBP to
ACVBP + rituximab (R-ACVBP) in previously untreated patients with low risk localized diffuse
large B-cell lymphoma (age-adjusted IPI = 0), and to extend the upper age limit from 60 to
Allocation: Randomized, Endpoint Classification: Safety/Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Event-free survival (EFS), events defined as death from any cause, relapse for complete responders (CR) and unconfirmed complete responders (CRu), progression during and after treatment and change of therapy.
Nicolas Ketterer, MD
Lymphoma Study Association
France: Afssaps - Agence française de sécurité sanitaire des produits de santé (Saint-Denis)