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Journal of Clinical Oncology, Vol 24, No 15 (May 20), 2006: pp. 2343-2351 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.05.0187 Clinical Outcomes and Prognostic Factors in Patients With Richter's Syndrome Treated With Chemotherapy or Chemoimmunotherapy With or Without Stem-Cell TransplantationFrom the Departments of Leukemia, Blood and Marrow Transplantation, and Biostatistics, The University of Texas M.D. Anderson Cancer Center, Houston, TX Address reprint requests to Apostolia-Maria Tsimberidou, MD, PhD, Department of Leukemia, Unit 428, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030; e-mail: atsimber{at}mdanderson.org
PURPOSE: The purpose of this study was to assess the incidence, presenting characteristics, and treatment outcomes of Richter's syndrome (RS) and factors predicting response and survival. PATIENTS AND METHODS: An electronic database search of patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL) who presented at The University of Texas M.D. Anderson Cancer Center (Houston, TX) between January 1975 and June 2005 was performed, and patient medical records were reviewed.
RESULTS: Of the 3,986 patients with CLL/SLL, 204 patients (5.1%) had possible RS, and 148 patients (3.7%) had biopsy- or fine-needle aspiration–proven RS. Treatment included chemotherapy alone and chemoimmunotherapy with rituximab. The overall response rate for the 130 assessable patients was 39% (chemotherapy, 34%; chemoimmunotherapy, 47%; P = .2). In multivariate analysis, factors predicting prolonged survival were Zubrod performance status 0-1 (P = .006), lactate dehydrogenase CONCLUSION: A score to predict an individual patient's risk of death is proposed. Chemotherapy and rituximab combinations are effective in RS. Patients with available donors may be considered for allogeneic SCT as postremission therapy.
Richter's syndrome (RS), first described in 1928 by Maurice N. Richter,1 refers to the development of high-grade non-Hodgkin's lymphoma (NHL) in patients with chronic lymphocytic leukemia (CLL)/small lymphocytic lymphoma (SLL). Richter's transformation is a process that has been reported to be triggered by viral infections, such as Epstein-Barr virus infection. The large cells of RS either arise through a transformation of the original CLL clone or, less frequently, represent a new or secondary neoplasm. Genetic defects are believed to cause CLL cells to proliferate and, by facilitating the acquisition of new genetic abnormalities, transform into RS cells.2 RS occurs in 2% to 8% of patients with CLL/SLL. The clinical outcome of the disease is generally poor. Numerous therapies can induce a response, but patients typically die within a few months after transformation to RS. In the management of RS, it is common to use regimens that are effective in high-grade NHL or acute lymphoblastic leukemia and, in particular, agents that are non–cross-resistant and have no overlapping toxicities. In 1993, Robertson et al3 reported our experience with 39 patients with RS. Despite multiagent therapy, the median survival duration was only 5 months.3 In 1998, we investigated the combination of fractionated cyclophosphamide, vincristine, liposomal daunorubicin, and dexamethasone (Hyper-CVXD). Hyper-CVXD induced complete responses (CRs) in 38% of patients, but the median overall survival was 10 months.4 In recent years, important advances in the treatment of lymphoma, such as the introduction of monoclonal antibodies, have prompted us to investigate rituximab in combination with cytotoxic chemotherapy in RS. In 1999, we combined rituximab with Hyper-CVAD, and alternated this regimen with methotrexate and cytarabine plus rituximab. The overall response rate of patients with RS was 43% (CR, 27%) and the median survival duration was 9 months.5 Although numerous regimens have been proposed for the treatment of RS, there is no consensus on the best therapeutic approach for these patients, and clinical features that independently predict the rates of response, survival, and failure-free survival (FFS) have not been identified as they have been for aggressive6 and follicular lymphoma.7 This study summarizes our experience with patients with RS and was designed to describe the presenting characteristics, incidence, treatment outcomes, and factors predicting response, survival, and FFS in patients with RS.
A database that includes all the untreated and treated patients with CLL/SLL who were referred to the Leukemia Service at The University of Texas M.D. Anderson Cancer Center (Houston, TX) between January 1975 and June 2005 was searched for patients with RS. All records were reviewed to determine clinical, laboratory, and pathologic features at presentation as well as disease stage, treatment, and clinical outcome. Staging evaluations at the time of presentation included complete physical examinations, bone marrow aspirations and biopsies, lymph node biopsies or fine-needle aspirations (FNA), and chest radiography or computed tomography of the chest, abdomen, and pelvis, if available. Staging and treatment were determined after review of all clinical, laboratory, and pathologic data in a multidisciplinary conference. Standard or investigational treatment was administered either at our center or in the community by collaborating physicians. The evaluation of response for all patients included in the study was performed at the M.D. Anderson Cancer Center. Signed informed consent was obtained from all patients before all procedures and before all experimental therapy, as required by the institutional review board. The response and end point assessments conformed to published International Workshop response criteria.8 CR was defined as complete disappearance of all detectable clinical and radiographic evidence of disease, disappearance of all disease-related symptoms, and normalization of biochemical abnormalities definitely assignable to RS for at least 1 month. Unconfirmed CR (CRu) included cases with minimal stable radiographic changes or with persistent lymphoid aggregates in the bone marrow without atypia. Partial remission (PR) was defined as a reduction of 50% or more in the sum of the products of the greatest diameters of bidimensionally measurable disease. Any lesser response was considered a failure. Survival was measured from the start of treatment until death from any cause or until last follow-up. FFS was defined as the time from the start of treatment until progression, relapse, or death. The following parameters were examined in univariate and multivariate analyses for assessment of response, survival, and FFS: age, sex, presence of B symptoms, performance status, time from diagnosis of CLL/SLL to Richter's transformation, number of prior therapies (for CLL/SLL), presence of splenomegaly, presence of hepatomegaly, WBC counts, absolute lymphocyte counts, hemoglobin levels, platelet counts, lactate dehydrogenase (LDH) levels, beta2-microglobulin (ß2-microglobulin) levels, albumin levels, cytogenetics, levels of immunoglobulins G, A, and M, proportion of lymphocytes and/or lymphoma cells in bone marrow biopsies, Ann Arbor stage, Rai stage,9 number of extranodal sites, maximum size of tumor, International Prognostic Index score,6 and number of disease-involved sites.7 The Fisher's exact test was used to assess the independence between two categoric variables. The t test was used to assess a difference between two groups for continuous variables. Survival curves were estimated using the Kaplan-Meier method. The two-sided log-rank test was used to test the association between variables for survival or FFS. Multivariate analysis was performed using the Cox proportional hazards regression model to determine which variables affected the duration of survival or FFS and the association between treatment and survival or FFS after adjusting for other factors. P values were derived from two-sided tests, and the statistical analyses were carried out using S Plus 2000 (Insightful Corp, Seattle, WA). A P value of less than .05 was considered significant.
Of the 3,986 patients with CLL/SLL, 204 patients (5.1%) had possible RS and 148 patients (3.7%) had biopsy- or FNA-proven large cell lymphoma, or RS. Thirteen patients had the Hodgkin's disease variant of RS. The remaining patients had indications of acceleration or transformation, as listed in Table 1. The characteristics of patients with classical RS are listed in Table 2. The median age of the 204 patients was 61 years (range, 29 to 83 years), and 142 patients were men. Of 148 patients with classical RS, 53% were  60 years, 79% had Zubrod performance status 0 to 1, 47% had LDH levels 1.5x the upper limits of normal, 57% had platelet counts 100 x 109/L, 40% had ß2-microglobulin levels 6 mg/L, and 45% had tumors larger than 5 cm. Epstein-Barr virus was detected by in situ hybridization in the involved site of the disease in two (13%) of 15 tested patients with RS and in three (100%) of three patients with Hodgkin's disease variant.
Therapy Of 148 patients with proven RS, 135 received therapy and 130 were assessable. Sixty-one percent of the patients received chemotherapy. Eighteen percent were treated with fludarabine or other purine analog-based therapy, 16% were treated with Hyper-CVXD and variants, 8% with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP), and 19% with other therapies such as etoposide, methylprednisolone, high-dose cytarabine, and cisplatin (ESHAP) and mesna, ifosfamide, mitoxantrone, and etoposide (MINE). Thirty-six percent received chemotherapy and rituximab combination therapy: Hyper-CVXD and variants combined with rituximab (27%), fludarabine, cyclophosphamide, and rituximab (FCR; 5%), and CHOP and rituximab combination therapy (4%). Three percent of the patients received immunotherapy alone with rituximab (n = 3) or alemtuzumab (n = 1).
Response to Therapy
Overall Survival The median survival of all patients with biopsy- or FNA-proven RS was 8 months (95% CI, 6 to 10 months; Fig 1). In univariate analysis, pretreatment factors that correlated with shorter survival were performance status more than 1, high lactate dehydrogenase levels, high ß2-microglobulin levels, low hemoglobin levels, low platelet counts, low albumin levels, presence of B symptoms, two or more prior therapies, large tumor size, prolonged time to Richter's transformation, and high International Prognostic Index score (Table 4). In multivariate analyses of all 130 treated patients, factors that independently correlated with shorter survival were Zubrod performance status more than 1 (P = .006), LDH levels higher than 1.5x the upper limit of normal (P = .003), platelet counts less than 100 x 109/L (P = .011), tumor size 5 cm (P = .021), and more than one prior therapy (P = .021; Table 5).
Failure-Free Survival The median FFS duration of the 130 treated patients was 7 months (95% CI, 5 to 10 months; Fig 2). In univariate analysis, factors predicting shorter FFS were Zubrod performance status 0 to 1, high LDH, high ß2-microglobulin levels, low hemoglobin levels, low platelet counts, low albumin levels, large tumor size, two or more prior therapies, presence of B symptoms, time to transformation of more than 5 years, and high International Prognostic Index score (Table 4). In the multivariate analysis of 130 treated patients, factors that independently correlated with shorter FFS were Zubrod performance status 0 to 1 (P = .006), high LDH levels (P = .019), tumor size 5 cm (P = .021), age 60 years (P = .025), more than one prior therapy (P = .041), and platelet counts  100 x 109/L (P = .045).
Other factors, such as age, sex, B symptoms, WBC count, absolute lymphocyte count, number of cytogenetic abnormalities, Ann Arbor or Rai stage,9 number of extranodal sites, and bone marrow involvement, did not reach statistical significance in univariate analysis for response, survival, or FFS.
Biopsy-Proven Versus Fine-Needle Aspiration–Proven RS
Independent Prognostic Factors and the Prognostic Factor Model
Stem-Cell Transplantation A total of 20 patients underwent subsequent stem-cell transplantation (SCT). Seven patients underwent SCT as postremission therapy, and 13 patients underwent allogeneic SCT (n = 10) or autologous SCT (n = 3) as salvage therapy. Patients' characteristics, therapies used for cytoreduction, conditioning regimens, response, and clinical outcome are listed in Tables 6 and 7.
The estimated cumulative survival at 3 years is 75% for patients who underwent allogeneic SCT after a CR, CRu, or PR, 27% for patients who responded to initial therapy and received no allogeneic SCT, and 21% for patients with relapsed or refractory RS who underwent allogeneic or autologous SCT as salvage therapy (P = .019; Fig 4). Survival from the time of SCT by type of transplantation and disease status are shown in Figure 5.
When allogeneic SCT as a postremission therapy variable was included in the Cox proportional hazards regression model (multivariate analysis), it independently correlated with prolonged survival (P = .002) in the final model after a step-wise model selection procedure, but platelet count became insignificant.
In this analysis, patients with biopsy- or FNA-proven large cell transformation of CLL/SLL were assessed for treatment outcomes and factors predicting response, survival, and FFS. Combinations of rituximab with Hyper-CVXD variants or CHOP induced responses in 47% of patients compared with a 34% response rate seen with chemotherapy alone (P = .2). This suggests that there is a benefit from chemotherapy and rituximab combination therapies. It is notable that the number of patients treated with chemotherapy and rituximab combinations compared with those treated with chemotherapy alone was relatively small. Further study with a larger sample size would be helpful to confirm our findings. In particular, 200 patients for each group are needed to achieve an 80% power at a significance level of .05. The incidence of RS in patients with CLL was 3.7% and is within the previously reported range of 2.2% to 8%.3,10-15 However, only patients with biopsy- or FNA-proven RS were included in this analysis. The superior response rates with rituximab and Hyper-CVXD or CHOP combination therapies are consistent with those attained incorporating rituximab to regimens for diffuse large B-cell lymphoma (DLBCL), such as R-CHOP (rituximab plus CHOP).16-19 The addition of rituximab to CHOP was shown to overcome bcl-2–mediated resistance and to prolong survival in elderly patients with DLBCL.20 The Hyper-CVXD variant and rituximab combination is also very effective in mantle cell lymphoma,21 lymphoblastic lymphoma, and acute lymphoblastic leukemia, but have not been broadly investigated in DLBCL.
Characterization of adverse prognostic features is important in identifying patients who may benefit from specific treatment strategies. Five characteristics were identified to independently predict shorter survival: Zubrod performance status of more than 1, LDH levels higher than 1.5x the upper limit of normal, platelet counts lower than 100 x 109/L, tumor size The RS score was developed to predict outcomes in patients with RS treated with chemotherapy with or without rituximab. The RS score may be used to identify specific risk groups and to compare different therapeutic approaches. More importantly, as patients in the high-risk group do not benefit from the above treatments, they should be considered for initial therapy with investigational agents. Allogeneic SCT appears to warrant further study. The value of additional information, such as mutational status,23 ZAP-70,24-26 and information from genomic and proteomic analyses is unknown at the present time. In addition, prognostic models identifying patients with CLL at risk of transforming to RS should be developed. Although some attempts have been made to predict risk factors for the development of RS in CLL/SLL,2,14,27 the results were either inconclusive14 or multivariate analyses were not performed.27 The rates of overall survival and FFS are disappointing, with a median survival duration of 8 months and a median FFS duration of 7 months. In contrast, the outcomes of the few patients who underwent allogeneic SCT as postremission therapy were encouraging, with a 3-year estimated cumulative survival of 75% in patients who underwent allogeneic SCT as postremission therapy. However, the number of patients was small and it is likely that some patients who underwent allogeneic SCT were carefully selected, as evidenced by the prolonged time from response to initial therapy to allogeneic SCT (Table 6). In this study, the use of relatively nontoxic, nonmyeloablative, or reduced-intensity conditioning regimens followed by donor lymphocyte infusions for progressive or relapsed disease resulted in tumor response and prolonged survival in patients with both chemosensitive and refractory or relapsed RS. These results are consistent with a previous report from our institution showing that allogeneic bone marrow transplantation can provide a better outcome than conventional chemotherapy in patients with RS.28 The results of the current study are also consistent with those we have observed with similar conditioning regimens in other lymphoid malignancies.29,30 A critical component of these preparative regimens, for both antitumor and immunomodulatory effects, is high-dose rituximab. Given the greater sensitivity of large cell lymphoma to single-agent rituximab, the antitumor effect of rituximab may be even more pronounced in RS than in CLL/SLL.31 Our results demonstrate that RS should be treated with cytoreductive therapy consisting of rituximab and cytotoxic combination therapy. Patients in the high-risk group should be offered investigational approaches. Nonmyeloablative allogeneic SCT appears to be beneficial as postremission therapy in some patients, although it does not cure the majority of patients. Patients with available donors may be considered for nonmyeloablative allogeneic SCT as postremission therapy.
Although all authors completed the disclosure declaration, the following authors or their immediate family members indicated a financial interest. No conflict exists for drugs or devices used in a study if they are not being evaluated as part of the investigation. For a detailed description of the disclosure categories, or for more information about ASCO's conflict of interest policy, please refer to the Author Disclosure Declaration and the Disclosures of Potential Conflicts of Interest section in Information for Contributors.
Dollar Amount Codes (A) < $10,000 (B) $10,000-99,999 (C)
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J Clin Oncol 16:2817-2824, 1998[Abstract] 30. Khouri IF, Saliba RM, Giralt SA, et al: Nonablative allogeneic hematopoietic transplantation as adoptive immunotherapy for indolent lymphoma: Low incidence of toxicity, acute graft-versus-host disease, and treatment-related mortality. Blood 98:3595-3599, 2001 31. Khouri IF, Lee MS, Saliba RM, et al: Nonablative allogeneic stem cell transplantation for chronic lymphocytic leukemia: Impact of rituximab on immunomodulation and survival. Exp Hematol 32:28-35, 2004[CrossRef][Medline] This article has been cited by other articles:
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
