Onkológia 1/2020

Long-term response and remission with pixantrone in 4th line treatment in patient with relapsed/refractory diffuse large B-cell non-Hodgkin lymphoma

Introduction: Patients with relapsed/refractory diffuse large B-cell non-Hodgkin lymphoma (R/R DLBCL) have an unfavorable prognosis with poor or no response to treatment. When responding to chemoimmunotherapy, remission is usually short and not complete (ORR 26%, CR 7%). They represent approximately 1/3 of all DLBCL patients, and in case of retained chemosensitivity, undergo salvage high-dose chemotherapy with autologous peripheral haematopoietic stem cell transplantation (ASCT) as the 2nd line, able to provide a long-term response. The treatment strategies for the 3rd and 4th lines remain unclear, and several regimens in combination or monotherapy are available, only with limited low efficacy and short overall patient survival. Purpose: In recent years, the new aza-anthracenedione pixantrone, a mitoxantrone analogue, with reduced cardiotoxicity and proven efficacy, has been available to DLBCL as 3rd and 4th line treatment, also in patients pretreated with anthracyclines. According to the results of the PIX-301 study, is a relatively well tolerated and effective drug compared to other chemotherapy regimens used. Our aim was to provide a prolonged response for the patient with refractory and relapsed DLBCL and to verify the tolerance and toxicity of pixantrone. Case: Pixantrone monotherapy was used as the fourth treatment line for a 60-year-old patient with R/R DLBCL. The previous lines of chemoimmunotherapy provided inadequate response and timely repeated progression of lymphoma. Grade 3 recurrent haematological toxicity was observed during treatment with pixantrone, omitting administration on day 15 of the 5th cycle. Other side effects did not occur. We did not record any cardiotoxicity, repeated ECG and ECHO of heart before, during and after treatment remained unchanged. After complete treatment of 6 cycles, metabolic remission was confirmed by whole-body PET-CT. During treatment, the patient‘s performance and clinical condition returned to the pre-disease state. The remission achieved was long lasting for exactly 24 months until symptoms of lymphoma progression, and the relapse was confirmed by PET-CT examination. Conclusion: In the case of a 60-year-old patient, we verified the possibility of achieving long-lasting metabolic remission with pixantrone, despite the refracterity to previous chemoimmunotherapy. Very good overall tolerance was noted, and the only haematological toxicity was well manageable by growth factors and haemosubstitution. Pixantrone has become a new option for us, as a relatively safe and effective treatment for R/R DLBCL in the 3rd and 4th line treatment, despite the persistence of poor prognosis and high risk of relapse of the disease.

Keywords: diffuse large B-cell non-Hodgkin lymphoma, pixantrone, long-term remission