Chemotherapeutic Agent Toxicity, Lymphoma, Mucositis, Neurotoxicity
Conditions
Keywords
neurotoxicity, chemotherapeutic agent toxicity, mucositis, primary central nervous system non-Hodgkin lymphoma, contiguous stage II adult diffuse large cell lymphoma, noncontiguous stage II adult diffuse large cell lymphoma, stage I adult diffuse large cell lymphoma, stage III adult diffuse large cell lymphoma, stage IV adult diffuse large cell lymphoma
Brief summary
RATIONALE: Drugs used in chemotherapy, such as methotrexate and leucovorin, work in different ways to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. Glucarpidase may help return the level of methotrexate in the blood to a safe range. Giving high-dose methotrexate together with glucarpidase and leucovorin may kill more cancer cells. PURPOSE: This phase I/II trial is studying the side effects and best dose of methotrexate when given together with glucarpidase and leucovorin in treating patients with newly diagnosed primary central nervous system lymphoma.
Detailed description
OBJECTIVES: Primary * To determine the dose-limiting toxicity of methotrexate (MTX) when given in combination with glucarpidase in patients with newly diagnosed primary CNS lymphoma (PCNSL). * To determine the incidence of immediate reactions related to the use of glucarpidase in these patients. * To define a safer, more practical, and simpler regimen for delivering multiple courses of high-dose MTX using glucarpidase and 'short' leucovorin calcium rescue in these patients. * To monitor quality of life and mental function during and after therapy in these patients. Secondary * To use this regimen as a platform for phase III studies in PCNSL. * To record disease response, duration of response, and overall survival of patients treated with this regimen. OUTLINE: This is a multicenter, dose-escalation study of high-dose methotrexate (HD-MTX). Patients receive HD-MTX IV over 4 hours on day 1. Beginning 22 hours after the start of HD-MTX, patients receive glucarpidase IV over 15 minutes on day 2 followed by leucovorin calcium orally or IV on days 2-7. Treatment repeats every 14 days for up to 6 courses in the absence of disease progression or unacceptable toxicity. Within 2-4 weeks after completion of study treatment, patients achieving maximum response are stratified according to age (\< 60 years vs ≥ 60 years) and may undergo whole brain radiotherapy (WBRT) once daily, 5 days a week, for 3 to 5 weeks. Patients undergo blood sample collection periodically to assess glucarpidase antibodies and MTX levels. Patients are assessed for mucositis incidence and severity periodically, and complete quality of life assessments using the EORTC QLQ-30 questionnaire and the Mini-Mental State questionnaire at baseline, during, and after completion of study. After completion of study treatment, patients are followed at 6 weeks after WBRT, every 3 months for 1 year, every 4 months for 1 year, every 6 months for 3 years, and then annually thereafter.
Interventions
DRUGglucarpidase
DRUGleucovorin calcium
DRUGmethotrexate
OTHERlaboratory biomarker analysis
PROCEDUREquality-of-life assessment
RADIATIONradiation therapy
Sponsors
Cancer Research UK
University College, London
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Eligibility
Sex/Gender
ALL
Age
18 Years to No maximum
Healthy volunteers
No
Inclusion criteria
DISEASE CHARACTERISTICS: * Histologically confirmed newly diagnosed primary CNS lymphoma (PCNSL) * Previously untreated disease * Diffuse large B-cell lymphoma histology * Must be clinically eligible to receive standard 3 g/m² methotrexate if outside trial * No clinically significant effusions or edema PATIENT CHARACTERISTICS: Inclusion criteria: * ECOG performance status 0-3 * Neutrophils ≥ 1 x 10\^9/L * Platelet count ≥ 100 x 10\^9/L * Bilirubin \< 1.5 times upper limit of normal * Glomerular filtration rate (initially measured by EDTA/isotope method) ≥ 50 mL/min * Not pregnant or nursing * Negative pregnancy test * Fertile patients must use effective contraception during and for 6 months after completion of study therapy
Exclusion criteria
* HIV positivity * Dementia or neurological dysfunction not considered to be due to the PCNSL * Other serious or uncontrolled medical conditions * Prior malignancy, except adequately treated nonmelanoma skin cancer or carcinoma in situ PRIOR CONCURRENT THERAPY: * No prior cytotoxic chemotherapy * No concurrent prophylactic antibiotics * No concurrent co-trimoxazole
Design outcomes
Primary
| Measure | Time frame |
|---|---|
| Immediate toxicity (incidence of reactions to glucarpidase) as determined by the NCI CTC | — |
| Incidence and severity of renal dysfunction as determined by the NCI CTC | — |
| Incidence and severity of mucositis as determined by the NCI CTC and WHO mucositis grading scale | — |
| Incidence and severity of CNS toxicity and neurocognitive changes taken from patients' medical records and measured using the Mini-Mental State questionnaire and MRI data | — |
Secondary
| Measure | Time frame |
|---|---|
| Disease response and remission rates measured by serial MRI scanning (and eye examination and lumbar puncture if necessary) | — |
| Disease outcome, time to progression, and overall survival at 2 years from start of therapy measured by clinical examination and serial MRI scanning | — |
| Relative dose intensity | — |
| Incidence of antibodies to glucarpidase measured serologically at the start of each methotrexate course and at follow-up visits if present during therapy | — |
| Methotrexate levels post-glucarpidase (expressed as a clinically important reduction, which is defined as a methotrexate level of < 1 μmol/L in all post-glucarpidase samples) | — |
| Hematological toxicity (i.e., number of courses of therapy associated with neutrophils < 0.5 x 10e9/L or platelets < 50 x 10e9/L as measured by routine blood counts) | — |
| Incidence of infection (i.e., number of days with fever ≥ 38 C° measured by clinical examination and days of intravenous antibiotics taken from patients' medical records) | — |
| Number of inpatient days taken from patients' medical records | — |
Countries
United Kingdom
Outcome results
None listed