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l-asparaginase-based regimens followed by allogeneic hematopoietic stem cell transplantation improve outcomes in aggressive natural killer cell leukemia

  • Ki Sun Jung1, 2,
  • Su-Hee Cho2,
  • Seok Jin Kim1,
  • Young Hyeh Ko3,
  • Eun-Suk Kang4 and
  • Won Seog Kim1Email author
Journal of Hematology & Oncology20169:41

https://doi.org/10.1186/s13045-016-0271-4

Received: 5 April 2016

Accepted: 11 April 2016

Published: 18 April 2016

Abstract

Aggressive nature killer cell leukemia (ANKL) is a mature NK-T cell lymphoma with worse prognosis, but optimal treatment is unclear. Therefore, we analyzed the efficacy of l-asparaginase-based regimens for ANKL patients. Twenty-one patients who received dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide (SMILE) or etoposide, ifosfamide, dexamethasone, and l-asparaginase (VIDL) chemotherapy at Samsung Medical Center were selected. The overall response rate for all patients was 33 % (7/21); 38 % (5/13) in SMILE and 40 % (2/5) in VIDL, respectively. The median progression-free survival was 3.9 months (95 % CI 0.0–8.1 months) and median overall survival was 7.0 months (95 % CI 2.3–11.7 months). Treatment response (P = 0.001), hematopoietic stem cell transplantation (HSCT) (P = 0.007) and negative conversion of Epstein-Barr virus (EBV) DNA titer after treatment (P = 0.004) were significantly associated with survival. Thus, l-asparaginase-based regimens followed by allogeneic HSCT seem to improve the outcome for ANKL patients.

Keywords

ANKL l-asparaginaseAllogeneic HSCTResponseSurvival

Findings

Aggressive natural killer cell leukemia (ANKL) is a rare lymphoma with aggressive clinical course [1, 2]. Treatment outcomes are worse and the median survival is less than 2 months [24]. However, optimal treatment of ANKL is not determined yet. Because the tumor cells of ANKL produce P-glycoproteins [5, 6], the treatment response to conventional chemotherapies such as cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) is ineffective [4, 7, 8]. Instead, methotrexate and l-asparaginase, which are not affected by P-glycoprotein, are effective agents against NK-T cell lymphoma [3, 7, 9]. Therefore, we conducted this study to determine the efficacy of l-asparaginase-based regimes for patients with ANKL.

ANKL patients diagnosed by current World Health Organization classification who received dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide (SMILE) or etoposide, ifosfamide, dexamethasone, and l-asparaginase (VIDL) as first-line or second-line chemotherapy were enrolled from a lymphoma cohort at Samsung Medical Center between January 2008 and May 2015. We conducted in accordance with the Helsinki Declaration in our study, and our study was approved by the institutional review board of Samsung Medical Center. Clinical characteristics at diagnosis were analyzed for enrolled patients. The treatment response was evaluated followed by criteria that reported previous studies [2, 10]. We defined complete response as (1) improved laboratory findings (cytopenia and liver function tests) and symptoms (organomegaly and B symptoms), (2) no residual ANKL cells in bone marrow, and (3) no definite abnormalities in imaging including positron emission tomography or computed tomography. We defined partial response as improved laboratory findings, symptoms, and imaging but minimal residual ANKL cells in bone marrow. The Kaplan-Meier method was used for survival analysis, and the log-rank test was used to test differences in survival on univariate analysis.

A total of 21 patients were analyzed in this study. The characteristics for them are presented in Table 1. Thirteen patients (62 %) received SMILE as first-line chemotherapy. Of these patients, five patients showed response to SMILE, either complete response (n = 3, 23 %) or partial response (n = 2, 15 %). Thus, overall response rate (ORR) to SMILE as initial treatment was 38 %. Of patients who responded to SMILE, the three complete responders underwent allogeneic hematopoietic stem cell transplantation (HSCT) and were alive. Of the two partial responders, one received mitoxantrone, etoposide and cytarabine induction chemotherapy and is alive without relapse. The other patient underwent autologous HSCT but died from relapse. Five patients (24 %) were given VIDL as initial treatment. Of these patients, two exhibited complete response to VIDL chemotherapy and received allogeneic HSCT. Thus, the ORR to VIDL was 40 %. Of three patients (14 %) treated with SMILE as second-line chemotherapy, one died from sepsis and the other patients showed disease progression despite receiving full-dose SMILE. Thus, the ORR for all patients was 33 % (7/21). Treatment outcomes and characteristics of patients who received HSCT are in Additional files 1 and 2.
Table 1

Baseline patient characteristics (N = 21)

Characteristics

Number of patients

Percentage

Median age, years (range)

50 (16–75)

 

Sex

  

 Male

14

67

 Female

7

33

PS

  

 0–1

12

57

 2–4

9

43

Initial presentation

  

 Fever

20

95

 General weakness

1

5

 DOE

1

5

 Lt. neck swelling

1

5

B symptom (+)

20

95

Hepatomegaly

13

62

Splenomegaly

17

81

Pancytopenia

11

52

LFT abnormality

20

95

DIC

9

43

AKI

4

19

LDH > normal

20

95

Stage IV

21

100

IPI score

  

 Low

1

5

 Low intermediate

7

33

 High intermediate

7

33

 High

6

29

Nodal involvement

7

33

Extranodal involvement

7

33

EBV ISH (+)

17

81

HLH feature

16

76

PET uptake at diagnosis

9

43

PS performance status, DOE dyspnea on exertion, LFT liver function test, DIC disseminated intravascular coagulopathy, AKI acute kidney injury, LDH lactate dehydrogenase, IPI international prognosis index, EBV ISH Epstein-Barr virus in situ hybridization, HLH hemophagocytic lymphohistiocytosis

The median progression-free survival (PFS) was 3.9 months (95 % CI 0.0–8.1 months, Fig. 1a) and median overall survival (OS) was 7.0 months (95 % CI 2.3–11.7 months, Fig. 1b). When univariate analysis for prognostic factors was performed, patients who received HSCT had a better OS (P = 0.007) and PFS (P = 0.042) than patients who did not undergo HSCT (Fig. 1c, d).
Fig 1

a Progression-free survival and b overall survival of 21 patients. c, d PFS and OS for patients who underwent HSCT and those who did not receive HSCT

We also analyzed correlations between Epstein-Barr virus (EBV) DNA titers and survival (Additional file 3). EBV DNA titer at diagnosis (P = 0.311) and baseline EBV negativity (P = 0.307) were not associated with OS. Negativity of EBV DNA titer after treatment was significantly associated with OS (P = 0.004). But, no significant difference was seen in OS between the two subgroups according to change pattern of EBV DNA titer during treatment (P = 0.069). Clinical treatment response showed significant association with OS (P < 0.001).

In conclusion, early diagnosis and the use of an l-asparaginase-based regimen at initial diagnosis had promising efficacy for patients with ANKL. Also, allogeneic HSCT for responders to an l-asparaginase-based regimen might improve treatment outcomes for patients with ANKL.

Abbreviations

ANKL: 

aggressive nature killer cell leukemia

CHOP: 

cyclophosphamide, doxorubicin, vincristine, and prednisone

EBV: 

Epstein-Barr virus

HSCT: 

hematopoietic stem cell transplantation

ORR: 

overall response rate

OS: 

overall survival

PFS: 

progression-free survival

SMILE: 

dexamethasone, methotrexate, ifosfamide, l-asparaginase, and etoposide

VIDL: 

etoposide, ifosfamide, dexamethasone, and l-asparaginase

Declarations

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Division of Hematology-Oncology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine
(2)
Division of Hematology-Oncology, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine
(3)
Department of Pathology, Samsung Medical Center, Sungkyunkwan University School of Medicine
(4)
Department of Laboratory Medicine and Genetics, Samsung Medical Center, Sungkyunkwan University School of Medicine

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Copyright

© Jung et al. 2016

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