Alternating triple therapy for the treatment of intermediate grade and immunoblastic lymphoma

Background: CHOP is currently considered the gold standard of treatment for intermediate grade lymphomas. We designed a new regimen known as ATT (alternating triple therapy) which uses three non-cross resistant combinations in alternating sequence for nine cycles. Materials and methods: This is a phase II clinical trial with comparison to CHOP/CMED historical controls using prognostic factors. The tumor score system was used to evaluate the results of this trial. Two hundred sixty-eight eligible patients who had one or more of the following adverse features: bulky disease, elevated LDH or > 1 extranodal site were analyzed. Outcome measures consist of survival and failure free survival. Results: At a median follow-up of 32 months, there was no statistically significant difference in survival for those with favorable prognostic factors (tumor score ≤ 2). However, there was a statistically significant difference in favor of ATT for those with unfavorable tumor scores. When we examined the failure-free survival of those with unfavorable tumor scores, we again observed a superiority for the ATT regimen over CHOP/CMED but the opposite was true for those with favorable tumor scores. We also found a statistically significant difference in favor of the ATT regimen when compared with CHOP/CMED for patients ≤ 60 years old with a tumor score ≤ 3, while no advantage was found for those > 60 years. Conclusions: ATT appears more effective but only for patients < 60 years old with unfavorable tumor scores. In those older than 60 years with favorable tumor score. CHOP/CMED appears superior. ATT might be an adequate regimen for young patients with poor prognostic features while CHOP/CMED might be a better choice for those with good prognosis irrespective of age. For those > 60 years with unfavorable tumor scores neither ATT or CHOP/CMED were adequate treatment. Because of the phase II nature of this study, these conclusions should be considered as hypotheses which require prospective testing.