EPOCH Is a Safe and Effective Treatment Option for Aggressive T-Cell Lymphomas

Background: T-cell lymphomas constitute heterogeneous subtypes of non-Hodgkin lymphoma (NHL). With the exception of brentuximab (BV) with cyclophosphamide, adriamycin, prednisone (CHP) in anaplastic large cell lymphoma (ALCL) establishing a standard of care in this subtype, the choice of first-line therapy in other subtypes are based on CHOP like regimens with or without etoposide. Few studies have evaluated the efficacy of etoposide, prednisone, vincristine, cyclophosphamide, and doxorubicin (EPOCH) in patients with aggressive T-cell lymphomas. We report our single center experience in patients receiving EPOCH in frontline or relapsed/refractory (R/R) setting for aggressive T-cell lymphomas including transformed cutaneous T-cell lymphomas (CTCL).

Methods:Adult patients with aggressive T-cell lymphomas who received EPOCH from May 2015 to October 2020 at Yale-New Haven Hospital were included in this analysis. Adverse effects were graded per the CTCAE criteria. Statistical analyses were performed using STATA 14.2. The primary objective was to determine the efficacy of EPOCH in terms of response rates and survival outcome. The secondary objective was to determine toxicity rates.

Results: Thirty-eight patients with aggressive T-cell lymphomas were included in the study. This included angioimmunoblastic T-cell lymphoma (AITL) (n=7), adult T-cell leukemia/lymphoma (ATLL) (n=9), ALCL (n=2), peripheral T-cell lymphoma - not otherwise specified (PTCL-NOS) (n=7), T follicular helper (Tfh) subtype (n=1), subcutaneous panniculitis-like T-cell lymphoma (SPTCL) (n=1) and CTCL (n=11). Eighteen patients received EPOCH in the first line and 21 patients in R/R setting. The overall response rate (ORR) for the entire cohort was 77% and complete response (CR) rate was 51%. The CR rate in the frontline was 60% and in R/R setting was 45%. At a median follow up of 22.1 months (95% CI: 17.3 to 28.4), the median progression free survival (PFS) was 7.8 months (95% CI 4.3 to 9.8), and median overall survival (OS) was 19.7 months (12.1 to NR). Fifteen patients went onto allogeneic stem cell transplant after remission with EPOCH. The most common grade 3 adverse effects were anemia (63%), thrombocytopenia (34%), and neutropenia (32%). The most common grade 4 adverse effects were neutropenia (71%) and thrombocytopenia (39%).

Discussion: This study reports the efficacy and safety results of EPOCH in T-cell lymphoma both in the first line in R/R setting.We found that EPOCH has excellent response rates and good tolerability in T-cell lymphomas. With CR rates of >50%, EPOCH is a promising backbone for combination trials in aggressive T-cell lymphomas targeting deep responses prior to consolidation with transplant. Our study is unique in including CTCL patients who required treatment with combination chemotherapy due to an aggressive clinical course and/or large cell transformation.