Letter to the Editor Gemcitabine and vinorelbine chemotherapy for refractory or relapsing aggressive non-Hodgkin lymphoma To the Editor Standard therapy for aggressive non-Hodgkin lymphoma is now well established. In our centre, first-line chemother- apy utilizes the regimens of Rituximab-CHOP for aggressive histology B-cell non-Hodgkin lymphoma including diffuse large B cell (DLBCL), and primary mediastinal subtypes and CODOX M-IVAC chemotherapy for Burkitt lymphoma. For patients aged less than 70years who are refractory to or relapse following first-line therapy then second-line salvage therapy, with cis-platinum based chemotherapy followed by autologous stem cell transplantation (ASCT) is an option. With this approach a significant proportion of cases will achieve a cure [1]. Nevertheless there remains a group of patients with ongoing disease specifically those who fail salvage therapy, and elderly patients ineligible for ASCT. Such patients may yet respond to and benefit from further chemotherapy. Gemcitabine is a nucleoside analogue, which as a single agent in heavily pretreated advanced and aggres- sive non-Hodgkin lymphoma (NHL) can achieve response rates from 20–30% [2]. Vinorelbine is a vinca alkaloid and in similar patient groups can achieve response rates from 18–46% [3]. Using these agents, Spencer et al. developed two outpatient-based chemotherapy approaches for advanced lymphoma patients. The first was a lesser intensity regimen using vinorelbine gemcitabine and dexamethasone with filgrastim (VGF), the second was a greater intensity regimen added ifosfamide (F-GIV) [4,5]. Other lymphoma chemotherapy protocols containing gemcitabine and vinorelbine have been reported; however, most incorporate a third agent such as cis-platin, ifosfamide or etoposide and are used as an alternative intensive salvage regimen. Using the regimen IGEV that incorporates ifosfamide as a third chemotherapy agent to treat 91 patients with relapsed refrac- tory Hodgkin lymphoma, Santoro et al. reported a 54% CR and 81% OR [6] In our centre, we adopted the less intensive two-drug regimen VGF for use in elderly patients or in younger patients who had failed ASCT. We report here the outcome in 22 cases of relapsed refractory aggressive NHL. In keeping with local ethical requirements and with informed consent, 22 patients were treated with VGF chemotherapy between April 2008 and November 2010. Patients eligible for VGF treatment were over the age of 18 years with relapsed or refractory aggressive lymphoma having failed ASCT or being ineligible for second-line therapy. Chemotherapy was administered as previously described by Spencer et al. On days 1 and 8, patients received vinorelbine 25 mg/m 2 , gemcitabine 1000 mg/m 2 and dexamethasone 16 mg/m 2 i.v. On day 9, they received peg-filgrastim 6 mg subcutaneously. Patients received 4–6 cycles of chemotherapy, mid-treatment CT or PET-CT scans were performed after two or three cycles, and treat- ment was discontinued in non-responding patients. Standard response and toxicity criteria as defined by Cheson and WHO were used [7,8]. Survival and progression free survival were calculated by using the Kaplan–Meier method, and groups were compared by using the log-rank test. P-values < 0.05 were deemed statistically significant. The baseline characteristics are outlined in Table 1. The median age was 67 (range 19–87), relapsed disease was present in 11 cases and refractory disease in 11 cases. The median number of previous lines of therapy was 2 (range 1–5.) A total of 22 patients were treated, and the number of cycles of VGF chemotherapy administered was 74 (six patients received two cycles, 13 patients received three to four cycles, and three patients received six cycles.) Haematological toxicity of WHO grade 3 or 4 severity was seen in 12 patients (55%). Neutropenic sepsis necessitating in-patient treatment occurred in five Table 1. Patient characteristics, histology, disease status and prior treatment Number 22 Gender Male/female 13/9 Patient age at diagnosis Median (range) in years 67 (range 19–87) Histology Aggressive NHL BL 1 DLBCL 18 PMBCL 1 MCL 2 Disease status Refractory 11 Relapse 11 LDH Elevated 8 Normal 14 Number of prior chemotherapy regimes Median (range) 2 (1–5) 1 6 2 7 3 6 >3 3 Prior ASCT Yes 11 No 11 NHL, non-Hodgkin lymphoma; BL, Burkitt lymphoma; DLBCL, diffuse large B-cell lymphoma; PMBCL, primary mediastinal B-cell lymphoma; MCL, mantle cell; LDH, lactate dehydrogenase; ASCT, autologous stem cell transplantation. Hematological Oncology Hematol Oncol 2012; 30: 214–215 Published online 16 March 2012 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/hon.2011 Copyright © 2012 John Wiley & Sons, Ltd.