Cyclophosphamide, vincristine, adriamycin, and prednisone (CHOP) with and without intermediate dose methotrexate for the treatment of non-Hodgkin's lymphomas of diffuse histology

Seventy three patients with disseminated diffuse non-Hodgkin's lymphomas were treated with combinations of cyclophosphamide, vincristine sulfate, prednisone, and doxorubicin with and without 2 weekly doses of oral methotrexate in "intermediate" doses, followed by calcium leucovorin rescue. The addition of methotrexate did not increase the complete remission rate, the remission duration, or the survival (P value = 1.0, 0.74, and 0.78, respectively) in patients who did not have previous chemotherapy treatment. In previously treated patients, the complete remission rate was somewhat higher and the remission duration and survival were longer among those patients treated with the methotrexate containing program; however these differences were not statistically significant (P values = 0.88, 0.81, and 0.46, respectively). There was substantial morbidity and mortality during treatment with both treatment arms, among patients aged more than 60 years.

Salvage chemotherapy for advanced Hodgkin's disease

Eleven patients with Hodgkin's disease refractory to chemotherapy were treated with six cycles of intermediate-dose methotrexate with calcium leucovorin rescue, followed by cyclophosphamide, doxorubicin, vincristine, and prednisone (MTX-CHOP). Three other patients were treated with a similar program of treatment minus doxorubicin (MTX-COP). The overall response rate was 57%, with four (29%) patients achieving a complete response and four patients achieving a partial response. None of the three patients treated with MTX-COP had a complete remission (CR); thus the complete remission rate with MTX-CHOP was somewhat higher (36%). Only one of the CR's is in continuous complete remission and free of disease at 99+ months. One patient died of overwhelming sepsis and pancytopenia during treatment. Hematologic toxicity in the other patients was acceptable. The overall median survival was 18 months. The search for an effective treatment program for this group of patients remains a major challenge.

Cytogenetic studies in hairy cell leukemia

Cytogenetic analyses were performed on cells from 17 patients with hairy cell leukemia stimulated with polyclonal B-cell activators (in 155 different cultures). No mitosis was obtained in samples from four cases (23.5%). Of 14 bone marrows, four (28.6%) showed mitoses, two with clonal abnormalities. All four samples from the spleen had mitoses with four clonal changes; eight of 13 (37.5%) blood samples had mitoses with three clonal changes. Of the polyclonal B-cell activators (PBA), lipopolysaccharide and protein A seemed to be effective for the detection of clonal abnormalities in hairy cell leukemia. Among the clonal aberrations, chromosomes #3, #10, and #17 were affected in two cases each; frequent numerical changes were monosomies of #10 and #17 and structural changes were deletions at band 3p21 (two cases), 6q-, and der(9)t(9;?)(p22;?). The chromosomal bands involved in structural changes were close to accepted constitutive fragile sites.

Cytogenetic evidence for clonal evolution in B-cell chronic lymphocytic leukemia

Sequential cytogenetic studies were performed in eight of ten patients with B-cell chronic lymphocytic leukemia presenting with trisomy 12 as the sole chromosomal abnormality. Follow-up studies of peripheral blood lymphocytes revealed that the karyotypes retained the sole abnormality of trisomy 12 in five cases, trisomy 12 converted to a normal karyotype during remission in one case, additional chromosome changes (-X,14q-) along with trisomy 12 appeared in one patient and multiple chromosome changes with or without trisomy 12 appeared in the remaining patient. The findings indicate that other chromosome changes in addition to trisomy 12 may develop as a result of clonal evolution or dedifferentiation, though the possibility that in two patients these changes may be related to chemotherapy and/or irradiation could not be ruled out entirely.

Recurrent chromosome changes at 3p21 in Epstein-Barr virus-transformed cells derived from human prolymphocytic leukemia

Cytogenetic studies of Epstein-Barr virus-transformed lymphoblastoid cells obtained from a patient with prolymphocytic leukemia revealed the cells to contain recurrent chromosome aberrations involving band 3p21. The in vivo leukemic cells from which the cell lines originated contained a der(3)t(3;17?)(p21;q11?) and a der(13)t(13;3)(q34;p21), as well as numerical (-Y, -8, and -17) and other structural [8p- and der(8)t(8;?)(q13?;?)] changes. The cells in established culture showed additional chromosome aberrations involving band 3p21 of the previously normal and abnormal chromosomes 3. After 200 days of culture, the cells contained a new translocation, i.e., t(3;14)(p21;q32). The cells showed further chromosomal breakage and reunion at band 3p21 at later passages. The affected chromosomal band (3p21) is close to one of the constitutive fragile sites, i.e., 3p14.2. Northern blot analysis of the messenger RNA of the cultured cells did not show an increased or altered expression of the c-raf-1 protooncogene (located at 3p25) when compared with the mRNA of Epstein-Barr virus-transformed lymphoblastoid cell lines from normal subjects with a normal karyotype. Also, the established cells did not show DNA rearrangements or RNA alterations of the c-myc gene.

B cell growth factor-induced proliferation of hairy cell lymphocytes and inhibition by type I interferon in vitro

Malignant B cells from hairy cell leukemia (HCL) patients are unable to proliferate when stimulated with standard B cell mitogens. Using chromatographically purified B cell growth factor (BCGF), HCL can be stimulated to proliferate as assessed by incorporation of tritiated thymidine [3HTdR] into DNA. Proliferation was found to be time dependent, with no detectable 3H-TdR incorporation in up to three days of culture, and significant stimulation evident at days 6 and 10. The presence of 10% BCGF in culture was an absolute requirement for HCL proliferation; however, this BCGF-induced DNA synthesis could be further augmented by the addition of anti-immunoglobulin heavy chain antibodies. BCGF-induced proliferation was abrogated in six of six patients by addition of 1,000 U/mL of recombinant alpha 2-interferon (IFN) at day 0, although 1,000 U/mL of recombinant gamma-IFN had no inhibitory effect in five of six patients studied. Specific cellular receptors for type I IFN were demonstrated in HCL by inhibition of binding of 125I-alpha 2-IFN by a 40-fold excess of unlabeled alpha 2 or beta IFN with no inhibition by unlabeled gamma-IFN. These data demonstrate that malignant HCL lymphoblasts express specific type I IFN receptors and that type I, but not type II IFN, can inhibit growth factor-induced DNA synthesis by hairy cells in vitro. They further suggest a direct antiproliferative mechanism of action for IFN in HCL and predict equivalent clinical activity by either alpha or beta, but not gamma IFN in this malignancy.

Bone formation within porous hydroxylapatite implants in human periodontal defects

Tissue samples from three subjects who had periodontal defects treated with a porous hydroxylapatite implant were investigated using light microscopy and scanning electron microscopy. The 3-month specimen showed connective tissue infiltration through the pores and a narrow zone of bone formation present along the walls of the pores. At 4 months, continued evidence of bone deposition was present with osteocytes, osteoblasts and organization of collagen fibers apparent throughout the implant. The 6-month implant had further evidence of continued bone formation with lamellar bone being the major component within the pores.

Treatment of early--stages I and II--nodular, poorly differentiated lymphocytic lymphoma

Twenty-nine patients with Stages I and II nodular, poorly differentiated lymphocytic lymphoma were treated with radiation therapy or radiation therapy plus chemotherapy. Twenty-two patients with Stage I received radiation to the involved field, the other seven with Stage II received total lymphoid radiation. Complete remission was achieved in all 29. There were no differences in remission duration or survival according to treatment modality. Five of 29 (17%) patients relapsed. No relapses were observed after 5 years. Ten patients died; one patient died of lymphoma, and nine others died in continuous complete remission of various other causes. Sixty-six percent of the patients were alive at 74-160 months (median 118 months). Involved field radiation with or without chemotherapy was well tolerated, producing acceptable toxicity. Substantially more toxicity was observed after total lymphoid irradiation and although cures were also achieved, less toxic treatment programs should be investigated. The low rate of relapse observed in early stages of this lymphoma in this and in other studies is suggestive that cures might be achieved in nearly one-half of the patients presenting in early stage.

Sequential chromosome abnormalities in B cell chronic lymphocytic leukemia: a study of 13 cases

The chromosomal constitution of stimulated lymphocytes in 13 patients with B cell chronic lymphocytic leukemia (B-CLL) were sequentially examined using polyclonal B cell activators (PBA), i.e., Epstein-Barr virus (EBV), lipopolysaccharide W from E. coli (LPS), pokeweed mitogen (PWM), and protein A from Staphylococcus aureus (PA). Of the 11 patients (44 samplings) with abnormal clones, 2 patients had only trisomy 12, 6 patients had trisomy 12 plus other clonal abnormalities, such as +8, +9, +16, +18, 6q-, 15q+, and t(4;15), and the remaining 3 cases had various clonal abnormalities other than trisomy 12, such as trisomy 3, 8, 20, 21, and insertion of #7 and #12. These findings suggest that even though trisomy 12 may be a common abnormality in B-CLL, various other abnormal clones may also be present in vivo for relatively long periods of time. It appears that stimulated lymphocytes in patients with previous therapy tend to show chromosome abnormalities more frequently than those in untreated patients.

In-vitro infection of chronic lymphocytic leukemia cells by Epstein-Barr virus (EBV)

We sought to determine the potential of infecting lymphoid cells from patients with chronic leukemia (CLL) with Epstein-Barr virus (EBV) by testing for EBV receptors (EBVR) by flow cytometry, assessing for infectability of these cells by culturing with B95-8-derived virus, and staining for EB nuclear-associated antigens (EBNA) at various times post-infection. EBVR were present on 54-91% of lymphoid cells in seven cases of CLL and on 46% of prolymphocytic leukemia cells. Dynamic changes regarding EBNA positivity, morphology, and viability occurred post-infection with the virus. On day 2 only a few EBNA-positive lymphoblasts were observed. On days 11-21 positivity increased from 2 to 34% of cells. Simultaneously, the viable cell number declined to approximately 1/10th of original number. A significant proportion of the EBNA-positive cells corresponded to the original CLL cells. In 3 of 7 cases of CLL a Pan T-cell phenotype was demonstrated by Leu-1 monoclonal antibody testing. The infected cells did not react with two monoclonal antibodies, EBV-CS 1 and 4, which react with B-cell lymphoblastoid cell lines (B-LCL). Moreover, the B-LCL derived at 1-2 months post-infection of CLL cells did not express the Leu-1 antigen, but expressed EBV-CS 1 or 4 defined antigens. In the prolymphocytic leukemia, 64% of the cells showed EBNA positivity on day 7 and giant cells with huge round or multiple nuclei appeared which were EBNA-positive. CLL and prolymphocytic leukemia cells can be infected as demonstrated by EBNA-positivity. This infection does not lead to immediate transformation, but evokes lymphoblast and multinucleated giant cell production prior to the death of cells.

Near-triploid Ph-positive leukemia

Tetraploid populations have been observed in various types of leukemia, but relatively few reports exist of triploid cell populations in acute or chronic leukemia. We report two cases of Ph-positive leukemia with a modal triploid cell population. Examination of peripheral blood from a 3-year-old boy with Ph-positive acute lymphoblastic leukemia (ALL) and a 68-year-old male with Ph-positive chronic myelocytic leukemia (CML) in blastic crisis revealed modal populations of 72 and 63 chromosomes, respectively. G-banding analysis of both cases revealed the following: karyotypic instability (no clonality), dominant trisomy, and the random association of the Ph chromosome with gains and losses of chromosomes involved in this translocation. The cytogenetic evidence obtained suggests that the triploid cell populations were not derived from a duplication of a hypodiploid cell population, but resulted from random loss of chromosomes from tetraploid cell populations derived from duplication of pseudodiploid cells.

Two 14q+ chromosomes in malignant lymphoma: crucial cytogenetic changes on 14q

We encountered a 36-year-old white male patient with poorly differentiated lymphocytic lymphoma, whose lymph node cells showed a clonal cytogenetic change involving chromosome #14, i.e., 47,XY, + 2,der(14),t(14;14)(14pter----14q32;14q24----14q32++ +). In addition to this change, cells with a translocation between chromosomes #2 and another #14 [t(2;14)(q21;q24)], as well as a missing chromosome #8 were found. We have reviewed the literature dealing with two or more changes affecting chromosome #14 and discussed the importance of the cytogenetic change at band 14q32 in malignant lymphoma.

Cytogenetic studies of stimulated lymphocytes in hairy cell leukemia

Using a sister chromatid differentiation (SCD) technique, cell cycle analysis in lymphocytes from two patients with hairy cell leukemia (HCL) revealed it to be similar to cell cycle progression of normal lymphocytes stimulated with lipopolysaccharide W from Escherichia coli 0.55:B5 (LPS). It appears that LPS can readily stimulate the leukemic cells of HCL into mitosis. In the two cases of B cell HCL studied, one (case 1) was revealed to have an abnormal clone with a missing chromosome #22 that was related to the production of lambda-chains.

Clonal chromosome abnormalities in prison-acquired lymphoproliferative syndrome

Lymph nodes from five male patients with prison-acquired lymphoproliferative syndrome (PALS), which seems to be a prodrome of acquired immune deficiency syndrome (AIDS), were examined cytogenetically. Two had clonal chromosome abnormalities, i.e., 11q- and -11, and another had multiple nonclonal chromosome changes, including t(2p-;3q+),6q-,+12,14q+. These chromosome changes are also common in malignant lymphoma and suggest that the patients with PALS may be predisposed to develop malignant lymphoma.

The use of a porous hydroxylapatite implant in periodontal defects. I. Clinical results after six months

Twenty-five patients with advanced periodontal destruction were used in the study. Following initial therapy, two angular interproximal defects were selected in each patient. During flap surgery a porous hydroxylapatite implant shaped to fit the periodontal defect was placed in one defect, the other defect was used as nonimplanted control. The material used for implantation was a hydroxylapatite replicate of coral from the genus Porites, with a pore size of 190 to 220 micron. Clinical parameters were measured prior to flap surgery for each of the defects. An occlusal acrylic stent was used to give a stable reference point for pocket depth, attachment level and gingival margin height measurements. Also gingival fluid, gingival inflammation, plaque index and tooth mobility were recorded. Periapical radiographs using a standardized positioning device were also taken. At the time of surgery, the depth of the osseous defect and the height of the alveolar crest were recorded. After 6 months the clinical measurements were repeated and a re-entry surgery was carried out in 15 selected sites. Results showed that the porous implant produced statistically significant reduction in pocket depth, in the depth of osseous lesion, and a statistically significant gain in attachment level, as compared to control areas.

Coexistence of myeloid metaplasia with myelofibrosis and hairy-cell leukemia

A 42-year-old man with severe pancytopenia and myelofibrosis underwent splenectomy seven months after onset of his symptoms; the leukocyte, platelet, and hematocrit levels became normal. Myeloid metaplasia was identified in the liver and spleen. Progressive lymphocytosis started eight months after splenectomy, and after 66 months a florid hairy-cell leukemia was diagnosed; the circulating cells were B type with micro K surface markers. Anemia and thrombocytopenia reappeared and were controlled initially with daily prednisone; chlorambucil was later added. At that time, the peripheral blood had more than 150 megaloblastoid-appearing normoblasts per 100 leukocytes. The PAS stain was positive in 95% to 100% of these cells; the B-cell surface markers were no longer identified. Further treatment failed to control the lymphoproliferative and myeloproliferative syndromes; the patient died 99 months after splenectomy. On autopsy, infiltration by hairy-cell leukemia cells and erythroid precursors was observed in the bone marrow, liver, lymph nodes, and other organs.

Salvage treatment for patient with multiple myeloma refractory to alkylating agents

Sixteen patients with multiple myeloma refractory to alkylating agents were treated with vincristine 0.25 mg/m2 i.v. on days 1 to 4 and prednisone 1 gm/m2 on days 1 and 3. Chemotherapy was repeated every 2 weeks. Of 15 evaluable patients, five achieved a partial response and four stable disease. Three patients with partial response and three with stable disease relapsed at 6, 7, and 16 and at 5, 9, and 10 months, respectively. The median survival for all patients was 10 1/2 months and it ranged from 1 to 21 + months. The median survival in responders was not reached at 13 months. Onset of antitumor effect was observed within the first 2 weeks. Symptomatic relief of bone pain was noted within 48 hours in responders and nonresponders. Improvement in bone marrow cellularity and decrease in plasma cell infiltration was documented in more than one-half of the responders. Tolerance to the treatment was good. No hematologic or other significant toxicity was observed.

Simultaneous low-dose radiation and low-dose chemotherapy in the treatment of advanced Hodgkin's disease

Simultaneous combination chemotherapy (CT) (BCNU 40 mg/m2, procarbazine 50 mg/m2, prednisone 40 mg/m2, and vincristine 1.4 mg/m2) with low-dose radiation therapy [(RT) 2000 rad] delivered to all areas of tumor involvement aside from the bone marrow was given to 28 patients with advanced Hodgkin's disease. Upon completion of RT and CT, the BCNU and procarbazine was increased by 100% until a total of six cycles of CT (with and without RT) were given. Eleven patients had received prior CT and had not achieved complete remission (CR) or had relapse from CT-induced CR within 1 year. Seventeen others had not had prior CT (7 had prior RT). Among the previously treated patients, one patient died in autopsy-proven CR during treatment. The other 10 patients achieved CR. Eight had relapsed at 4-36 months (median time to relapse, 6 months). Five patients died of Hodgkin's disease, three others died of status asthmaticus and pneumonia, radiation pneumonitis, and acute nonlymphocytic leukemia, respectively. Three patients are still alive (2 in continuous CR) at 28, 89, and 90 months. Among the previously untreated patients, four died during treatment, one of acute myocardial infarction, two of liver failure, and one of radiation pneumonitis. Twelve of the other 13 patients achieved CR. One of the CR died of pneumonia and sepsis 3 months after completion of treatment; two other patients relapsed at 10 and 15 months. Nine remain in continuous CR at 42-89 months of follow-up, (median follow-up, 81 months). Of 107 tumor areas treated with RT, in-field relapse occurred in two areas (1.9%). Hematologic tolerance to this treatment was good in both groups of patients. Radiation pneumonitis occurred in 50% of the patients whose lungs were irradiated, and it was fatal in two. By design or for other reasons, the median and mean doses of BCNU and procarbazine given to previously treated patients were 62% and 65.2%, respectively. In untreated patients, the median and mean doses of these two agents were 66.6% and 61.4%, respectively. There were no differences in dosage of these two agents between patients who remain alive in CR and those who relapsed and died. The potential of similar programs of radiation and chemotherapy is discussed.

Cytogenetic studies in 77 patients with chronic lymphocytic leukemia: correlations with clinical, immunologic, and phenotypic data

Cytogenetic analyses by G-banding and/or Q-banding techniques of polyclonal B cell mitogen-stimulated peripheral blood lymphocytes in 77 patients with chronic lymphocytic leukemia were carried out in the present study. Adequate metaphases were obtained in 65 patients (84%). Of 29 patients with abnormal karyotypes, ten (34%) had trisomy 12 as the sole abnormality, eight (28%) had trisomy 12 in combination with other karyotypic changes, and the remaining 11 had various karyotypic changes other than trisomy 12. There was a significant relationship between the abnormal karyotype and disease status, clinical stage, lymphocyte count, bone marrow infiltration pattern, monoclonal IgM gammopathy, and urinary monoclonal-free light chain status. Six of seven patients (87%) with trisomy 12 only had stage 0-11 disease, whereas all eight patients with trisomy 12 with other changes had stage III or IV disease (P less than .02). However, of nine patients with other karyotypic changes without trisomy 12, five had stage 0-II and four had stage III or IV disease. These observations suggest that trisomy 12 may be the primary or the earliest karyotypic change in a majority of aneuploid patients with chronic lymphocytic leukemia, and that other karyotypic changes in addition to trisomy 12 may develop as a result of clonal evolution, dedifferentiation, or therapy. Of nine patients in whom autopsy studies were carried out, four were found to have diffuse histiocytic lymphoma or Richter's syndrome (three with trisomy 12 in combination with other chromosome changes and one with normal karyotype). Our findings clearly demonstrate that cytogenetic study may be of value in the clinical and prognostic evaluation of patients with chronic lymphocytic leukemia.

Staging laparotomy and splenectomy in early Hodgkin's disease. No therapeutic benefit

In a prospective randomized study of treatment for early-stage Hodgkin's disease presenting above the diaphragm, 76 patients had staging by laparotomy (Group I) and 28 had staging by closed techniques (Group II). Treatment consisted of involved-field radiotherapy alone (44 patients), involved-field radiotherapy followed by chemotherapy (38 patients), total nodal radiotherapy alone (15 patients), or total nodal radiotherapy followed by chemotherapy (seven patients). On presentation, both groups had similar clinical features and similar treatment distribution. With similar follow-up (87 months), no significant differences in remission or survival were observed between Groups I and II: remission 59 versus 68 percent; survival 74 versus 92 percent; p value 0.27 and 0.09, respectively. Multiple areas of relapse were more frequently observed in Group I (11 of 32 had relapse) as compared with Group II (none of nine had relapse, p less than 0.082). In Group I, relapse in the abdomen was observed as an isolated event or as part of disseminated relapse in 12 percent of patients compared with 3 percent (one patient) in Group II with abdominal relapse alone. Seven patients in Group I and two patients in Group II died with Hodgkin's disease. Six other patients in Group I died with complete remission of non-Hodgkin's lymphoma (one patient), leukoencephalopathy (one patient), sepsis during chemotherapy (two patients), myocardial infarction (one patient), and cerebrovascular accident (one patient). Three other patients in this group had other secondary malignancies successfully controlled (histiocytic lymphoma, squamous cell carcinoma of the cervix, and malignant schwannoma). No second primary lesions or death with complete remission were observed in Group II. Staging laparotomy with splenectomy in early-stage Hodgkin's disease did not improve the duration of remission or survival or decrease the number of abdominal relapses compared with closed staging.

T-suppressor cell chronic lymphocytic leukemia. Phenotypic characterization by monoclonal antibodies

A patient with long standing seropositive rheumatoid arthritis developed lymphocytosis which phenotypically involved the cytotoxic/suppressor T-lymphocyte population. There are 10 reported instances of this new disease entity described as "chronic T-cell lymphocytosis with neutropenia" or "chronic suppressor T-cell lymphocytic leukemia." The disease is characterized by hepatosplenomegaly, neutropenia, and the frequent presence of rheumatoid factor without clinical evidence of rheumatoid arthritis. Splenectomy in our patient, as well as in other instances where undertaken, has been ineffective in alleviating the neutropenia. The peripheral blood lymphocytes in our patient were OKT-3+, OKT-5+, OKT-8+, OKT-11+, cALL-, OKT-6-, TdT-. They possessed ADCC but no NK activity and did not suppress PWM-induced B-cell differentiation in spite of the presence of Fc receptor for IgG. Since the lymphocytosis of OKT-8+ cells appears to be clonal, it is suggested that the disease be designated chronic suppressor T-cell lymphocytic leukemia.