Long-term follow-up of patients with Stage III follicular lymphoma treated with primary radiotherapy at Stanford University

PURPOSE

To report the long-term survival and late toxicity data of Stage III follicular lymphoma patients treated with primary radiotherapy.

METHODS AND MATERIALS

Sixty-six patients with Stage III follicular small cleaved (FSC) or follicular mixed (FM) non-Hodgkin's lymphoma were treated with total lymphoid irradiation (61 patients) or whole body irradiation (5 patients) as their primary treatment modality from 1963 to 1982 at Stanford University. Adjuvant chemotherapy was given to 13 patients.

RESULTS

Median follow-up was 9.5 years with a range of 0.5-24.3 years. Median overall survival, cause-specific survival, freedom from relapse, and event-free survival were 9.5, 18.9, 7.1, and 5.1 years, respectively. Few initial relapses or lymphoma-related deaths were seen beyond the first decade of follow-up. Patient age and number of disease sites were the two strongest predictors of overall survival. The cohort of patients with limited Stage III disease demonstrated an 88% freedom from relapse and a 100% cause-specific survival with up to 23.5 years follow-up.

CONCLUSION

The long-term survival data for Stage III FSC or FM non-Hodgkin's lymphoma treated with primary radiotherapy are at least comparable and possibly better than results achieved with other therapeutic approaches. Patients with limited Stage III disease do particularly well. Whether these results are superior to an initial approach of deferred therapy until clinically indicated is currently unknown.

Sequence analyses of the olfactory receptor gene cluster mOR37 on mouse chromosome 4

The olfactory receptor multigene family is organized in clusters spread throughout the genome. In the present study, we have sequenced two subregions of the mOR37 gene cluster on mouse chromosome 4. The resulting 100 kb of sequence revealed seven odorant receptor coding regions and one gene fragment. Sequence analyses reveal that the mOR37 gene cluster may represent a rather ancient cluster. The mOR37 genes exhibit a complex intron/exon structure, and some appear to be differentially spliced. All genes in the cluster share conserved sequence motifs 5' of their putative initial exons, which represent potential binding sites for transcription factors. The clustered organization and conserved sequence motifs suggest common expression control mechanisms for these genes.

Small subfamily of olfactory receptor genes: structural features, expression pattern and genomic organization

Olfactory receptors of the OR37 subfamily are characterized by distinct sequence features and are expressed in neurons segregated in a restricted area of the olfactory epithelium. In the present study, we have characterized the complement of OR37-like genes in the mouse. Five OR37-like genes were identified. They reside within only 60kb of DNA on chromosome 4. About 70kb distant from this cluster, two additional olfactory receptor genes are located, which are members of distinct receptor subfamilies. Phylogenetic analysis demonstrated that the two physically linked receptors are closely related to the OR37 subfamily. Studies of gene expression showed that both genes are also expressed in clustered neuron populations located in the typical OR37 region of the epithelium. These data suggest the involvement of locus-dependent mechanisms for the spatial control of OR gene expression.

Report of an international workshop to standardize response criteria for non-Hodgkin's lymphomas. NCI Sponsored International Working Group

Standardized guidelines for response assessment are needed to ensure comparability among clinical trials in non-Hodgkin's lymphomas (NHL). To achieve this, two meetings were convened among United States and international lymphoma experts representing medical hematology/oncology, radiology, radiation oncology, and pathology to review currently used response definitions and to develop a uniform set of criteria for assessing response in clinical trials. The criteria that were developed include anatomic definitions of response, with normal lymph node size after treatment of 1.5 cm in the longest transverse diameter by computer-assisted tomography scan. A designation of complete response/unconfirmed was adopted to include patients with a greater than 75% reduction in tumor size after therapy but with a residual mass, to include patients-especially those with large-cell NHL-who may not have residual disease. Single-photon emission computed tomography gallium scans are encouraged as a valuable adjunct to assessment of patients with large-cell NHL, but such scans require appropriate expertise. Flow cytometric, cytogenetic, and molecular studies are not currently included in response definitions. Response rates may be the most important objective in phase II trials where the activity of a new agent is important and may provide support for approval by regulatory agencies. However, the goals of most phase III trials are to identify therapies that will prolong the progression-free survival, if not the overall survival, of the treated patients. We hope that these guidelines will serve to improve communication among investigators and comparability among clinical trials until clinically relevant laboratory and imaging studies are identified and become more widely available.

The relative effectiveness of two styles of educational package to change practice nurses' management of obesity

OBJECTIVE

To examine the impact of two styles of educational package on practice nurses' management of obesity.

SUBJECTS AND MEASURES

A questionnaire was completed by 66 practice nurses concerning their obesity related beliefs and the content and style of their weight related practices before and one month after being randomly allocated to either the 'learner centred' group (who received a leaflet and were invited to attend an interactive seminar), the 'expert group' (who received the leaflet) or the control group. At the one month follow up, practice nurses were also asked to give a brief questionnaire to five consecutive patients, who they saw for weight loss advice, concerning the content and style of the consultation. After 6 months, practice nurses, and patients were sent a questionnaire about their consultation style and weight loss, respectively.

RESULTS

The packages had no differential effects on practice nurses' beliefs about obesity. However, practice nurses in the 'learner group' reported spending longer on their consultations and being more patient centred. Their patients rated themselves as more satisfied with the consultation and reported that they were offered calorie controlled diets less often. In contrast, practice nurses in the 'expert group' reported giving weight loss advice more frequently, being less patient centred and their patients reported greater confidence in, and likelihood of, weight loss and reported that they were more likely to be offered traditional weight loss interventions. The packages had no differential effects on patient weight.

CONCLUSION

Practice nurses' and patients' beliefs and behaviour and the style of their interactions can be changed by both expert and learner centred educational packages. The style of packages should be chosen in terms of both the available resources and the desired outcomes.

Long-term depletion of naive T cells in patients treated for Hodgkin's disease

We investigated the representation of T cells in patients who had been treated for Hodgkin's disease (HD). We found a marked depletion in both CD4 and CD8 naive T-cell counts that persists up to 30 years after completion of treatment. In contrast, CD4 and CD8 memory T-cell subsets recovered to normal or above normal levels by 5 years posttreatment. Thus, the previously-reported long-term deficit in total CD4 T-cell counts after treatment for HD is due to specific depletion of naive T cells. Similarly, total CD8 T-cell counts return to normal by 5 years only because CD8 memory T cells expand to higher than normal levels. These findings suggest that the treatment (mediastinal irradiation) results in a longterm dysregulation of T-cell subset homeostasis. The profound depletion of naive T cells may explain the altered T-cell function in treated patients, including the poor response to immunization after treatment for HD. Further, in some individuals, we identified expansions of unusual subsets expressing low levels of CD8. Eight-color fluorescence-activated cell sorting analyses showed that these cells largely express CD8alphaalpha homodimers and CD57, consistent with the phenotype of potentially extrathymically derived T cells. In addition, these cells, both CD4+ and CD4-, are probably cytotoxic lymphocytes, as they express high levels of intracellular perforin. In adults treated for HD, an increased activity of extrathymic T-cell differentiation may partially compensate for the loss of thymic-derived T cells.

Non-Hodgkin's lymphoma of the paranasal sinuses: clinical and pathological features, and response to combined-modality therapy

PURPOSE

Lymphomas of the paranasal sinuses may have poorer prognoses compared with other extranodal lymphomas of the head and neck, and are not well defined as a particular clinicopathologic entity. The outcome of combined-modality therapy and central nervous system (CNS) prophylaxis has not been fully determined.

PATIENTS AND METHODS

We retrospectively reviewed our experience with 16 consecutive, carefully defined patients, all treated with both chemotherapy and radiotherapy.

RESULTS

There were 11 men and five women, mean age 52. All presented with local symptoms; 13 had stage I or II disease. Thirteen had diffuse large cell lymphoma, two diffuse mixed, and one small noncleaved. Phenotyping revealed 10 B-cell, four T-cell, and two T or natural killer (NK). Most received CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) chemotherapy; the order of chemotherapy and radiotherapy varied. Twelve received CNS prophylaxis. Of 12 complete responses, six relapsed, all at distant sites, and two died during initial therapy. Five-year survival was 29%, and median survival 18 months. Four of 10 B-lineage patients were relapse-free at 4 years; all six T- or T/NK-lineage patients relapsed or were dead within 6 months. Tumors of T or NK lineage often expressed CD56 and showed evidence of Epstein-Barr viral infection; otherwise, pathological features were not predictive of lineage or outcome. Neither age nor lactate dehydrogenase predicted prognosis. No complete responder recurred in the CNS as site of first relapse.

CONCLUSION

Despite localized stage at presentation, sinus lymphoma is an aggressive disease, characterized by distant relapse and early mortality. Combined-modality therapy with CNS prophylaxis improves outcome compared with radiotherapy alone; however, prognosis remains poor. Patients with T-lineage disease appear to have a particularly bad outcome. Autologous bone marrow transplantation should be evaluated as first-line therapy for those at high risk of relapse.

Long-term amelioration of rat adjuvant arthritis following systemic elimination of macrophages by clodronate-containing liposomes

OBJECTIVE

To determine whether systemic elimination of macrophages by means of clodronate-containing liposomes counteracts inflammation and joint destruction in rats with established adjuvant arthritis (AA).

METHODS

Rats with AA received a total of 2.7 mg of clodronate encapsulated in liposomes in 3 intravenous doses on days 10, 11, and 12 of arthritis. Phosphate buffered saline (PBS), PBS-laden liposomes, or free clodronate were used as negative controls. Clinical, hematologic, and histopathologic signs of AA were monitored, and depletion of macrophages by clodronate-liposomes was evaluated both in the synovial membrane (SM) and in organs of the mononuclear phagocyte system (MPS).

RESULTS

Clodronate-laden liposomes led to significant, long-term amelioration of the clinical signs of AA, a reduction in the erythrocyte sedimentation rate (ESR), and counteraction of joint destruction, not only immediately after treatment, but also for 2 weeks thereafter. Free clodronate induced moderate clinical improvement and a significant decrease in the ESR, but only during the late phase of AA. Drug-free vesicles even aggravated the joint destruction. Clodronate-laden liposomes did not induce significant depletion of resident macrophages in the SM, but rather, in the paracortical region of popliteal lymph nodes, in the liver, and in the marginal zone and periarteriolar lymphatic sheaths of the spleen.

CONCLUSION

Clodronate-laden liposomes induce long-term amelioration of AA, even if administered for a brief period during the florid phase of the disease. The amelioration is paralleled by the elimination of macrophages in immunocompetent areas of the spleen and draining lymph nodes, but not locally in the SM. This suggests an influence of the treatment on the immunoregulatory rather than effector, functions of macrophages.

Treatment planning for Hodgkin's disease: a patterns of care study

PURPOSE

To conduct a survey of the process of treatment planning for the radiation treatment of Hodgkin's Disease in the United States, and to compare survey results with consensus guidelines as determined by recognized experts.

METHODS AND MATERIALS

A consensus committee developed guidelines for the radiotherapeutic management of Hodgkin's Disease. A series of survey forms were designed to evaluate the standards of practice and compare these with the consensus guidelines. A total of 61 facilities divided evenly into the strata of academic, hospital based, and free standing had eligible Hodgkin's Disease cases. There were 275 eligible cases of Hodgkin's Disease evaluated. Data collected from the radiation oncology records included treatment-specific parameters such as energy, dose, blocking, and calculations, as well as treatment planning practices. Statistical analysis was performed on each data element and for all institution strata.

RESULTS

For a number of treatment parameters, there were some discrepancies note between the current United States practice and the consensus guidelines. Some significant differences were found in practice between the stratified institution types. A representative sample of results are: the majority of Hodgkin's Disease patients are treated with x-ray energies in the recommended range, between 4 and 10 MV. Standard mantle (for upper extended field treatment) and modified spade (for lower extended field treatments) are the fields of choice for all types of facilities. The consensus guidelines recommended that dose calculations at multiple points be obtained; however, 15% of patients in the survey received only a single point calculation. Current irregular field dosimetry calculation software does not take account of inhomogeneities. Thirty percent of Hodgkin's Disease patients do not receive a gap calculation for the abutment of upper and lower extended fields. In 70% of treatment fields, no compensation is used. Very few patients receive any kind of in vivo dosimetry check.

CONCLUSION

The survey served to verify that, in general, Hodgkin's Disease treatment planning at all strata of institution has kept pace with recommended practice as delineated in current literature and texts. Small pockets of practice still need improvement in technique and equipment. Changes in practice were identified that can contribute to improved dose uniformity and accuracy.

A non-ionic vesicle lipid enhances mastoparan-stimulated GTPase activity of heterotrimeric G-proteins

Isolated heterotrimeric G-proteins exhibit full biological activity when reconstituted into liposomes. Here, we investigated the non-ionic surfactant macrogol-260-cetylstearylether (TA 6) as an efficient vehicle for the reconstitution of G-proteins. Reconstitution efficiency of G-proteins was recorded by GTP gamma S-binding. Their biological potency was measured as basal and mastoparan-stimulated GTPase-activity. G-proteins were fully active when associated with liposomes. On the other hand, G-proteins solubilized by TA 6 micelles or reconstituted into pure TA 6 vesicles exhibited impaired biological activity. However, vesicles containing different ratios of azolectin and non-ionic TA 6 showed about 50% higher reconstitution efficiency as compared to pure liposomes. In addition, basal and mastoparan-stimulated GTPase-activity in vesicles containing an axolectin/TA 6 ratio of 3:1 were 2.7 and 9.1 fold higher than in pure liposomes, respectively. These data emphasize that the composition of the lipid membranous environment significantly influences G-protein activity.