Second primary malignancies after treatment for malignant lymphoma

To determine the incidence and possible causes of second primary malignancies after treatment for Hodgkin's and Non-Hodgkin's lymphoma (HL and NHL). A cohort of 3764 consecutive patients diagnosed with HL or NHL between January 1970 and July 2001 was identified using the Sheffield Lymphoma Group database. A search was undertaken for all patients diagnosed with a subsequent primary malignancy. Two matched controls were identified for each case. Odds ratios were calculated to detect and quantify any risk factors in the cases compared to their matched controls. Mean follow-up for the cohort was 5.2 years. A total of 68 patients who developed second cancers at least 6 months after their primary diagnosis were identified, giving a crude incidence of 1.89% overall: 3.21% among the patients treated for HL, 1.32% in those treated for NHL. Most common were bronchial, breast, colorectal and haematological malignancies. High stage at diagnosis almost reached statistical significance in the analysis of just the NHL patients (odds ratio = 3.48; P = 0.068) after adjustment for other factors. Treatment modality was not statistically significant in any analysis. High stage at diagnosis of NHL may be a risk factor for developing a second primary cancer.

Hodgkin Lymphoma in adolescents

With the development of an integrated treatment approach, the cure rate and survival of patients with Hodgkin Lymphoma (HL) is now high. Treatment tailored to stage, using chemotherapy, with or without involved field radiotherapy is the standard of care. Paediatric oncologists have been developing treatment regimens to maximise cure rate whilst trying to minimise the associated late side-effects, and cure rates in children are now often greater than 90%. It has been suggested that the outcome of adolescents with HL does not match that of younger children, but published data focusing on this group of patients is scarce. Future treatment strategies may direct the treatment of adolescents with HL away from the current "adult" regimens, and closer to that currently received by children, but prospective randomised trials are required. Rationalisation of both chemotherapy and radiotherapy administered to children and adolescents aims to minimise the risk of significant long-term side effects without sacrificing high cure rates. Infertility, secondary malignancies, cardiac and respiratory morbidity are all significant risks of current combined modality treatment that need to be discussed when obtaining informed consent and may influence the choice of treatment offered or accepted. Monitoring late effects of treatment (both physical and psychological) is especially important in this group of young patients.

Cutaneous CD56 positive natural killer and cytotoxic T-cell lymphomas

We report two cases of CD56 positive natural killer (NK) cell and cytotoxic T-cell cutaneous lymphomas and review the literature on these rare forms of non-Hodgkin's lymphoma. The first case was diagnosed to have extra nodal NK/T-cell lymphoma, nasal-type. She had a rapid downhill clinical course and died within 3 months of presentation. She had been started on systemic chemotherapy but did not respond. The second case was diagnosed as subcutaneous panniculitis-like T-cell lymphoma, CD56 positive variant. She presented with skin nodules that were quiescent for 10 years. Then the course of the disease suddenly changed and progressed rapidly. She had systemic chemotherapy and initially had a complete response, but she relapsed within 1 month of completion of chemotherapy. She then had partial response with further chemotherapy but relapsed rapidly. She died within 15 months of her lymphoma changing to its aggressive form. These cases illustrate the often poor prognosis of cutaneous CD56 positive lymphomas.

Localised non-Hodgkin lymphoma of the testis: the Sheffield Lymphoma Group experience

We evaluated clinical features, management and survival of patients with localised (stage 1E or 2E) testicular non-Hodgkin lymphoma (NHL) presenting to the Sheffield Lymphoma Group between 1972 and 2002. Thirty consecutive eligible patients were identified from the lymphoma database and clinical records of all were reviewed. Survival data were statistically analysed. The median age of patients was 74 years (range 38-87). Sixty-three percent were >70 years of age. The median duration of follow-up was 15 months (range 2.1-211). All patients had orchidectomy. Eleven (37%) had orchidectomy alone. Twelve (40%) had orchidectomy and chemotherapy, 4 (13%) had orchidectomy and radiotherapy. Three (10%) had orchidectomy, chemotherapy and radio-therapy. Five (17%) had immediate disease progression following orchidectomy or whilst on treatment. A complete response was seen in the remaining 25 (84%) irrespective of treatment modality. Seven (23%) of patients remain alive, with a median follow-up of 73 months (range 9.9-211). Six (20%) died of causes not related to their lymphoma. Twelve (40%) relapsed following a complete response and median time to relapse was 9 months. Only 1 of these relapses was in the central nervous system; 1 in bone, 1 in skin, 2 in the contralateral testis. The majority of relapses (58%) occurred in the lymph nodes. Primary testicular lymphoma is an uncommon and poor prognosis disease usually affecting older men. The data and experience available to guide the treatment strategies for testicular lymphoma are limited. However, the evidence points to a combined modality approach being the most likely effective treatment, comprising surgery, anthracycline-containing combination chemotherapy with or without prophylactic contralateral testis and regional lymph node irradiation.

Phase II study of ISIS 3521, an antisense oligodeoxynucleotide to protein kinase C alpha, in patients with previously treated low-grade non-Hodgkin's lymphoma

BACKGROUND

The purpose of this study was to assess the efficacy and safety of ISIS 3521, an antisense phosphorothioate oligonucleotide to protein kinase C alpha in patients with relapsed low-grade non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

Twenty-six patients received ISIS 3521 (2 mg/kg/day) as a continuous infusion over 21 days of each 28-day cycle.

RESULTS

The median age of the patients was 53 years (range 37-77). Histological subtypes were low-grade follicular lymphoma (n = 22) and B-cell small lymphocytic lymphoma (n = 4). Twenty-one (81%) had stage III/IV disease. The median number of previous lines of chemotherapy was two (range one to six). A total of 87 cycles of ISIS 3521 were administered. Twenty-three patients were assessable for response. Three patients achieved a partial response. No complete responses were observed. Ten patients had stable disease. Grade 3-4 toxicity was as follows: neutropenia (3.8%) and thrombocytopenia (26.9%).

CONCLUSIONS

ISIS 3521 has demonstrated anti-tumour activity in patients with relapsed low-grade NHL. There may be a potential role for this agent in combination with conventional chemotherapy for advanced low-grade lymphoma, and further trials are warranted.

The role of repeat uterine evacuation in the management of persistent gestational trophoblastic disease

OBJECTIVE

To evaluate the role of second (and third) uterine evacuation in the management of persistent gestational trophoblastic disease (GTD).

METHODS

This was an observational study of all cases registered over a 10-year period at the Trophoblastic Disease Centre at Weston Park Hospital, Sheffield. Five hundred and forty-four of 4050 women registered during 1991-2000 underwent a second uterine evacuation following a presumptive diagnosis of persistent GTD. The reason for evacuation, hCG level prior to the procedure, histological appearances of evacuated products and the clinical outcome (in terms of the need for chemotherapy) were determined.

RESULTS

After a second uterine evacuation 368 patients (68%) completed the follow-up programme without further evidence of persistent disease or need for chemotherapy. If the diagnosis of persistent GTD was confirmed solely on the basis of elevated hCG levels then 171 of 282 (60%) patients did not require chemotherapy. Chemotherapy was more likely where there was histological evidence of persistent trophoblastic disease and where the urinary hCG was >1500 IU/L at the time of the repeat evacuation. Twenty-eight of 60 patients (46%) undergoing a third evacuation required chemotherapy.

CONCLUSION

Second uterine evacuation can be a useful therapeutic option for patients with presumed persistent trophoblastic disease not mandating immediate chemotherapy, particularly where the hCG level is <1500 IU/L. Patients with documented persistent trophoblastic disease on histological examination of the second evacuation sample are more likely to require chemotherapy. Third evacuation is not now recommended.

Trials in Advanced Hodgkin's Disease: More than 30 Years Experience of the British National Lymphoma Investigation

Hodgkin's disease demonstrates an exquisite sensitivity to chemotherapy and radiation therapy. This necessitates investigation of modes of delivering these modalities in the best possible fashion to improve outcomes. The British National Lymphoma Investigation (BNLI) has conducted randomized trials in advanced Hodgkin's disease for > 30 years. The results of BNLI studies have demonstrated that MOPP (mechlorethamine/vincristine/procarbazine/prednisone) chemotherapy is superior to MOP (mechlorethamine/vincristine/procarbazine) chemotherapy; that there are no significant differences between MOPP and B-MOPP (MOPP plus bleomycin); that there is no significant benefit from maintenance therapy with lomustine/vinblastine/bleomycin; that LOPP (chlorambucil/vincristine/procarbazine/prednisone) is as effective as MOPP and has less acute toxicity; that alternating therapy with LOPP and EVAP (etoposide/vinblastine/doxorubicin/prednisolone) is superior to EVAP alone or hybrid LOPP and EVA (etoposide/vinblastine/doxorubicin); that alternating therapy with ChlVPP (a substitute for MOPP) and prednisolone/doxorubicin/bleomycin/vincristine/etoposide regimens is superior to the latter regimen alone; that the Stanford V regimen (doxorubicin/vinblastine/mechlorethamine/vincristine/bleomycin/etoposide/prednisone) combined with disciplined radiation therapy is safe and effective; that hybrid therapy with ChlVPP and EVA and alternating therapy with ChlVPP and prednisolone/doxorubicin/bleomycin/vincristine/etoposide are as effective as ABVD (doxorubicin/bleomycin/vinblastine/dacarbazine) alone; and that there is no additional benefit from total nodal irradiation or combined-modality therapy compared with MOPP; and that treatment with high-dose BEAM (carmustine/etoposide/cytarabine/melphalan) and autologous bone marrow transplantation is superior to mini-BEAM (lower-dose BEAM not requiring bone marrow rescue) for poor-risk relapsed and refractory disease.

Primary B-cell lymphoma of the skin: the Sheffield Lymphoma Group Experience (1984-2003)

The clinical presentation, treatment and outcome were retrospectively evaluated in a series of 66 patients with primary B-cell lymphoma of the skin, referred to the Sheffield lymphoma group (SLG) between 1984 and 2003. This is the largest series reported from the UK. The lymphoma database was searched and clinical records were reviewed. Absence of any detectable extracutaneous lesion and the expression of B-cell restricted antigens by neoplastic cells were the essential criteria for selection of cases. The cohort included 37 (56%) males and 29 (44%) females with a mean age of 59 years. The most commonly involved site was the trunk and the disorder typically showed non-aggressive clinical behaviour; the majority of the patients presented with stage I (82%) disease with a tendency to remain localised to a limited area of the skin. Follicular lymphoma was the most common histologic subtype (35%), the next most frequent was the diffuse large cell lymphoma (32%) whereas marginal zone lymphoma constituted 15%. The majority (47%) of patients were treated with radiotherapy for localised disease whereas chemotherapy was given in 20% of patients, with single agent chlorambucil being most frequently used. Surgical excision as the sole modality of treatment was adequate in 33%. Disease-free survival (DFS) was 91% at 1 year, 82% at 2 years and 60% at 5 years. DFS was significantly lower with older age (>45 years), leg lesions, generalised and multiple lesions, and for those treated with chemotherapy. The survival at 5 and 10 years was 80%. The histologic grade, leg involvement and the number of lesions were the most significant variables affecting overall survival. Only 7 patients died of lymphoma. In conclusion, primary cutaneous B-cell lymphoma represents a specific entity concerning clinical behaviour, response to treatment, and overall prognosis.

Localised extranodal lymphoma of the head and neck: the Sheffield Lymphoma Group experience (1971-2000)

AIMS

Over the 30-year period from 1971-2000, 3750 cases of lymphoma were referred to the Sheffield Lymphoma Group for investigation and treatment. Of these, 580 were extranodal presentations and, of these, 190 (33%) were localised to the head and neck region. The aim of this lymphoma database review was to evaluate the patient characteristics and survival rates for these patients.

MATERIALS AND METHODS

The sample included 98 women and 92 men, with a median age at presentation of 65 years.

RESULTS

The most common site affected was tonsil (34%), followed by salivary glands (16%). Other common sites were the thyroid, orbit and nasopharynx. The most frequent presenting feature was a swelling or mass, with pain, dysphagia and nasal obstruction also comprising large groups. All cases were non-Hodgkin's lymphoma. Fifty-five cases were histological grade 1; 132 were grade 2. Diffuse large B cell was the most common histological subtype. The overall 5- and 10-year survival rates were 55% (95% CI 47-62) and 44%, (95% CI 36-53), respectively, with a median survival of 92 months (95% CI 56-128). Stage and grade were both found to influence survival.

CONCLUSION

This data concords with and extends information available from previous studies. More detail is now required on specific head and neck sites.

Management of persistent, unexplained, low-level human chorionic gonadotropin elevation: a report of 5 cases

BACKGROUND

Persistent low-level elevation of human chorionic gonadotropin (hCG) without a history of gestational trophoblastic disease has often been treated unsuccessfully with chemotherapy and/or hysterectomy on the presumption that this was trophoblastic disease.

CASES

We report on 5 patients diagnosed with this condition who were closely monitored and did not receive intensive or prolonged chemotherapy. Four patients received a short therapeutic trial of methotrexate without a significant change in hCG levels. All patients have remained healthy. Three patients successfully conceived, and 2 delivered healthy infants.

CONCLUSION

Immediate chemotherapy or hysterectomy can be avoided in patients with persistent, unexplained, low-level elevation of hCG. Failure of normalization of hCG levels with chemotherapy suggests that highly differentiated normal trophoblastic noninvasive cells, rather than invasive cytotrophoblastic cells, are responsible.

Low-risk persistent gestational trophoblastic disease treated with low-dose methotrexate: efficacy, acute and long-term effects

The aim of this study was to evaluate the efficacy and toxicity of low-dose methotrexate with folinic acid rescue in a large series of consecutively treated patients with low-risk persistent gestational trophoblastic disease. Between January 1987 and December 2000, 250 patients were treated with intramuscular methotrexate (50 mg on alternate days 1, 3, 5, 7) with folinic acid (7.5 mg orally on alternate days 2, 4, 6, 8) rescue. The overall complete response rate without recurrence was 72% for first-line treatment and 95% for those who required second-line chemotherapy. Eight women (3.2%) had recurrence following remission and two (0.8%) had new moles. Two women (0.8%) died of their disease giving an overall cure of 99%. Only 10 women (4%) experienced grade III/IV toxicity during the first course of treatment and 13 women (5.2%) subsequently. Toxicity included mucositis and stomatitis, pleuritic chest pain, thrombocytopenia, uterine bleeding, abdominal pain, liver function changes, rash and pericardial effusion. A total of 59 women (23.6%) required second-line chemotherapy; 48 women had methotrexate resistance, eight had methotrexate toxicity and an empirical decision to change therapy was made in three. In all, 11 women (4.4%) had a hysterectomy before, during or after treatment; 141 women (56.4%) became pregnant following treatment: in 128 (90.7%), the outcome was successful. Methotrexate with folinic acid rescue is an effective treatment for low-risk persistent trophoblastic disease. It has minimal severe toxicity, excellent cure rates and does not appear to affect fertility.

The clinical presentation, treatment, and outcome of patients diagnosed with possible ectopic molar gestation

The objective of this study was to determine the clinical presentation, treatment, and outcome of patients diagnosed with possible ectopic molar gestation registered with the Trophoblastic Disease Screening and Treatment Centre, Weston Park Hospital, Sheffield between 1986 and 2000. From the 5581 women registered, those with a diagnosis of ectopic molar pregnancy were identified from a computer database. Information regarding the relevant history of each patient and the clinical presentation, treatment, and outcomes of gestational trophoblastic disease (GTD) was determined by reviewing referral forms, case notes, and pro formas completed by the referring gynecologist. Histological review of the cases was undertaken where possible. Suspected ectopic molar gestations comprised 31/5581 (0.55%) of registrations. Known risk factors for ectopic pregnancy were identified in 79% of cases. Central histological review confirmed only six cases of GTD: three choriocarcinoma and three early complete moles. Four patients subsequently required chemotherapy. All patients are now in complete remission. We conclude that ectopic GTD is uncommon, with a UK incidence of approximately 1.5 per 1,000,000 births. Initial management is usually surgical removal of the conceptus, pathological suspicion of the diagnosis and registration with a screening center. Chemotherapy may be required and the prognosis is excellent.

Is there a relationship between treatment for infertility and gestational trophoblastic disease?

BACKGROUND

The aim of the study was to record the incidence of treatment for infertility prior to development of gestational trophoblastic disease (GTD).

METHODS AND RESULTS

A retrospective analysis was undertaken of 231 consecutive women receiving chemotherapy for persistent GTD at Weston Park Hospital, Sheffield, from 1991 to 2001. Three patients in this group had received treatment for infertility prior to their molar pregnancy. In a control group of 226 patients not requiring treatment for persistent GTD, four had had treatment for infertility just before their molar pregnancy, and in a further control group of 208 'normal' pregnancies, eight patients had had treatment for infertility prior to conception.

CONCLUSION

We conclude that we can demonstrate no relationship between infertility treatment and subsequent development of GTD.

The Management and Survival of Patients with Advanced Germ-Cell Tumours: Improving Outcome in Intermediate and Poor Prognosis Patients

AIMS

The survival of germ-cell tumours (GCT) was transformed after the introduction of cisplatin-based therapy. Previous trials have indicated BEP (bleomycin, etoposide and cisplatin) as the optimum treatment, although some centres including our own advocate the use of the alternating regimen POMB-ACE (cisplatin, vincristine, methotrexate, bleomycin and dactinomycin, cyclophosphamide and etoposide) for men with intermediate or poor prognosis disease. We analysed the survival and management of GCT patients treated at a specialist cancer centre in relation to internationally recognised prognostic groupings.

MATERIALS AND METHODS

We retrieved patient information using the Trent Testicular Tumour Registry and supplemented it with information from patient notes. This included all patients with Royal Marsden Hospital Stage II, III and IV disease and patients with stage I disease at diagnosis with raised markers or subsequent relapse. We compared the efficacy and toxicity of the BEP and POMB-ACE chemotherapy regimens, and assessed relapse-free and overall survival.

RESULTS

We identified 178 non-seminomatous germ cell tumours (NSGCT) and 71 seminoma patients. Overall survival was similar to the International Germ Cell Cancer Collaborative Group (IGCCCG) classification for the good (95% vs 92%) and intermediate groups (82% vs 80%). The outcome for the poor prognosis group was better than expected in our series (57% vs 48%). There was a higher proportion of both immediate and late side-effects with POMB-ACE.

CONCLUSION

Survival and disease progression rates at this single institution were at least as good as reported by the IGCCCG and somewhat better for the poor-prognosis group. This may reflect use of the POMB-ACE chemotherapy regimen as opposed to standard BEP regimen. However, a randomised comparison of BEP and POMB-ACE would be required to validate this.

Adjuvant interferon in high-risk melanoma: the AIM HIGH Study--United Kingdom Coordinating Committee on Cancer Research randomized study of adjuvant low-dose extended-duration interferon Alfa-2a in high-risk resected malignant melanoma

PURPOSE

To evaluate low-dose extended duration interferon alfa-2a as adjuvant therapy in patients with thick (> or = 4 mm) primary cutaneous melanoma and/or locoregional metastases.

PATIENTS AND METHODS

In this randomized controlled trial involving 674 patients, the effect of interferon alfa-2a (3 megaunits three times per week for 2 years or until recurrence) on overall survival (OS) and recurrence-free survival (RFS) was compared with that of no further treatment in radically resected stage IIB and stage III cutaneous malignant melanoma.

RESULTS

The OS and RFS rates at 5 years were 44% (SE, 2.6) and 32% (SE, 2.1), respectively. There was no significant difference in OS or RFS between the interferon-treated and control arms (odds ratio [OR], 0.94; 95% CI, 0.75 to 1.18; P =.6; and OR, 0.91; 95% CI, 0.75 to 1.10; P =.3; respectively). Male sex (P =.003) and regional lymph node involvement (P =.0009), but not age (P =.7), were statistically significant adverse features for OS. Subgroup analysis by disease stage, age, and sex did not show any clear differences between interferon-treated and control groups in either OS or RFS. Interferon-related toxicities were modest: grade 3 (and in only one case, grade 4) fatigue or mood disturbance was seen in 7% and 4% respectively, of patients. However, there were 50 withdrawals (15%) from interferon treatment due to toxicity.

CONCLUSION

The results from this study, taken in isolation, do not indicate that extended-duration low-dose interferon is significantly better than observation alone in the initial treatment of completely resected high-risk malignant melanoma.

Long-term effect of a watch and wait policy versus immediate systemic treatment for asymptomatic advanced-stage non-Hodgkin lymphoma: a randomised controlled trial

BACKGROUND

Neither chemotherapy with a single-alkylating agent nor aggressive combination chemotherapy cures advanced stage low-grade non-Hodgkin lymphomas, even when combined with radiotherapy. Our aim was to compare administration of immediate chlorambucil treatment with a policy of delaying chlorambucil until clinical progression necessitated its use, in asymptomatic patients with advanced-stage, low-grade non-Hodgkin lymphoma.

METHODS

309 patients with asymptomatic, advanced-stage, low-grade non-Hodgkin lymphomas were recruited from 44 UK centres between Feb 1, 1981, and July 31, 1990. 158 patients were randomised to receive immediate systemic therapy with oral chlorambucil 10 mg per day continuously. The remaining 151 were randomised to an initial policy of observation, with systemic therapy delayed until disease progression. In both groups, local radiotherapy to symptomatic nodes was allowed.

FINDINGS

Median length of follow-up was 16 years. Overall survival or cause-specific survival did not differ between the two groups (median overall survival for oral chlorambucil 5.9 [range 0-17.8] years and for observation 6.7 [0.5-18.9] years, p=0.84; median cause-specific survival 9 [0-17.8] years and 9.1 [0.67-18.9] years, respectively p=0.44). In a multivariate analysis, age younger than 60 years, erythrocyte sedimentation rate (ESR) 20 mm/h or less, and stage III disease, conferred significant advantages in both overall survival (p<0.0001, 0.03, and 0.03, respectively) and cause-specific survival (p=0.002, 0.008, and 0.001, respectively). In the observation group, at 10 years' follow-up, 19 patients were alive and had not received chemotherapy. The actuarial chance of not needing chemotherapy (non-lymphoma deaths censored) at 10 years was 19% (40% if older than 70 years).

INTERPRETATION

An initial policy of watchful waiting in patients with asymptomatic, advanced stage low-grade non-Hodgkin lymphoma is appropriate, especially in patients older than age 70 years.

Non-Hodgkin lymphoma

Non-Hodgkin lymphoma is a non-specific term that includes several lymphoproliferative malignant diseases with different clinical and histological appearances. Here, we concentrate on adult lymphomas. We look at their molecular basis, at the development of a classification system based on a better understanding of the biology of the various subgroups, and at how refinement of adverse prognostic factor groupings helps in clinical management. Lymphomas can present in various ways and be difficult to diagnose. About a quarter of cases arise extranodally and might present special problems. Developments in cytotoxic chemotherapy have led to good long-term survival prospects for aggressive lymphoma; introduction of novel approaches, including monoclonal antibody therapy, offers promise for indolent lymphoma, and should further improve prognosis for aggressive tumours.

Gestational trophoblastic disease in the Asian population of Northern England and North Wales

OBJECTIVE

To determine the incidence and trends of gestational trophoblastic disease in the Asian population of Northern England and North Wales.A prospective observational study.

SETTING

Trophoblastic Screening and Treatment Centre, Weston Park Hospital.

POPULATION

A total of 3660 women registered with gestational trophoblastic disease between 1991 and 1999.

MAIN OUTCOME MEASURES

1. The incidence of gestational trophoblastic disease in Asian and non-Asian population. 2. Trend in incidence over study period.

RESULTS

Three hundred and twenty-two Asian patients were registered. The incidence of gestational trophoblastic disease in the northern part of England and Wales averaged 1 per 714 live births. The incidence of gestational trophoblastic disease in the Asian population was 1.95 times higher than in the non-Asian population (1 per 387 live births vs 1 per 752 live births). There was an excess of molar pregnancies in the extreme maternal age groups; the incidence in these women was twice as high as in the whole reproductive cohort. The ratio of partial to complete hydatidiform mole increased from 0.9 in the lower age to 2.6 in the older age group. There appeared to be a slowly rising trend in the incidence of gestational trophoblastic disease; the increase was higher in the Asian than in the non-Asian population. The ratio of partial to complete moles increased with age in both populations.

CONCLUSION

Asian women are at increased risk of having molar pregnancies. Molar pregnancies are more common at the extremes of reproductive age. The setting up of regional or national registration centres has helped to provide more accurate estimates of the true incidence of the disease.

Peripheral T cell lymphoma: The Sheffield Lymphoma Group experience (1977-2001)

Peripheral T-cell lymphomas (PTCL) account for approximately 10% of all non-Hodgkin's lymphomas. The aim of this retrospective study was to analyse the presentation, management, outcome and significant prognostic factors in a large series of patients with PTCL. It includes 104 consecutive patients who presented to the Sheffield Lymphoma Group between 1977 and 2001. Clinical parameters were recorded for each subgroup. End points were response to treatment and survival. Survival analysis was used to assess the prognostic value of the variables. PTCL not otherwise specified contributed 52% of cases followed by anaplastic large cell lymphoma with 17% and angiocentric type with 13% of cases. The overall complete remission (CR) of the series was 59%. Stage at diagnosis affected response to treatment with 81% of cases in stage 1 and 2 achieving CR compared to 43% in stages 3 and 4 (p</=0.001). Extranodal presentations also showed a favourable response with 74% obtaining CR compared to 46% of nodal presentations (p<0.01). Median survival of all patients was 87 months with a five-year probability of survival of 52%. Variables found to be related to poor outcome are age >60 years (p<0.05), high grade histology (p<0.001), presence of B symptoms (p<0.005), nodal presentation (p<0.005) and advanced stage at diagnosis (p<0.001). Histological sub-type did not significantly correlate to outcome. In conclusion whilst a number of prognostic indicators can assist in determining the outcome in PTCL, these lymphomas are complex and often follow an unpredictable course. In order to make the best clinical decisions in individual cases, more clinical study is required.

Phase II study of docetaxel in patients with relapsed or refractory malignant lymphoma

We report the activity and toxicity of docetaxel in 12 evaluable heavily pretreated patients with relapsed and refractory non-Hodgkin's lymphoma and Hodgkin's disease. In all, 42% achieved a partial response, 25% achieved stable disease. Median duration of response was 16 (10-21) weeks. The median overall survival was 70 (9-178) weeks and for responders it was 120 (22-178) weeks. One patient developed one episode of neutropenic sepsis. Docetaxel has limited activity in this group of patients.

A phase II protection study of BB-10010 in patients with high grade non-Hodgkin's lymphoma undergoing intensive chemotherapy

The aim of this study was to determine whether administration of BB-10010, a synthetic stem cell inhibitor, would allow more intensive chemotherapy to be administered to patients with newly diagnosed high grade NHL. Thirteen patients were randomised to receive BB-10010 concurrently with dose-intensified BEMOP/CA chemotherapy (7 patients) or chemotherapy alone (6 patients). Although the mean neutrophil count of BB-10010 treated patients was higher following cycles 1, 2 and 3 of chemotherapy compared with those receiving chemotherapy alone, there was no difference in the mean number of cycles tolerated, blood component usage and hospital admissions due to infections. No specific toxicity of BB-10010 was identified. Whilst BB-10010 can be administered safely, it does not improve the ability of patients to tolerate intensive chemotherapy for high grade NHL.

Risk-adjusted prognostic models for Hodgkin's disease (HD) and grade II non-Hodgkin's lymphoma (NHL II): validation on 6728 British National Lymphoma Investigation patients

Using significant factors from multivariate analyses, based on 20 putative markers from a consecutive series of 1198 Sheffield Lymphoma Group patients, risk-adjusted prognostic models had been previously derived for Hodgkin's disease (HD) (using age, albumin and lymphocyte count) and non-Hodgkin's lymphoma (NHL) grade II (based on albumin, age, erythrocyte sedimentation rate, lactate dehydrogenase and stage). Data from 6728 patients on the British National Lymphoma Investigation database were used for validation: thus the models were applied to 4411 patients with HD and 2317 patients with NHL grade II. Survival curves derived from these validation groups confirmed our risk models.

Adjuvant therapy of malignant melanoma

High risk surgically resected melanoma is associated with a less than 50% 5-year survival. Adjuvant therapy is an appropriate treatment modality in this setting, and is more likely to be effective as the tumour burden here is small. Clinical observations of spontaneous tumour regressions and a highly variable rate of disease progression suggest a role of the immune system in the natural history of melanoma. Biological agents have therefore been the subjects of numerous adjuvant studies. Early, randomised controlled trials (RCTs) of Bacillus Calmette-Guerin (BCG), levamisole, Corynebacterium parvum, chemotherapy, isolated limb perfusion (ILP), radiotherapy, transfer factor (TF), megestrol acetate and vitamin A yielded largely negative results. Current trials focus on vaccines and the interferons. To date the latter is the only therapy to have shown a significant benefit in the prospective randomised controlled phase III setting. This report represents a systematic review of studies in adjuvant therapy in melanoma. Data from ongoing studies is awaited before a role for adjuvant agents in high risk melanoma is confirmed.