Computed tomographic scanning in patients with lymphoma

Computed tomography (CT) of the chest and abdomen was performed in 40 patients with lymphoma and the results compared to conventional diagnostic techniques. Overall 34 (85%) of 40 CT scans correctly reflected the presence or absence of lymphoma. Close agreement between the findings of lymphography and CT was noted in 26 of 27 cases. CT has particular utility for assessment of lymphomatous involvement of mesenteric lymph nodes, high retroperitoneal lymph nodes, and extranodal abdominal sites other than the spleen or liver (e.g., pancreas, kidney). Abdominal CT is a useful noninvasive diagnostic technique for the initial staging and subsequent evaluation of selected patients with lymphoma.

Predictive value of bone scans in an adjuvant breast cancer program

Technetium 99m phosphate-complex bone scans were performed in 43 women within two months of mastectomy for stage I (1 patient), stage II (28 patients), and stage III (14 patients) breast cancer. Twelve (28%) initial bone scans were interpreted as either equivocally abnormal (6 scans) or definitely abnormal (6 scans). Radiographs confirmed metastatic disease in 2 patients who were then considered ineligible for adjuvant therapy (adriamycin-cyclophosphamide with or without local radiotherapy). Of the remaining 41 eligible patients, all have received adjuvant therapy and 36 have had at least one additional bone scan at 6-month intervals. Among 20 patients whose serial bone scans were unchanged, there has been no clinical recurrence with a mean followup of 20 months. In contrast, among 16 patients whose serial bone scans have changed (e.g., appearance of new focal lesions, disappearance of old lesions), there have been 6 clinical recurrences (p = 0.01) with a mean followup of 43 months. We conclude that carefully performed technetium pyrophosphate bone scans are helpful in the accurate initial staging of patients being considered for adjuvant breat cancer treatment, and that serial changes in the bone scan identify a group of patients at high risk for early recurrence.

Chemoimmunotherapy versus chemotherapy for remission induction in patients with non-Hodgkin's lymphoma: progress report of a Southwest Oncology Group study

The Southwestern Oncology Group is conducting a controlled clinical trial for patients with all types of advanced non-Hodgkin's lymphoma in which chemoimmunotherapy (CHOP + BCG) is being compared with chemotherapy alone (CHOP + bleomycin or COP + bleomycin) for remission induction. Patients achieving a complete remission confirmed by systematic restaging are then randomly assigned to maintenance BCG or to no further therapy. As of April, 1977, 669 patients had been registered on this trial and 420 were fully evaluable. No significant differences in response rates between the three remission induction regimens are apparent. After restaging, early relapses have occurred with equal frequency in the BCG and no-further-therapy groups. Longer follow-up and further analysis will be required to fully evaluate the potential effects of BCG on remission duration or survival in this study.

Phase II trial of piperazinedione in Hodgkin's disease, non-Hodgkin's lymphoma, and multiple myeloma: a Southwest Oncology Group study

Piperazinedione given iv once every 3-4 weeks at a starting dose of 9-12 mg/m2 (4.5-12 mg/m2 for patients with myeloma) was evaluated in a Southwest Oncology Group phase II study for patients with far-advanced refractory lymphoma or multiple myeloma. Among 36 patients fully evaluable for tumor response (adequate trial), partial responses were observed in five (71%) of seven patients with Hodgkin's disease, in three (19%) of 16 patients with non-Hodgkin's lymphoma, and in none of 13 patients with multiple myeloma. Response was observed by the time of the second (five patients) or third (three patients) course. The median duration of response was 3.7 months (range, 1-17+ months). The dose-limiting toxic effects were hematologic, with 18 (50%) of 36 patients evaluable for toxicity experiencing severe leukopenia (wbc count less than 2000/mm3) and 22 (61%) experiencing severe thrombocytopenia (platelet count less than 50,000/mm3). Twenty patients had a decrease from their pretreatment hemoglobin level of greater than or equal to 2 g/100 ml. Hematologic toxic effects were often unpredictable and in several patients quite prolonged. This study indicates that piperazinedione had definite antitumor activity in patients with Hodgkin's disease and further trials in this disease using the drug at a reduced dose in combination with other effective drugs appear warranted.

Nabilone: a potent antiemetic cannabinol with minimal euphoria

Nabilone is a cannabinol derivative which has potent central antiemetic effects in animals. We observed that the drug significantly reduced the nausea and vomiting induced by cancer chemotherapy in 10 of 13 patients who were refractory to conventional antiemetics. A dose-response effect was apparent. The drug was generally well-tolerated, although it also had sedative effects. Additionally, dizziness, decreased coordination and postural hypotension were observed in some patients. Euphoric effects of the agent were minimal at antiemetic dosage levels.

Chemotherapy of non-Hodgkin's lymphoma: 10 years' experience in the Southwest Oncology Group

The Southwest Oncology Group (SWOG) has completed five studies of high-dose intermittent combination chemotherapy for the management of advanced (stage III and IV) non-Hodgkin's lymphoma involving 1143 patients from May 1966 to September 1974. Lack of uniform histopathologic interpretation precludes precise analysis of these data. Although there has been little change in complete response duration over the years of this study, there has been an overall improvement in response rate and survival though there is no statistically significant improvement in the best overall survival when compared to the Stanford experience in stage III and IV disease (1960-71). The response rate and survival in diffuse histiocytic lymphoma have improved since the first study. There is definite evidence of a plateau in the survival curve beyond 2 years. The percentage of survival at which the plateau appears has increased over the years to 40% in the most recent studies, and the survival is suggestively better than the Stanford experience (P = 0.09). Over the years there has been a distinct improvement in response rate and survival of patients with nodular lymphocytic lymphoma, although the best SWOG survival is no different than the Stanford experience (P = 0.36).

Combination chemotherapy of metastatic malignant schwannoma with vincristine, adriamycin, cyclophosphamide, and imidazole carboxamide: a case report

This report describes a patient with a 15-year history of schwannoma (peripheral nerve sheath sarcoma) who developed extensive pulmonary metastases associated with hypoxemia. Treatment with chemotherapy consisting of cyclophosphamide, vincristine, Adriamycin, and imidazole carboxamide resulted in a complete remission lasting 17+ months. Malignant schwannoma should probably be regarded as a drug sensitive neoplasm.

Radionuclides in oncology

Radionuclides already have a major role in the daily practice of oncology and will, undoubtedly, be of even greater importance in the future. The variety of current and potential applications is shown in tab. 1. Their major use at this time is, in the broadest sense, for 'tumour scanning', which includes the evaluation of specific organs for the presence of tumour (usually with different radiopharmaceuticals for each organ) and the entire body (generalized tumour searches with radiopharmaceuticals like 67Ga-citrate or 111In-labeled bleomycin). The clinician uses these agents in the initial evaluation of extent of tumour (staging) and in the subsequent management of the patient with cancer to assess response to treatment, to reveal early relapse, and to assist in making decisions concerning treatment. The other potential roles for radionuclides are also briefly considered in this review.

Histopathologic review of lymphoma cases from the Southwest Oncology Group

Lymphoma Pathology Panel and Repository (LPPR) review of pathologic material from 354 patients registered on Southwest Oncology Group clinical trials substantiated the diagnosis of Hodgkin's disease (Lukes-Butler classification) in 175 (94%) of 186 cases and the diagnosis of non-Hodgkin's lymphoma (Rappaport classification) in 162 (96%) of 168 cases. However, complete agreement (type and subtype) between institutional and LPPR review diagnoses was found in only 66% of confirmed cases of Hodgkin's disease and in only 58% of confirmed cases of non-Hodgkin's lymphomas. In 26 (16%) of 160 cases of non-Hodgkin's lymphoma, the initial interpretation of pattern (nodular vs diffuse) differed: 20 (25%) of 81 nodular lymphomas had been thought to be diffuse and 6 (8%) of 79 diffuse lymphomas had been diagnosed as nodular. The frequency with which initial diagnoses were confirmed on LPPR review was highest for three subtypes of lymphoma: nodular sclerosis Hodgkin's disease (88%), diffuse histiocytic lymphoma (86%), and nodular lymphocytic lymphoma (78%); rates of confirmation for all other subtypes ranged from 13-50%. The results of this analysis emphasize the necessity of having pathologic review of all cases entered on major lymphoma studies so that comparability of cases can be assured and the results of those studies placed in proper perspective.

Immunodeficiency in patients with non-Hodgkin lymphomas

Seventy-one previously untreated patients with non-Hodgkin lymphomas were studied with several readilyvailable tests of immune function: number of peripheral blood lymphocytes, serum immunoglobulins, and delayed hypersensitivity to six recall antigens. The results were correlated to histology (Rappaport classification), stage (Ann Arbor classification), the presence of symptoms, and survival. As a group, 38 patients with diffuse lymphomas exhibited marked impairment in reactivity to five of six antigens (p less than 0.03 to p less than 0.001). In addition, lymphopenia and reduced levels of serum IgA were found in association with diffuse histiocytic lymphoma. Among patients with diffuse lymphoma, lymphocyte number and skin test reactivity tended to be greater in those with localized disease or without constitutional symptoms, and survival was superior for patients free of symptoms (p less than 0.01). As a group, 33 patients with nodular lymphoma had normal numbers of lymphocytes, lower levels of serum IgG and IgA, and significant impairment of reactivity to two antigens (streptokinase-streptodornase and mumps; p less than 0.01); reactivity to three other antigens (Candida albicans, coccidiodin, and tuberculin) was normal. Survival for patients with nodular lymphoma was superior (p less than 0.01) compared to those with diffuse lymphomas. In summary, severe immunodeficiency was found in patients with diffuse lymphoma (particularly diffuse histiocytic lymphoma), and definite but much less severe immunodeficiency was characteristic of patients with nodular lymphoma.

Hydroxyldaunomycin (Adriamycin) combination chemotherapy in malignant lymphoma

Combination chemotherapy with CHOP (cyclophosphamide, Adriamycin, vincristine, and prednisone) and HOP (Adrimycin, vincristine, and prednisone, was used as treatment for patients with pathologically staged, advanced non-Hodgkin's lymphoma. Among 204 evaluable patients treated on CHOP there were 71% complete remissions with 92% overall responses. Among the 216 evaluable patients on HOP there were 61% complete remissions and 88% responses. Complete remission rates among patients with histiocytic lymphoma were comparable to those of patients with lymphocytic disease. Patients with nodular lymphoma had higher rates of complete remission than their counterparts with diffuse lymphoma. This was noted with both CHOP (78% vs. 67%) and HOP (67% vs. 60%) induction therapy. Rapid responses were common, as more than 14% of complete remissions and 66% of overall responses were achieved with the first course of treatment. Patients in complete remission have been maintained with either cyclophosphamide, vincristine, and prednisone (COP) or arabinosyl cytosine, vincristine, and prednisone (OAP). After 1 year, 86% of patients on COP and 80% on OAP are projected to be free of disease.

The role of radionuclides in clinical oncology

The major role of radionuclides in clinical oncology is, in the broadest sense, "tumor scanning". This includes evaluating specific organs for the presence of tumor (usually with different radiopharmaceuticals for each organ) or the entire body (generalized tumor searches with radiopharmaceuticals with 67Ga-citrate or 111Inlabeled bleomycin). The clinician uses these agents in the initial evaluation of the extent of tumor (staging) and in the subsequent management of the patient with cancer to assess response to treatment, to detect early relapse, and to assist in making decisions concerning treatment. The uses and limitations of the agents currently available for tumor scanning are summarized in this review (by major tumor type) from the perspective of the practicing oncologist. Other potential roles for radionuclides, including use as components of combined modality treatment programs, use as labels for antibodies or as drugs for both diagnosis and treatment, and use in the prediction of response to treatment, which are of great interest now and which will become realities for the oncologist in the future, are also considered.

Bone scanning in lymphoma

The results of bone scanning with the newer technetium-99m complexes were correlated with clinical, laboratory, and radiographic findings in 26 patients with malignant lymphoma (10 with Hodgkin's disease and 16 with non-Hodgkin's lymphomas). Abnormalities on bone scan compatible with lymphomatous involvement of the skeleton appeared to occur more commonly in patients with diffuse lymphomas than in patients with nodular lymphomas and were generally observed in the setting of advanced disease (15 of 23 patients). Twenty-seven (73%) of the 37 scans obtained were abnormal. Although abnormal scans were observed with the greatest frequency in patients with bone pain (11 of 11), bone marrow involvement (11 of 12), abnormal skeletal radiographs (11 of 11), and elevated serum alkaline phosphatase levels (5 of 6), bone scanning also detected lymphomatous involvement in patients free of pain or with normal laboratory tests. Moreover, conventional radiography was entirely normal in six (35%) of 17 patients with abnormal scans and revealed only nonspecific osteopenia in another two patients (12%). Serial bone scans in nine patients reflected their response to chemotherapy. Of the 37 scans, only one was judged falsely positive and one falsey negative. Bone scanning with 99mTc complexes is a safe, simple, and sensitive screening procedure for detecting both extensive and focal lymphomatous involvement of the skeletal system and is a useful means of following such involvement in response to treatment.

Phase III comparison of the treatment of advanced gastrointestinal cancer with bolus weekly 5-FU vs. methyl-CCNU plus bolus weekly 5-FU. A Southwest Oncology Group study

In a randomized and stratified study, 294 patients with advanced gastrointestinal cancer were treated either with 5-fluorouracil (5-FU) 400 mg/m2 weekly intravenously (i.v.) or 5-FU 400 mg/m2 i.v. weekly plus methyl-CCNU 175 mg/m2 orally (p.o.) every 6 weeks. The response rate in colorectal cancer with 5-FU was 9.5% while the two-drug treatment produced a response of 31.8% (p=.009). The response in all gastrointestinal cancers to 5-FU was 10.6% as compared with29.3% for the combination (p=.012). All responses were partial. The two-drug regimen is more effective and more toxic than weekly 5-FU therapy.

Combination chemotherapy with adriamycin (NSC-123127) and cyclophosphamide (NSC-26271) for solid tumors: a phase II trial

One hundred and nine adult patients with metastatic carcinoma were treated at 3-4-week intervas with a combination of adriamycin (40 mg/m2 given iv on Day 1) and cyclophosphamide (200 mg/m2/day given orally in divided doses on Days 3-6). Ninety-two of 96 patients who had an adequate trial (minumum of two courses or progression of disease after one course) had follow-up observations of tumor sites and were considered evaluable for response. Overall objective response rates by tumor type were as follows: stage III or IV ovarian adenocarcinoma, 61% (14 of 23 patients); endometrial adenocarcinoma, 67% (four of six patients); cervical adenocarcinoma, 33% (one of three patients); prostatic adenocarcinoma, 18% (two of 11 patients); testicular carcinoma, 33% (one of three patients); lung carcinoma, 21% (four of 19 patients); renal adenocarcinoma, 14% (one of seven patients); gastrointestinal adenocarcinoma, 18% (two of 11 patients); melanoma, 25% (one of four patients); and miscellaneous tumors, no responses in five patients. In patients with ovarian adenocarcinoma who had not previously received any cytotoxic chemotherapy the response rate was 80% (12 of 15 patients) with 33% five of 15 patients achieving complete clinical remission. CRs in these patients have now been maintained for periods ranging from 7 to 12 months. The major toxic effects were mild to moderate leukopenia, alopecia, and nausea with vomiting. Hemorrhagic cystitis was observed in three patients. The combination of adriamycin and cyclophosphamide is an effective treatment for carcinoma of the breast (reported elsewhere), ovary, and endometrium and should be considered for initial chemotherapy in patients with these tumors. Further investigations of its use for melanoma and carcinoma of the lung, prostate, kidney, and gastrointestinal tract are also warranted.

Combination chemotherapy with methyl-CCNU (NSC-95441), cyclophosphamide (NSC-26271), vincristine (NSC-67574), methotrexate (NSC-740), and bleomycin (NSC-125066) in advanced bronchogenic carcinoma

Forty consecutive eligible patients with advanced bronchogenic carcinoma and no prior chemotherapy were treated with a 5-drug combination of methyl-CCNU, cyclophosphamide, methotrexate, vincristine, and bleomycin. Of the 36 patients who completed at least one 6-week course of treatment and were considered evaluable, 4 (11%) had partial tumor response. Response by cell type was as follows: 2(14%) of 14 patients with squamous cell carcinoma, 2(18%) of 11 with oat cell carcinoma, and none of 11 with adenocarcinoma. Toxicity in the group of 36 evaluable patients consisted of nausea and vomiting in 24 patients (67%), severe leukopenia (white blood cell count less than 1000 cells/-mm3) in 7 patients (19%), severe thrombocytopenia (platelet count less than 100,000 platelets/mm3) in 14 patients (39%), and bleomycin pulmonary toxicity in 2 patients (6%). This combination does not appear to be more effective than single-agent chemotherapy for bronchogenic carcinoma.

Combination chemotherapy with adriamycin and cyclophosphamide for advanced breast cancer

Fifty-five consecutive women with advanced breast cancer were treated with a combination of adriamycin (40 mg/m2 administered intravenously on day 1) and cyclophosphamide (200 mg/m2/day given orally in divided doses for 4 days on days 3-6). Courses were repeated at 21-28-day intervals. The mean age for the 55 patients was 55 years (range, 37-77 years); 20% of the patients were 65 years or older. All patients were evaluable. Objective response (at least a 50% decrease in the size of all measurable lesions lasting for at least 1 month) was noted in 40 (80%) of the 50 patients who received an adequate trial of chemotherapy (a minimum of two courses). Six of the 40 responses observed were complete. The median duration of response was 10 months. Actuarial survival for the entire group of 55 patients was 80% at 6 months after initiating chemotherapy and 70% at 12 months. Survival for the 40 responding patients was 95% at 6 months and 80% at 12 months. Response rates by site of involvement were: soft tissue, 20/25 (80%); lymph node, 15/19 (79%); bone, 21/25 (84%); lung, 15/18 (83%); pleural effusion, 6/8 (75%); and liver, 7/10 (70%). Eighty-three percent of the responses were apparent after two courses of treatment and 98% were apparent after four courses. Toxicity was acceptable and included nausea, myelosuppression, alopecia, and reversible congestive heart failure (in 2 patients who received 550 mg/m2 of adriamycin). Chemotherapy with adriamycin and cyclophosphamide proved to be safe and effective for out-patient treatment of advanced breast cancer.

A clinical evaluation of indium-111 bleomycin as a tumor-imaging agent

In an evaluation of indium-111-bleomycin as a tumor-imaging agent, 357 whole-body tumor scans were performed in 293 patients. Of 246 studies performed in patients with a variety of active solid tumors, 218 (89%) were true-positive studies and 28 (11%) were false-negative. Of 69 scans in patients thought to be free of tumor after therapy, 32 (46%) were false-positive studies and 37 (54%) were true-negative. The true-positive rates by major tumor type were: adenocarcinoma of gastrointestinal tract origin (95%), lymphoma (88%), melanoma (87%), sarcomas (82%), lung (77%), breast (77%), childhood tumors (71%), gynecologic tumors (70%), and genitourinary tumors (68%). Soft tissue and lymphatic sites of tumor, both above and below the diaphragm, were easily visualized, whereas hepatic and bone marrow sites of involvement were less easily discerned. False-positive uptake with 111In-bleomycin was noted in lungs (6%), gut (3%), mediastinum (2%), normal breast tissue (0.8%), and in occasional inflammatory lesions. In 19 patients with multiple myeloma or leukemia, a pattern of diminished bone marrow uptake associated with abnormal accumulation of 111In-bleomycin in extramedullary sites of involvement was the rule. In another 23 patients in whom scans were performed because an occult tumor was suspected, scanning did not lead to specific diagnosis of tumor in a single instance. We conclude that 111In-bleomycin is a safe, effective, and useful new tumor-imaging agent in the initial staging and followup of patients with a variety of solid tumors. Significant advantages of this agent over other currently available radiopharmaceuticals include: A) a broader spectrum of tumors taking up the radio-pharmaceutical, and B) generally better delineation of abdominal and pelvic disease due to lack of interference from gut uptake.

Indium-111 bleomycin tumor scanning in lymphoma

A new radiopharmaceutical, indium-111 labeled bleomycin (IB), was evaluated as a tumor-imaging agent in 55 patients with lymphoma. Overall disease activity was correctly identified in 79% of 75 whole-body scan obtained 48 hours after intravenous administration of IB. Serial scans in 19 patients accurately reflected changes in their disease status. Lymphatic and soft tissues sites of involvement both above and below the diaphragm were most readily identified by scanning. Bone marrow and hepatic involvements were more difficult to detect because of normal tissue background in the considered organs. Five patients manifested diffuse pulmonary uptake of IB and only in one case was it explained. To determine the accuracy of scanning with IB, we evaluated 731 individual sites of potential tumor involvement with these results: true positives 90%, false negatives 10%, false positives 4%, and true negatives 96%. Thus, tumor scanning with indium-111 bleomycin is an important new technique for the initial staging and serial evaluation of patients with lymphoma.

Immunologic Aspects of the Hematologic Neoplasms

Understanding the pathogenesis and pathophysiology of the hematologic malignancies now requires knowledge of their immunology. Many of these tumors appear to arise from the immune cells themselves (B or T cell tumors); most have associated disturbances in immune cell function. New immunodiagnostic methods may become potentially useful clinical tools for evaluating extent of disease, tumor cell kinetics, response to treatment, and prognosis.