Maintenance chlorambucil after CVP in the management of advanced stage, low-grade histologic type non-Hodgkin's lymphoma. A randomized prospective study with an assessment of prognostic factors

CHOP-Bleo plus interferon for stage IV low-grade lymphoma

BACKGROUND

Alpha interferon (IFN) is an effective single agent for patients with low-grade lymphoma, but until 1982 had not been integrated with standard chemotherapy for these patients. Since relapse from complete remission (CR) is the rule for patients with advanced stage low-grade lymphoma, a maintenance IFN schedule was explored for patients in CR.

PATIENTS AND METHODS

From 1982-1987, 127 patients with stage IV low-grade lymphoma were treated with cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-Bleo) for 9-18 mo. (median 13 mo.), followed by interferon alfa-n-1 (Wellferon) maintenance therapy for 24 mo. for CRs.

RESULTS

The overall response rate for the entire treatment program was 73% CR and 23% partial remission. The median follow up was 59 months. At 5 years, survival was 74%, failure-free survival (FFS) 47%, and FFS of CRs 60%. Compared to a group of 96 patients with similar pretreatment clinical features treated with CHOP-Bleo from 1972-1982, this represents a significant improvement for both overall FFS (p = 0.01) and FFS of CRs (P < 0.01). Toxicity from the IFN maintenance was generally acceptable, but even at the modest dose employed in this trial (3 x 10(6) U/m2 three times weekly), dose modification was required in more than 30% of patients, usually because of fatigue.

CONCLUSIONS

The integration of IFN and conventional chemotherapy is feasible and effective. Maintenance IFN prolongs remission duration for patients with stage IV low-grade lymphoma.

Can we identify patients with low grade lymphoma for frontline ABMT?

Autologous Bone Marrow Transplant (ABMT), at this point, is an experimental procedure reserved for patients without cure potential with available conventional chemotherapy. Unfortunately, the Ann Arbor staging system has not been able to identify these cases since there are patients with Stage IV who do well and others who do not. We have reported on a risk model based on gender and tumor burden (TB) assessment that can stratify patients with uniform Ann Arbor stage IV follicular low-grade lymphoma (FLGL) into three prognostic groups: (a) a group of females with low TB who have achieved a plateau of failure free survival (FFS) and survival of 50% and 92%, respectively, and who should not receive frontline ABMT; (b) a group of males with high TB having a median FFS and survival of only 12 and 48 months, respectively, and who could potentially benefit from ABMT; (c) a large group of patients with other TB-sex combinations, who are continuously relapsing at ten year follow-up, and whose survival is dismal. Even some of these, who have at best a 50% ten year survival, have not reached a plateau in their survival curves. This large group of patients, like all stage IV patients, will have a median age of 60 years at the time of initial diagnosis and treatment, and will be probably over 60 years old by the time they relapse, at which time salvage therapy will have increased morbidity and mortality, more so if it includes ABMT.(ABSTRACT TRUNCATED AT 250 WORDS)

Combination chemotherapy in the treatment of follicular low-grade lymphoma

The therapeutic approach to patients with follicular low-grade non-Hodgkin's lymphoma is controversial and has varied over a wide spectrum. A "watch and wait" approach in asymptomatic patients has been taken in some studies. In other series, single agent therapy with alkylating agents as cyclophosphamide or chlorambucil has been employed. Response rates including complete responses are high, but relapses inevitably occur. Three-drug combination chemotherapy regimens consisting of cyclophosphamide, vincristine, and prednisone (CVP) have been utilized, in addition to more intensive regimens consisting of four or more drugs. Although responses are commonly achieved, there is no consistent survival advantage conferred by these more aggressive regimens. However, the remission duration may be prolonged in some subsets of patients as those with follicular mixed lymphoma. Due to the prolonged natural history of follicular low-grade lymphoma, a long period of follow-up is necessary to adequately evaluate the impact of a therapeutic regimen on remission duration and overall survival. Future trials may employ more aggressive therapy in combination with growth factors or biologic response modifiers in an effort to improve the outcome of patients with follicular low-grade lymphoma.

Interferon alfa combined with cytotoxic chemotherapy for patients with non-Hodgkin's lymphoma

BACKGROUND

Interferon alfa has been found to be effective as an antitumor agent (with a response rate of 30 percent) in patients with low-grade non-Hodgkin's lymphoma, but its effectiveness in those with intermediate-grade non-Hodgkin's lymphoma has been less adequately tested. In a prospective randomized study we evaluated the effectiveness of adding interferon alfa to cytotoxic chemotherapy in patients with clinically aggressive, low-grade non-Hodgkin's lymphoma and certain histologic variants of intermediate-grade non-Hodgkin's lymphoma, not including diffuse histiocytic lymphoma.

METHODS

The patients were randomly assigned to a regimen of cyclophosphamide, vincristine, prednisone, and doxorubicin or to this regimen combined with recombinant interferon alfa. Treatment was administered every four weeks, for 8 to 10 cycles.

RESULTS

The two regimens produced comparable objective responses, but the regimen including interferon had a greater effect in prolonging the time to treatment failure (P < 0.001) and the duration of complete response (P = 0.03). Interferon alfa also had a greater effect on overall survival (P = 0.014) when the results were adjusted for important covariates.

CONCLUSIONS

Interferon alfa, when added to a four-drug doxorubicin-based chemotherapy regimen, is an effective antitumor agent in patients with clinically aggressive low-grade or intermediate-grade non-Hodgkin's lymphoma.

Prednimustine and mitoxantrone (PmM) in patients with low-grade malignant non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL), and prolymphocytic leukemia (PLL)

Thirty-five patients with a mean age of 60.6 years (44-78 years, 22 male, 13 female) with advanced low-grade non-Hodgkin's lymphoma (NHL), chronic lymphocytic leukemia (CLL), or prolymphocytic leukemia (PLL) were treated every 4 weeks with prednimustine 100 mg/m2 p.o. d 1-d 5 and mitoxantrone 8 mg/m2 i.v. d 1 and d 2. Seven patients had CLL, one lymphocytic NHL, two PLL, 13 immunocytoma, nine centroblastic/centrocytic NHL, and three centrocytic NHL. Twenty-five patients were pretreated. The subjective toxicity of the treatment was mild, with no WHO grade-3 alopecia, polyneuropathy, cardiotoxicity, mucositis, nausea, or vomiting. Hematologic side effects with WHO grade-4 granulopenia and thrombopenia were experienced by 26% and 23% of the patients, respectively. The overall response rate (CR+PR) was 72% for lymphoma patients and 37% for CLL patients, with a median remission duration of 14.6 months. The maximum response was achieved after a median of two treatment courses. Prednimustine with mitoxantrone is a subjectively well tolerated treatment for low-grade malignant NHL, to be further evaluated in phase-III studies. The regimen may shorten the duration of treatment, saving time-consuming out-patient visits and costs.

Chronological age is a multifactorial prognostic variable in patients with non-Hodgkin's lymphoma

In order to assess the predictive capacity of chronological age for survival, an analysis of prognostic variables was performed on 277 patients with Non-Hodgkin's Lymphoma, 84 of whom were older than 65 years. All patients were seen at a single institution, and elderly patients, who might otherwise have been excluded from study analysis, were included. Seventeen clinical, radiological and laboratory parameters were evaluated and subjected to univariate and multivariate analyses. Patients older than 65 years had a significantly poorer survival than those younger than 65 years. When the whole group was considered in a multivariate (Cox) model, the factors that independently predicted a longer survival were a good performance status, age less than 65 years and a low grade histological subtype. When patients older and younger than 65 years were analyzed separately the prognostic variables in the elderly were found to be similar to those in younger patients. The predictive capacity of chronological age was found to be influenced by a poor performance status, the presence of concomitant disease, the dose intensity and tolerance of the treatment given, as well as the physiological reserve of the patient. It is concluded that chronological age is a multifactorial prognostic parameter encompassing a number of patient and treatment factors, all of which must be considered when evaluating the capacity of chronological age to predict survival in patients with Non-Hodgkin's Lymphoma.

Interferon alfa-2b in addition to chlorambucil in the treatment of follicular lymphoma: preliminary results of a randomized trial in progress

One hundred and twenty four patients with follicular lymphoma (32 with Stage III and 92 with Stage IV disease) have been randomized to receive chlorambucil alone or chlorambucil plus interferon alfa-2b. Responding patients are then randomized to receive either interferon alfa-2b maintenance therapy for up to 12 months or no further treatment. One hundred and eight patients are evaluable for response, the remainder are still receiving initial therapy. Clinical remission (complete or good partial remission) was achieved in 42/59 (71%) patients receiving chlorambucil alone and in 27/49 (55%) patients receiving the combination (P = NS). Preliminary analysis of remission duration shows a trend in favour of those patients receiving interferon throughout (P = 0.02). There is no significant difference between the groups in terms of survival, at a median follow up of 2.5 years. Interferon-associated toxicity was minor in most patients but led to discontinuation of therapy in six cases. Larger trials with longer follow-up periods are needed to confirm the beneficial role of interferon in the treatment of follicular lymphoma.

The identification of discrete prognostic groups in low grade non-Hodgkin's lymphoma. The Scotland and Newcastle Lymphoma Group Therapy Working Party

A prognostic model was developed by examination of the prospectively recorded presentation characteristics of patients presenting with low grade non-Hodgkin's lymphomas (LGL). A geographically distinct group (Edinburgh and Borders) was excluded in order to test the validity of the model based on the rest of the Scotland and Newcastle Lymphoma Group (SNLG) population. Between 1979 and 1987 506 patients presented with low grade lymphoma according to Working Formulation definition within one of each of the three main pathology categories. The median available follow-up was 47 months. In a multivariate analysis performance status, age, stage, gender and haemoglobin all contributed separately. 25% of all patients had relatively good prognosis with a median survival not reached and 84% alive at 5 years. Conversely for the worst prognostic group of 25% of patients the median survival is 18 months with only 26% surviving at 5 years. Finally for the intermediate group of 50% of all patients, median survival is 69 months with 58% alive at 5 years. These striking prognostic separations are shown also to be valid in sub-group analysis. Thus young patients within any pathology subgroup have been identified with bad prognostic lymphoma for whom novel strategies in therapy should be devised.

Cytotoxicity of chlorambucil and chlorambucil-fatty acid conjugates against human lymphomas and normal human peripheral blood lymphocytes

The cytotoxic activity of chlorambucil (Chl) and of chlorambucil-fatty acid conjugates of different degree of unsaturation have been assayed in vitro upon two human lymphoma cell lines and comparatively, upon quiescent and mitogen-activated lymphocytes from healthy blood donors. The cell toxicity observed with Chl-arachidonic acid and Chl-docosahexaenoic acid against lymphoma cells was, at any experimental condition used, equal or higher than the individual toxic potential of either chlorambucil or fatty acids. The two conjugates, like chlorambucil alone, were toxic against mitogen-activated lymphocytes. Contrary to chlorambucil, Chl-arachidonic at any concentration tested, lacked of toxicity towards normal non-activated lymphocytes. Chl-oleic acid conjugate was, whatever the cell species tested, much less toxic than Chl alone. In conclusion, the coupling of chlorambucil with polyunsaturated fatty acids increases: (a) the selectivity against neoplastic versus quiescent lymphocytes and (b) the toxicity for B-lymphoma cells. The selective effect of Chl-fatty acid conjugates is discussed in relation with the expression of an AFP/AFP-receptor autocrine system in malignant lymphoblastoid cells and in mitogen-activated lymphocytes.