The epidemiology of non-Hodgkin lymphoma

Differential characteristics of Waldenström macroglobulinemia according to patterns of familial aggregation

Familial aggregation of Waldenström macroglobulinemia (WM) and related B-cell disorders (BCDs) suggests a role for genetic factors, but few data address environmental influences. We designed a questionnaire-based study to examine clinical and environmental factors in a cohort of WM families with various patterns of case aggregation. We analyzed data on 103 WM patients and 272 unaffected relatives from 35 multiple-case WM and 46 mixed WM/BCD kindred and 28 nonfamilial (sporadic) WM patients, using logistic regression models with generalized estimating equations to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for association. In this study population, the WM disease process appeared similar among patients regardless of family history. Familial WM patients were more likely than unaffected relatives to report a history of autoimmune disease (OR, 2.27; 95% CI = 1.21-4.28) and infections (OR, 2.13; 95% CI = 1.25-3.64). Familial WM patients were also more likely to report exposure to farming (OR, 2.70; 95% CI = 1.34-5.42), pesticides (OR, 2.83; 95% CI = 1.56-5.11), wood dust (OR, 2.86; 95% CI = 1.54-5.33), and organic solvents (multiple-case WM OR, 4.21; 95% CI = 1.69-10.51) compared with unaffected family members. These data provide clues to both genetic and environmental factors that may influence development of WM. Well-designed case-control studies are needed to confirm these findings.

Risk of non-Hodgkin lymphoma and nitrate and nitrite from the diet in Connecticut women

It has been estimated that 65,980 individuals were diagnosed with non-Hodgkin lymphoma (NHL) and 19,500 died from NHL in the United States in 2009. Although established risk factors such as immunodeficiency and viral infections may be responsible for a portion of the cases, the majority of NHL cases remain unexplained. Dietary nitrate and nitrite intake are exposures of particular interest for NHL risk as they are precursors in the endogenous formation of N-nitroso compounds, which cause lymphomas in animal studies. We investigated NHL risk overall and by histologic type in relation to dietary nitrate and nitrite intake in a population-based case-control study of 1,304 women in Connecticut. Nitrate and nitrite intake were assessed using a 120-item food frequency questionnaire. We found no association between risk of NHL overall and dietary nitrate and a slightly increased risk of NHL with higher dietary nitrite intake (highest vs. lowest intake quartile OR = 1.4; 95% CI: 0.9-2.2). When we evaluated intake by subtype, a significant positive trend was observed for follicular lymphoma and nitrate (p-trend = 0.04) and nitrite (p-trend < 0.01) with an over twofold risk in the highest nitrite intake quartile (OR = 2.3; 95% CI: 1.1-4.9). An increased risk in the highest quartile of nitrite intake was also observed for T-cell lymphoma (OR = 3.4; 95% CI: 1.0-11.9). Animal products containing nitrite were more strongly associated with risk of follicular lymphoma; whereas, both animal and plant sources of nitrite were associated with elevated ORs for T-cell lymphoma. Our results confirm a previous finding for nitrite intake and NHL risk and highlight the importance of evaluating histologic type. We conclude that these results should be replicated in a larger study with data on drinking water as well as dietary sources of nitrate intake.

Plasma organochlorine levels and risk of non-Hodgkin lymphoma in a cohort of men

BACKGROUND

Environmental exposure to polychlorinated biphenyls (PCBs) and p,p'-dichlorodiphenyldichloroethylene (p, p'-DDE) has been associated with the risk of non-Hodgkin lymphoma.

METHODS

We conducted a case-control study nested within the Physicians' Health Study, a prospective cohort established in 1982. We measured concentrations of PCBs and p,p'-DDE in baseline blood samples from 205 men later diagnosed with non-Hodgkin lymphoma and 409 age- and race-matched controls. Lipid-adjusted organochlorine concentrations were categorized into quintiles based on the distribution among controls. We used conditional logistic regression to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) for each quintile relative to the lowest quintile. We also evaluated these associations for major histologic subtypes of non-Hodgkin lymphoma.

RESULTS

The risk of non-Hodgkin lymphoma was positively associated with the sum of 51 PCB congeners assayed (SigmaPCB); the group of immunotoxic congeners; the individual congeners 118, 138, 153, and 180; and the sum of these 4 congeners. The simple OR for the highest quintile of lipid-adjusted SigmaPCB versus the lowest was 1.9 (95% CI = 1.1-3.2; test for trend, P = 0.001), with similar trends for individual congeners and groups defined as above. Adjustment for height, body mass index, alcohol intake, smoking, and fish intake did not substantially change the effect estimates. No association was observed for p,p'-DDE. There was no evidence of statistical heterogeneity in effects by histologic subtype of lymphoma; however, this analysis was underpowered.

CONCLUSIONS

These results support the hypothesis of a positive association between PCB exposure and development of NHL in men.

Temporal and demographic patterns of non-Hodgkin's lymphoma incidence in Pennsylvania

Our study analyzed temporal and demographic patterns of non-Hodgkin's lymphoma (NHL) incidence in Pennsylvania and compared Pennsylvania time trends with national trends. Joinpoint and age-period-cohort analyses summarized sex- and race-specific NHL incidence time trends between 1985 and 2004. Ecologic analysis identified demographic factors associated with age-adjusted county-specific NHL incidence. NHL incidence in Pennsylvania increased annually: 1.6% and 2.5% in white and black men and 1.6% and 3.2% in white and black women. National trends were similar, except for smaller increases in white men. Diffuse lymphoma appeared to be the major contributor to the increases. NHL incidence was higher in Pennsylvania counties with greater percentages of urban residents. NHL incidence patterns in Pennsylvania were parallel to those seen nationally, with the highest rates occurring in white men and in persons residing in urban areas.

Urinary biomarkers suggest that estrogen-DNA adducts may play a role in the aetiology of non-Hodgkin lymphoma

A variety of evidence suggests that estrogens may induce non-Hodgkin lymphoma (NHL). The reaction of catechol estrogen quinones with DNA to form depurinating estrogen-DNA adducts is hypothesized to initiate this process. These adducts are released from DNA, shed from cells into the bloodstream and excreted in urine. The aim of this study was to determine whether or not the depurinating estrogen-DNA adducts might be involved in the aetiology of human NHL. Estrogen metabolites, conjugates and depurinating DNA adducts were identified and quantified in spot urine samples from 15 men with NHL and 30 healthy control men by using ultraperformance liquid chromatography/tandem mass spectrometry. The levels of estrogen-DNA adducts were significantly higher in the men with NHL than in the healthy control men. Thus, formation of estrogen-DNA adducts may play a critical role in the aetiology of NHL, and these adducts could be potential biomarkers of NHL risk.

Mortality among United States Coast Guard marine inspectors: a follow up

We previously assessed mortality among U.S. Coast Guard (USCG) marine inspectors (inspectors) and Coast Guard officers who were not marine inspectors (noninspectors). Here, we extended follow-up of the cohort by 14 years, ascertaining vital status 1980-1994, calculating standardized mortality ratios (SMRs) for inspectors and noninspectors, and comparing mortality rates via directly adjusted rate ratios (RRs). Both inspectors and noninspectors had deficits for all causes of death (SMR = 75 and 61, respectively) and all malignant neoplasms (SMR = 86 and 69, respectively). Compared with noninspectors, inspectors had nonstatistically significant excesses of liver cirrhosis (SMR = 124; RR = 2.2) and chronic rheumatic heart disease (SMR = 129; RR = 2.6) and deficits of cancer of the respiratory system (SMR = 59; RR = 0.8). SMRs and RRs rose with increasing probability of exposure to chemicals for cirrhosis of the liver, all accidents and motor vehicle accidents, although they fell for all causes of death, diseases of the nervous system, diseases of the circulatory system, and cancers of the respiratory system. These results suggest that contact with chemicals during inspection of merchant vessels may be involved in the development of these diseases, although other aspects of the job, such as physical activity may account for deficits in respiratory cancers.

Risk of lymphoma and leukaemia after bacille Calmette-Guérin and smallpox vaccination: a Danish case-cohort study

Vaccines may have non-specific effects as suggested mainly in mortality studies from low-income countries. The objective was to examine the effects of BCG and smallpox vaccinations on subsequent risk of lymphoma and leukaemia in a Danish population experiencing rapid out-phasing of these vaccines. In a background cohort (N=47,622) from the Copenhagen School Health Records Register, cases of leukaemia (N=20) and lymphoma (N=51) were identified through the Danish Cancer Registry. The vaccination status of the cases was compared with the vaccination status of a 5% random sample (N=2073) of the background cohort and analysed in a case-cohort design. BCG vaccination reduced the risk of lymphomas (HR=0.49 (95% CI: 0.26-0.93)), whereas smallpox vaccination did not (HR=1.32 (0.56-3.08)). With the small number of leukaemia cases, the analysis of leukaemia had limited power (BCG vaccination HR=0.81 (0.31-2.16); smallpox vaccination HR=1.32 (0.49-3.53)). The present study with very reliable vaccine history information indicates a beneficial effect of BCG vaccination on the risk of lymphomas.

Interventions for previously untreated patients with AIDS-associated non-Hodgkin's lymphoma

BACKGROUND

Human immunodeficiency virus (HIV) infection is known to be associated with an increased risk of non-Hodgkin's lymphoma (NHL). The majority of lymphomas (>80%) occurring during immunosuppression are aggressive B-cell in origin and have a high-to-intermediate histology grade. Treatment of NHL is not standardized.

OBJECTIVES

To assess the clinical effectiveness and safety of single agent or combination chemotherapy with or without immunochemotherapy (rituximab) and with or without highly active antiretroviral therapy (HAART) on overall survival (OS) and disease-free survival (DFS) for previously untreated patients with AIDS-related NHL.

SEARCH STRATEGY

The Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 1, 2009), MEDLINE (1966-March 6, 2009), EMBASE (1988-March 6, 2009), LlLACS (1982 to February 17, 2009), Gateway (March 6, 2009), and AIDSearch (2006 -February 2008) were used to identify published, potentially eligible trials. Further, we searched several electronic sources. For additional information see the Cochrane HIV/AIDS Group search strategy.

SELECTION CRITERIA

Randomized controlled trials (RCTs) assessing the effectiveness of systemic treatments for previously untreated AIDS-related NHL. There were no age or language restrictions.

DATA COLLECTION AND ANALYSIS

Authors independently assessed relevant studies for inclusion; four RCTs were selected. No meta-analysis was attempted due to clinical heterogeneity.

MAIN RESULTS

Four RCTs that included 857 patients (number range: 30 to 485) met the inclusion criteria. The studies have a high risk of bias; three RCTs were conducted in the United States and one was a multi-national, multi-centre RCT performed in France and Italy. One of the trials included only men. It was impossible to pool data for any of the outcomes due to the differences in the interventions assessed in these RCTs. Overall survival did not differ significantly between treatment groups. Disease free survival (DFS) was reported in two of the four RCTs, but it was not statistically significant between treatment groups.

AUTHORS' CONCLUSIONS

We found no evidence that the systemic interventions for untreated patients with AIDS-related NHL provide superior clinical effectiveness for improving OS, DSF, and tumour response rate; however, this conclusion is based on four RCTs with limited sample size and variable quality. More adequately powered RCTs that have low risk of bias are necessary to determine the real benefit or harm of interventions to treat this population. Overall survival (OS), DFS, and quality of life should be included as endpoints.

Effects of pesticide exposure on the human immune system

Epidemiological evidence from Western countries indicates that the prevalence of diseases associated with alterations in the immune response, such as asthma, certain autoimmune diseases and cancer, are increasing to such an extent that it cannot be attributed to improved diagnostics alone. There is some concern that this trend could be, at least, partially attributable to new or modified patterns of exposures to chemicals, including pesticides. The purpose of this article is to review the evidence on pesticide immunotoxicity in humans. Overall, the available data are inadequate to draw firm conclusions on the immunotoxic risk associated with pesticide exposure. The available studies on the effects of pesticides on the human immune system have several limitations, including limited data on exposure levels, heterogeneity of the applied methods, and difficulties in assessing the prognostic significance of observed slight changes and in the interpretation of the reported findings. Further studies are needed and preferably as prospective studies, comparing pre- and post-exposure data in the same group of subjects and including an appropriate non-exposed control group. More knowledge is required regarding the prognostic significance of the small changes observed.

Enteropathy associated T cell lymphoma: common in coeliac disease

A 56-year-old male admitted with haematemesis and epigastric pain and severe weight loss on a background of coeliac disease. Computed tomography (CT) abdomen revealed a thickening of the mucosal folds of a short segment of jejunum. He deteriorated and had an exploratory laparotomy and bowel resection with side-side jejojejunal stapled anastomosis and extended right hemicolectomy and ileocolic anastomosis. Histology demonstrated multifocal high-grade malignant T cell lymphoma. Coeliac disease is a very common lifelong disorder. It is associated with osteoporosis, infertility, autoimmune disorders and increased risk of malignancy including an increased risk of non-Hodgkin's lymphoma (NHL) especially of the T cell type. Enteropathy-type T cell lymphoma is associated with a very poor prognosis. There is significant evidence that adherence to a gluten-free diet decreases the risk of developing enteropathy-type T cell lymphoma and helps to prevent development of autoimmune diseases, diabetes mellitus and osteoporosis in patients with coeliac disease.

Cancer and immune response: old and new evidence for future challenges

Cancer may occur as a result of abnormal host immune system tolerance. Recent studies have confirmed the occurrence of spontaneous and induced antitumor immune responses expressed as the presence of tumor-infiltrating T cells in the tumor microenvironment in some cancer models. This finding has been recognized as a good prognostic factor in several types of tumors. Some chemotherapy agents, such as anthracyclines and gemcitabine, are effective boosters of the immune response through tumor-specific antigen overexpression after apoptotic tumor cell destruction. Other strategies, such as GM-CSF or interleukin-2, are pursued to increase immune cell availability in the tumor vicinity, and thus improve both antigen presentation and T-cell activation and proliferation. In addition, cytotoxic T lymphocyte antigen 4-blocking monoclonal antibodies enhance immune activity by prolonging T-cell activation. Strategies to stimulate the dormant immune system against tumors are varied and warrant further investigation of their applications to cancer therapy in the future.

Waldenström macroglobulinaemia and IgM monoclonal gammopathy of undetermined significance: emerging understanding of a potential precursor condition

Previously thought to be best described as a plasma cell disorder, Waldenström macroglobulinaemia (WM) is now understood to be a distinct clinicobiological entity. WM shares B-cell origin and certain other features with both chronic lymphocytic leukaemia (CLL) and multiple myeloma (MM). WM and CLL arise from B-cells at discrete stages in their maturation process, and MM arises from B-cells that have fully differentiated into plasma cells. While MM has a well-known precursor condition, monoclonal gammopathy of undetermined significance (MGUS), CLL and WM may also have associated precursor states, monoclonal B-cell lymphocytosis (MBL) and IgM MGUS, respectively. This review explores the features that link or distinguish these haematolymphoid malignancies, with special attention to emerging data regarding IgM MGUS and its unique relationship to WM, and identifies important gaps in our understanding of the putative precursor conditions, MBL and IgM MGUS.

Polymorphisms in xenobiotic-metabolizing genes and the risk of chronic lymphocytic leukemia and non-Hodgkin's lymphoma in adult Russian patients

Polymorphisms in genes coding xenobiotic-metabolizing enzymes are considered as risk factors modifying susceptibility to cancer. We developed a biochip for the analysis of 18 mutations in 10 genes of metabolizing system: CYP1A1, CYP2D6, GSTT1, GSTM1, MTHFR, MTRR, NQO1, CYP2C9, CYP2C19, and NAT2. Using allele-specific hybridization on the biochip 76 T-cell non-Hodgkin's lymphoma (NHL) patients, 83 B-cell chronic lymphocytic leukemia (B-CLL) patients, and 177 healthy donors were tested. Polymorphic CYP1A1 alleles were more frequent in B-CLL patients relative to normal controls, for example, a combination of polymorphic variants 4887C > A, 4889A > G, and 6235T > C (OR = 1.76, 95% CI = 1.0-3.1). The GSTM1 null genotype was more frequent in NHL patients relative to controls (OR = 1.82, 95% CI = 1.1-3.1). The combination of unfavorable polymorphic CYP1A1 variants and GSTM1 null genotype was found more frequently in B-CLL patients relative to controls (OR = 2.52, 95% CI = 1.3-4.9). In addition, male B-CLL patients demonstrated a significantly increased occurrence of heterozygous and homozygous allele *2 of CYP2C9 gene (OR = 2.38, 95% CI = 1.1-5.2) as well as a combination of alleles *2 and *3 of the gene (OR = 2.09, 95% CI = 1.1-3.9). Thus, our findings show the association between polymorphic alleles of CYP1A1, GSTM1, and CYP2C9 genes and the risk to develop NHL or B-CLL. The developed biochip can be considered as a convenient analytical tool for research studies and predictive analysis in oncohematology.

Methods for identifying long-term adverse effects of treatment in patients with eye diseases: the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study

PURPOSE

To evaluate potential epidemiologic methods for studying long-term effects of immunosuppression on the risk of mortality and fatal malignancy, and present the methodological details of the Systemic Immunosuppressive Therapy for Eye Diseases (SITE) Cohort Study.

METHODS

Advantages and disadvantages of potential study designs for evaluating rare, late-occurring events are reviewed, and the SITE Cohort Study approach is presented.

RESULTS

The randomized, controlled trial is the most robust method for evaluating treatment effects, but long study duration, high costs, and ethical concerns when studying toxicity limit its use in this setting. Retrospective cohort studies are potentially more cost-effective and timely, if records exist providing the desired information over sufficient follow-up time in the past. Case-control methods require extremely large sample sizes to evaluate risk associated with rare exposures, and recall bias is problematic when studying mortality. The SITE Cohort Study is a retrospective cohort study. Past use of antimetabolites, T-cell inhibitors, alkylating agents, and other immunosuppressives is ascertained from medical records of approximately 9,250 ocular inflammation patients at five tertiary centers over up to 30 years. Mortality and cause-specific mortality outcomes over approximately 100,000 person-years are ascertained using the National Death Index. Immunosuppressed and non-immunosuppressed groups of patients are compared with each other and general population mortality rates from US vital statistics. Calculated detectable differences for mortality/fatal malignancy with respect to the general population are 22%/49% for antimetabolites, 28%/62% for T-cell inhibitors, and 36%/81% for alkylating agents.

CONCLUSIONS

Information from the SITE Cohort Study should clarify whether use of these immunosuppressive drugs for ocular inflammation increases the risk of mortality and fatal cancer. This epidemiologic approach may be useful for evaluating long-term risks of systemic therapies for other ocular diseases.

Burkitt's lymphoma of the duodenum in a patient with AIDS

Non-Hodgkin's lymphoma of B-cell type is the second most common neoplasm after Kaposi's sarcoma, among patients with human immunodeficiency virus infection. Most non-Hodgkin's lymphoma cases that are associated with acquired immunodeficiency syndrome involve extranodal sites, especially the digestive tract and the central nervous system. We report a case of primary lymphoma of the duodenum in a patient with AIDS. Upper gastrointestinal endoscopy revealed pseudopolypoid masses found in the second portion of the duodenum. A complete diagnostic study including histological, immunohistochemical and virological analyses showed high-grade B-cell Burkitt's lymphoma. The Epstein-Barr virus genome was detected in biopsies by immunohistochemical and in situ hybridization.

Joint effect between regular use of non-steroidal anti-inflammatory drugs, variants in inflammatory genes and risk of lymphoma

OBJECTIVE

Limited evidence suggests the importance of inflammatory processes for the etiology of lymphomas. To further research in this area, we investigated the role of genetic variants in key inflammatory factors, non-steroidal anti-inflammatory drug [NSAID] use, and their joint effect in lymphomagenesis.

METHODS

The study comprised 710 case-control pairs, matched for gender, age, and study region. We examined the association of regular NSAID use and polymorphisms in prostaglandin-endoperoxide synthase-2 (COX2), prostaglandin E synthase (PTGES), interleukin-1 alpha (IL1A), IL-1 beta (IL1B), and IL-1 receptor antagonist (IL1RA), and lymphoma risk by applying logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI).

RESULTS

Regular NSAID use was associated with a slightly reduced risk of B-NHL (OR = 0.8, 95% CI = 0.6-1.1). For T-NHL, the COX2 rs2745557 A-allele conferred a 2.2-fold (95% CI = 1.1-4.5) and homozygosis for the IL1RN rs454078 T-allele was associated with a 4.5-fold (95% CI = 1.4-13.9) elevated risk, however, based on sparse data. IL1 haplotype 5 was associated with a statistically significant 43% increased risk for B-NHL among non-regular users of NSAIDs, but a 70% decreased risk for regular users (p-value for interaction < 0.001).

CONCLUSIONS

These results suggest the relevance of joint effects between NSAID use and IL1 haplotypes on the risk of B-NHL.

The role of dietary factors in the epidemiology of non-Hodgkin's lymphoma

The incidence of non-Hodgkin's lymphoma (NHL) has risen dramatically over recent decades and, despite some known risk factors, such as compromised immunity, the etiology of NHL and the reasons for most of this increase are unknown. Dietary components may be a common and critical source of immunologic antigens and promoters, which needs to be incorporated more in the etiologic research of NHL. To date, epidemiologic evidence suggests that obesity and fat intake, in particular saturated or animal fat, may increase the risk of NHL; whereas whole-grains, vegetables and moderate consumption of alcohol may be inversely associated with NHL risk. Much of the current evidence is obtained from case-control studies, which are subject to dietary recall bias; therefore, this area of research requires further study within prospective cohorts with detailed dietary information and with a large number of cases to examine disease sub-type heterogeneity.

Immune mechanisms in non-Hodgkin lymphoma: joint effects of the TNF G308A and IL10 T3575A polymorphisms with non-Hodgkin lymphoma risk factors

Two common single nucleotide polymorphisms in immunoregulatory genes (TNF G308A, rs1800629 and IL10 T3575A, rs1800890) have been recently reported as risk factors for non-Hodgkin lymphoma (NHL) in a large pooled analysis. We systematically investigated the effects of other established NHL risk factors in relation to the tumor necrosis factor (TNF) G308A or interleukin 10 (IL10) T3575A genotypes. We calculated odds ratios (OR) and 95% confidence intervals (95% CI) from 1,172 cases and 982 population-based controls in a U.S. multicenter study. We investigated NHL overall and two common subtypes [diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma]. NHL risks were increased among those with both an autoimmune condition and the TNF G308A GA/AA (OR(NHL), 2.1; 95% CI, 1.0-4.2) or the IL10 T3575A TA/AA genotype (OR(NHL), 1.6; 95% CI, 0.9-2.6) compared with individuals without an autoimmune condition and with the common TNF G308A GG or IL10 T3575A TT genotype, respectively; results were similar for DLBCL and follicular lymphoma. We found that elevated DLBCL risk associated with last-born status was more pronounced among those with TNF G308A GA/AA (OR(DLBCL), 2.7; 95% CI, 1.1-6.4) or IL10 T3575A TA/AA (OR(DLBCL), 2.9; 95% CI, 1.6-5.2). Similarly, elevated DLBCL risk associated with obesity (body mass index, > or = 35 versus <25 kg/m(2)) was observed only among those with TNF G308A GA/AA (OR(DLBCL), 2.5; 95% CI, 1.1-5.7) or IL10 T3575A TA/AA genotypes (OR(DLBCL), 2.0; 95% CI, 1.1-3.5). These exploratory results require replication but provide evidence that autoimmune conditions, late birth order, and obesity act partly through a common inflammatory pathway, posing a greater risk to individuals with variant TNF and IL10 genotypes than those with wild-type alleles.

Anterior Segment and External Ocular Disorders Associated with Human Immunodeficiency Virus Disease

The eye is a common site for complications of human immunodeficiency virus (HIV) infection. Although cytomegalovirus retinitis remains the most prevalent of the blinding ocular disorders that can occur in individuals with the acquired immunodeficiency syndrome (AIDS), several important HIV-associated disorders may involve the anterior segment, ocular surface, and adnexae. Some of these entities, such as Kaposi sarcoma, were well described, but uncommon, before the HIV epidemic. Others, like microsporidial keratoconjunctivitis, have presentations that differ between affected individuals with HIV disease and those from the general population who are immunocompetent. The treatment of many of these diseases is challenging because of host immunodeficiency. Survival after the diagnosis of AIDS has increased among individuals with HIV disease because of more effective antiretroviral therapies and improved prophylaxis against, and treatment of, opportunistic infections. This longer survival may lead to an increased prevalence of anterior segment and external ocular disorders. In addition, the evaluation and management of disorders such as blepharitis and dry eye, which were previously overshadowed by more severe, blinding disorders, may demand increased attention, as the general health of this population improves. Not all individuals infected with HIV receive potent antiretroviral therapy, however, because of socioeconomic or other factors, and others will be intolerant of these drugs or experience drug failure. Ophthalmologists must, therefore, still be aware of the ocular findings that develop in the setting of severe immunosuppression. This article reviews the spectrum of HIV-associated anterior segment and external ocular disorders, with recommendations for their evaluation and management.

Atopy, exposure to pesticides and risk of non-Hodgkin lymphoma

Pesticide exposure has been associated with non-Hodgkin lymphoma (NHL) risk in a number of studies, and two recent studies suggest that the increased risk may be confined to those with a history of asthma. We examined the interaction between occupational pesticide exposure and atopy on risk of NHL in an Australian population-based case-control study. Incident cases (n = 694) were diagnosed in New South Wales or the Australian Capital Territory between 2000 and 2001 and controls (n = 694) were randomly selected from electoral rolls and frequency-matched to cases by age, sex and state of residence. Occupational pesticide exposure was determined by an expert occupational hygienist's assessment of job-specific questionnaires administered by telephone. History of atopy (asthma, hay fever, eczema and food allergy) was self-reported. Logistic regression models included the three matching variables, ethnicity and sun exposure. The OR for NHL with substantial pesticide exposure and any history of asthma was 3.07 (95% CI 0.55-17.10) and with substantial pesticide exposure and no asthma history it was 4.23 (95% CI 1.76-10.16). The p-value for interaction was 0.29. A similar pattern of risk was observed for each of the pesticide subtypes; for asthma at various times of life; for hay fever, eczema, food allergy and any atopy, in men only and for follicular lymphomas only. Although this study had limited power, the findings do not suggest modification of the association between pesticide exposure and NHL risk by asthma or atopic disease more generally.

The effect of atopy, childhood crowding, and other immune-related factors on non-Hodgkin lymphoma risk

OBJECTIVE

Since adult immune responsiveness is influenced by early childhood exposures, we examined the role of family size, history of atopic disease, and other childhood immune-related exposures in a multi-center case-control study of NHL.

METHODS

Interviews were completed with 1,321 cases ascertained from population-based cancer registries in Seattle, Detroit, Los Angeles and Iowa, and with 1,057 frequency-matched controls, selected by random-digit dialing and from the Medicare files database. Multivariable logistic regression was used to estimate risk.

RESULTS

A history of any allergy (excluding drug allergies), decreased risk of all NHL (Odds Ratio [OR] = 0.7, 95% Confidence Interval [CI] = 0.6-1.0), diffuse large B-cell lymphoma [DLBCL] (OR = 0.6, 95% CI = 0.4-0.9), and follicular NHL (OR = 0.7, 95 CI = 0.5, 1.0). A similar effect was observed for hay fever. A history of eczema was associated with an increased risk of follicular lymphoma (OR = 1.9, 95% CI = 1.1-3.4), but not DLBCL (OR = 1.1, 95% CI = 0.6-2.0). Asthma did not affect risk. Youngest compared to oldest siblings had a 90% increased risk of DLBCL (95% CI = 1.2-3.1; p for trend with increasing birth order = 0.006), but not follicular lymphoma (OR = 1.1, 95% CI = 0.6-1.8).

CONCLUSIONS

We infer that some childhood and immune-related factors may alter NHL risk.

High incidence of hepatitis B virus infection in B-cell subtype non-Hodgkin lymphoma compared with other cancers

BACKGROUND

The authors investigated the prevalence of hepatitis B virus (HBV) infection by using serologic markers in non-Hodgkin lymphoma (NHL) compared with other types of cancers in Chinese patients.

METHODS

In this case-control study, HBV and other hepatitis markers were compared between a study group and a control group. The study group included 587 patients with NHL (age range, 16-86 years), and the control group included 1237 patients (age range, 16-89 years) who were diagnosed with other cancers except liver cancer. An enzyme-linked immunosorbent assay was used to test serum samples from both groups for HBV markers and other hepatitis markers.

RESULTS

Logistic regression analysis showed that there was a higher prevalence of HBV infection in patients with the B-cell subtype of NHL (30.2%) than in patients with other cancers (14.8%; odds ratio [OR], 2.6; 95% confidence interval [95% CI], 2.0-3.4); however, in patients with the T-cell subtype of NHL, the HBV infection rate (19.8%) was similar to that among patients with other cancers (OR, 1.2; 95% CI, 0.8-1.8). A significant difference in HBV prevalence was found between B-cell and T-cell NHL (OR, 2.3; 95% CI, 1.4-3.6). In the patients with B-cell NHL, those who were infected with HBV had a significantly earlier disease onset (9.5 years) than those who were not infected with HBV. CONCLUSIONS.: The current results demonstrated that patients with B-cell NHL, but not patients with T-cell NHL, had a higher prevalence of HBV infection. HBV infection was associated with a significantly earlier disease onset (P < .001), a finding that suggested the possibility that HBV may play an etiologic role in the induction of B-cell NHL.

Rheumatic manifestations of human immunodeficiency virus infection

Rheumatic complaints are common in patients with HIV, and HIV positivity confers an increased susceptibility in populations with similar risk factors for HIV infection. With the advent of the modern combined antiretroviral treatment, HAART has had a profound beneficial effect on survival in HIV-infected patients, with lifelong control of HIV infection and normalization of life expectancy; but it has also contributed to both an altered frequency and a different nature of rheumatic complications now being observed in this population, with new rheumatic complications, such as osteoporosis, osteonecrosis, gout, mycobacterial, mycotic osteoarticular infections, and neoplasia perhaps more prevalent. Rheumatologists, internists, and general physicians need to be aware of these changes to provide optimal diagnosis and how to disclose the results to their patients. They also need to be familiar with the management of HIV infection and to direct careful attention to the prevention of HIV transmission in health care facilities.

Current management of follicular lymphomas

After decades of stagnation, the prognosis of patients with follicular lymphomas (FL) has changed substantially within the last few years due to new and effective therapeutic modalities. These include myeloablative therapy followed by autologous stem cell transplantation (ASCT) in younger patients in first remission, which showed a significant prolongation of remission duration in three prospective randomised trials while the impact on overall survival still needs to be determined. Adding the anti-CD 20 antibody Rituximab to conventional chemotherapy resulted in a significant increase in remission rate, remission duration and, in two of four currently available prospective randomised studies, even in a longer overall survival. A prolongation of remission duration was also seen when Rituximab was given as maintenance after cytoreductive therapy including Rituximab. Radio-immunotherapy (RIT) with radioisotopes coupled to monoclonal antibodies produced encouraging data in several phase II studies. New therapeutic perspectives have also emerged from increasing insights into the biology of the disease that unravel molecular targets for novel agents, some of which have entered clinical evaluation already.

Occupational exposure to meat and risk of lymphoma: A multicenter case-control study from Europe

Several studies have suggested an increased risk of lymphoma among workers exposed to meat, without conclusive evidence. We conducted a multicenter case-control study during 1998-2004 in the Czech Republic, France, Germany, Ireland, Italy and Spain, including 2,007 cases of non-Hodgkin lymphoma, 339 cases of Hodgkin lymphoma and 2,462 controls. We collected detailed information on occupational history and assessed exposure to meat in general and several types of meat via expert assessment of the questionnaires. The odds ratio (OR) of non-Hodgkin lymphoma for ever occupational exposure to meat was 1.18 (95% confidence interval [CI] 0.95-1.46), that for exposure to beef meat was 1.22 (95% CI 0.90-1.67), and that for exposure to chicken meat was 1.19 (95% CI 0.91-1.55). The ORs were higher among workers with longer duration of exposure. An increased risk among workers exposed to beef meat was mainly apparent for diffuse large B-cell lymphoma (OR 1.49, 95%CI 0.96-2.33), chronic lymphocytic leukemia (OR 1.35, 95% CI 0.78-2.34) and multiple myeloma (OR 1.40, 95%CI 0.67-2.94). The latter 2 types were also associated with exposure to chicken meat (OR 1.55, 95% CI 1.01-2.37, and OR 2.05, 95%CI 1.14-3.69). Follicular lymphoma and T-cell lymphoma, as well as Hodgkin lymphoma did not show any increase in risk. Occupational exposure to meat does not appear to represent an important risk factor of lymphoma, although an increased risk of specific types of non-Hodgkin lymphoma cannot be excluded.

Gene polymorphisms in Toll-like receptors, interleukin-10, and interleukin-10 receptor alpha and lymphoma risk

Interactions between environment and immune system play an essential role in the aetiology of immunopathologies, including lymphomas. Toll-like receptors (TLR) belong to a group of pattern recognition receptors, with importance for innate immune response and inflammatory processes. Interleukin-10 (IL-10) is a key regulatory cytokine and has been implicated in lymphomagenesis. Functional polymorphisms in these inflammation-associated genes may affect the susceptibility towards lymphoma. To test this hypothesis, we have genotyped DNA of 710 lymphoma cases and 710 controls within the context of a population-based epidemiological study for 11 functionally important single-nucleotide polymorphisms in TLR1, -2, -4, -5, -9, IL10 and IL10 receptor (IL10RA). The IL10RA Ser138Gly variant was underrepresented among lymphoma cases (odds ratio (OR)=0.81, 95 per cent confidence interval (95% CI)=0.65-1.02), mainly owing to an inverse association with Hodgkin's lymphoma (HL). The TLR2 -16933T>A variant was associated with a 2.8-fold increased risk of follicular lymphoma (95% CI=1.43-5.59) and a decreased risk of chronic lymphocytic leukaemia (OR=0.61, 95% CI=0.38-0.95). Furthermore, the TLR4 Asp299Gly variant was positively associated with the risk of mucosa-associated lymphoid tissue lymphoma (OR=2.76, 95% CI=1.12-6.81) and HL (OR=1.80, 95% CI=0.99-3.26). In conclusion, this study suggests an effect of polymorphisms in factors of the innate immune response in the aetiology of some lymphoma subtypes.