Stage III nodular lymphoreticular tumors (non-Hodgkin's lymphoma): results of central lymphatic irradiation

Follicular lymphoma: a historical overview

Lymphoma was first described in 1862 and follicular lymphoma in 1925. Initially considered a benign disorder, and named Brill - Symmers disease after the authors of the original papers, it was rapidly recognized as a malignancy with a variable but often indolent course. Most of its clinical features were described by the early 1940s. Despite discussion about its cell of origin, and in contrast to many other lymphoma subtypes, follicular lymphoma could always be accurately recognized and diagnosed using light microscopy morphological features. B-cell origin was demonstrated in the 1970s and the important role of t(14;18) and bcl-2 gene rearrangement in the pathogenesis of follicular lymphoma was established shortly thereafter. The etiology of follicular lymphoma, the reason for marked geographic variation in its incidence, the role of alternative molecular pathways in its pathogenesis, and the cause for its variable clinical behavior all remain unknown. Several observations suggest an important role for the normal immune response in regulating the clinical behavior of follicular lymphoma. From the earliest descriptions, radiation therapy was shown to be very effective in follicular lymphoma, but not curative. Combination chemotherapy was tested in the 1970s, but despite high rates of response, there was only minimal impact on survival. Interferon combined with anthracycline based chemotherapy was the first treatment to improve survival, but was not widely adopted in the USA. Randomized studies have shown an impact of autologous transplantation on progression free survival. Allogeneic transplantation is a curative therapy, but is too toxic for widespread application. Targeted therapies, particularly rituximab have revolutionized the treatment of follicular lymphoma. A convergence of technological and biological advances will likely lead to further dramatic progress in the next decade. For the first time consistent improvements in survival of follicular lymphoma are reported.

Whole-abdomen radiotherapy for non-Hodgkin's lymphoma using twice-daily fractionation

PURPOSE

To report the tolerability and efficacy of twice-daily whole-abdomen irradiation (WAI) for non-Hodgkin's lymphoma (NHL).

METHODS AND MATERIALS

Of 123 patients treated for NHL with WAI, 37% received previous chemotherapy, 28% received WAI as part of comprehensive lymphatic irradiation (CLI), and 32% received WAI for palliation. The median dose to the whole abdomen was 25.0 Gy, followed by a median tumor boost of 9.8 Gy in 58 patients. Fractionation was 1.0 Gy once daily (54%) or 0.8 Gy twice daily (46%). Blood counts were measured weekly.

RESULTS

At a median follow-up of 4.3 years, local control was 72% and overall survival was 55% at 5 years. Median time of WAI was 42 days for once-daily treatment and 32 days for twice-daily treatment. Patients receiving twice-daily WAI did not have a significantly higher rate of acute side effects (e.g., nausea, diarrhea, platelet or red blood cell toxicity). Overall, acute thrombocytopenia was the most frequent side effect of treatment; 24 of 96 patients (25%) with available hematologic data had Grade 3+ toxicity. There was no acute Grade 3 gastrointestinal toxicity and no late small bowel obstruction. Multiple regression indicated that patients with four or less involved sites and disease size < or =6 cm had improved local control and overall survival.

CONCLUSIONS

Twice-daily WAI using 0.8 Gy/fraction does not appear to have any greater toxicity compared with once-daily treatment using 1 Gy/fraction. Small doses per fraction (0.8-1 Gy/fx) are effective, tolerated well in the acute setting, and associated with a low rate of late toxicity.

Incidental non-Hodgkin's lymphoma in patients with localized prostate cancer

OBJECTIVES

To determine the outcome of patients with clinically organ-confined prostate cancer undergoing radical retropubic prostatectomy for cure and incidentally discovered concurrent low-grade non-Hodgkin's lymphoma at time of surgery.

METHODS

From September 1986 to September 1997, 4319 patients underwent radical retropubic prostatectomy at our institution. The records of 10 patients incidentally diagnosed to have low-grade non-Hodgkin's lymphoma at the time of radical prostatectomy were retrospectively reviewed.

RESULTS

Of 4319 patients requiring radical prostatectomy, 10 (0.2%) were found to have low-grade non-Hodgkin's lymphoma. All 10 men had an uneventful postoperative course. Two patients subsequently developed progression of lymphoma, one of whom required treatment. One patient died of sepsis associated with his lymphoma and 1 patient died of an unrelated malignancy (lung cancer), both 7 years following surgery. Two patients developed biochemical prostate-specific antigen recurrence. The remainder of men were free of prostate cancer recurrence and experienced no progression of lymphoma at an average of 45 months (range 12 to 142).

CONCLUSIONS

Patients with organ-confined prostate cancer, who are candidates for radical prostatectomy, experience long-term prostate cancer-free survival in the face of incidentally diagnosed low-grade lymphoma. Because the management of most incidentally discovered low-grade lymphomas is expectant, patients discovered at surgery to have this clinical entity should not be denied radical prostatectomy.

Extended field and total central lymphatic radiotherapy in the treatment of early stage lymph node centroblastic-centrocytic lymphomas: results of a prospective multicenter study. Study Group NHL-frühe Stadien

BACKGROUND

A prospective multicenter trial was performed to evaluate survival, patterns of relapse, and toxicity for clinically staged patients with lymph node centroblastic-centrocytic (cb/cc) lymphomas in Stages I-IIIA after large extended field irradiation (EFI) or total central lymphatic irradiation (TCLI).

METHODS

Between January 1986 and August 1993, 117 adults with clinical Stage I-IIIA lymph node cb/cc lymphoma (Kiel classification) were recruited. Patients in Stages I or II with mediastinal, hilar, periaortic, iliac, or mesenteric involvement and in Stage IIIA received TCLI, whereas patients with more peripherally located cb/cc lymphomas were treated with EFI. TCLI and EFI were administered to a total dose of 26 gray (Gy) with 2 Gy per daily fraction, with the exception of the whole abdomen, which was irradiated to a total dose of 25.5 Gy with 1.5 Gy per fraction. A boost of 10 Gy with 2 Gy per fraction was administered to enlarged and involved lymph nodes at the start of radiotherapy.

RESULTS

Sixty, 40, and 17 patients had Stage I, II, and limited IIIA disease (no bulk and less than 6 involved lymph node regions), respectively. Overall survival was 86% at 5 and 7 years; median follow-up was 68 months. The probabilities of relapse at any site, recurrences in lymph nodes, and in-field lymph node recurrences after TCLI were 17% in Stage I; 56%, 43%, and 40% in Stage II, respectively; and 44%, 35%, and 35% in Stage IIIA, respectively. The risk of disseminated extralymphatic relapses was 9% at 7 years. The most important adverse prognostic factor for in-field lymph node recurrences was a deviation of >20% from the assigned total radiation dose. After EFI, patients in Stage I had a significantly lower risk of recurrences in adjuvant irradiated lymph node regions than in unirradiated lymph node regions. Acute toxicity of EFI and TCLI was moderate.

CONCLUSIONS

In-field lymph node recurrences remained the main risk after TCLI, and a deviation of >20% from the assigned radiation dose was the major risk factor for in-field recurrences. From these data, a total dose of 40-44 Gy in conventional fractionation for the treatment of macroscopic cb/cc lymphomas and 30 Gy for the treatment of subclinical disease is recommended. A randomized study comparing TCLI with EFI is now being organized by this group.

Response to radiation in chemotherapy-refractory monocytoid B-cell lymphoma: a case report

A 39-year-old man had monocytoid lymphoma including a large retroperitoneal mass, retrocrural and porta hepatic adenopathy with localized pain, but no B symptoms. The tumor did not respond clinically or radiographically to CHOP or mini-ICE chemotherapy but has responded dramatically to radiotherapy. The patient's disease remains controlled 3 years after treatment. This case documents radioresponsiveness in a chemotherapy-refractory monocytoid lymphoma.

Current status and future perspectives in the treatment of low-grade non-Hodgkin's lymphomas

Low-grade non-Hodgkin lymphomas (NHL) comprise a heterogeneous group of disorders both in terms of their cellular and histological composition as well as in terms of their clinical course. The most usually applied classification systems, the Working Formulation and the Kiel classification as well as the recently proposed Revised European American Lymphoma classification, discriminate between low-, intermediate- and high-grade subtypes. In general, low-grade NHL are characterized by a low to moderate proliferative activity and a long clinical course with median survival times ranging from approximately 3 years for centrocytic (CC) or mantle-cell lymphomas (MCL) to 5-8 years for centroblastic-centrocytic (CB-CC) or follicular lymphomas (FL). Recent cytogenetic and molecular biologic analyses indicate that these differences may result from distinct genetic abnormalities such as the translocation t(14;18), which is frequently observed in FL-NHL and is associated with a bcl-2 overexpression and inhibition of apoptosis, or the deregulation of PRAD1 in MCL-NHL induced by the translocation t(11;14). Therapy of low-grade lymphomas depends mainly on the extent of the disease. In the early stages I and II, at which approximately 15 to 20% of low-grade NHL are diagnosed, radiotherapy may be applied with curative intention. The treatment of patients with more advanced stages III and IV is controversial. The currently available information justifies a conservative approach of observing the natural course of the disease until therapeutic intervention is required due to the occurrence of B-symptoms, hematopoietic insufficiency or lymphoma progression.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term results in patients with low-grade nodular non-Hodgkin's lymphoma. A randomized trial comparing chemotherapy plus radiotherapy with chemotherapy alone

One hundred and eighteen patients with nodular non-Hodgkin's lymphoma were randomized to receive either chemotherapy alone or chemotherapy plus radiotherapy (total nodal or involved field irradiation). Although the complete remission rate was similar in the three programs (about 90%) the relapse-free survival rate (RFS) among patients with complete remission was significantly higher in the groups treated with chemotherapy plus radiotherapy than among those treated with chemotherapy alone. The 7-year RFS in the groups treated with total node irradiation and involved field irradiation was 71% and 66% respectively, compared to only 33% in the group treated by chemotherapy alone (p less than 0.01). The results suggest that combined chemoradiotherapy may achieve complete long-term remission and potential cure in more than 60% of patients with nodular low-grade non-Hodgkin's lymphoma. Toxicity was moderate in all three arms. Bulky disease and a high level of lactic dehydrogenase were associated with a poor prognosis.

Malignant lymphomas of follicular centre cell origin in man. VII. Prognostic features in small cleaved cell lymphoma

To extend the clinical-pathologic description of small cleaved cell lymphoma (SCCL), we reviewed the records of 106 patients with SCCL who were treated in accordance with a policy of watchful waiting and palliative therapy. Median age was 58 years. A pure diffuse pattern was seen in only 16 per cent of cases. Stage III or IV disease was present in 85 per cent of patients; marrow involvement was noted in 60 per cent of patients. 'B' symptoms were present in 25 per cent of patients. By univariate analysis, age greater than 60, diffuse pattern, stage IV disease, involvement of liver, lung, pleura, or g-i tract, 'B' symptoms, surface heavy chain IgM or IgM-D, and LDH greater than 200 IU/dl were found to be significantly associated with a poor prognosis. Marrow involvement, increased (5-25 per cent) transformed (non-cleaved) cells, and surface light chain had no prognostic significance. By multivariate analysis, only age greater than 60, stage IV disease, and LDH greater than 200 IU/dl were prognostically significant. For patients with all three unfavourable prognostic features, median survival was only 11 months. For patients with age less than or equal to 60, stage I, II, or III disease, and LDH less than or equal to 200 IU/dl, median survival was not reached at 180 months. Recognition of prognostic features in indolent lymphoma can help clarify whether the results of treatment protocols represent true advances or the mere selection of favourable patients.

The non-Hodgkin's lymphomas: pathology, staging, treatment

The non-Hodgkin's lymphomas include a broad range of neoplasms derived from the T cells and B cells and their precursors in the lymphoid system. Although they are not among the most common cancers, the lymphomas have engendered a great deal of interest among researchers because of their interesting biology and responsiveness to therapy. The non-Hodgkin's lymphomas include at least ten major subtypes of diseases with different morphologic characteristics and clinical behavior. Based upon survival characteristics, it is convenient to divide the lymphomas into three broad categories, low grade, intermediate grade, and high grade. The low grade lymphomas usually arise in middle age or older individuals (median age, 55 years). They are derived from B cells and often have a follicular architectural pattern. They usually present with advanced stages of disease, often by virtue of bone marrow involvement. Nevertheless, patients are usually asymptomatic and may even have spontaneous regressions of disease. These lymphomas are responsive to a broad range of therapies including irradiation, single agent or multi-agent chemotherapy, or combined modality therapy. They are also affected by treatment with biologicals such as alpha interferon and monoclonal antibodies. Unfortunately, response to any of these therapies is often transient and relapse is common. The intermediate grade lymphomas include the common large cell lymphomas (follicular or diffuse) and diffuse mixed cell lymphoma. The lymphomas, together with the high grade immunoblastic lymphoma, are often grouped together for the development of management strategies. These lymphomas may be derived from B cells or T cells. They occur over a broader age range than the low grade lymphomas and they are much more aggressive in their natural behavior. Effective treatment programs have been developed for both limited and advanced clinical stages of disease. In limited disease, moderately intensive chemotherapy is often combined with involved field irradiation. In advanced stage disease, more aggressive combination chemotherapy programs are usually employed. From 40% to 80% of patients may be cured with these approaches, depending upon the initial extent of disease. Two types of high grade lymphoma-lymphoblastic and small noncleaved cell are particularly aggressive in their behavior. Lymphoblastic lymphoma is a T cell lymphoma that often arises in adolescent males and presents with a large mediastinal mass, marrow, and CNS involvement. It closely resembles acute lymphoblastic leukemia (ALL) and similarly intensive chemotherapy programs as are utilized in ALL may be successful in its management.(ABSTRACT TRUNCATED AT 400 WORDS)

Prognostic factors in non-Hodgkin's lymphoma

The results obtained with the various types of treatment in non-Hodgkin's lymphoma are reviewed and the data from the recent EORTC trials are summarized. In patients with Stage I follicular histology, regional radiotherapy (RT) alone gives excellent results. The long-term relapse-free survival (RFS) is high and relapsing patients can be rescued by aggressive combination chemotherapy; initial chemotherapy with CVP improves RFS but not total survival (TS). In patients with Stage I diffuse histology, the long-term survival is less satisfactory. CVP chemotherapy does not improve either RFS or TS; therefore if adjuvant chemotherapy is justified, it should be more aggressive than CVP. In patients with Stage II follicular type, regional radiotherapy alone gives good results. The addition of abdominal bath irradiation to regional RT increases RFS but not TS. After relapse, patients can be rescued by combination chemotherapy. In patients with Stage II diffuse histology, extended RT followed by CVP gives poor results and RT should be combined with more aggressive combination CT; the preliminary results of an integrated alternating regimen being excellent. In patients with Stage III and IV follicular type, the 8 year TS of patients treated with combination CT regimen (CHVP) followed by localized irradiation is approximately 55%, however the indications for the various types of treatment are still unclear. In patients with diffuse Stage III and IV, the results obtained with a combination CT regimen (CHVP) are still unsatisfactory, but are better in patients treated by a more aggressive CT regimen (CHVP-Bleo-VCR). Therefore aggressive CT associated with localized irradiation appears to be the best treatment. Further research should aim to identify the optimal combination CT regimen. In patients with high grade lymphomas who have relapsed the use of bone marrow autografts will be investigated. The present data show that besides histological type and age, the main prognostic factor is total tumor body burden as assessed by clinical stage, number of involved lymph node areas, and bulk of the disease. The study of the biological characteristics of the disease may provide more powerful prognostic indicators.

Nodular lymphomas: current concepts

The past several years have witnessed innovative approaches to clinical management as well as significant insights into the basic biology of the nodular lymphomas. Clinical studies have explored two apparently widely disparate approaches to the treatment of patients with nodular lymphoma. On the one hand, withholding initial therapy (watch and wait) has proved to be a viable option in the management of some patients. This approach has provided information regarding the natural history of disease, such as the relative incidence of spontaneous tumor regression vs. histologic transformation to more aggressive forms of lymphoma. Alternatively, recent data also suggest that the administration of intensive chemotherapy, shown to induce long-term remissions in a high percentage of patients with diffuse aggressive lymphomas, may also produce a significant number of durable remissions in at least certain histologic subtypes of nodular lymphomas. Clinical studies which attempt to achieve a synthesis of the above two approaches are currently in progress. Advances in immunology and molecular biology have also found application in the study of nodular lymphoma. Monoclonal antibodies have been employed diagnostically, as, for example, in detecting small numbers of persistent abnormal lymphoid clones in patients in apparent remission, and therapeutically, as exemplified by the clinical use in vivo of monoclonal antibodies directed against unique idiotypic determinants expressed by surface immunoglobulin on the malignant B lymphocytes. The demonstration of the immunoglobulin gene rearrangements in nodular lymphoma cells has established a more definitive criterion for their phenotypic characterization. Finally, molecular cloning of the breakpoint of the t(14; 18) chromosome translocation frequently found in nodular lymphoma cells has led to the identification of a potential new transforming gene which could be activated as a direct consequence of its rearrangement in proximity to the immunoglobulin in heavy chain gene locus.

The role of radiation therapy in the management of the non-Hodgkin's lymphomas

Radiation therapy has a broad range of applications in the management of patients with non-Hodgkin's lymphoma. It has curative potential for patients with Stage I to II low-grade lymphoma (small lymphocytic, follicular small cleaved, and follicular mixed) and has substantial palliative efficacy in patients with more advanced stage low-grade lymphoma. Low-dose whole-body irradiation may be used as palliative therapy even in patients with bone marrow involvement by these lymphomas. In the management of the large cell lymphomas (diffuse large cell, diffuse mixed, and immunoblastic), radiation alone has curative potential in only the most favorable early-stage presentations. However, since radiation can achieve significant responses in these tumors, it should be considered for inclusion in combined-modality programs. Reports that have appeared in the literature as well as results of treatment at Stanford that bear upon these issues are reviewed.

Stage III nodular lymphomas. Preliminary results of a combined chemotherapy/radiotherapy program

Since 1975, all histologic subtypes of Stage III and IIIE nodular lymphoma patients were treated with a combination of radiotherapy and multiple-agent chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-Bleo). Fifty-eight patients were treated through 1979. Treatment consisted of two cycles of CHOP-Bleo alternating with sequential radiotherapy to clinically involved regions, and further CHOP-Bleo to a total of ten cycles. Radiotherapy doses ranged between 3000 and 4000 rad delivered in three to four weeks. Forty-six patients completed treatment. In the other 12 patients, treatment was interrupted because of progressive disease in seven, and myelosuppression in five. Overall five-year survival and disease-free survival results were 82% and 47%, respectively. Survival for those patients who completed therapy was 93%. By histopathology, survivals for all patients were: poorly differentiated lymphocytic, 100%; mixed cell, 80%; and histiocytic, 39%. Disease-free figures for all 58 patients were: poorly differentiated lymphocytic, 44%; mixed cell, 65%; and histiocytic, 35%. The extent of abdominal disease influenced five-year survival as follows: 100% for those who had only occult disease at staging laparotomy; 88% for those who were Stage III on the basis of a positive lymphangiogram; and 50% for those who had a palpable mass or required an exploratory laparotomy for symptoms. Five of seven patients with progression during protocol therapy have died. No patients died as a result of myelosuppression. A number of patients developed complications during treatment, none of which were fatal. Eight patients developed herpes zoster, four patients developed transient radiation hepatitis, and four patients had miscellaneous complications.