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

Outcomes of patients with indolent lymphoma treated with bendamustine plus rituximab compared to rituximab plus CVP or CHOP chemoimmunotherapy in Ontario

Bendamustine (B) with rituximab (R) has become the preferred regimen for patients with indolent lymphoma in Ontario, Canada, compared to R with cyclophosphamide, vincristine, prednisone (CVP) or cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP). We conducted a propensity-matched retrospective cohort population-based study of patients treated with R-CVP/CHOP from 2005 to 2012 and patients treated with BR from 2013 to 2018. The primary outcome was 5-year overall survival (OS), and secondary outcomes included toxicities and healthcare utilization. The 5-year OS for patients treated with BR (n = 2023) and R-CVP/CHOP (n = 2023) was 80% and 75% respectively. Treatment with BR was associated with improved OS (HR 0.79, 95% CI 0.69-0.91). During the first 9 months, patients treated with BR versus R-CVP/CHOP had a higher number of admissions for infection (22% compared to 17%, p < 0.01) and a higher number of mean ED visits (mean 1.01 ± 1.68 visits vs. 0.85 ± 1.51 visits, p < 0.01). This trend persisted for 3 years. The adjusted 5-year OS for patients 75 years and older did not differ based on treatment regimen (55.5% for BR vs. 55.4% for R-CVP/CHOP). Our study supports the use of BR for patients with indolent lymphoma requiring treatment but suggests increased risk of certain toxicities warranting careful patient selection.

Past, present and future of prognostic scores in follicular lymphoma

Although most follicular lymphoma (FL) patients have prolonged survival, the identification of those at risk of early progression, multiple relapses or histological transformation is essential for the improvement of long-term outcomes. In this sense, a plethora of prognostic indexes have been developed in the last decades. However, determining which one is more accurate and clinically meaningful remains a challenge. Key factors for the external validity of available indexes include characteristics of the study population, treatment intervention, and design of the study. While initial risk scores were composed of clinical, biochemical, and hematological variables, genomic and imaging data have been incorporated in recent years. Despite an obvious step forward in the knowledge of the natural history and biology of FL, predictions remain inaccurate. Further research will likely incorporate information from circulating tumor DNA and artificial intelligence models to refine the prognostic classification of the heterogeneous FL population.

Antibody Therapy Maintenance in Follicular Lymphoma

Because patients with follicular lymphoma (FL) usually experience repeated disease recurrences, maintenance treatment is an attractive option to prolong remission after induction therapy. Rituximab maintenance therapy has been shown in multiple randomized studies to significantly improve progression-free survival in FL with both low and high tumor burden after induction therapy, independently of patient and disease characteristics. Several questions regarding the use of antibody directed against CD20 (anti-CD20) maintenance remain open, including the optimal antibody administration schedule and duration, the risk/benefit ratio of maintenance in the context of previous bendamustine administration, and its cost-effectiveness.

Maintenance rituximab in follicular non-Hodgkin lymphoma: facts and controversies

The advent of rituximab, a chimeric monoclonal antibody against CD20, has arguably improved and changed the natural history of non-Hodgkin lymphoma and has become an essential component of front-line and relapsed disease treatment strategies. Given its tolerability and long half-life, rituximab has been investigated in the maintenance setting in follicular lymphoma. Several landmark studies have demonstrated improvement in progression-free survival in patients receiving maintenance rituximab compared to those observed. These favorable results were witnessed in front-line and in the relapsed setting using a variety of induction programs such as rituximab monotherapy or chemoimmunotherapy. Importantly, toxicities were predictable and manageable. Despite these encouraging results, many vital and practical questions remain unanswered. In this review, we critically analyze the data that led to the widespread use of maintenance rituximab in follicular lymphoma and attempt to answer the most important questions facing practicing oncologists when deciding on using this approach in their patients.

Rituximab maintenance in follicular lymphoma patients

Rituximab maintenance (RM) therapy following successful induction has recently emerged as a highly effective treatment for follicular lymphoma (FL). Randomized trials analyzing the impact of RM compared to observation alone have demonstrated a significantly better outcome in terms of progression-free survival (but not overall survival) in patients (pts) who received as first-line treatment single-agent rituximab, standard chemotherapy (CVP) and recently also immunochemotherapy (R-CHOP, R-CVP or R-FND), as shown by preliminary results of the PRIMA trial. Also in the setting of relapsed disease, RM has shown significant benefit either after chemotherapy or immunochemotherapy. RM has been generally well tolerated, and treated pts developed only mild toxicity, mainly a small increased rate of neutropenia, hypogammaglobulinaemia and self-limiting upper-respiratory tract infections. Moreover, no cumulative or unexpected toxicities were observed and quality of life was not affected. These data have established RM therapy as an important part of multi-modal therapeutic strategies in patients affected by FL.

Treatment strategies in advanced stage follicular lymphoma

Although the introduction of anti-CD20 monoclonal antibodies has improved the outcome of patients with follicular lymphoma, a curative treatment is still not available. Many questions still remain to be answered: when should treatment be initiated? Is there an optimal first line treatment and can this treatment be individualized on the basis of prognostic markers? What is the best treatment strategy for relapsed follicular lymphoma and what is the place of the many novel agents? Should maintenance treatment be given to all patients and how? In the present review we will address these questions.

Prognostic tools in follicular lymphomas

Despite significant improvements in treatment modalities over the 10 years, the clinical course of patients with follicular lymphoma (FL) remains heterogeneous. Thus, prognostic indexes are still required to direct treatment choices and for the design of clinical trials. Investigators have conducted a variety of studies aimed at integrated assessment of biological and clinical features in order to identify novel prognostic factors and scoring systems. Genetic studies focused on tumor cells and the tumor microenvironment represent a step forward in understanding the biology of FL and are likely to provide new prognostic tools for future clinical use. Several prognostic factors have been identified and are currently used in combination to establish prognostic scores and to support therapeutic decisions. The FL International Prognostic Index (FLIPI) is currently used for defining individual risk of death. More recently, FLIPI2 was developed by the same group that built FLIPI as a new model for prognostic definition of patients with FL. The model was defined using prospectively collected data from patients who also received the monoclonal therapeutic antibody rituximab and stratifies patients into three risk categories for disease progression. Since many biological factors are not yet clinically validated or easily assessable, clinical data still represent the major source of prognostic information. The progressive development of new and more effective therapies for the treatment of FL makes the study of prognosis a dynamic and evolving area of clinical research.

Treatment of follicular non-Hodgkin's lymphoma with or without rituximab: cost-effectiveness and value of information based on a 5-year follow-up

Background: Rituximab induction together with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) and rituximab maintenance (RCHOP-R) resulted to significant progression-free survival (PFS) benefit in comparison to RCHOP in the EORTC20981 trial of relapsed/refractory follicular non-Hodgkin's lymphoma (FL). However, the overall survival (OS) difference between RCHOP-R and RCHOP was insignificant. This study evaluated the cost-effectiveness of RCHOP, RCHOP-R, and CHOP in the treatment of relapsed/refractory FL.

Design: A lifetime Markov modeling based on the 5-year EORTC20981 survivals (Weibull regressions) was carried out from the public health care payer perspective. Finnish costs (drug, routine, adverse event, and relapse management) were employed. The main outcomes were incremental cost (€2008) per quality-adjusted life-year (QALY), progression-free year (PFY), and life-years gained (LYG). Analyses included cost-effectiveness acceptability frontier and multinomial expected value of perfect information (mEVPI).

Results: RCHOP-R resulted to OS (PFS) benefit compared with RCHOP and CHOP: 6 (10) and 17 (25) months, respectively. The incremental costs per QALY gained/LYG/PFY gained were €18 147/€16 380/€10 416 for RCHOP-R versus RCHOP (mEVPI €5196); €14 360/€13 041/€8976 for RCHOP-R versus CHOP (mEVPI €1986); and €12 123/€11 049/€8004 for RCHOP versus CHOP (mEVPI €1,240). RCHOP-R was the optimal option when the willingness to pay per QALY gained exceeded €18 399.

Conclusion: RCHOP-R is a potentially cost-effective treatment option for the FL.

Survival outcomes and prognostic factors in mycosis fungoides/Sézary syndrome: validation of the revised International Society for Cutaneous Lymphomas/European Organisation for Research and Treatment of Cancer staging proposal

PURPOSE

We have analyzed the outcome of mycosis fungoides (MF) and Sézary syndrome (SS) patients using the recent International Society for Cutaneous Lymphomas (ISCL)/European Organisation for Research and Treatment of Cancer (EORTC) revised staging proposal.

PATIENTS AND METHODS

Overall survival (OS), disease-specific survival (DSS), and risk of disease progression (RDP) were calculated for a cohort of 1,502 patients using univariate and multivariate models.

RESULTS

The mean age at diagnosis was 54 years, and 71% of patients presented with early-stage disease. Disease progression occurred in 34%, and 26% of patients died due to MF/SS. A significant difference in survival and progression was noted for patients with early-stage disease having patches alone (T1a/T2a) compared with those having patches and plaques (T1b/T2b). Univariate analysis established that (1) advanced skin and overall clinical stage, increased age, male sex, increased lactate dehydrogenase (LDH), and large-cell transformation were associated with reduced survival and increased RDP; (2) hypopigmented MF, MF with lymphomatoid papulosis, and poikilodermatous MF were associated with improved survival and reduced RDP; and (3) folliculotropic MF was associated with an increased RDP. Multivariate analysis established that (1) advanced skin (T) stage, the presence in peripheral blood of the tumor clone without Sézary cells (B0b), increased LDH, and folliculotropic MF were independent predictors of poor survival and increased RDP; (2) large-cell transformation and tumor distribution were independent predictors of increased RDP only; and (3) N, M, and B stages; age; male sex; and poikilodermatous MF were only significant for survival.

CONCLUSION

This study has validated the recently proposed ISCL/EORTC staging system and identified new prognostic factors.

Rituximab in indolent lymphomas

Indolent non-Hodgkin lymphoma (NHL) comprises a group of incurable, generally slow-growing lymphomas highly responsive to initial therapy, with a relapsing and progressive course. Rituximab, an anti-CD20 antibody, has had a large impact on the treatment of indolent NHL. Its effectiveness as a single agent and in conjunction with known chemotherapy regimens has made it a standard of care in the treatment of NHL. Analysis of data obtained from NHL clinical trials, as well as data from the National Cancer Institute, indicate that the overall survival (OS) of patients with indolent NHL has improved since the discovery of rituximab. Given its effectiveness and tolerability, rituximab is currently being investigated as a maintenance agent with encouraging results. This review summarizes several landmark trials utilizing rituximab as a single agent and in combination with chemotherapy for treatment of NHL. In addition, a review of the studied rituximab maintenance dosing schedules and its impact on NHL will be presented. Overall, rituximab has changed the landscape for treatment of indolent NHL; however, additional research is necessary to identify the optimal dosing schedule, as well as patients most likely to respond to prolonged rituximab therapy.

Clinical outcome of patients with follicular lymphoma and bulky disease after rituximab-CHOP immunochemotherapy with and without consolidating radiotherapy

BACKGROUND

The strategy to apply involved-field radiotherapy (IF-RT) after immunochemotherapy in patients with bulky follicular lymphoma (FL) remains controversial.

PATIENTS AND METHODS

To evaluate the benefit of consolidating IF-RT, we retrospectively analysed relapse patterns and survival of patients with bulky FL. All patients were treated within a multicenter prospective randomized trial on 126 patients with one, three or six cycles Rituximab and six cycles CHOP. According to the protocol, patients presenting with bulky disease were to undergo consolidating IF-RT after immunochemotherapy. Forty-two eligible patients with bulky disease were identified, of which 26 were irradiated and 16 were not, contrary to the demand of the protocol.

RESULTS

There was no significant difference between the irradiated and the non-irradiated group regarding presenting characteristics (P > 0.05). After a median follow-up of 60 months, 21 patients relapsed. In the irradiated group, relapse occurred in 12 of 26 patients. Fifty percent of relapses were located within the original bulk or within the bulk plus a new location. In the non-irradiated group, 9 of 16 patients relapsed. There was no statistically significant difference between exposure to IF-RT and the likelihood of a relapse per se (P = 0.751) or at a specific location (P = 0.66). Six-yr-PFS- (P = 1.0) and OS-rates (P = 0.68) were 52% and 80% after IF-RT and 48% and 73% without IF-RT.

CONCLUSION

There was no difference in relapse rate, PFS and OS between patients treated with and without consolidating IF-RT. This is the first analysis of its kind conducted in the Rituximab era. However, these results are based on a relatively small cohort size and are derived from a retrospective analysis, with the limitations of such an analysis being well known.

Role of anemia in survival of patients with elderly aggressive non-Hodgkin's lymphoma after chemotherapy

Baseline anemia is a relevant prognostic factor in the overall population of non-Hodgkin's lymphoma (NHL) patients, and studies focusing on elderly NHL are awaited. We conducted a pooled analysis of a cohort of comparable patients enrolled (1993 - 2001) in three multicenter clinical trials on use of a MACOP-B-like regimen (VNCOP-B) for front-line treatment of elderly aggressive NHL. Models of Cox's proportional hazards regression analysis of prognostic value of pre-/post-treatment hemoglobin values in terms of 5-year overall survival included age, sex, initial tumor staging and response to treatment. Of the 168 patients screened, 16 were excluded due to missing data or lack of 5-year follow-up. In addition to achievement of complete/partial remission (adjusted relative risk [RR], 0.215; p = 0.0001) and advanced stage (II-IV vs. I - II; adjusted RR, 1.55; p = 0.0023), post-treatment hemoglobin values were an independent predictor of survival (adjusted RR per 1-g/dL increment, 0.76; p = 0.0041). In the present analysis, pretreatment hemoglobin values were associated with only marginal risk reduction (adjusted RR per 1-g/dL increment, 0.985; p = 0.049). Post-treatment hemoglobin values appear to provide a strong independent predictor of 5-year survival in elderly aggressive NHL, supporting the potential role of anemia correction in this group of patients.

Maintenance rituximab after cyclophosphamide, vincristine, and prednisone prolongs progression-free survival in advanced indolent lymphoma: results of the randomized phase III ECOG1496 Study

PURPOSE

To determine if maintenance rituximab (MR) after standard chemotherapy improves progression-free survival (PFS) in advanced-stage indolent lymphoma.

PATIENTS AND METHODS

Patients with stage III-IV indolent lymphoma with responding or stable disease after cyclophosphamide, vincristine, and prednisone (CVP) chemotherapy were stratified by initial tumor burden, residual disease after CVP (minimal or gross), and histology, and randomly assigned to observation (OBS) or MR 375 mg/m(2) once per week for 4 weeks every 6 months for 2 years. PFS was the primary end point.

RESULTS

Three hundred eleven (282 with follicular lymphoma) evaluable patients who received CVP were randomly assigned to OBS (n = 158) or MR (n = 153). Best response improved in 22% MR versus 7% OBS patients (P = .00006). Toxicity was minimal in both study arms. Three-year PFS after random assignment was 68% MR versus 33% OBS (hazard ratio [HR] = 0.4; P = 4.4 x 10(-10) [all patients]) and 64% MR v 33% OBS (HR = 0.4; P = 9.2 x 10(-8) [patients with follicular lymphoma]). There was an advantage for MR regardless of Follicular Lymphoma International Prognostic Index score, tumor burden, residual disease, or histology. In multivariate analysis of MR patients, minimal disease after CVP was a favorable prognostic factor. OS at 3 years was 92% MR versus 86% OBS (HR = 0.6; log-rank one-sided P = .05) and, among patients with follicular lymphoma, OS was 91% MR versus 86% (HR = 0.6; log-rank one-sided P = .08). A trend favoring MR was observed among patients with high tumor burden (log-rank one-sided P = .03).

CONCLUSION

The E1496 study provides the first phase III data in untreated indolent lymphoma that MR after chemotherapy significantly prolongs PFS.

Rituximab maintenance in indolent lymphoma: indications and controversies

Over the past few years it has been shown in previously untreated and relapsed/refractory follicular lymphoma that rituximab maintenance has a clear clinical benefit after induction with rituximab plus chemotherapy, chemotherapy alone, or rituximab monotherapy. However, the optimal dose, schedule, and duration of rituximab maintenance therapy still need to be established. The important issue of maintenance treatment versus retreatment upon relapse is the topic of the ongoing large randomized phase III Rituximab Extended Schedule or Retreatment Trial (RESORT). Current data indicate that rituximab maintenance can be safely administered for up to 2 years, although assessment of long-term safety requires longer follow-up.

Maintenance therapy for low-grade lymphomas: has the time come?

PURPOSE OF REVIEW

The introduction of rituximab (MabThera, Rituxan) maintenance treatment has initiated a new era in the management of low-grade non-Hodgkin's lymphomas.

RECENT FINDINGS

Five randomized trials have recently reported on rituximab maintenance in the treatment of indolent non-Hodgkin's lymphomas. These trials enrolled patients with follicular, mantle cell and small lymphocytic non-Hodgkin's lymphomas, mostly in relapse. Patients responding to either rituximab monotherapy, chemotherapy alone or rituximab associated with chemotherapy were randomly assigned between observation and rituximab maintenance. Maintenance treatment significantly improved progression-free survival and response duration, and resulted in increased overall survival in two patients. In one trial, rituximab maintenance therapy produced significantly longer progression-free survival compared with rituximab retreatment at disease progression.

SUMMARY

Rituximab maintenance therapy has demonstrated an impact on survival in patients with follicular lymphoma. These data justify recommending rituximab maintenance for patients with relapsed follicular lymphoma. Further trials are needed to determine its efficacy in first-line follicular lymphoma and other histological subtypes. The optimal schedule of maintenance therapy has not been established. Although these trials did not report severe adverse drug reactions, information concerning long-term toxicity is scarce, and careful monitoring of patients is therefore recommended.

Prognosis of follicular lymphomas

Follicular lymphoma (FL) is as an indolent neoplasia with median survival measured in decades. Nevertheless, some patients have poor progression-free survival and overall survival. Several treatment approaches are proposed for patients with FL, however criteria to rationalize treatment decisions are lacking. Studies have been performed to build up prognostic indices that are useful for defining risk-adapted treatment recommendations. Available indices are based on parameters that have an independent role in predicting patient survival and that are variably correlated with the features of the disease, with the characteristics of the patient and with the effects of treatment. Two new prognostic indices have recently been proposed for FL: the Italian Lymphoma Intergroup (ILI) index and the Follicular Lymphoma International prognostic Index (FLIPI). Both indices are based on large series of patients and exhibit differences in their ability to discriminate between patients with different probabilities of survival. In recent years, with the advent of gene expression profile studies, our knowledge of the biology of FL is changing as novel data become available about the lymphoma cell and about the role of the microenvironment; these studies have already provided novel prognostic tools for identifying patients with more aggressive disease. Further data and large international cooperative studies are needed to translate into clinical practice the novel acquisitions of biology and therapeutics.

Rituximab maintenance improves clinical outcome of relapsed/resistant follicular non-Hodgkin lymphoma in patients both with and without rituximab during induction: results of a prospective randomized phase 3 intergroup trial

We evaluated the role of rituximab (R) both in remission induction and maintenance treatment of relapsed/resistant follicular lymphoma (FL). A total of 465 patients were randomized to induction with 6 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) (every 3 weeks) or R-CHOP (R: 375 mg/m(2) intravenously, day 1). Those in complete remission (CR) or partial remission (PR) were randomized to maintenance with R (375 mg/m(2) intravenously once every 3 months for a maximum of 2 years) or observation. R-CHOP induction yielded an increased overall response rate (CHOP, 72.3%; R-CHOP, 85.1%; P < .001) and CR rate (CHOP, 15.6%; R-CHOP, 29.5%; P < .001). Median progression-free survival (PFS) from first randomization was 20.2 months after CHOP versus 33.1 months after R-CHOP (hazard ratio [HR], 0.65; P < .001). Rituximab maintenance yielded a median PFS from second randomization of 51.5 months versus 14.9 months with observation (HR, 0.40; P < .001). Improved PFS was found both after induction with CHOP (HR, 0.30; P < .001) and R-CHOP (HR, 0.54; P = .004). R maintenance also improved overall survival from second randomization: 85% at 3 years versus 77% with observation (HR, 0.52; P = .011). This is the first trial showing that in relapsed/resistant FL rituximab maintenance considerably improves PFS not only after CHOP but also after R-CHOP induction.

Meta-Analysis to Evaluate the Role of Interferon in Follicular Lymphoma

Purpose

To determine whether interferon (IFN) -α2, when given with or following chemotherapy, influences response rate, remission duration, and survival in newly diagnosed patients with follicular lymphoma.

Patients and Methods

Ten phase III studies evaluating the role of IFN-α2 in 1,922 newly diagnosed patients with follicular lymphoma were analyzed. Updated individual patient data were used to perform meta-analyses for response, survival, and remission duration.

Results

The addition of IFN-α2 to initial chemotherapy did not significantly influence response rate. An overall meta-analysis for survival showed a significant difference in favor of IFN-α2, but also showed significant heterogeneity between studies. Further analyses were carried out in order to explain this heterogeneity, and to define the circumstances in which IFN-α2 prolonged survival. The survival advantage was seen when IFN-α2 was given: (1) in conjunction with relatively intensive initial chemotherapy (2P = .00005), (2) at a dose ≥ 5 million units (2P = .000002), (3) at a cumulative dose ≥ 36 million units per month (2P = .000008), and (4) with chemotherapy rather than as maintenance therapy (P = .004). With regard to remission duration, there was also a significant difference in favor of IFN-α2, irrespective of the intensity of chemotherapy used, IFN dose, or whether IFN was given as a maintenance strategy or with chemotherapy.

Conclusion

When given in the context of relatively intensive initial chemotherapy, and at a dose ≥ 5 million units (≥ 36 × 106 units per month), IFN-α2 prolongs survival and remission duration in patients with follicular lymphoma.

Long-term follow-up of a randomized trial of fludarabine–mitoxantrone, compared with cyclophosphamide, doxorubicin, vindesine, prednisone (CHVP), as first-line treatment of elderly patients with advanced, low-grade non-Hodgkin's lymphoma before the era of monoclonal antibodies

BACKGROUND

This randomized study compared the efficacy and safety of fludarabine-mitoxantrone (FM) with mini-CHVP (cyclophosphamide, doxorubicin, vindesine, prednisone) in elderly patients with advanced, low-grade non-Hodgkin's lymphoma.

PATIENTS AND METHODS

End points were remission rates [overall response (OR) and complete response (CR)], failure-free survival (FFS), survival and toxicity. One hundred and fifty-five patients were randomized, 144 were evaluable for safety and 142 for response. Each treatment arm was given as six monthly cycles, followed by three bimonthly cycles. FM comprised fludarabine (20 mg/m(2) i.v.), days 1-5, plus mitoxantrone (10 mg/m(2) i.v.), day 1. CHVP cycles comprised cyclophosphamide (750 mg/m(2) i.v. infusion), doxorubicin (25 mg/m(2) i.v.) and vindesine (3 mg/m(2) i.v.) on day 1, and prednisone (50 mg/m(2)) on days 1-5.

RESULTS

FM therapy resulted in superior remission rates (OR 81% versus 64%, CR 49% versus 17%; P = 0.0004). Median FFS for FM patients was 36 months, compared with 19 months for CHVP patients, and has not yet been reached for early CR patients at 53 months. Treatment arm was the major risk factor influencing survival. Both treatments were well tolerated, with only few infectious complications.

CONCLUSION

FM was more effective than CHVP in achieving OR and CR, and favorably affected the outcome.

Durable response but prolonged cytopenia after cladribine treatment in relapsed patients with indolent non-Hodgkin's lymphomas: results of a Japanese phase II study

We conducted a phase II study to evaluate the efficacy and safety of cladribine (2-chlorodeoxyadenosine [2-CdA]) for patients with refractory or relapsed indolent B-cell lymphoma or mycosis fungoides. Forty-five patients were enrolled, and 43 patients, including 34 with follicular lymphoma, were eligible. 2-CdA was given by continuous intravenous infusion at a dose of 0.09 mg/kg daily for 7 consecutive days, and this schedule was repeated every 4 weeks up to a maximum of 6 cycles. The overall and complete response rates were 58.1% (25/43; 90% confidence interval, 44.5%-70.9%) and 14.0% (6/43), respectively. The disease progression-free proportions of all 43 eligible and all 25 responding patients at 2 years were 30.3% and 48.1%, respectively. Neutropenia and thrombocytopenia of grade 3 or 4 were observed in 53.3% and 37.8% of patients, respectively, with prolonged cytopenia observed in patients with increased numbers of treatment cycles. Nonhematologic toxicities of grade 3 or greater included diarrhea, arrhythmia, malaise, and gastrointestinal bleeding in 1 patient each, an increase in glutamic-pyruvic transaminase level in 2 patients, and infection in 5 patients. Two treatment-related deaths were observed. Four patients developed myelodysplastic syndrome (MDS) at 13 months to 2 years after completion of the 2-CdA treatments. 2-CdA is an active agent with acceptable toxicity for refractory or relapsed indolent lymphoma; however, prolonged myelosuppression and the potential development of MDS should be carefully monitored.

High response rates and lasting remissions after low-dose involved field radiotherapy in indolent lymphomas

PURPOSE

To study the response rates and duration of response after low-dose (4 Gy) involved field radiotherapy (LD-IF-RT) in patients with recurrent indolent lymphoma.

PATIENTS AND METHODS

A total of 109 assessable patients (304 symptomatic sites) were irradiated (53 males and 56 females; median age, 62 years; range, 35 to 93), including 98 patients with follicular lymphoma (43 grade 1 and 55 grade 2), nine extranodal marginal zone lymphomas of mucosa-associated lymphoid tissue-type and two patients with lymphoplasmacytoid lymphoma. Bulky disease (> or =5 cm) was present in 52% of all patients. A median of two prior regimens (range, 0 to 11) preceded LD-IF-RT. The median time since diagnosis was 41 months (range, 2 to 358 months). Time to (local) progression was calculated according to the Kaplan-Meier method. Differences in response rates between treatments within the same patient were compared using the McNemar test.

RESULTS

The overall response rate was 92%; complete response was reached in 67 patients (61%), partial response in 34 patients (31%), stable disease in six patients (6%), and progressive disease in two patients (2%). The median time to progression was 14 months. The median time to local progression was 25 months. The 67 patients with complete response showed a median time to progression of 25 months and a median time to local progression of 42 months. None of the factors studied (age, sex, follicular lymphoma grade, radiotherapy regimen, number of previous regimens and previous history, number of positive sites or largest lymphoma diameter) were found to be related to response rate.

CONCLUSION

LD-IF-RT is a valuable asset in the management of patients with follicular lymphoma and should be considered in patients with recurrent disease.

Prolonged single-agent versus combination chemotherapy in indolent follicular lymphomas: a study of the cancer and leukemia group B

PURPOSE

The array of options for the initial management of follicular small cleaved lymphoma (FSCL) and follicular mixed lymphoma (FML) ranges from little or no therapy to the use of intensive combinations of drugs. The Cancer and Leukemia Group B (CALGB) compared two contrasting approaches: a single agent, and combination chemotherapy capable of curing diffuse aggressive lymphomas.

PATIENTS AND METHODS

A total of 228 patients with stage III or IV FSCL or FML were randomized to cyclophosphamide or the combination of cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-B). Treatment was continued in responders for 2 years beyond maximal response. The primary end point was survival in the most common subtype, FSCL.

RESULTS

Ninety-one percent of all patients responded; complete responses were seen in 66% of those treated with cyclophosphamide and in 60% treated with CHOP-B (P =.36). At 10 years with either cyclophosphamide or CHOP-B, respectively, overall time to failure (25% failure free v 33%; P =.107) and survival (44% alive v 46%; P =.79) were similar by treatment. Outcomes in FSCL also were similar. In 46 patients with FML, at 10 years the combination was associated with better failure-free (9% v 48%; P =.005) and overall (25% v 61%; P =.024) survival. Acute toxic effects were more common with combination chemotherapy. Second malignancies, which might be attributed to treatment, were seen with both approaches.

CONCLUSION

There is no advantage to the initial use of the relatively intensive combination, CHOP-B, for patients with FSCL compared with the less toxic single agent, cyclophosphamide. However, in an unplanned subgroup analysis, patients with FML who received the combination experienced improved disease control and survival.

Randomized phase III study of fludarabine phosphate versus cyclophosphamide, vincristine, and prednisone in patients with recurrent low-grade non-Hodgkin's lymphoma previously treated with an alkylating agent or alkylator-containing regimen

PURPOSE

To compare in a phase III study the safety and efficacy of fludarabine to that of cyclophosphamide, vincristine, and prednisone (CVP) in recurrent, low-grade, non-Hodgkin's lymphoma after previous response to systemic treatment.

PATIENTS AND METHODS

Patients were randomized to fludarabine (25 mg/m(2) intravenously on days 1 to 5, every 28 days) or CVP (cyclophosphamide 750 mg/m(2) and vincristine 1.2 mg/m(2) both intravenously on day 1 and prednisone 40 mg/m(2) orally on days 1 to 5, every 21 days). The primary outcome assessed was progression-free survival (PFS); secondary outcomes included treatment-free survival (TFS), overall survival (OS), treatment-related toxicity, and quality of life (QoL) according to the European Organization for Research and Treatment of Cancer's Quality of Life Questionnaire C-30 version 1.0 instrument.

RESULTS

Ninety-one patients were randomized, 47 to fludarabine and 44 to CVP. There was no difference in response rates, with 64% (complete response [CR], 9%) for fludarabine versus 52% (CR, 7%) for CVP (P =.72). With a median follow-up of 42 months, median PFS (11 months v 9.1 months; P =.03) and TFS (15 months v 11 months; P =.02) were superior in patients receiving fludarabine. No difference in median overall survival was detected (57 months for fludarabine v 44 months for CVP; P =.95). Three patients receiving fludarabine died of treatment-related toxicity compared with none of the patients receiving CVP. Peripheral neuropathy and alopecia were more common with CVP. Patients receiving fludarabine had higher scores for social function (P =.008); no other differences in QoL were detected.

CONCLUSION

In recurrent low-grade lymphoma, fludarabine improves PFS, TFS, and social function scores in comparison with CVP but does not improve OS.

A randomized controlled trial to evaluate the role of interferon as initial and maintenance therapy in patients with follicular lymphoma

The purpose of this study was to evaluate the role of interferon as initial and maintenance therapy in patients with newly diagnosed follicular lymphoma. Between 1984 and 1994, 204 patients with newly diagnosed Stage III or Stage IV follicular lymphoma were randomized to receive either, Chlorambucil (CB): 10 mg daily for 6 weeks, followed by a 2-week interval, with 3 subsequent 2-week treatment periods at the same dose, separated by 2-week intervals, or, CB given concurrently with interferon (IFN). IFN was given at a dose of 3 x 10(6)units thrice weekly, subcutaneously, throughout the 18-week treatment period. Responding patients were subsequently randomized to receive maintenance IFN at the dose and schedule described above, or to expectant management. The overall response rate was 161/204 (78%), complete remission being achieved in 24% of patients. Neither the addition of IFN to the initial treatment, nor the use of maintenance IFN influenced response rate, remission duration or survival. This study was undertaken to determine whether IFN, given in combination with, and then subsequent to, CB would alter the clinical course of patients with follicular lymphoma. Disappointingly, this objective was not achieved, no advantage having been demonstrated for the addition of IFN.

Assessment of prognostic factors in follicular lymphoma patients

Prognostic factors, including clinical, biological, and histological parameters, were assessed for 94 patients with follicular lymphomas at our institute. Follicular lymphomas constituted 7.7% (94/1208) of malignant lymphomas in this study. Eighteen patients were diagnosed with stage I follicular lymphoma, 20 with stage II, 23 with stage III, and 33 with stage IV. The cases of follicular lymphoma were subclassified as: follicular small cleaved cell lymphoma (FSC) in 20 cases, follicular mixed cell lymphoma (FMX) in 59 cases, and follicular large cell lymphoma (FLC) in 15 cases. The patients comprised 49 men and 45 women with a median age of 54 years (range, 25-84 years). The complete response rate was 76.5%, and the median survival time was 13 years. The expected 10-year overall survival and event-free survival rates were 61.9% and 38.2%, respectively. Univariate analysis identified the factors associated with poor survival as elevated serum lactate dehydrogenase (LDH) level (P < .0001), age of >60 (P < .0001), Ann Arbor stage III/IV (P < .01), and Eastern Cooperative Oncology Group performance status (PS) of 2 to 4 (P = .048). Multivariate analysis showed that LDH, age, and PS were independent predictors. After application of the International Prognostic Index (IPI), the 10-year survival rates for the low-risk, low-intermediate risk, high-intermediate risk and high-risk groups were 80.4%, 48.7%, 21.9%, and 0.0%, respectively. The differences among these groups were significant at P < .01. The IPI for aggressive non-Hodgkin's lymphoma was found to be applicable to survival prediction for Japanese follicular lymphoma patients.

Follicular lymphomas--a review of treatment modalities

Follicular lymphoma is the most common low-grade non Hodgkin's lymphoma and represent an homogeneous entity as defined by pathological, molecular and clinical data. This indolent disease is characterised by a slow growth pattern with possible spontaneous regression, is often disseminated but remains incurable with available treatments when disseminated. For localised stages, involved field radiotherapy remains the standard choice but other approaches remain to be investigated. In advanced disease, chemotherapy has been demonstrated to produce high response rates but recent trials with new treatment strategies including interferon and monoclonal antibodies may improve the current situation. In this article, we will review treatment of follicular lymphomas, specially emphasising published phase III trials.

Low-grade stage III-IV follicular lymphoma: multivariate analysis of prognostic factors in 484 patients--a study of the groupe d'Etude des lymphomes de l'Adulte

PURPOSE

To identify the prognostic factors that influence overall survival (OS) in patients with stage III-IV follicular lymphomas and evaluate the clinical usefulness and the prognostic value of the International Prognostic Index (IPI).

PATIENTS AND METHODS

Four hundred eighty-four patients with Ann Arbor stage III-IV follicular lymphomas treated in two phase III trials from 1986 to 1995 were screened for this study. All histologic slides were reviewed by two hematopathologists. The influence of the initial parameters on survival was defined by univariate (log-rank test) and multivariate (Cox model) analyses.

RESULTS

The poor prognostic factors for OS (age > 60 years, "B" symptom(s), > or = two extranodal sites, stage IV disease, tumor bulk > 7 cm, at least three nodal sites > 3 cm, liver involvement, serous effusion-compression or orbital/epidural involvement, and erythrocyte sedimentation rate > 30 mm/h) that were significant in univariate analysis were subjected to multivariate analysis. Three factors remained significant: B symptom(s) (risk ratio = 1.80), age greater than 60 years (risk ratio = 1.60), and at least three nodal sites greater than 3 cm (risk ratio = 1.71). When the IPI was applied to these patients, the score was 1, 2, 3, and 4-5 in 49%, 39%, 11%, and 2%, respectively, and it was significant for progression-free survival (P =.002) and OS (P =.0001).

CONCLUSION

Three prognostic factors for poor OS were identified: B symptoms, age greater than 60 years, and at least three nodal sites greater than 3 cm. The IPI was prognostic for OS, but in this population, a very low number of patients belonged to the high-risk groups.

Frequency and significance of anemia in non-Hodgkin's lymphoma patients

OBJECTIVES

Retrospective evaluation of anemia frequency and its prognostic value in patients with different subtypes of non-Hodgkin's lymphoma and comparison with other clinical characteristics.

PATIENTS AND METHODS

Anemia was defined as a hemoglobin value less than or equal to 12 g/dl for all men and women over 50 years of age, and less than or equal to 11 g/dl for women under 50 years of age. The study included 1077 adult lymphoma patients treated between 1980 and 1995 with the following histologic subtypes: 127 patients with small lymphocytic or lymphoplasmacytoid, 62 with marginal zone, 50 with mantle-cell, 208 with follicular, 104 with T-cell lymphoma, 426 with diffuse large-cell and, finally, 73 patients with other high-grade lymphomas.

RESULTS

Anemia was present in 341 patients (32%). It was an adverse prognostic factor (P < 0.0001) for overall survival (OS) and progression-free survival (PFS) but not for relapse-free survival (RFS). When patients with and those without bone marrow involvement were considered separately, anemia remained an adverse factor. Anemia was significantly associated with shorter PFS in small lymphocytic or lymphoplasmacytoid, mantle cell, diffuse large cell and high-grade lymphomas and with shorter OS in all histologic subgroups except marginal zone lymphoma. In multivariate analysis, anemia was a significant prognostic factor for OS and PFS for the population as a whole (P = 0.0001 and P = 0.0048, respectively) and in patients with bone marrow involvement (P = 0.007 and P = 0.005, respectively) but not in patients without bone marrow involvement. Finally, the addition of anemia to the International Prognostic Index led to an improvement for OS (P = 0.0004) and PFS (P = 0.0004).

CONCLUSIONS

Anemia is an important adverse prognostic factor for the outcome of lymphoma patients, particularly in some histologic subgroups and in patients with bone marrow involvement.

High serum interleukin-6 levels correlate with a shorter failure-free survival in indolent lymphoma

Interleukin-6 (IL-6) is a potent immunomodulatory cytokine that may have pathogenetic and prognostic significance in a number of disorders. The objective of this study was to examine the correlation between serum IL-6 levels and phenotypic characteristics, as well as failure-free survival of patients with low-grade non-Hodgkin's lymphomas (NHL). Using a sensitive enzyme-linked immunoabsorbent assay (ELISA), we measured IL-6 in frozen sera from 55 healthy controls and in the pre-treatment frozen sera from 100 low-grade lymphoma patients who were enrolled on protocols at MD Anderson Cancer Center. Serum IL-6 levels were correlated with clinical and laboratory features at diagnosis and with failure-free survival. The serum IL-6 levels were > or =2 pg/mL in 9% (median, <0.91 pg/mL; range, <0.91-4.31 pg/mL) of controls versus 25% of the indolent lymphoma patients (median, <0.91 pg/mL; range <0.91 to 225.97) (p = 0.0118). Serum IL-6 levels were higher in patients with B-symptoms (p = 0.02), an elevated P2-microglobulin level (> or =3.0 mg/L) (p = 0.00013), and unfavorable International Index (p = 0.03). Patients with elevated serum IL-6 levels had an inferior failure-free survival (log rank p = 0.008) compared with those with normal serum IL-6 levels (three-year-failure-free-survival = 55% versus 81%, respectively). In conclusion a minority (25%) of patients with indolent non-Hodgkin's lymphomas have elevated serum levels of IL-6 at diagnosis. In these individuals, high IL-6 levels are associated with adverse disease features, and predictive of a shorter failure-free survival.

Prolonged survival in follicular non Hodgkins lymphoma is predicted by achievement of complete remission with initial treatment: results of a long-term study with multivariate analysis of prognostic factors

Prognostic factors among 200 patients with follicular non-Hodgkin's Lymphoma (NHL) (categories B to D of the Working Formulation) requiring systemic therapy were investigated. In univariate analyses factors that had a favourable influence on survival included complete response to treatment, female sex and age < 60 years, while the presence of B-symptoms was a weakly adverse prognostic factor. In a multivariate analysis only the achievement of CR (chi square = 5.9, p = 0.015) and sex (chi 2 = 5.9, p = 0.015) were significant prognostic factors for survival. Not only was achievement of CR predictive of survival, CR duration > or = 2 years was associated with median overall survival in excess of 6 years. These results suggest that patients who are responsive to first line chemotherapy have a good prognosis and that experimental treatments such as high dose chemotherapy with hemopoetic rescue should be reserved for patients who either fail to achieve CR with initial therapy or who relapse within 2 years of initial treatment.

FMP regimen (fludarabine, mitoxantrone, prednisone) as therapy in recurrent low-grade non-Hodgkin's lymphoma

Fludarabine (FLU) is a new antimetabolite chemotherapeutic agent with promising therapeutic activity in the lymphoproliferative disorders and in particular in low-grade non-Hodgkin's lymphoma (LG-NHL). In order to evaluate FLU in combination with other antineoplastic agents, we used a three-drug combination of FLU, mitoxantrone and prednisone (FMP) to treat 18 patients with recurrent LG-NHL. The FMP regimen was as follows: FLU, 25 mg/m2 i.v. on days 1 to 3; mitoxantrone, 10 mg/m2 i.v. on day 1; prednisone 40 mg i.v. on days 1 to 5. Of the 18 patients, 4 (22%) achieved complete response (CR), 9 (50%) partial response, and the remaining 5 showed no benefit from the treatment. The 4 CR patients are still in remission after 4, 6, 6, and 8 months, respectively. The median duration of overall survival of all patients was 9 months. The major toxic effects observed were neutropenia (50%) and infections and/or febrile episodes (17%); no fatalities due to drug side effects occurred. These results confirm the efficacy of the fludarabine-mitoxantrone combination-containing regimen in inducting a good remission rate with moderate side effects in recurrent LG-NHL.

Bone marrow transplantation in low-grade non-Hodgkin's lymphoma

The low-grade histologic types constitute one quarter of all non-Hodgkin's lymphomas (NHL). Conventional chemotherapy and chemo-radiation therapy have failed to significantly alter the course of this disease, and most patients eventually succumb to lymphoma. Despite the fact that NHLs exhibit a steep dose-response relation to cytotoxic therapy, fewer than 30% of eligible patients undergo bone marrow transplantation. Reasons for fewer patients receiving this course of treatment include: elderly patient population, extensive previous chemotherapy and/or radiation therapy, high incidence of bone marrow involvement, and transformation to higher grade NHLs. In recent years, improvements in several areas have enhanced the therapeutic index for bone marrow transplantation. These advances include the use of more effective preparative regimens, recombinant hematopoietic growth factors, extended-spectrum antibiotics, and an increased expertise in blood transfusion techniques and practices. Other, more effective strategies include sophisticated in vitro bone marrow purging approaches and peripheral blood progenitor cell collection. As a result, more patients have been able to receive dose-intensive therapy followed by hematopoietic cellular rescue. Although follow up is short in most series, encouraging results have stimulated some centers to begin transplanting responding patients earlier in their disease course; in more than 200 patients treated in this fashion, long-term disease-free survival has been achieved in nearly 70% of patients, some patients for a period of greater than 6 years. The new purine analogues fludarabine, pentostatin, and 2-chlorodeoxyadenosine also have shown promise in both initial and salvage treatment of low-grade NHLs. It remains to be determined whether this group of drugs will be complimentary to the bone marrow and/or peripheral blood progenitor cell transplant approach.

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)

Low-grade lymphoma: clinical and prognostic studies in a series of 143 patients from a single institution

Clinical and prognostic studies were carried out in a series of 143 patients with low-grade (small-lymphocytic, follicular small cleaved cell, follicular mixed small- and large-cell) lymphoma. After treatment with alkylating agents (21.5% cases), combination chemotherapy (73.3%) or other therapies (5.2%), complete response (CR) was obtained in 40.7% of cases and partial response (PR) in 43.7%. The stage of the disease was the most important factor for response. With a median follow-up of 6.5 years, 48.0% (95% Cl: 37.5-58.5) of patients were alive 10 years after diagnosis. Among the initial parameters, advanced stage. B-symptoms, poor performance status, nodal involvement > 3 sites, extranodal involvement > or = 2 sites, WBC count > or = 10 x 10(9)/L, leukemic expression, high serum LDH levels, and bone marrow infiltration were all related to survival; treatment modality, however, had no influence on survival. In the multivariate analysis, stage (p = 0.008) and age (p = 0.053) were the most important prognostic factors. When considering response to therapy, both CR (p < 0.001) and PR (p = 0.003) emerged as the most important predictive variables, with only the absence of B-symptoms retaining its prognostic significance (p = 0.014) among the other parameters. In addition, in CR patients the duration of the response (< or = 1 year vs. > 1 year) was the most significant parameter for survival (p < 0.001). Finally, the initial stage (p = 0.011) and the histologic subtype (those patients with follicular mixed lymphoma relapsing less frequently than the others) (p = 0.052) were the only significant factors for relapse.

Recombinant interferon alfa-2b combined with a regimen containing doxorubicin in patients with advanced follicular lymphoma. Groupe d'Etude des Lymphomes de l'Adulte

BACKGROUND

Interferon alfa and cytotoxic drugs have synergistic effects in patients with non-Hodgkin's lymphoma. In 1986, we designed a clinical trial to evaluate the benefit of concomitant administration of recombinant interferon alfa with a regimen containing doxorubicin in patients with follicular non-Hodgkin's lymphoma.

METHODS

The trial involved 242 patients with advanced low-grade follicular non-Hodgkin's lymphoma selected on the basis of clinical, radiographic, and biologic criteria. All patients were treated with a regimen consisting of cyclophosphamide, doxorubicin, teniposide, and prednisone (CHVP), given monthly for six cycles and then every two months for one year. After randomization, 123 patients also received interferon alfa-2b at a dosage of 5 million units three times weekly for 18 months. The remaining 119 patients received chemotherapy alone.

RESULTS

As compared with the patients treated with CHVP only, the patients treated with CHVP plus interferon alfa had a higher overall rate of response (85 percent vs. 69 percent, P = 0.006), a longer median event-free survival (34 months vs. 19 months, P < 0.001), and a higher rate of survival at 3 years (86 percent vs. 69 percent, P = 0.02). Granulocyte toxicity was greater in the patients treated with CHVP plus interferon alfa than in those treated with CHVP alone. There were no treatment-related deaths. Interferon alfa had to be stopped because of toxic effects (fatigue and hepatitis) in 13 patients (11 percent).

CONCLUSIONS

The addition of interferon alfa to a regimen containing doxorubicin increased the rate of response, event-free survival, and overall survival in patients with advanced follicular non-Hodgkin's lymphoma, without serious toxicity, although some patients were unable to tolerate the side effects.

Long-term outcome of follicular low-grade lymphoma. A report of 91 patients

We retrospectively analyzed overall survival and survival after progression in 91 patients with low-grade follicular lymphoma (LGFL). Histological subtype was B in 75 patients and C in 16 patients. Twelve patients with localized disease received involved-field radiotherapy; seven patients without bulky disease had no initial therapy. The remaining 72 patients received long-term chlorambucil (9 patients), MOPP or COPBleo (42 patients), or a CHOP-derived regimen (21 patients). Forty-two patients (46%) achieved a complete remission (CR) and 28 patients (31%) achieved a partial remission; 48 of these 70 patients relapsed or progressed. Nineteen of the other 21 patients with stable LGFL progressed. Two other patients failed to respond and rapidly died. Thirty-two of the 67 patients with progressive or relapsed LGFL have died. Median overall survival was 111 months. Age > or = 70 years, male sex, B symptoms, histological subtype follicular mixed-cell NHL, tumor size > or = 10 cm, number of extranodal sites of disease > or = 2, pleural effusion, and Ann Arbor stage III or IV were found to adversely influence overall survival. Failure-free survival < 24 months, failure to achieve a CR after the progression, initial histological subtype follicular mixed cell, initial Ann Arbor stage III or IV, and initial tumoral size > or = 10 cm were found to adversely influence survival after progression. Our results suggest that most prognostic factors for overall survival in LGFL are related to histological subtype or tumor burden. Some initial adverse prognostic factors for survival may be also associated with a poor survival after progression.