Hodgkin's disease

Chronic fatigue in long-term survivors of Hodgkin's lymphoma after contemporary risk-adapted treatment

BACKGROUND

Chronic fatigue (CF), substantial fatigue for ≥ six months, can manifest as a late effect (LE) after cancer treatment, and may affect several aspects of life. In a Norwegian cohort of Hodgkin's lymphoma survivors (HLS), more than a decade after contemporary risk-adapted treatment regimens with limited use of radiotherapy (RT), we assessed: (1) Prevalence of, (2) factors associated with (3) and implications of CF on socioeconomic status (SES) and work ability (WA).

MATERIAL AND METHODS

HLS treated between 1997-2006, aged 8-49 years at diagnosis, were invited to participate in a population-based cross-sectional study on late effects in 2018-2019. In a mailed questionnaire, HLS responded to a fatigue questionnaire (FQ), work ability score (WAS) and short-form health survey (SF-36). Disease- and treatment data were extracted from hospital records. Factors associated with CF were identified by uni- and multivariate analysis. To study the implications of CF on SES and WA, a multinomial regression analysis was performed.

RESULTS

Invitations were extended to 518 HLS and 298 (58%) responded to FQ, of whom 42% had CF with mean (standard deviation [SD]) physical- and mental fatigue scores of 10.2 (4.3) and 5.5 (2.1) respectively. Median age at survey was 45 years, 47% were females. In multivariate analysis female sex (p = 0.03), lower education (p = 0.03), body mass index ≥30 kg/m² (p = 0.04), and an increasing number of comorbidities (p = 0.01) were associated with CF. No association with disease stage, chemotherapy or RT was found. CF was associated with poorer WAS scores at survey (p < 0.001), unemployment (p = 0.03), and receiving disability pension (p = 0.003).

CONCLUSION

After risk-adapted treatment, CF is still a frequent LE among long-term HLS, without apparent association with disease or treatment-related parameters. CF is associated with reduced WA and SES. As no apparent risk reduction is seen with contemporary treatment, further studies should emphasize etiological factors of CF and treatment to alleviate this common LE.

An Update on the Pathology and Molecular Features of Hodgkin Lymphoma

Simple Summary

Hodgkin lymphomas (HLs) include two main types, classic HL (CHL) and nodular lymphocyte predominant HL (NLPHL). Recent molecular findings in HLs have contributed to dramatic changes in the treatment and identification of tumor characteristics. For example, PD-1/PD-L1 blockade and brentuximab vedotin, an anti-CD30 antibody bearing a cytotoxic compound, are now widely used in patients with CHL. Biological continuity between NLPHL and T-cell/histiocyte-rich large B-cell lymphoma has been highlighted. An era of novel therapeutics for HL has begun. The aim of this paper is to review the morphologic, immunophenotypic, and molecular features of CHL and NLPHL, which must be understood for the development of novel therapeutics.

Abstract

Hodgkin lymphomas (HLs) are lymphoid neoplasms derived from B cells and consist histologically of large neoplastic cells known as Hodgkin and Reed–Sternberg cells and abundant reactive bystander cells. HLs include two main types, classic HL (CHL) and nodular lymphocyte predominant HL (NLPHL). Recent molecular analyses have revealed that an immune evasion mechanism, particularly the PD-1/PD-L1 pathway, plays a key role in the development of CHL. Other highlighted key pathways in CHL are NF-κB and JAK/STAT. These advances have dramatically changed the treatment for CHL, particularly relapsed/refractory CHL. For example, PD-1 inhibitors are now widely used in relapsed/refractory CHL. Compared with CHL, NLPHL is more characterized by preserved B cell features. Overlapping morphological and molecular features between NLPHL and T-cell/histiocyte-rich large B-cell lymphoma (THRLBCL) have been reported, and biological continuity between these two entities has been highlighted. Some THRLBCLs are considered to represent progression from NLPHLs. With considerable new understanding becoming available from molecular studies in HLs, therapies and classification of HLs are continually evolving. This paper offers a summary of and update on the pathological and molecular features of HLs for a better understanding of the diseases.

HIV and Hodgkin Lymphoma Survival: A Prospective Study in Botswana

PURPOSE

People living with HIV (PLWH) experience increased risk of Hodgkin lymphoma (HL) despite effective initiation of antiretroviral therapy (ART). In high-income countries, outcomes following HIV HL have been reported to be non-differential, or inferior for PLWH. We sought to assess the effect of HIV on HL survival in Botswana, an African country with a generalized HIV epidemic and high ART coverage, to describe a context more reflective of global HIV populations.

PATIENTS AND METHODS

In the Thabatse Cancer Cohort, consenting participants initiating treatment for HL at one of four cancer centers in Botswana were enrolled from 2010 to 2020. Patients were followed quarterly for up to 5 years. The impact of HIV on survival following treatment initiation was assessed using an inverse probability-weighted Cox marginal structural model adjusted for age, performance status, and disease stage.

RESULTS

Seventy-eight new HL cases were enrolled, 47 (60%) were PLWH and 31 (40%) were HIV-uninfected. Baseline characteristics were similar between groups. The majority (61%) of patients presented with regional disease (stage I or II) with no statistically significant difference by HIV status (P = .38). Nearly all (87%) PLWH participants were on ART before their HL diagnosis (median ART duration 42 months), and median CD4 count was 413 cells/μL (interquartile range 253-691). Survival, in unadjusted analyses, was lower among patients without HIV compared with PLWH (log rank P = .021). In adjusted analysis, HIV infection was not significantly associated with survival in inverse probability-weighted Cox model (hazard ratio 0.43; 95% CI, 0.16 to 1.16; P = .094).

CONCLUSION

In this cohort of patients treated for HL in Botswana, survival in PLWH (87% on long-standing ART) was at least as good as in individuals without HIV.

Clinicopathological features of syncytial variant nodular sclerosis Hodgkin lymphoma

The syncytial variant of nodular sclerosis Hodgkin lymphoma (SV-NSHL) is uncommon, and its clinicopathological features have not been well analyzed. In this study, we collected 142 cases of SV-NSHL. There were 76 (53.5%) males and 66 (46.5%) females with a median age of 28 years (range, 12-78); 59.9% were younger than 30 years. Patients usually presented with a mediastinal mass (97.6%) and often with bulky (35.7%) and advanced stage disease (3 or 4) (39.7%). Follow-up showed that 61.1% of patients developed relapse after standard therapy. Morphologically, the neoplasms were composed of sheets or large clusters of pleomorphic neoplastic cells with a cohesive appearance that were frequently associated with necrosis. Neutrophils and eosinophils were frequent in the background, whereas small lymphocytes were decreased. Immunohistochemical analysis showed that the following markers were frequently positive: CD30 (100%), MUM1/IRF4 (96%), PAX5 (95%), PD-L1 (91%), and CD15 (80%). CD45 was negative in all cases. Epstein-Barr virus-encoded small RNA (EBER) was detected in 19% of cases. In this cohort, age above 30 years (P = .0430), presence of B-type symptoms (P = .0394), elevated serum lactate dehydrogenase level (P = .0004), and disease relapse (P = .0108) were associated with a poorer overall survival. In contrast, patients with EBER-positive neoplasms had a better survival (P = .0418). Compared with a control group of non-SV-NSHL patients, patients with SV-NSHL were associated with a poorer overall survival (P = .011). These data suggest that SV morphology is associated with a poorer prognosis in patients treated with traditional standard-of-care therapy for classic Hodgkin lymphoma.

Hodgkin Lymphoma in Children and Adolescents: Advances in Pathology, Diagnosis, and Treatment Strategies

Strategies used for the treatment of children with Hodgkin lymphoma (HL) over the last four decades have resulted in excellent long-term survivals. However, the short- and long-term treatment-associated morbidities were high. In an attempt to reduce complications, the current treatment strategies apply initial risk stratification principles based on certain host and tumor risk factors to help assign patients to the appropriate risk group and tailor therapy based on response to chemotherapy (CTR). Radiotherapy (RT) was only given to certain groups of patients who show suboptimal response to CTR. Enrollment of patients in clinical trials allowed testing newer treatment strategies, which has improved the outcome significantly. High-dose CTR with stem cell support remains the mainstay of treatment for relapsed and refractory HL. Newer targeted medications are being increasingly used for the treatment of patients with relapsed and refractory HL, but results are variable. In this review report, we give extensive account about the pathophysiology, clinical presentation, histopathological diagnosis, modern investigation techniques, the most recent risk adapted treatment strategies, and the use and effect of novel medications. In addition, we discuss in details the short- and long-term therapy-related complications and future prospects in the management of HL.

A 12-Year Comparative Analysis of Hodgkin and Non-Hodgkin Lymphomas in Lebanon: Trend Characteristics and 10-Year Projections

Background  Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) are two common malignancies worldwide and in Lebanon. Analysis of their trends plays a crucial role to better understand their origins and risk factors. This study will probe incidences of both types of lymphomas from 2005 to 2016, aiming to compare between the two malignancies according to age and sex and plot projections until 2026. Methods HL and NHL cases from 2005 to 2016 were collected from the National Cancer Registry of Lebanon. Data was stratified according to age and sex. Age-specific and age-standardized incidence rates were analysed using joinpoint regression; 10-year projections were predicted based on logarithmic models. Results Between 2005 and 2016, NHL was significantly more common than HL. NHL was higher in both genders. HL showed a bimodal age distribution while NHL peaked in elderly patients. NHL incidence rates in males increased significantly from 2005 to 2014 while HL incidence rates showed an insignificant rise. Over the next 10 years, NHL and HL cases are expected to increase in Lebanon. Conclusion HL and NHL are on the rise in Lebanon. Extensive research into the main factors contributing to these lymphomas is crucial in the fight against them. More efforts must be done by the government and health organizations to better control the disease.

Characteristics and Survival Outcomes of Children With Hodgkin Lymphoma Treated Primarily With Chemotherapy

BACKGROUND

Hodgkin disease is a malignant tumor of the lymphatic system that comprises ∼6% of childhood cancers. In developing countries, efforts are made to ensure adherence to standard protocol/regimens, study patients' outcomes, and compare with that in developed world.

MATERIALS AND METHODS

We conducted a retrospective medical records' review of 212 children younger than 20 years presenting to The Indus Hospital in Pakistan with previously untreated Hodgkin lymphoma between August 2000 and December 2012. We collected demographic and other epidemiologic variables such as age, sex, stage, subtype of disease, and survival outcomes.

RESULTS

The mean±SD age of patients at time of diagnosis was 9.0±3.8 years with a male to female ratio of ∼4.7:1. In total, 44 (20.8%) patients were 5 years of age or above at presentation. Overall, 131 (61.8%) patients presented with B-symptoms and mixed cellularity was the most frequently diagnosed subtype in 65.1% of cases. In total, 170 (80.2%) achieved full remission after completion of chemotherapy. Patients were treated with alternating cycles of ABVD (Adriamycin, Bleomycin, Vincristine, and Dacarbazine) and COPDAC (Cyclophosphamide, Vincristine, Prednisolone, and Dacarbazine). The majority (n=114, 59.1%) received 6 cycles of chemotherapy, 44 (22.8%) received ≤4 cycles followed by 24 (12.4%) receiving 8 cycles. Radiotherapy was administered only to those patients with significant residual disease at the end of chemotherapy (n=20, 10%). The 5-year overall survival and event-free survival in our cohort was 89.6% and 82.1%, respectively.

CONCLUSION

Our findings suggest that treatment with 4 to 8 alternating cycles of ABVD/COPDAC has an excellent outcome in childhood Hodgkin disease.

Age over Fifty-Five Years at Diagnosis Increases Risk of Second Malignancies after Autologous Transplantation for Patients with Hodgkin Lymphoma

The impact of age at diagnosis on outcomes of patients with Hodgkin lymphoma (HL) undergoing autologous hematopoietic transplantation (auto-HCT) is unclear. We retrospectively evaluated the impact of age on outcomes of 310 consecutive patients with relapsed/refractory HL who underwent auto-HCT between January 1996 and December 2010 with carmustine, etoposide, cytarabine, and melphalan conditioning therapy. Patients were stratified into ≤ 55 and >55-year-age groups based on age at diagnosis. At a median follow-up of 80 (range, 1 to 180) months, progression-free survival was similar between both age groups. However, age older than 55 years at diagnosis was associated with significantly poor overall survival with a hazard ratio [HR] of  2.3 (P = .003) from higher rate of second malignancies (HR, 3.8; P = .015) compared with patients 55 years or younger. In conclusion age > 55 years at diagnosis increases risk of second malignancies after auto-HCT.

Phase 2 study of frontline brentuximab vedotin monotherapy in Hodgkin lymphoma patients aged 60 years and older

Outcomes in older patients with Hodgkin lymphoma (HL) tend to be poor following conventional chemotherapy regimens. Treatment-related toxicity is significant and comorbidities often limit therapeutic options. This phase 2, open-label study evaluated the efficacy and safety of brentuximab vedotin, a CD30-directed antibody-drug conjugate, as frontline therapy in 27 HL patients aged ≥60 years. The objective response rate (ORR) was 92%, with 73% achieving complete remission. All patients achieved stable disease or better, and had decreased tumor volume following treatment. At the time of this analysis, the median duration of objective response for efficacy-evaluable patients (N = 26) was 9.1 months (range, 2.8 to 20.9+ months), median progression-free survival was 10.5 months (range, 2.6+ to 22.3+ months), and median overall survival had not been reached (range, 4.6+ to 24.9+ months). The observed adverse events (AEs) were generally consistent with the known safety profile of brentuximab vedotin. The most common AEs were peripheral sensory neuropathy (78%), fatigue (44%), and nausea (44%), and were ≤ grade 2 for most patients. The incidence of grade 3 peripheral neuropathy events was relatively high (30% overall), particularly among patients with the known risk factors of diabetes and/or hypothyroidism (46% vs 14% for those without). However, these risk factors were not associated with delayed time to resolution/improvement of peripheral neuropathy. Preliminary data showed no substantial age-related changes in brentuximab vedotin pharmacokinetics. Brentuximab vedotin monotherapy may provide a frontline treatment option for older patients who cannot tolerate conventional combination chemotherapy. This trial was registered at www.clinicaltrials.gov as #NCT01716806.

Pediatric Hodgkin lymphoma in a South Indian regional cancer center: its immunomorphology, tumor-associated macrophages, and association with Epstein-Barr virus

Pediatric Hodgkin lymphoma (HL) comprises approximately a fifth of all patients with HL in India. Seventy-four cases of pediatric classical Hodgkin Lymphoma (cHL) from a regional cancer center in southern India were analyzed on a tissue microarray (TMA) for the stage of B-cell differentiation of the Hodgkin/Reed Sternberg (HRS) cell by immunohistochemistry (IHC) using CD10, bcl6, MUM1/IRF4, and CD 138. Fifty-two of seventy-four (70.3%) cases were of late germinal center/early post-germinal center phenotype (CD10-/bcl6-/MUM1+/CD138-). Epstein-Barr virus (EBV) association using Epstein-Barr virus encoded RNA (EBER) RISH and EBV-LMP1 immunohistochemistry (IHC) revealed an EBV association of 93%. Tumor-associated macrophages (TAM) in the microenvironment were also assessed on the TMA by CD68 IHC, and most cases (59.7%) showed >25% TAMs, with no case showing ≤5%. These findings indicate that pediatric cHL in India is a tumor, predominantly, of late germinal center/early post-germinal center B cells, is almost invariably EBV associated, and with a high number of TAMs in the microenvironment. This latter finding suggests that criteria other than TAM scores need to be developed for risk stratification of pediatric EBV-associated HL especially in developing countries.

Hodgkin lymphoma incidence in California Hispanics: influence of nativity and tumor Epstein-Barr virus

PURPOSE

For classical Hodgkin lymphoma (HL), migrant studies could elucidate contributions of environmental factors (including Epstein-Barr virus (EBV)) to the lower rates in non-whites. Given the well-described etiologic complexity of HL, this research requires a large, immigrant population, such as California Hispanics.

METHODS

With 1988-2004 California Cancer Registry data (2,595 Hispanic, 8,637 white HL cases) and tumor cell EBV status on a subset (218 Hispanics, 656 whites), we calculated ethnicity- and nativity-specific HL incidence rates simultaneously by age, sex, and histologic subtype, and tumor cell EBV prevalence.

RESULTS

Compared with white rates, Hispanic HL rates were lower overall (70 %) and for nodular sclerosis HL, particularly among young adults (60-65 % for females). However, they were higher among children (200 %) and older adults, and for mixed cellularity HL. Compared with rates in foreign-born Hispanics, rates in US-born Hispanics were higher among young adults (>threefold in females), lower for children and adults over age 70, and consistently intermediate compared with rates in whites. EBV tumor prevalence was 67, 32, and 23 % among foreign-born Hispanics, US-born Hispanics, and whites, respectively, although with variation by age, sex, and histology.

CONCLUSIONS

Findings strongly implicate environmental influences, such as nativity-related sociodemographic differences, on HL occurrence. In addition, lower young adult rates and higher EBV prevalence in US-born Hispanics than in whites raise questions about the duration/extent of environmental change for affecting HL rates and also point to ethnic differences in genetic susceptibility. Lesser variation in mixed cellularity HL rates and greater variation in rates for females across groups suggest less modifiable factors interacting with environmental influences.

Epstein-Barr virus-positive nodular lymphocyte predominant Hodgkin lymphoma

Hodgkin lymphoma (HL) is classified into 2 largely distinct subgroups, namely nodular lymphocyte predominant HL (NLPHL) and classic HL (CHL). CHL is further divided into nodular sclerosis, lymphocyte-rich, mixed cellularity (MCCHL) and lymphocyte-depleted (LDCHL) subtypes. In industrialized nations, Epstein-Barr virus (EBV) has been associated with all types of CHL, especially the MCCHL and LDCHL subtypes, but is rare in NLPHL. We report 8 cases of EBV-positive NLPHL occurring in patients in the United States. All 8 patients have no history of immunosuppression and presented with localized or systemic lymphadenopathy. Histologically, 6 cases had a vaguely nodular pattern and 2 cases had a nodular and diffuse pattern. In all cases, lymphocyte predominant (LP) cells were observed in a background of small lymphocytes and histiocytes. Immunohistochemical analysis showed that the LP cells in all cases were positive for CD20, CD79a, PAX5, OCT2, and CD45 and were negative for CD15. CD30 was expressed variably in 7 cases. EBV encoded RNA was present in all LP cells in 5 cases and in a subset of LP cells in 3 cases. One patient was treated with radiation therapy and 7 patients received chemotherapy, including 4 of 7 patients who underwent autologous stem cell transplantation. EBV infection is a rare primary or secondary event in NLPHL that correlates with poorer prognosis and often requires more aggressive therapy. The variable expression of CD30 in most of these cases could be the result of EBV infection.

Prevalence of HIV Infection among U.S. Hodgkin lymphoma cases

BACKGROUND

Hodgkin lymphoma is uncommon in the U.S. general population; however, Hodgkin lymphoma risk is elevated in people with human immunodeficiency virus (HIV) infection. Thus, despite the low HIV prevalence in the United States, the HIV epidemic may have contributed substantially to the general population burden of Hodgkin lymphoma.

METHODS

We used data from 14 U.S. cancer registries in the Surveillance, Epidemiology, and End Results Program that recorded HIV status of Hodgkin lymphoma cases at diagnosis during 2000 to 2010. We computed the HIV prevalence in Hodgkin lymphoma cases by demographic and tumor characteristics, the proportion of deaths among Hodgkin lymphoma cases because of HIV, and 5-year mortality by HIV status.

RESULTS

Of 22,355 Hodgkin lymphoma cases, 848 (3.79%) were HIV infected at diagnosis. HIV prevalence in Hodgkin lymphoma cases was greater among males than females (6.0% vs. 1.2%). Among males, HIV prevalence was greatest among 40- to 59-year-olds (14.2%), non-Hispanic blacks (16.9%), Hispanics (9.9%), and among cases of lymphocyte-depleted (15.1%), and mixed cellularity Hodgkin lymphoma (10.5%). Eight percent of male and 1.5% of female Hodgkin lymphoma cases died from HIV. Five-year mortality was two-fold higher in HIV-infected Hodgkin lymphoma cases (36.9% vs. 17.5%).

CONCLUSION

In the United States, a substantial proportion of lymphocyte-depleted and mixed cellularity Hodgkin lymphoma cases and Hodgkin lymphoma cases among non-Hispanic black, Hispanic, and middle-aged men are HIV infected. In addition, HIV is an important cause of death among Hodgkin lymphoma cases.

IMPACT

Clinicians should be aware of the high prevalence of HIV in certain subgroups of patients with Hodgkin lymphoma and routine HIV testing should be recommended for all patients presenting with Hodgkin lymphoma.

Subtype of dietary fat in relation to risk of Hodgkin lymphoma: a population-based case-control study in Connecticut and Massachusetts

Few epidemiological studies have examined the relationship between dietary fat, which may affect immune function and risk of Hodgkin lymphoma (HL). The aim of this study was to test the hypothesis that high dietary intake of fat and specific subtypes of fat is associated with the risk of HL among 486 HL cases and 630 population-based controls recruited between 1997 and 2000 in Connecticut and Massachusetts. Unconditional logistic regression was used to calculate odds ratios (ORs) and 95 % confidence intervals (CIs) stratified by age and gender. Among younger adults, HL risk was significantly and positively associated with higher intake of saturated fat [ORs for increasing quartiles = 1.3, 1.8, and 2.1; p trend = 0.04] and negatively associated with higher intake of monounsaturated fat [ORs for increasing quartiles = 0.5, 0.5, and 0.4; p trend = 0.03), after adjustment for potential confounders including lifestyle and other dietary factors. The associations with saturated fat (ORs for increasing quartile = 2.4, 3.2, and 4.4; p trend < 0.01] and monounsaturated fat (ORs for increasing quartile = 0.3, 0.6, and 0.3; p trend = 0.04) were most apparent in younger women, whereas there was no significant association between intake of total fat or any type of fat and risk of HL in older females or younger or older males. These findings show that the associations between dietary fat and risk of HL may vary by gender and age and require confirmation in other populations.

Body size and risk of Hodgkin's lymphoma by age and gender: a population-based case-control study in Connecticut and Massachusetts

PURPOSE

Descriptive studies have indicated a rising trend in Hodgkin's lymphoma (HL) incidence in young adults, especially females. Increasing evidence has suggested that some risk factors associated with HL may vary by age or gender. Recent studies have reported an increased risk of HL associated with increasing body mass index (BMI), but the results have been inconsistent. The objectives of this study were to examine whether the associations between measures of body size (height, weight, and BMI) and HL risk vary by age and/or gender.

METHODS

A population-based case-control study was conducted in Connecticut and Massachusetts. A total of 567 HL cases and 679 controls were recruited in 1997-2000. Unconditional logistic regression was used to calculate odds ratios (ORs) and 95 % confidence intervals (CIs).

RESULTS

Among younger women <35 years old, being overweight (25-29.9 kg/m(2)) versus normal weight (18.5-24.9 kg/m(2)) was significantly associated with an increased risk of HL (OR = 2.1, 95 % CI = 1.1-4.0). The risk increased with increasing weight and BMI (p trends <0.01). Among women ≥35 years old, by contrast, higher weight and BMI were associated with a reduced risk of HL (p trends <0.01). Conversely, there was no significant association between BMI and risk of HL in younger or older males.

CONCLUSIONS

These findings show that the associations between body size and risk of HL vary by gender and age, and require confirmation in other populations.

Hodgkin's lymphoma with cutaneous involvement

We report a case of a 22-year-old previously healthy woman with Hodgkin's lymphoma who presented initially with multiple lymphadenopathy and later, with a solitary cutaneous ulcer. Unlike Non-Hodgkin's lymphoma subtypes, skin involvement of Hodgkin's lymphoma is extremely rare. The prognosis of Hodgkin's lymphoma with skin infiltration is felt to be extremely poor. Contrary to other reports, this case demonstrates that a good response with standard therapy is possible.

Incidence patterns and outcomes for hodgkin lymphoma patients in the United States

Hodgkin lymphoma (HL) demonstrates heterogenous histologic findings, clinical presentation, and outcomes. Using the United States Surveillance, Epidemiology, and End Results (SEER) data we examined relationships between patient characteristics, clinical features at diagnosis, and survival in HL patients. From 2000 to 2007, 16,710 cases were recorded in 17 SEER registries. Blacks and Asians had low incidence (black/white incidence rate ratio (IRR) 0.86, P < .01; Asian/white IRR 0.43, P < .01). The bimodal pattern of incidence was less prominent for black males. Asians and Blacks presented at a mean age of 38 years compared to 42 years for Whites (P < .001). Race was a predictor for survival with HR of 1.19 (95% CI 1.11-1.28) for Blacks. Age was the most important predictor of survival (HR for patients ≥45 years 5.08, 95% CI 4.86-5.31). These current patterns for presentation and outcomes of HL help to delineate key populations in order to explore risk factors for HL and strategies to improve treatment outcomes.

Are patients with Hodgkin lymphoma and high-grade non-Hodgkin lymphoma in clinical therapy optimization protocols representative of these groups of patients in Germany?

BACKGROUND

Improvement of lymphoma therapy is largely driven by clinical therapy optimization protocols (TOPs). It is unclear, however, whether the patients treated in clinical TOP are representative for all patients.

PATIENTS AND METHODS

TOP participants were compared with nonstudy patients in a population-based approach. The study included patients with Hodgkin lymphoma (HL) and high-grade non-Hodgkin lymphoma (hgNHL). Incident cases (N = 743) were ascertained in a large population-based epidemiologic survey. Each patient's status with respect to exclusion criteria of the pertinent TOP was abstracted from primary data sources. TOP participants were identified on the basis of the trial databases. Baseline characteristics and risk factor prevalence were compared between nonstudy and TOP patients.

RESULTS

Eligible for the respective TOPs were 64.1% of all incident HL patients and 29.6% of all hgNHL patients in the population. Main exclusion criterion was age (HL: 15.2%; hgNHL: 27.4%). Only 71 HL patients (23.0%) and 11 hgNHL patients (3.4%) had actually been enrolled in the respective TOPs.

CONCLUSIONS

TOP participants do not represent all patients with hgNHL and HL in the population. TOP inclusion criteria caused considerable selection among the participants. Further investigation is required to clarify possible limitations for the application of the outcomes observed in TOP patients for all patients with these diseases.

Hodgkin's lymphoma in the elderly: The results of 10 years of follow-up

Elderly patients with Hodgkin's lymphoma carry a worse prognosis than younger patients because of a higher incidence of advanced stages, a worse performance status and the intolerance of full-dose curative treatment. A retrospective analysis of patients treated at our institution was performed. Our retrospective study summarizes the treatment results for 52 Hodgkin's lymphoma patients aged older than 60 years between 1973 and 1993. These patients were treated with combination of less toxic chemotherapy schedule (cyclophosphamide, vincristine, procarbazine and prednisone) and/or involved-field radiotherapy. The aim was to maintain an acceptable quality of life in spite of lower remission rate. The 5- and 10-year overall survival rates were 48% and 33%, respectively. We found two independent prognostic factors for overall survival: (i) stage of the disease and (ii) accomplishment of the treatment. Combined modality treatment yielded better results than chemotherapy. Tolerance of the treatment was acceptable. The present study demonstrates that a combination of mild chemotherapy with limited radiotherapy is a feasible way of treating elderly patients with Hodgkin's lymphoma.

Epstein – Barr virus infection is not the sole cause of high prevalence for Hodgkin's lymphoma in Saudi Arabia

The age-adjusted incidence of Hodgkin's lymphoma (HL) is markedly higher in Saudi Arabia than in the USA, and accounts for 10.5% of all neoplasias in children aged 15 years or older in Saudi Arabia. Epstein-Barr virus (EBV) infection has been suspected to cause high HL incidence in developing countries. To investigate the role of EBV for the high frequency of HL in Saudi Arabia, we analysed 169 HLs from Saudi Arabia and 30 HLs from Europe for EBV infection by in situ hybridization with fluorescence in-conjugated EBV on tissue microarray sections. All Saudi Arabian and European HLs were analysed in one experiment under identical conditions. Unexpectedly, our data show only minor, insignificant differences in EBV infection rates between Saudi Arabian (42 out of 147 informative cases 28.6%) and European HL (nine out of 30 informative cases; 30%; P = 0.8752). Within the Saudi Arabian population, EBV infection was most frequently seen in mixed cellularity HL (52.4%). This was significantly more frequent than in nodular sclerosing HL (26.1%; P = 0.0236). EBV positivity was unrelated to patient prognosis. In conclusion, our data strongly suggest that EBV is not the main cause for the high prevalence of HL in Saudi Arabia. This would be consistent with a major role of genetic susceptibility genes for HL in these populations. The Saudi Arabian population, with high consanguinity and large families, would prove ideal for identifying HL susceptibility genes.

Clinico-pathologic profile of Hodgkin's lymphoma in a rural medical college

PURPOSE OF STUDY

A prospective study was done at North Bengal Medical College and Hospital (NBMCH), Darjeeling, West Bengal, which caters predominantly to the rural and hilly population. All patients diagnosed as Hodgkin's lymphoma (HL) were analyzed for clinical presentation, histological classified and staging.

RESULTS

Total of 48 cases reported for HL were studied (n=48). A lower median age of onset (28.1year) and higher male to female ratio (3.8:1) as compared to western countries were observed. We found neck swelling was the commonest presenting symptom (58.28%) and peripheral lymphadenopathy was the commonest sign (83.33%). "B symptoms" was noted in 79.17% cases. Cervical lymph nodes were commonly involved (79.17%), followed by inguinal (45.83%) and axillary (29.17%). Thoracic lymph nodes and abdominal lymph nodes were enlarged in 29.17% of the cases and 25% of the cases respectively. Eosinophilia was noted in 29.17% of cases. Marrow involvement by neoplastic process was observed in 8.33% of cases and reactive changes in the marrow were observed in 12.5% of cases. We found mixed cellularity subtypes was the commonest (45.83%) followed by nodular sclerosis subtypes (33.33%). At presentation 54.17% of cases were of advanced stage of disease (stage III and IV).

CONCLUSION

We noticed a distinct geographical pattern of HL in respect of age, sex, presentation, histological typing and staging of the disease, which is comparable to some other Indian studies but is noticeably different from patterns noted in Western countries.

Up-to-date monitoring of childhood cancer long-term survival in Europe: leukaemias and lymphomas

BACKGROUND

In recent decades, following the introduction of effective chemotherapy, the prognosis of children with leukaemia and lymphoma has dramatically improved, but data reflecting further possible improvement achieved in the 1990s are scarce.

METHODS

Using the Automated Childhood Cancer Information (ACCIS) database, we carried out a period analysis of 10-year survival for the 1995-99 period. Analyses were carried out by diagnostic groups, age-group at diagnosis, sex and four European regions.

RESULTS

Ten-year survival estimates for the 1995-99 period were 73% for any type of leukaemia, 78% for acute lymphoid leukaemia and 52% for acute non-lymphocytic leukaemia. The corresponding 10-year survival rates for all types of lymphomas, Hodgkin lymphoma, and non-Hodgkin lymphoma were 84, 91 and 79%, respectively. These figures are much higher than those obtained by traditional (cohort-based) methods of survival analysis. A large difference in prognosis is still observed between the East and other parts of Europe.

CONCLUSION

Major improvement in prognosis for children with leukaemia or lymphoma has been ongoing in Europe during the 1990s, but further monitoring and investments are required to remove the large regional differences between European regions.

Clinico-pathological study of Hodgkin's lymphoma in a cancer center in Taiwan

The incidence rate of Hodgkin's lymphoma (HL) in Asia is much lower than that of western countries. This study demonstrates the incidence rate and the clinico-pathological features of HL in a cancer center in Taiwan with respect to demographics, histological subtypes and clinical outcomes. We evaluated the clinical, morphological and immunohistochemical features of 42 patients with HL during the period of 1995-2002. Clinico-pathological features and follow-up were scrutinized. There were 21 males and 21 females. The incidence rate of HL in malignant lymphoma in our center was 7%. The median age was 26 years old. There was no apparent bimodal age distribution. The most prevalent histological subtype was nodular sclerosis (69%). Mixed cellularity, lymphocyte rich, lymphocyte depletion, nodular lymphocyte predominance and unclassified was 4.8%, 4.8%, 0%, 7% and 14% respectively. The most common site at presentation was the cervical lymph node (31 cases; 74%). Clinically, 1 (2%) had stage I disease, 23 (55%) stage II, 8 (19%) stage III and 10 (24%) stage IV. Two cases had rare primary bone marrow HL of stage IV. Both cases died within 1 month. Clinical stage (P=0.09) and age (P<0.001) were prognostic parameters determining the overall survival.

Malignant lymphoma in Jordan: a retrospective analysis of 347 cases according to the World Health Organization classification

BACKGROUND

Most studies describing the subtypes of lymphoma in Jordan were carried out in the 1980s at a time when immunohistochemical facilities were unavailable. Using a database established after immunohistochemical studies were introduced, we determined the frequency of the various types of nodal and extranodal lymphomas in the adult and paediatric Jordanian population. We also assessed the incidence of bone marrow involvement at the initial presentation for each lymphoma type.

METHODS

A retrospective analysis of the histopathological subtypes of various lymphomas was conducted on all primary lymphoma cases diagnosed during a 3-year period between January 2001 and December 2003.

RESULTS

Of 347 patients included in the study, 78.4% had non-Hodgkin's lymphoma (NHL) and 21.6% had Hodgkin's lymphoma (HL). In the NHL group, diffuse large B-cell lymphoma was the most common (28.2%) followed by follicular lymphoma (15.6%). In the HL group, the nodular sclerosis variant was the most frequent (7.8%) followed by the mixed cellularity type (5.5%). Of all the lymphoma cases, the highest incidence of marrow involvement was seen in patients with lymphoplasmacytic lymphoma. Forty-nine patients were children (age <15 years) in whom Burkitt's lymphoma (15 cases) and HL (14 cases) were the commonest subtypes. One-hundred six patients with primary extranodal lymphomas (ENL) accounted for 30.5% of all lymphomas.

CONCLUSIONS

There is a higher incidence of NHL in Jordan compared with other series in the Middle East. Among the various lymphomas, diffuse large B-cell lymphoma is the most commonly encountered lymphoma in adults. Burkitt's lymphoma and Hodgkin's disease are the most frequent childhood lymphomas, followed closely by lymphoblastic lymphoma.

The link between T helper balance and lymphoproliferative disease

Lymphoproliferative disorders comprise a heterogeneous group of neoplasms whose behaviors range from indolent to very aggressive. The increased incidence seen in the context of immunodeficiency provides evidence that the host immune system plays a vital role in their pathogenesis. We believe that T-helper (Th)-2 dominant states favor development of lymphoproliferative disorders, including lymphoma, and conversely T-helper (Th)-1 immunity protects against lymphoproliferative disease. The age distribution of lymphomas favors childhood and post-reproductive senescence, suggesting that exposure to these periods of Th-2 bias constitutes a key risk factor for developing the disease. The tendency of lymphomas to arise in Th-2 biased locations such as mucosal interfaces, immunoprivileged sites, and regions of B-cell differentiation may likewise reflect a corresponding spatial predilection. Various clinical conditions or treatments that shift Th1/Th2 balance, including HIV infection, transplant-related immune suppression, and autoimmune disorders, can also influence the status of lymphoproliferative diseases.

The genetics of familial lymphomas

Whereas familial clustering of malignant lymphoma is well documented, the molecular changes underlying familial lymphoma syndromes remain unclear. An understanding of the hereditary basis of lymphoma may lead to the identification of new molecular markers for disease or novel therapeutic targets. This paper reviews the genetics of familial lymphoma, focusing on germline susceptibilities to lymphoma as well as germline susceptibilities to environmental exposures that have been linked to lymphoma.

Peripheral T-cell lymphomas expressing CD30 and CD15

Coexpression of CD30 and CD15 is typically associated with classic Hodgkin's lymphoma (HL). Peripheral T-cell lymphomas (PTCLs) can often display histologic features that simulate classic HL. However, reports of PTCLs coexpressing both CD30 and CD15 have been infrequently described. We report 11 cases of PTCL in which at least a subset of the neoplastic cells coexpressed CD30 and CD15. The patients included 4 women and 7 men and age ranged from 43 to 83 years (median, 62 years). Nine of 10 patients had advanced stage III or IV disease at presentation. Nodal involvement predominated in 8 of 11 patients, whereas 2 patients presented primarily with skin involvement. Two distinct groups were identified based on morphologic and immunophenotypic features. The first group of 5 cases had histologic features mimicking classic HL with CD30+, CD15+ Reed-Sternberg (RS)-like cells in an inflammatory background of varied extent and composition. The background lymphoid cells showed minimal cytologic atypia. The RS-like cells were negative for CD20 and CD79a in all cases, and CD45 expression was absent in 4 of 5 cases. The RS-like cells expressed CD25 and at least one T-cell-associated marker in all cases. The background T-cell population showed convincing subset predominance in 4 of 5 cases and loss of T-cell-associated antigens in 3 of 5 cases and coexpression of CD30 and CD15 in one case. The second group of 6 cases had morphologic features more in keeping with PTCL than classic HL. The proportion of neoplastic cells coexpressing CD30 and CD15 varied. Loss of T-cell antigens was noted in all cases and CD4 predominated in 4 of 5 cases. Three of the 6 cases expressed CD45. PCR analysis revealed clonal T-cell receptor gamma (TCR-gamma) chain gene rearrangements in 9 of 11 cases, but no immunoglobulin heavy (IgH) chain gene rearrangements. In situ hybridization studies for Epstein-Barr virus were negative in all cases. In some PTCL cases, the overlap with classic HL can be striking, and combined immunophenotypic and molecular studies are often necessary to confirm the diagnosis.

Cytokines : as useful Prognostic Markers in Lymphoma Cases

Cytokines are believed to be involved in the pathogenesis and enhanced expression in patients with Hodgkin's and Non-Hodgkins lymphoma. Based on this phenomenon, a multicentric study was carried out in various lymphoma cases. The diagnosis of lymphoma was made on tissue biopsies and fine needle aspiration cytology (FNAC). Out of a total of 72 cases studied, 45 were of Hodgkin's lymphoma (62.5%) and 27 cases were of Non-Hodgkin's lymphoma (37.5%). Maximum cases of Hodgkin's disease occurred in the age group of 30-40 years and males outnumbered females. Hodgkin's lymphoma cases were predominantly of mixed cellularity histologic type (46.66%) whereas majority cases of Non-Hodgkin's lymphoma were of high grade histologic type (48.14%) with predominance in the age group 51-60 years. In both these type of lymphomas, the IL-2R and IL-6 levels were found to be increased more than four fold (as compared to healthy controls) (p<0.05). The cytokine levels decreased after chemotherapy in patients showing response to therapy. However, there were few conflicting and unreliable trends in the IL-6 levels after chemotherapy where elevated IL-6 levels persisted in patients in clinical remission. Overall, it was seen that both IL-2R and IL-6 can be used as an indicator for assessing prognosis and drug therapy in lymphoma cases. IL-2R was found to be a better prognostic marker than IL-6 in assessing the response of lymphoma patient to chemotherapy, more so in Hodgkin's disease.

Hodgkin's disease in HIV

The outcome of patients with HIV-HD has improved with better, combined antineoplastic and antiretroviral approaches. New and effective antiretroviral drugs (ie, protease inhibitors), in conjunction with nucleoside analogs, improve the control of the underlying HIV infection when used during treatment of HD with chemotherapy. In fact, the possibility of reducing viral load to undetectable levels and increasing the CD4+ cell count reduces the risk of OIs during antineoplastic treatment. The inclusion of hematopoietic growth factors in the treatment of patients with HIV-HD may allow for the administration of higher dose-intensity chemotherapy and the prolonged use of antiretroviral drugs, with the aim of improving the survival. Finally, more effective antineoplastic regimens--such as high-dose chemotherapy with autologous stem cell transplantation (which is required in the case of HIV-HD, due to its aggressiveness)--should be considered to improve the response rate and disease-free survival of these patients.

Cancer incidence in adolescents and young adults in the United States, 1992-1997

PURPOSE

To examine cancer incidence patterns among adolescents and young adults in the United States.

METHODS

Cancer incidence data from 26 population-based central cancer registries for 1992-1997 were used. Individual cancers were grouped into specific diagnostic groups and subgroups using an integrated classification scheme. The integrated scheme was developed for this study and was based on the most commonly used schemes in population-based epidemiologic studies: Surveillance, Epidemiology, and End Results Program's site groups, International Classification of Childhood Cancer, and International Agency for Research on Cancer's Histological Groups for Comparative Studies. Percent distributions and age-specific incidence rates per million population were computed for adolescents (aged 15-19 years) and young adults (aged 20-24 years) by gender.

RESULTS

The data for 26,010 cancer cases were examined. Among 15-19-year-olds, the five most common cancers were Hodgkin's disease, leukemia, cancer in the brain and other nervous system, bone cancer, and non-Hodgkin's disease. Among 20-24-year-olds, the five most common cancers were Hodgkin's disease, testicular cancer, thyroid cancer, melanoma of the skin, and leukemia. The proportions and rates of the histologic subtypes for most of the common cancers changed with advancing age. For example, among 15-19-year-olds, acute lymphocytic leukemia accounted for approximately 60% of leukemias in males and 50% in females. Among 20-24-year-olds, however, the corresponding percentages of acute lymphocytic leukemia were 37% in males and 31% in females. For ovarian cancer, the germ cell tumor was the most common subtype (54.6% of all ovarian cancers) among 15-19-year-olds. In contrast, ovarian carcinoma was the predominant subtype (70.4%) among 20-24-year-olds. For both age groups, the incidence rates of nodular Hodgkin's disease, melanoma of the skin, and thyroid cancer were significantly greater in females than in males.

CONCLUSIONS

Cancer incidence patterns among adolescents and young adults are distinctive. In these age groups, a transition from predominantly pediatric histologic subtypes to adult subtypes was observed for Hodgkin's disease, leukemia, ovarian cancer, and soft tissue sarcoma. Gender differences were found for Hodgkin's disease, melanoma of the skin, and thyroid cancer.

Regional variation in the distribution of subtypes of lymphoid neoplasms in India

Lymphoid malignancies (LM) are a heterogeneous group of tumours. The relative frequencies of the various types of LMs vary across geographic regions. The pattern in India shows significant differences from the rest of the world. As India is a vast country, we set out to investigate whether there are regional differences in the relative frequencies of the various LMs. A total of 562 LMs from three different regions in India--Barshi (western India, 102 cases), Pondicherry (southern India, 156 cases) and Jaipur (northern India, 304 cases) were analysed according to the WHO classification. The non-Hodgkin lymphoma (NHL) to Hodgkin disease (HD) ratio was 6.28 in Barshi, 1.26 in Pondicherry and 2.27 in Jaipur. The frequency of HD's various subtypes did not significantly differ among the three regions. While T-cell NHLs constituted only 12.5% of NHLs at Barshi, they accounted for 31 and 27.5% of all NHLs at Pondicherry and Jaipur, respectively. There were also notable differences in the specific subtypes of NHL between the three different geographic regions in India.

Treatment of elderly Hodgkin's lymphoma patients with a novel 5-drug regimen (ODBEP): a phase II study

Elderly patients with Hodgkin's lymphoma (HL) have a worse outcome than young patients. In an effort to improve the outcome in elderly HL patients, we used a 5-drug chemotherapy regimen called ODBEP (vincristine, doxorubicin, bleomycin, etoposide, prednisone) from 1986-1995. We hoped that by increasing dose intensity through delivery of treatment without delays, and increasing the number of non-cross-resistant chemotherapeutic drugs that were selected for minimal cumulative myelotoxicity, we might improve the cure rate in elderly patients with Hodgkin's lymphoma. Comparison was made with a similar group of patients treated from 1981-1986 with MOPP/ABV-variant chemotherapy. Ninety-nine patients who were 65 years or older, were diagnosed with HL from 1981-1995. Seventy-one patients had advanced disease and 55 of this group were treated with curative intent using multi-agent chemotherapy (ODBEP = 38; MOPP/ABV-variant = 17). ODBEP and MOPP/ABV-type treatment gave a median survival of 43 and 39 months, with 5-year overall survival (OS) of 42 and 32%, respectively. There was no statistically significant difference in OS or disease specific survival between the treatments. Both treatments were well tolerated, but ODBEP was less myelotoxic. ODBEP patients had a relative risk of 0.47 of developing febrile neutropenia compared to the MOPP/ABV-variant patients. In conclusion, treatment of elderly Hodgkin's lymphoma patients with ODBEP resulted in a similar OS and disease-specific survival compared to those treated with MOPP/ABV type chemotherapy, but appeared to be less toxic.

Social class and risk of Hodgkin's disease in young-adult women in 1988-94

Hodgkin's disease (HD) risk in young adults has been associated with higher childhood social class. Although recent decades have witnessed increases in both young-adult HD incidence rates and the socioeconomic affluence reported to influence risk, social class risk factors have not been reexamined. For 204 cases and 254 controls aged 19-44 years from a population-based case-control study of HD diagnosed in 1988-94 in San Francisco area females, we evaluated social class predictors of HD overall and for subgroups defined by age and by ethnicity. HD was associated weakly with a few childhood social class markers but more strongly with combinations of these variables. Risk was higher for women with family-owned than rented childhood homes; for US-born women with single vs. shared bedrooms at age 11; and for women with 2+ births who were from smaller than larger childhood households. These patterns differed by age, with risk appearing to increase over the young-adult years for some factors and to decrease for others. In whites, risk was additionally associated with having a single childhood bedroom in larger households, and with tall adult height in women from smaller childhood households. In nonwhites, risk was higher for single bedrooms at age 11 in smaller childhood households, taller height and higher maternal education. Most study findings support the hypothesis that HD development in young adults follows protection from early exposure to other children. Variation in risk by age suggests differing etiologies across young adulthood, or the importance of birth cohort-appropriate social-class measures. Negative findings for previously reported risk factors may reflect their insufficient heterogeneity of exposure or their failure to measure cohort-relevant exposures in this population.

Lymphoma and lymphoid leukemia incidence in Florida children: ethnic and racial distribution

BACKGROUND

Incidence reports for pediatric lymphoma and lymphoid leukemia in Hispanic subpopulations in the United States are rare. The authors hypothesized that Florida's Hispanic children would have higher risks of lymphoma and lymphoid leukemia compared with non-Hispanic white children.

METHODS

All cases of lymphoid leukemia, Hodgkin, non-Hodgkin, and Burkitt lymphoma (SEER International Classification of Diseases for Oncology codes) in children (< 15 years) in the Florida Cancer Data System (FCDS) from 1985 to 1997 were studied. Cases were classified as: 1) white, 2) Hispanic, or 3) black, and stratified by age. Age-adjusted rates for the three race-ethnic groups were calculated. Rates for Hispanics and blacks were compared with whites as standardized rate ratios (SRR) with 95% confidence intervals.

RESULTS

Seven hundred thirty-one incident cases of pediatric lymphoma and 1231 cases of lymphoid leukemia were identified during the study period. For children with lymphoma, the SRR for Hispanics was 1.32 (95% CI, 1.20-1.44), and for blacks, the SRR was 0.68 (95% CI, 0.63-0.72. For lymphoid leukemia, the SRR for Hispanics was 1.29 (95% CI, 1.28-1.30), and for blacks, the SRR was 0.55 (95% CI, 0.54-0.56). Similar rates were found for the Hodgkin and non-Hodgkin subgroups.

CONCLUSIONS

Incidences of Hodgkin and non-Hodgkin lymphoma were significantly higher in Florida's Hispanic children, with 30% increased relative risks, compared with whites. Black children had significantly decreased incidences and risk. Results for lymphoid leukemia were similar. Incidence of lymphoma in Florida's Hispanic children (primarily Cuban and Central American origin) differed from similar reports from Texas and California, where Hispanics are primarily of Mexican origin.

Space-time clustering of Hodgkin's Disease in parts of the UK, 1984-1993

The object of this study was to examine cases of Hodgkin's Disease (HD) for evidence of space-time clustering of onsets by age group, sex and disease subtype. Data comprised 2024 cases of HD aged 0-79 years arising throughout the period 1984 to 1993 in the areas covered by a specialist population based register of leukaemias and lymphomas. Knox space-time analysis was used separately for 3 different age groups: childhood (0-14 years), young adult (15-34 years) and older adults (35-79 years); for adult cases separate analysis was carried out by sex and for the nodular and non-nodular sclerosing subtypes. Results showed that space-time clustering of onsets was limited to the nodular sclerosing cases. It was more prominent in young adult nodular sclerosing cases aged 15-34 years (particularly females) diagnosed in the period 1984-88, than in those diagnosed in 1989-93. We conclude that clustering may provide further evidence that an infectious process is involved in the aetiology of young adult nodular sclerosing cases of HD.

Increased incidence of Hodgkin's disease after allogeneic bone marrow transplantation

PURPOSE

Immune dysregulation associated with allogeneic bone marrow transplantation (BMT) is linked to an increased risk of posttransplant lymphoproliferative disorders (PTLD); however, reports of Hodgkin's disease (HD) after transplantation are rare.

PATIENTS AND METHODS

We evaluated the risk of HD among 18,531 persons receiving allogeneic BMT between 1964 and 1992 at 235 centers. The number of HD cases was compared with that expected in the general population. Risk factors were identified using Poisson regression and a nested case-control study.

RESULTS

Risk of HD was increased in the postBMT population compared with the general population with an observed-to-expected incidence ratio (O/E) of 6.2 (observed cases, n = 8; 95% confidence interval [CI], 2.7 to 12). A significantly increased risk of HD remained after excluding two human immunodeficiency virus-positive patients (observed cases, n = 6; O/E = 4.7, 95% CI, 1.7 to 10.3). Mixed cellularity subtype predominated (five of eight cases, 63%). Five of six assessable cases contained Epstein-Barr virus (EBV) genome. Posttransplant HD differed from PTLD by later onset (> 2.5 years) and lack of association with established risk factors (such as T-cell depletion and HLA disparity). Patients with HD were more likely than matched controls to have had grade 2 to 4 acute graft-versus-host disease (GVHD), required therapy for chronic GVHD, or both (P =.002), although analysis included small numbers of patients.

CONCLUSION

The increased incidence of HD among BMT recipients adds support to current theories which link overstimulation of cell-mediated immunity and exposure to EBV with various subtypes of HD. The long latency of HD after transplant and lack of association with risk factors for PTLD is noteworthy and should be explored further for possible insights into pathogenesis.

Incidence of haematological malignancies in French Polynesia between 1990 and 1995

To determine the incidence of haematological malignancies in French Polynesia from 1990 to 1995, we collected cases from the local cancer registry, sanitary evacuation files and all the histopathology and clinical biology laboratories. All leukaemias, non Hodgkin's lymphomas, and multiple myelomas incidence was slightly lower among French Polynesians than among Maoris from New-Zealand and Hawaiians of Hawaii. Standardised Incidence Ratio (SIR) for Hodgkin's disease among females was 0.08 when comparing to Hawaiians and 0.33 when comparing to Maoris. Other salient features were a high proportion of high grade and Burkitt's lymphoma, the absence of Hodgkin's disease after 40 years of age, a low incidence of chronic lymphoid leukaemia, and a high non lymphoblastic/lymphoblastic acute leukaemia ratio in childhood. This study stresses the peculiar incidence of some haematological malignancies in this south pacific area.

Hodgkin's disease in Turkish children: clinical characteristics and treatment results of 210 patients

Although Hodgkin's disease (HD) is one of the common malignancies in childhood, there is limited information from developing countries in English literature. The aim of this study is to give epidemiologic features and treatment results of 210 previously untreated children with HD from a developing country. Between 1 June 1984 and 31 December 1992, all children seen who were younger than 18 years old with newly diagnosed, untreated, biopsy-proven Hodgkin's disease were included in this study. A clinical staging system was used to determine the dissemination of the disease. While patients with stage I-II disease received canapé treatment protocol (three cycles COPP [cyclophosphamide, vincristine, procarbazine, prednisolone] or ABVD [doxorubicin, bleomycine, vinblastine, dacarbazine] plus low-dose involved-field radiotherapy), patients with stage III-IV disease were treated by sandwich protocol (six cycles COPP plus low-dose involved-field radiotherapy). A total of 210 patients with a median age of 8 years were eligible for this study. Male to female ratio was 3:1 and 37 (17.6%) were less than 5 years of age. The major histologic subtype was mixed cellularity (69.6%). Overall survival rates were 91.5 and 87.7%, and event-free survival rates were 71.5 and 70.5% at 5 and 10 years, respectively. No secondary malignancy has been observed so far. The prevalence of Hodgkin's disease in young children is higher and the distribution of histologic subtypes is also different from many Western countries. Canapé and sandwich treatment protocols could be used safely in clinically staged childhood HD with tolerable toxicity.

Hodgkin's disease

OBJECTIVES

To review current approaches to the diagnosis and treatment of Hodgkin's disease (HD).

DATA SOURCES

Review articles, research studies, and book chapters related to HD.

CONCLUSIONS

The treatment of HD has progressed to be one of the most successful therapies in oncology. Researchers currently seek to improve the positive outcomes of therapy while decreasing the toxicity associated with therapy.

IMPLICATIONS FOR NURSING PRACTICE

Nursing care of the patient with HD requires physical, educational, and psychological support. Within this scope of nursing care, the patient receives essential information to participate as a partner in care.

Incidence and time trends in Hodgkin's disease: from parts of the United Kingdom (1984-1993)

Over 3,000 cases of Hodgkin's Disease diagnosed between 1984-93 were used to examine incidence and time trends. These data are part of the Leukaemia Research Fund's specialist Data Collection Study, which is the only large, population-based data set of its type in Europe. The age specific incidence curves showed different patterns for nodular sclerosis contrasted with all other subtypes combined (non-nodular sclerosis). For nodular sclerosis, there was a female excess for young adults, while for non-nodular sclerosis a gradual rise in incidence with age in both sexes was observed. Incidence varied over time, showing a complex pattern with a decreasing trend in males in all Rye-subtypes and no significant change among females diagnosed with nodular sclerosis. These complex patterns of change are different from those seen in other countries. It is concluded that the results provide clear evidence of the heterogeneity of Hodgkin's disease between the sexes and between subtypes, which should be taken into account in future studies.

What causes Hodgkin's disease in children?

Hodgkin's disease is one of the commonest cancers of older children and adolescents, but little is known about its aetiology. Recent data, particularly in descriptive epidemiology and virology, tend to confirm the 'two-disease' hypothesis. Mixed cellularity Hodgkin's disease is more common, especially at younger ages, in poorer socioeconomic environments, whereas nodular sclerosing Hodgkin's disease has a higher incidence in more affluent societies. Approximately three-quarters of childhood Hodgkin's disease, and a higher proportion of the mixed cellularity subtype, may be a rare response to Epstein-Barr virus infection, together with an unidentified cofactor related to the degree of affluence of the population. Other infectious agents may be implicated in some cases. The already low incidence, especially of nodular sclerosis, among populations of East Asian ethnic origin and the high incidence, especially of mixed cellularity, among some populations of South Asian origin are apparently independent of socioeconomic status. This ethnic variation in risk suggests that genetic predisposition also plays a role. Detailed HLA studies may help to elucidate the complex variations between populations in the risk of Hodgkin's disease and its principal subtypes.