Management of localized non-Hodgkin's lymphoma: the experience at St. Bartholomew's Hospital 1972-1985

Overview of lymphoma diagnosis and management

The malignant lymphomas, including both Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL), represent a diverse group of diseases that arise from a clonal proliferation of lymphocytes. Each of the more than 30 unique types of lymphoma is a disease with a distinct natural history. This biologic heterogeneity gives rise to marked differences among the lymphomas with respect to epidemiology, pathologic characteristics, clinical presentation, and optimal management. This article emphasizes the principles of diagnosis, including appropriate pathologic evaluation and staging considerations, and focuses on the clinical presentation, staging, and optimal management strategies for the most common types of lymphoma.

Myeloablative therapy with autologous bone marrow transplantation for follicular lymphoma at the time of second or subsequent remission: long-term follow-up

PURPOSE

The aim of this retrospective analysis was to determine the outcome of patients with follicular lymphoma who received myeloablative therapy supported by autologous bone marrow transplantation as consolidation of second or subsequent remission, with a minimum follow-up of 12 years.

PATIENTS AND METHODS

One hundred twenty-one adults received cyclophosphamide (CY) and total-body irradiation (TBI) supported by autologous bone marrow transplantation, with the marrow mononuclear cell fraction having been treated with monoclonal antibodies and complement. Data from St Bartholomew's Hospital and Dana-Farber Cancer Institute were combined for the purpose of this analysis because the patients were treated in an identical manner.

RESULTS

Fifty-seven patients are alive, 41 without progression between 9 and 19 years; 64 patients have died, 20 without progression. With a median follow-up of 13.5 years, 60 patients have developed recurrent lymphoma. There is an apparent plateau on the remission duration curve at 48% at 12 years. Survival of patients treated in second remission was significantly longer than the survival of patients treated later in the course of the illness. Both remission duration and overall survival were also significantly longer for patients treated in second remission compared with an age-matched, remission-matched group of patients treated at St Bartholomew's Hospital before the introduction of this treatment. However, use of CY+TBI was associated with a significant risk of secondary myelodysplasia and secondary acute myeloblastic leukemia, resulting in 15 patient deaths.

CONCLUSION

These mature data confirm that prolonged freedom from recurrence may be achieved with myeloablative therapy and that a plateau on the curve seems to emerge with long follow-up.

Long-term follow-up of a prospective study of combined modality therapy for stage I-II indolent non-Hodgkin's lymphoma

PURPOSE

Standard therapy for patients with stage I-II indolent lymphoma has been involved-field radiation therapy (IF-XRT), which achieves 10-year disease-free survival in 40% to 50% of patients, with many of these patients cured. We investigated the potential for combined-modality therapy to increase the disease-free survival for such patients.

PATIENTS AND METHODS

A total of 102 eligible patients with stage I-II low grade lymphoma (International Working Formulation criteria) were enrolled from 1984 to 1992. Treatment comprised 10 cycles of risk-adapted chemotherapy (cyclophosphamide, vincristine, prednisone, bleomycin [COP-Bleo], and with doxorubicin added for some [CHOP-Bleo]) and 30 to 40 Gy IF-XRT.

RESULTS

The patients' median age was 56 years (range, 28 to 77), with follicular histology in 83%, bulky disease (>/= 5 cm) in 24%, and stage II in 52%. There were no treatment-related deaths and 99% of patients attained complete remission. With a median follow-up of 10 years, the 10-year time to treatment failure and overall survival were 76% and 82%, respectively. For patients with follicular lymphoma, these figures were 72% and 80%, respectively. The only factor associated with treatment failure, for follicular lymphoma patients, was stage-modified International Prognostic Factors Index score (P =.02). None of 17 patients with diffuse small lymphocytic or mucosa-associated lymphoid tissue histology have relapsed. Elevated serum beta2-microglobulin was associated with shorter survival (P <.0001). The 10-year survival after relapse was 46%. There have been two cases of myelodysplasia and 12 other new malignancies, including four arising within radiation fields.

CONCLUSION

With prolonged follow-up, combined-modality therapy with risk-adapted COP-/CHOP-Bleo and IF radiation has attained higher rates of disease control and survival than previously reported with IF-XRT alone. This apparent improvement is being further explored in an ongoing randomized trial.

Prognostic factors in localized aggressive non-Hodgkin's lymphoma

To identify the prognostic factors that specifically predict survival rates of patients with localized aggressive non-Hodgkin's lymphoma (NHL), a retrospective study including 118 patients with clinical stage I and II NHL treated at the Institute of oncology, Istanbul University between 1989 and 1998 was conducted. Patients were treated either with radiotherapy alone, radiotherapy and adjuvant chemotherapy, or chemotherapy (with or without adjuvant radiotherapy). The 5-year disease-free survival (DFS) and overall survival rates were calculated, and univariate and multivariate analyses were performed to identify the significance of various prognostic factors such as gender, age, performance status, stage (I versus II), B symptoms, extranodal involvement, gastrointestinal tract disease, erythrocyte sedimentation rate, bulky disease, histologic grade, serum lactate dehydrogenase level, serum beta2-microglobulin level, serum albumin level, treatment regimen, remission status, and the International Prognostic Index risk groups, which may have an influence on the outcome of patients with NHL. The overall 5-year survival rate was 52% with a median follow-up of 30 months. The complete response rate was 68%, and the 5-year DFS of complete responders was 70%. Cox multivariate regression analysis showed that incomplete response, low serum albumin, bulky disease (>10 cm), and high grade histology were the pretreatment factors associated with shorter survival. When remission status was included in the model, the attainment of a complete response was the major determinant of long-term survival; however, low albumin level was still a significant adverse predictor for survival in multivariate analysis. These factors need to be evaluated for analyzing the outcome of treatment and to identify better therapeutic strategies.

Management of localized low-grade follicular lymphomas

Long-term follow-up data from Stanford and other centres suggest that 40-50% of patients with clinical stages I and II follicular low-grade lymphoma can be cured by radiotherapy (RT). Relapse generally occurs outside radiation fields and most relapsed patients ultimately die from lymphoma. No randomized data exist to support adjuvant chemotherapy but only one trial of low-intensity chemotherapy was sufficiently powerful to address the question. Nevertheless, data from a large phase-II study from MD Anderson suggest that combined chemotherapy and RT can produce progression-free survival results that are far superior to historical series, with survival at 10 years to be approximately 20% superior to radiation alone. These results have encouraged the development of a joint phase III study by the Trans Tasman Radiation Oncology Group (TROG) and the Australasian Leukaemia and Lymphoma Group (ALLG) in which patients with clinical stage I/II follicular lymphoma are randomized to involved field RT with or without six cycles of cytotoxic chemotherapy. In an era of rapid development in immunological and molecular therapies the potential for improved results with new combinations of more established treatment modalities should not be forgotten. This report reviews the literature on the management of localized low-grade lymphoma and discusses the rationale for the TROG/ALLG study, which began recruitment in early 2000.

MALT Lymphomas

This review addresses the biology and the treatment of lymphomas arising from mucosa-associated lymphoid tissue (MALT). This entity, first described in 1983, represents about 8% of all non-Hodgkin's lymphomas and was recently re-classified as "extranodal marginal zone lymphomas of MALT-type." The term marginal zone lymphoma (MZL) encompasses the three closely related lymphoma subtypes of nodal, primary splenic and extranodal lymphomas of MALT type: the latter represent the vast majority of MZL. These lymphomas arise at different anatomic sites, are composed of mature B-cells lacking expression of CD5 and CD10, often present with overlapping morphologic features, but typically quite distinct clinical behaviors. Only very recently cytogenetic/molecular genetic observations have underlined the distinctiveness of these three lymphoid neoplasms, which in both the R.E.A.L. and WHO-classifications are included in the general term of MZL. MALT lymphomas arise in numerous extranodal sites, but gastric MALT lymphoma is the most common and best studied and is, therefore, the paradigm for the group as a whole. Dr. Isaacson describes the principal histological features of these lymphomas, including criteria to distinguish this entity from other small B-cell lymphomas. Several lines of evidence suggest that gastric lymphoma arises from MALT acquired as the result of aH. pyloriinfection. However, at least 1/3 of cases do not respond to eradication ofH. pylori. Very recent data suggest that both t(11;18) (q21;q21) and bcl10 nuclear expression are associated with failure to respond to this treatment. Dr. Gascoyne discusses the biologic function of proteins deregulated through the different translocations, which play a role in pathogenesis of MALT lymphomas, emphasizing particularly their influence in disrupting the apoptotic pathway. Dr. Zucca reviews findings suggesting that MALT lymphoma is an antigen driven neoplasm. He also presents specific guidelines for treatment of gastric lymphomas trying to shed some light on the amazingly inconsistent and confusing data in the literature. Taking advantage on the more than 300 non-gastric MALT lymphomas collected by the International Extranodal Lymphoma Study Group (ILESG), Dr. Cavalli compares gastric lymphomas with those arising in many other sites. Overall, the data presented in this session will underline the fact, that MALT lymphomas are characterized by some unique biological properties.

Expression of LFA-1 identifies different prognostic subgroups in patients with advanced follicle center lymphoma (FCL)

In a retrospective immunohistochemical study based on 27 patients with stage IV follicle center lymphoma (FCL) the expression of CD44standard (CD44s), LFA-1 (CD11a, CD18), VLA-4 (CD49d, CD29) and ICAM-1 (CD54) was analysed on lymphoma cells in bone marrow infiltrates. The results were correlated to clinical data and overall survival. Our data demonstrate that the expression of LFA-1 on lymphoma cells is predictive for the prognosis of patients with advanced FCL. In detail, patients exhibiting weak to moderate expression (+/++) of CD11 and CD18 showed a significantly shorter median survival (51 months and 33 months, respectively) than did those presenting with strong expression ( ) of the LFA-1 adhesion molecule (P = 0.04 and P = 0.0051, respectively). Furthermore, multivariate analysis identified CD18 as a new independent prognostic factor in patients with advanced FCL. Our findings emphasize the relevance of adhesion molecules for the pathology of FCL and give further support for their impact on clinical course and overall survival.

Overview of treatment of localized low-grade lymphomas

The results of treatment of localized low-grade lymphoma have been reviewed with particular emphasis on the results of long-term follow-up of patients treated with radiation therapy at Stanford University. These data and results from numerous other centers suggest that 40% to 50% of patients with stage I and II follicular low-grade lymphomas can expect to achieve clinical cure of their disease with radiation therapy. Randomized trials published to date do not support the use of adjuvant chemotherapy. Although a policy of initial observation with deferral of treatment until the occurrence of disease progression is a well established approach to patients with advanced disease, no randomized studies exist that support this as a safe alternative to radiation therapy for early stage disease. New systemic therapies are required for the treatment of occult disease to prevent the occurrence of relapse outside of irradiated volumes.

High rate of prolonged remissions following combined modality therapy for patients with localized low-grade lymphoma

PURPOSE

Involved field (IF) radiation can cure as many as 40% to 50% of patients with stage I-II low-grade lymphoma. We sought to improve these results by prospectively evaluating the combination of IF radiation and chemotherapy consisting of 10 courses of cyclophosphamide, vincristine, prednisone, and bleomycin, with doxorubicin added in a risk-adapted manner (COP/CHOP-Bleo).

PATIENTS AND METHODS

From 1984 until December 1992, 91 patients, median age 56 years (range 28 to 77 years), with clinical stage I-II low-grade lymphoma were treated. No patients were excluded on the basis of age or organ function.

RESULTS

A complete response was attained in 99% of evaluable patients. Treatment-related toxicity was mild, and no deaths occurred during therapy. With a median follow-up of 60 months, there have been only 16 relapses. The actuarial freedom from relapse rate at five years is 82% (95% confidence interval 71% to 89%) and at 10 years is 73%. At five years the overall survival rate is 90% (95% confidence interval 81% to 95%) and at ten years it is 82%. Of the clinical features examined, only older age (> 56 years; p = 0.07) was associated with shorter survival. No features examined were predictive of disease relapse.

CONCLUSION

The combination of IF radiation and risk-adapted COP/CHOP-Bleo chemotherapy is well-tolerated, produces a very high rate of complete remission, and with a median follow-up of five years, has produced lower rates of relapse and better overall survival than has been reported for IF radiation alone in patients with clinically-staged I-II low-grade lymphoma.

High-grade non-Hodgkin's lymphoma stage I. A retrospective study of treatment, outcome and prognostic factors in 213 patients

In a retrospective study of 213 patients with high-grade non-Hodgkin's lymphomas clinical stage I, diagnosed 1985-1990, pretreatment prognostic variables and result of treatment were analysed. The median age of the patients was 67 years. Treatment consisted of radiotherapy in 61%, chemotherapy (10%) chemotherapy followed by radiotherapy (23%) and surgery alone (5%) of the patients. Complete response was achieved in 89% of the patients with estimated relapse-free survival at 5 years of 73%. Relative 5-year survival of all patients was 73%. After chemotherapy followed by radiotherapy the relapse rate was 15% compared with 29% after radiotherapy only. The 5-year relative survival differed between 58% and 74% in the treatment groups. Age, sex, nodal versus extranodal lymphoma, systemic symptoms, bulk of tumor and level of serum lactic dehydrogenase (s-LDH) were analysed as prognostic factors. In multivariate variate analysis, only age 65 years or older and elevated s-LDH were significant independent adverse prognostic factors.

Non-Hodgkin's lymphomas (NHL)

This synthesis of the literature on radiotherapy for non-Hodgkin's lymphomas is based on 158 scientific articles, including 16 randomized studies, 18 prospective studies, and 90 retrospective studies. These studies involve 14,137 patients. Non-Hodgkin's lymphomas are highly radiosensitive, and local recurrence following radiotherapy is unusual. Radiotherapy probably cures approximately 50% of both low-grade and high-grade malignant NHL at stage I. Involved field is apparently sufficient, however, higher doses are required for high-grade malignant lymphomas. Chemotherapy is recommended for stage II. Consolidation radiotherapy after chemotherapy may increase the number of complete remissions. The value of adjuvant radiotherapy has not been confirmed. Radiotherapy plays a limited role at stages III and IV. Radiotherapy is clearly indicated for extranodal localized disease in the skin and in the orbit of the eye. It is important to identify groups and subgroups in whom radiotherapy alone is sufficient, ie, the risk for distant recurrence is small. MALT lymphoma belongs to this group. Radiotherapy is often valuable in palliative situations.

Non-Hodgkin's lymphomas--current status of therapy and future perspectives

Non-Hodgkin's lymphomas (NHL) are a heterogeneous group of disorders which can either be classified according to their biology, represented by corresponding counterparts of normal lymphocyte development as in the Kiel classification, or according to their clinical course, used in the Working Formulation. The recently proposed Revised European-American Lymphoma (R.E.A.L.) classification may unify both aspects and facilitate the comparability of international studies. Besides histology, the extent of disease still comprises the major determinant of therapy. In high-grade lymphomas combination chemotherapy with cyclophosphamide, hydroxydaunorubin, vincristine and prednisone (CHOP) represents the treatment of first choice, and may be restricted to 3-4 cycles in patients with limited stages of the disease when followed by involved field radiotherapy. In more extended, bulky stage II to IV disease, treatment must be extended to six courses of CHOP and, potentially, additional irradiation. Even in advanced states of the disease, long-term remission and potential cure are achieved in 30-50% of cases. In low-grade lymphomas, most patients present with advanced stages III and IV for which chemotherapy can be applied with palliative intention only. Hence, a watch-and-wait approach still seems appropriate outside clinical investigations until the disease requires a therapeutic intervention. This consists preferentially of chemotherapy of moderate intensity such as cyclophosphamide, vincristine and prednisone (COP) or prednimustine and mitoxantrone (PmM). In responding patients, maintenance therapy with interferon-alpha is currently being explored and may result in prolongation of disease-free and, possibly also, overall survival. In both high- and low-grade lymphomas, intensification of therapy by myeloablative chemotherapy or combined chemoradiotherapy followed by autologous bone marrow transplantation (ABMT) or peripheral stem cell transplantation provides a promising and potentially curative prospective. In addition, new cytostatic agents such as the purine analogues--fludarabine, chlorodeoxyadenosine and deoxycoformycin--enlarge the therapeutic spectrum. More experimental approaches consist of the application of immunotoxins or radioisotypes, coupled to monoclonal antibodies directed against lymphoma-specific antigens. Overall, the substantial advances that have been achieved in the understanding of the biology and pathogenesis of malignant lymphomas, as well as the current achievements of therapy and the new promising perspectives, justify the hope that curative therapy can soon be offered to an increasing proportion of patients with NHL.

Presenting features, natural history, and prognostic factors in localized non-Hodgkin's lymphomas: analysis of 117 cases from a single institution

Clinical features and prognostic factors were analyzed in a series of 117 patients with localized non-Hodgkin's lymphoma (stage I-II). Median age of the patients was 53 years and 52% were men; 22% had a lymphoma of low-grade histology and one-third presented with extranodal involvement. Eighty percent of the patients achieved a complete response (CR); stage of disease and histology were revealed as the most important factors for response. When analysis was restricted to intermediate/high-grade cases, stage showed a predictive value for response. With a median follow-up of 4.5 years, median overall survival was 12.0 years, with 73% and 62.5% of patients being alive at 5 and 10 years, respectively. Main initial parameters significantly related to a shorter survival were intermediate/high-grade histology, stage II, poor performance status, bulky disease, high serum LDH levels, increased ESR, and advanced International Index. In the multivariate analysis, stage, histology and performance status (PS) were statistically significant. Among intermediate/high-grade lymphoma patients, stage and PS provided prognostic value for survival. Twenty-six patients relapsed after CR; median survival after relapse was 2.7 years. Stage (I vs II) was the only predictive variable for relapse in both the whole series and the intermediate/high-grade subset.

Long term assessment of patterns of treatment failure and survival in patients with stage I or II follicular lymphoma

BACKGROUND

Follicular lymphoma is a clearly defined type of malignant lymphoma. The many treatment approaches reported in the literature attest to the lack of agreement on its best management. The treatment experiences of patients with Stage I or II follicular lymphoma who were at risk for at least 5 years were reviewed to assess their survival, disease free survival, and patterns of failure.

METHODS

Between 1974 and 1988, 144 patients with Stage I or II follicular lymphoma were treated at The University of Texas M. D. Anderson Cancer Center. Initial staging studies included lymphangiography in 87% of the patients, computerized tomography of the abdomen and pelvis in 60%, bone marrow biopsy in 98%, and diagnostic or staging laparotomy in 33%. Forty-five patients were treated with regional radiotherapy, 84 patients with combined chemotherapy and radiotherapy, and 15 patients were treated with chemotherapy alone.

RESULTS

With a median follow-up of 8.7 years (range, 48-182 months) the actuarial survival rates at 5, 10, and 15 years were 81, 69, and 63%, respectively. The freedom from relapse (FFR) rates were 66, 56, and 46%, respectively. The FFR rate was better for patients treated with chemotherapy-radiotherapy than for patients treated with radiotherapy alone (63 vs. 35% at 15 years). In addition, there were no relapses after 7.5 years in patients treated with chemotherapy-radiotherapy, but relapses continued even beyond 15 years in patients treated with radiotherapy alone. Univariate analysis for each of the treatment groups revealed age to be the only significant prognostic factor. There was no significant difference in survival or disease free survival rates for the three histologic subtypes of follicular lymphoma.

CONCLUSION

The addition of chemotherapy to radiotherapy may have increased the probability of cure for patients with Stages I or II follicular lymphoma.

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.

Mantle cell lymphoma: natural history defined in a serially biopsied population over a 20-year period

BACKGROUND

The histological, immunological and molecular characteristics of mantle cell lymphoma have only recently been delineated. Amongst these characteristics possible factors of prognostic significance include histological growth pattern and blastoid change.

PATIENTS AND METHODS

66 previously untreated cases of mantle cell lymphoma were identified in a retrospective analysis. In 50 cases serial biopsies had been taken during the disease and in 20 cases autopsies had been performed. Besides established factors of prognostic significance, histological growth pattern and blastoid change were examined.

RESULTS

32 patients achieved an initial complete remission or good partial remission with most cases relapsing or progressing within 2 years. The median survival was 36 months. Factors predicting a poor outcome were high presenting stage, age > 70, low sodium, low albumin and splenomegaly. Blastoid transformation was also a poor prognostic feature, occurring in 32% of cases during life and in 70% of autopsies. Histological growth pattern had no influence on outcome.

CONCLUSION

This study emphasises the difficulties in treating mantle cell lymphoma and the high frequency and prognostic importance of histological transformation.

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)

Clinical stage 1 non-Hodgkin's lymphoma: long-term follow-up of patients treated by the British National Lymphoma Investigation with radiotherapy alone as initial therapy

A retrospective analysis was performed of 451 adult patients with clinical stage 1/1E non-Hodgkin's lymphoma treated initially with radiotherapy alone. Histopathologically 208 patients had low-grade disease and 243 patients high-grade disease. The complete remission (CR) rate was higher in patients with low-grade disease (98%) than in those with high-grade disease (84%) (P < 0.0001). The relapse rate was similar in both histological categories, and relapse usually occurred within 5 years. The resulting overall actuarial percentage of patients achieving CR and remaining disease free (at 10 years) was 47% in patients with low-grade disease and 45% for those with high-grade disease. Salvage therapy was frequently successful in younger patients, and the overall cause-specific survival at 10 years was 71% for low-grade disease and 67% for high-grade disease. In those patients under 60 years of age at diagnosis, the overall cause-specific survival at 10 years was 84% and 80% for those with low-grade and high-grade disease respectively. These long-term results in young patients with clinical stage 1 disease are encouraging, and it will be difficult to demonstrate improved survival with initial chemotherapy either with or without radiotherapy, until new prognostic factors are found to identify poor-risk patients.

Primary digestive tract lymphoma: a prospective multicentric study of 91 patients. Groupe d'Etude des Lymphomes Digestifs

BACKGROUND

The optimal management of primary gastrointestinal lymphoma including the use of surgery remains unsettled. This prospective study aimed to determine the prognostic factors of primary gastrointestinal lymphoma and to evaluate a therapeutic strategy based on surgical tumor reduction, followed by chemotherapy adapted to the histological type of tumor and tumor removal or nonremoval.

METHODS

Ninety-one patients were included (mean age, 50.4 years) with mainly gastric (61%) or several digestive tract organ (18%) involved sites in clinical stages IE (43%), IIE (27%), and IV (30%). Three therapeutic groups were defined: group I, patients with low-grade lymphoma (n = 28); group II, patients with high-grade lymphoma who had complete tumor removal (n = 24); and group III, patients with high-grade lymphoma who had only partial or no tumor removal (n = 39). Each group underwent adapted chemotherapy.

RESULTS

The respective overall 5-year survival rates for groups I, II, and III were 81% +/- 6%, 100%, and 56% +/- 8%, respectively (P < 0.0001). By Cox multivariate analysis, the prognostic factors of survival were age under 65 (P < 0.05), gastric localization (P < 0.05), stage IE (P < 0.001), and radical or incomplete surgery (P < 0.01).

CONCLUSIONS

Combined radical surgery and chemotherapy according to histological grading is associated with prolonged remission in patients with primary digestive tract lymphoma. Moreover, compared with chemotherapy alone, incomplete resection of tumor is associated with increased survival of high-grade lymphomas.

E-SHAP: inadequate treatment for poor-prognosis recurrent lymphoma

BACKGROUND

The treatment of refractory and recurrent lymphomas remains problematic, with the majority of patients showing no response to 'salvage' therapies. One regimen which has been suggested as showing particular efficacy is etoposide (40 mg/m2 daily x 4), cytosine arabinoside (2.0 g/m2 one dose), cisplatin (25 mg/m2/day infused over 4 days) and methylprednisolone (500 mg daily x 4) (E-SHAP). This study attempted to reproduce the encouraging results seen with this regimen in North America.

PATIENTS AND METHODS

Twenty-eight patients with recurrent or refractory lymphoma were treated with E-SHAP given 3 to 4 weekly. Thirteen patients were treated at first recurrence and twenty-two had previously received etoposide.

RESULTS

No objective responses were seen although five patients had a transient reduction in tumour before regrowth despite continued treatment. Sixteen patients received further chemotherapy after failure of E-SHAP of whom four had responses. The principal toxicity was myelosuppression with over half the patients requiring hospital admission for neutropenia-associated fever. Median time to treatment failure was 2.5 months and median survival 7 months from the start of E-SHAP.

CONCLUSIONS

These results are in marked contrast to those reported from North America, possibly due to differing patient selection. E-SHAP shows strictly limited efficacy but marked toxicity in the treatment of recurrent or refractory lymphomas with poor prognostic features.

Primary lymphoma of the penis with rationale of treatment

Appropriate care of a patient with primary lymphoma of the penis requires consideration of the diagnoses, thorough evaluation, and knowledge of the various therapeutic approaches. A patient is presented with brief review of similar cases together with the rationale for the use of radiation therapy and chemotherapy rather than surgery.

New approaches to the treatment of follicular lymphoma

The major avenues of clinical research into the treatment of follicular lymphoma, 'more, if so when?', interferon therapy, and antibody therapy, have been presented in the light of present knowledge about the clinical course of the disease. They must be seen within the context of the current philosophical approach to the illness, and the economic climate which prevails, at a time when new drugs, for example fludarabine (Leiby et al, 1987; Reman et al, 1988; Whelan et al, 1991), are showing promise, and differentiating agents are being tested in remission (Cunningham et al, 1985). There can be little doubt that the objective of future research should be to eliminate the disease altogether at the time of initial presentation, since patients entering remission and never having a recurrence have a far greater probability of longevity than those in whom recurrences occur (Lister, 1991). There can also be little doubt that when lymphoma is present and causing symptoms, treatment should be given, since survival is longer for those in whom a response is achieved, at least at presentation, and at first recurrence (Lister, 1991). Since the latter is sadly the reality for the majority, improving treatment at the time of recurrence must also be a priority. Time will tell whether any of the options presently under investigation will be appropriate at all, and if so when. It is certainly the case that some of them will be entirely inappropriate for some patients, because the risk of toxicity will outweigh the potential benefit, especially for the elderly. Further careful identification of prognostic variables may allow for individualization of therapy. It would be comforting to know that the newly found molecular marker of the disease would help us. Its absence may do--but its presence certainly does not, since t(14;18) containing cells may seemingly be present for many years of clinical normality (Price et al, 1991, in press). The challenge to find the right treatment at the right time--or perhaps to identify the 'right patient' for the therapy continues.

Stage I-II low-grade lymphomas: a prospective trial of combination chemotherapy and radiotherapy

Between 1984-1989, 44 patients with stage I-II low grade lymphoma were treated prospectively with sequential chemotherapy and involved-field radiotherapy. The chemotherapy was cyclophosphamide, vincristine, prednisone, and bleomycin (COP-Bleo); doxorubicin was included (CHOP-Bleo) for patients with adverse prognostic features (high LDH; extranodal sites; bulky nodes). Of the 44 patients, 37 had measurable disease and all have responded. With a median follow-up of 32 months, the 5-year survival and failure-free survival were 89% and 74%, respectively. Compared to past experience with involved-field radiotherapy alone, the failure-free survival is significantly better with COP-Bleo plus radiotherapy. The potentially cured fraction has risen from 40% to 74%.

Continuous cyclophosphamide, doxorubicin, vincristine, and prednisolone. A new, innovative protocol for diffuse aggressive lymphomas

One hundred eight patients with aggressive non-Hodgkin's lymphoma (high and intermediate grade) were treated with a new protocol: continuous cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP). They were evaluated for long-term survival and pretreatment characteristics predictive of response and survival. Continuous CHOP protocol consists of initial 8 weeks of intensive chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisolone, followed by local/cranial radiotherapy and maintenance therapy. Complete remission (CR) was achieved in 84 of 108 (78%) patients; seven (6%) had a moderate response and 17 (16%) had a poor response. A statistically significant difference in CR rate was found only in patients with different stages. Seventeen of 84 (20%) complete responders have had a relapse of the disease. The median survival has not been reached. Results show an actuarial disease-free survival (DFS) of 77% for the 84 patients who had a complete response. The overall survival for all patients was 53% at 5 years of follow-up. The difference in DFS at the end of 5 years between different stages, main histologic subgroups, and age groups was not statistically significant. The toxicity observed was acceptable. Thus continuous CHOP appears to be an effective protocol for the treatment of intermediate-grade and high-grade lymphomas.

Lymphoplasmacytoid and small cell centrocytic non-Hodgkin's lymphoma--a retrospective analysis from St Bartholomew's Hospital 1972-1986

Lymphoplasmacytoid (lpc) and small cell centrocytic (scc) lymphoma are the two major sub-types of diffuse low grade non-Hodgkin's Lymphoma (NHL) within the Kiel classification. The presentation features and outcome for all 112 patients with these diagnoses (60 lpc, 52 scc) managed at St Bartholomew's Hospital between 1972 and 1986 are presented. The outcome for these patients is compared with that for patients with follicular and high grade lymphomas managed at this hospital during the same period. Nineteen of the 112 patients had localized (stages I-IIE) disease. In 18 of these cases the primary site of disease was extranodal, the gastrointestinal tract being involved in 12 cases. The survival for patients with localized disease was excellent. Eighteen are currently alive with median follow-up of 8 years. Ninety-three patients had advanced disease. A high incidence of splenomegaly, hepatomegaly, bone marrow and peripheral blood involvement was observed in both histological subgroups. A monoclonal paraprotein band was detected in the serum of nearly 50 per cent of patients with advanced lpc lymphoma. Patients with advanced disease were treated with either chlorambucil or cyclophosphamide, vincristine and prednisolone (CVP). The outcome was similar for both histological groups. Survival for these patients was poor (median 40 months) with less than 20 per cent surviving 5 years. Advanced age, elevated aspartate transaminase and failure to respond to treatment were identified by multivariate regression analysis as adverse prognostic factors.