The low-grade lymphomas

Evolving role of radiation therapy for hematologic malignancies

Radiation therapy continues to play a paramount role in the therapy of hematologic malignancies, whether as definitive therapy, as consolidation after chemotherapy, as part of bone marrow transplantation protocols, or in palliation. During the past 2 decades, significant advances in radiation therapy have occurred, including the evolution of involved-field irradiation and the adoption of conformal radiation administration. It is hoped that modern techniques will reduce the long-term sequelae associated with radiation-based treatments.

A prospective randomized study to compare the molecular response rates between central lymphatic irradiation and intensive alternating triple chemotherapy in the treatment of stage I–III follicular lymphoma

PURPOSE

This study was undertaken to compare the molecular response (MR) rates of 2 regimens, central lymphatic irradiation (CLI) and alternating triple therapy (ATT), in the treatment of Stage I-III follicular lymphoma. MR was defined as disappearance of t(14;18) (q32;q21) amplified by polymerase chain reaction (PCR).

PATIENTS AND METHODS

Sixty-five patients with Stage I to III follicular lymphoma were randomized. CLI consisted of the mantle, abdomen, and pelvic radiation fields. ATT alternated among CHOD-Bleo, ESHAP, and NOPP for 12 courses. Bone marrow (BM) and peripheral blood (PB) samples were obtained before treatment for PCR analysis. PCR-positive patients were followed by PCR analysis. The random-effects logistic model was fitted to the data from the posttreatment PCRs. The factors included in the model were treatment arm, type of PCR (BM vs. PB), and time to PCR sample procurement from the date of registration.

RESULTS

At a median follow-up of 71 months, the 5-year relapse-free survival (RFS) rates were 45% and 54% for CLI and ATT, respectively (p = 0.42). The probability of attaining an MR increased with time after registration (p = 0.007), was lower for BM compared with PB (p = 0.012), and was higher for ATT than for CLI (p = 0.020).

CONCLUSION

ATT regimen achieved a higher MR than CLI, although both arms had similar 5-year RFS.

Stage III follicular lymphoma: long-term follow-up and patterns of failure

PURPOSE

To analyze the long-term outcomes and pattern of failures for Stage III follicular lymphomas.

METHODS AND MATERIALS

A retrospective review of all patients with Stage III follicular lymphoma presented to our institution between 1978 and 1993 was performed. One hundred ten patients were eligible and form the basis of this analysis. Fifty-seven patients were male. The median age was 57 years (range: 21-82 years). The treatments were as follows: chemotherapy alone (CTX), 39 patients; combined modality with chemotherapy and radiation therapy (CMT), 69; radiation therapy alone, 2. Radiation therapy fields were as follows: regional, 13 patients; extended, 6; subtotal, 44; and central lymphatic, 8. The median number of chemotherapy cycles was 8, and 98 patients received doxorubicin-containing regimens. Enough information was available to calculate the International Prognostic Index for 107 patients. The following prognostic factors were examined for predictive value in overall survival (OS) and freedom from progression (FFP) by univariate and multivariate analyses: International Prognostic Index, gender, lactate dehydrogenase (LDH) (normal vs. elevated), B symptoms, performance status, beta-2 microglobulin, presence or absence of a bulky disease, age (</= vs. >60 years), number of sites of involvement, treatment (CTX vs. CMT), and pathology. To minimize patient selection biases given the nature of the retrospective analysis, the patterns of relapse were analyzed only for the patients who achieved a complete response.

RESULTS

The median follow-up for the alive patients was 9.5 years (range: 1.1-19.5 years). Complete response was achieved in 80 patients: 24 of 39 patients in the CTX group (62%), 54 of 69 patients in the CMT group (78%), and 2 of 2 patients in the radiation therapy alone group. The actuarial 5- and 10-year OS rates were 65% and 42%, respectively. The 5- and 10-year FFP was 42% and 26%, respectively. Significant prognostic factors by multivariate analyses were age and LDH for OS and LDH for FFP. For complete responders, 5-year freedom from recurrence in the original sites of involvement (with or without recurrence in the new sites) was 43% for CTX and 60% for CMT patients (p = 0.03, Wilcoxon). Five-year freedom from isolated recurrence in the original sites of involvement was 60% for CTX and 69% for CMT patients (p = 0.17). The 5-year overall FFP was 43% for CTX patients and 56% for CMT patients (p = 0.06).

CONCLUSION

Combined modality treatment seems to give an advantage in terms of disease control in the primary sites compared to chemotherapy alone, though the advantages in OS and FFP were not statistically significant in our patient population. By multivariate analyses, LDH was a significant prognostic indicator for OS and FFP, whereas age was for OS.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Combined therapy in advanced stages (III and IV) of follicular lymphoma increases the possibility of cure: results of a large controlled clinical trial

OBJECTIVES

We evaluate the long-term results of a randomized clinical trial in patients with advanced stages (III and IV) of follicular lymphoma using chemotherapy or combined therapy (chemotherapy following by adjuvant radiotherapy in patients with nodal bulky disease).

MATERIAL AND METHODS

Between 1981 and 1995, patients with follicular lymphoma were treated with combined chemotherapy, mostly anthracycline-based regimens; patients who achieved complete response were randomly assigned either to receive adjuvant radiotherapy to sites or to nodal bulky disease or not (control group).

RESULTS

Four hundred and sixty-nine patients were randomized; in an intent-to-treat analysis all were evaluable for efficacy and toxicity. Actuarial curves at 20yr showed that event-free survival (EFS) and overall survival (OS) in the control group were 41% [95% confidence interval (CI) 36-56%) and 71% (95% CI 65-78%), respectively; these were statistically different from results for the patients who received adjuvant radiotherapy: 68% (95% CI 62-72%) and 89% (95% CI 79-96%), respectively (P<0.01). Acute and late toxicity were minimal; only four patients (<1%) developed myelodysplastic syndrome/acute leukemia. Cardiac toxicity was 2%, but one case was lethal. Thirty-six patients (8%) died secondary to unrelated causes, in complete remission.

CONCLUSIONS

The use of adjuvant radiotherapy in patients with poor-prognosis follicular lymphoma increases EFS and OS with minimal toxicity. We feel that follicular lymphoma should be treated curatively because <80% of patients will be in first complete response at <20yr. The use of adjuvant radiotherapy will be considered in the first line of treatment in this set of patients.

Salvage extended-field irradiation in follicular non-Hodgkin's lymphoma after failure of chemotherapy

PURPOSE

To evaluate the efficacy of total abdominopelvic (TAI) and total body irradiation (TBI) in heavily pretreated follicular non-Hodgkin's lymphoma (NHL).

PATIENTS AND METHODS

From 1983 to 1998, 34 patients received TAI (n = 22) or TBI (n = 12). All had Stage III or IV, Class B, C, D NHL in the working formulation and failed after receiving 1-5 regimens of chemotherapy. TAI was given at 20 Gy over a 3-week period. TBI was delivered in two successive half-body irradiations of 15 Gy over a 2-week period with a 4-week interval between each.

RESULTS

Mean follow-up from TAI or TBI was 120 months (range, 6-180). Seventy-six percent of patients achieved complete response and 24% partial response. Median survival was 62 months, 5-year and 10-year overall survival was 59% and 41%, and disease-free survival was 56% and 30%, respectively. Grade III or IV toxicity was gastrointestinal in 38% of patients and hematologic in 30%. No toxic death or delayed complications were observed.

CONCLUSION

Extended-field irradiation is feasible and efficient after failure of chemotherapy in follicular NHL.

Salvage central lymphatic irradiation in follicular lymphomas following failure of chemotherapy: a feasibility study

PURPOSE

Management of follicular lymphoma after chemotherapy failure has been controversial and has ranged from watchful waiting to high-dose chemotherapy. High-dose chemotherapy with bone marrow reconstitution may produce clinical and molecular complete responses at the risk of serious morbidity and mortality. It has been previously reported that central lymphatic irradiation (CLI) can achieve long-term relapse-free survival in patients with Stage I, II, or III follicular lymphoma. Therefore, we investigated the feasibility of treating patients in whom front-line chemotherapy failed with salvage CLI instead of instituting more intensive chemotherapy.

METHODS AND MATERIALS

Salvage CLI with curative intent for patients with follicular lymphoma was started at The University of Texas M. D. Anderson Cancer Center in 1992. Eleven patients whose disease showed poor response to or relapsed after chemotherapy were managed with this approach. The median age of the patients was 61 years. Criteria for exclusion included bone marrow involvement or other evidence of Ann Arbor Stage IV disease at any time during the course of the disease. Overall survival and relapse-free survival were calculated from the first day of CLI.

RESULTS

Ten patients were alive at a median follow-up of 25 months (range 9-73 months). The treatment was well tolerated in general. Two patients could not complete CLI: one 75-year-old patient owing to prolonged platelet count depression and deterioration in general medical condition, and a 66-year-old patient because of exacerbation of preexisting pancytopenia and worsening of heart disease. Everyone who completed CLI remains in remission at the time of this report, except for one patient who had a relapse in the right lacrimal gland at 32 months. This patient was treated with local radiation therapy and is free of disease. Eventual recovery of the blood counts was observed for the patients who completed CLI.

CONCLUSION

These results demonstrate for the first time that with CLI, it is possible to achieve complete remission of acceptable quality in follicular lymphoma patients who experience a chemotherapy failure. The main toxicity is limited to transient depression in hematological profiles. The treatment is fairly well tolerated and seems to carry little risk compared with high-dose chemotherapy and bone marrow rescue. Salvage CLI may not necessarily compromise future treatment with chemotherapy, including autologous bone marrow or stem cell transplantation, because the patients' blood counts recover.

Non-Hodgkin's lymphoma of the head and neck: a 30-year experience at the University of Florida

BACKGROUND

Outcome in previously untreated patients with non-Hodgkin's lymphoma of the head and neck needed to be assessed.

METHODS

A retrospective review was performed of 79 patients with stage I or II non-Hodgkin's lymphoma of the head and neck treated between 1964 and 1994 with radiotherapy (RT) or combined modality therapy (CMT) at the University of Florida. Freedom from relapse, cause-specific survival, and absolute survival were analyzed by the Kaplan-Meier method. Patterns of failure were defined, and the relationship between dose and infield recurrence was studied. Histology was classified as low grade or intermediate/high grade.

RESULTS

At 10 years, absolute survival for patients with low-grade lymphoma treated with RT was 45%; absolute survival for patients with intermediate/high-grade lymphoma was 41% for those treated with RT and 57% for those who received CMT. Twenty-seven patients had a recurrence of lymphoma after initial treatment. Twenty patients (74%) had recurrences outside the radiation treatment field; 90% of these failures were in predictable sites that would be included in comprehensive lymphatic irradiation fields (Waldeyer's ring, mantle, and whole abdomen). No clear dose response was observed. Multivariate analysis showed that patients with tumors <5 cm in diameter had improved cause-specific survival, absolute survival, and freedom from relapse compared with patients with tumors > or = 5 cm in diameter.

CONCLUSIONS

Patients with non-Hodgkin's lymphoma in the head and neck with tumors > or = 5 cm in diameter appear to have a worse prognosis than those with smaller tumors. The patterns of failure suggest that initial treatment with comprehensive lymphatic irradiation fields could potentially eliminate the majority of treatment failures.

Apoptosis and the Bcl-2 gene family -- patterns of expression and prognostic value in stage I and II follicular center lymphoma

PURPOSE

The prognostic significance of spontaneous levels of apoptosis and Bcl-2, Bax, and Bcl-x protein expression in follicular center lymphoma (FCL) is unknown. The objectives of this retrospective study were (1) to investigate the relationship between pretreatment apoptosis levels and long-term treatment outcome in patients with Stage I and II FCL; (2) to define the incidence and patterns of Bax and Bcl-x protein expression in human FC; and (3) to determine the relationship of Bcl-2, Bax, and Bcl-x expression with spontaneous apoptosis levels and clinical outcome in localized FCL.

METHODS AND MATERIALS

Between 1974 and 1988, 144 patients with Stage I or II FCL were treated. Hematoxylin and eosin (H & E) stained tissue sections of pretreatment specimens were retrieved for 96 patients. Treatment consisted of regional radiation therapy (XRT) for 25 patients, combined modality therapy (CMT) consisting of combination chemotherapy and XRT for 57 patients, and other treatments for 14 patients. Median follow-up for living patients was nearly 12 years. The apoptotic index (AI) was calculated by dividing the number of apoptotic cells by the total number of cells counted and multiplying by 100. Expression of Bcl-2, Bax, and Bcl-x proteins was assessed using immunohistochemistry.

RESULTS

The mean and median AI values for the entire group were 0.53 and 0.4, respectively (range: 0-5.2). The AI strongly correlated with cytologic grade, with mean AI values of 0.25 for grade 1, 0.56 for grade 2, and 0.84 for grade 3 (p < 0.0005; Kendall correlation). A positive correlation was present between grouped AI and grouped mitotic index (MI) (p = 0.014). For patients treated with CMT, an AI < 0.4 correlated with improved freedom from relapse (FFR) p = 0.0145) and overall survival (OS) (p = 0.0081). An AI < 0.4 did not correlate with clinical outcome for the entire cohort or for patients receiving XRT only. Staining of tumor follicles for the Bcl-2 protein was positive, variable, and negative in 73%, 15%, and 12% of cases, respectively. Positive staining of tumor follicles was observed in 96% of cases for both the Bax and Bcl-x proteins. Expression of Bcl-2, Bax, or Bcl-x did not correlate with AI or clinical outcome.

CONCLUSION

The level of spontaneous apoptosis in pretreatment specimens correlates with cytologic grade of FCL and is a significant predictor of FFR and OS for patients with localized FCL receiving CMT.

Stages I-III follicular lymphoma: role of CT of the abdomen and pelvis in follow-up studies

PURPOSE

To evaluate the efficiency of axial computed tomography (CT) in detecting relapses of stage I, II, or III follicular lymphoma.

MATERIALS AND METHODS

A total of 328 patients with previously untreated stage I, II, or III follicular lymphoma were treated between 1978 and 1994. Two hundred fifty-seven patients achieved complete response; 78 who relapsed form the basis of this study. Fifteen patients had stage I; 28, stage II; and 35, stage III disease. Fifteen patients underwent radiation therapy; 12, chemotherapy; and 51, radiation and chemotherapy. Medical records were reviewed to analyze the yield of abdominal and pelvic CT in detecting recurrence relative to the yield of standard clinical, hematologic, and imaging studies. A positive study was defined as one that led to or was abnormal at the diagnosis of recurrence.

RESULTS

The median follow-up was 101 months. Eleven relapses were detected only at abdominal, pelvic, or both abdominal and pelvic CT.

CONCLUSION

Fourteen percent (11 of 78) of the relapses were detected solely at abdominal and/or pelvic CT. Eleven (4.3%) of the 257 patients who achieved complete response benefited from abdominal and pelvic CT. The yield of the routine use of abdominal and pelvic CT in follow-up studies appears to be low for stages I-III follicular lymphoma.

Lymphocyte predominant Hodgkin disease: clinico-pathologic features and results of treatment--the Pediatric Oncology Group experience

PURPOSE

In this report, the Pediatric Oncology Group (POG) experience with lymphocyte predominant Hodgkin Disease (LPHD) in children is reviewed.

MATERIALS AND METHODS

From 1984-1993, the POG conducted 3 clinical trials for advanced stage HD and 2 for early stage HD. There were 26 cases of LPHD in 613 patients in these trials. Patients' ages ranged from 3.1-17.8 years (mean of 12.9 years). There was a marked male predominance.

RESULTS

Histologic subtypes were 17 nodular, 8 diffuse pattern; 1 was indeterminant. The sites involved at diagnosis were primarily the peripheral lymph nodes. Fourteen patients had stage (S) I disease; 9 had SII; 3 had SIII; there was no SIV disease. Only 4 of 26 patients had B symptoms. All 26 patients achieved complete remission, 10 with radiotherapy, 6 with chemotherapy and 10 with combined modality therapy. Treatment was not uniform since patients were registered on different protocols. Event-free survival after 5 years was 86.5 percent. Two patients developed and succumbed to large cell, T-cell type, non-Hodgkin lymphoma (NHL).

CONCLUSIONS

Optimal treatment for LPHD should focus on efforts to limit the risk of second malignancy.

Primary pulmonary lymphoma--clinical review from a single institution in Singapore

Primary pulmonary lymphoma is a rare and vexing subset of extranodal non-Hodgkin's lymphoma. We report 11 cases and provide a brief literature review. We also highlight an unusual case of a relapsed peripheral T-cell primary lung lymphoma that underwent apparent spontaneous remission. Eleven cases of primary pulmonary lymphoma treated in our institution were studied for their clinical characteristics, behaviour, response to treatment and clinical outcome. The median duration of follow up was 26 months. The mean age was in the 50s and the presenting symptoms generally respiratory and non-specific. LDH levels did not correlate with either stage or grade of disease. Lower lobe involvement was most common and nodules and mass-like lesions the main radiologic feature. Small lymphocytic lymphoma accounted for the majority of cases and were indolent in behaviour. Good symptom control and radiologic response was achieved with chemotherapy in disseminated low grade lung lymphomas. Combination chemotherapy was effective in the aggressive lymphomas. In conclusion, Small lymphocytic lymphoma of the lung is an indolent disease with a long symptom-free survival even after recurrence. Our series confirms the clinical characteristics of primary pulmonary lymphoma. The role of Ling Zhi in effecting the spontaneous remission in the peripheral T-cell lymphoma is speculative.