Treatment of advanced non-Hodgkin's lymphoma with recombinant leukocyte A interferon

Biological and Exploitable Crossroads for the Immune Response in Cancer and COVID-19

The outbreak of novel coronavirus disease 2019 (COVID-19) has exacted a disproportionate toll on cancer patients. The effects of anticancer treatments and cancer patients’ characteristics shared significant responsibilities for this dismal outcome; however, the underlying immunopathological mechanisms are far from being completely understood. Indeed, despite their different etiologies, SARS-CoV-2 infection and cancer unexpectedly share relevant immunobiological connections. In the pathogenesis and natural history of both conditions, there emerges the centrality of the immune response, orchestrating the timed appearance, functional and dysfunctional roles of multiple effectors in acute and chronic phases. A significant number (more than 600) of observational and interventional studies have explored the interconnections between COVID-19 and cancer, focusing on aspects as diverse as psychological implications and prognostic factors, with more than 4000 manuscripts published so far. In this review, we reported and discussed the dynamic behavior of the main cytokines and immune system signaling pathways involved in acute vs. early, and chronic vs. advanced stages of SARS-CoV-2 infection and cancer. We highlighted the biological similarities and active connections within these dynamic disease scenarios, exploring and speculating on possible therapeutic crossroads from one setting to the other.

Type I interferons in anticancer immunity

Type I interferons (IFNs) are known for their key role in antiviral immune responses. In this Review, we discuss accumulating evidence indicating that type I IFNs produced by malignant cells or tumour-infiltrating dendritic cells also control the autocrine or paracrine circuits that underlie cancer immunosurveillance. Many conventional chemotherapeutics, targeted anticancer agents, immunological adjuvants and oncolytic viruses are only fully efficient in the presence of intact type I IFN signalling. Moreover, the intratumoural expression levels of type I IFNs or of IFN-stimulated genes correlate with favourable disease outcome in several cohorts of patients with cancer. Finally, new anticancer immunotherapies are being developed that are based on recombinant type I IFNs, type I IFN-encoding vectors and type I IFN-expressing cells.

CC-122, a pleiotropic pathway modifier, mimics an interferon response and has antitumor activity in DLBCL

Cereblon (CRBN), a substrate receptor of the Cullin 4 RING E3 ubiquitin ligase complex, is the target of the immunomodulatory drugs lenalidomide and pomalidomide. Recently, it was demonstrated that binding of these drugs to CRBN promotes the ubiquitination and subsequent degradation of 2 common substrates, transcription factors Aiolos and Ikaros. Here we report that CC-122, a new chemical entity termed pleiotropic pathway modifier, binds CRBN and promotes degradation of Aiolos and Ikaros in diffuse large B-cell lymphoma (DLBCL) and T cells in vitro, in vivo, and in patients, resulting in both cell autonomous as well as immunostimulatory effects. In DLBCL cell lines, CC-122-induced degradation or short hairpin RNA-mediated knockdown of Aiolos and Ikaros correlates with increased transcription of interferon (IFN)-stimulated genes independent of IFN-α, -β, and -γ production and/or secretion and results in apoptosis in both activated B-cell (ABC) and germinal center B-cell DLBCL cell lines. Our results provide mechanistic insight into the cell-of-origin independent antilymphoma activity of CC-122, in contrast to the ABC subtype selective activity of lenalidomide.

Recombinant interferon-alpha2b added to oral cyclophosphamide either as induction or maintenance in treatment-naive follicular lymphoma: final analysis of CALGB 8691

Recombinant interferon alpha-2b (IFN-alpha2) has direct and indirect antiproliferative effects in lymphoma, and may augment cytotoxicity when combined with chemotherapy. CALGB 8691 is a randomized study of daily oral cyclophosphamide (CPA) at 100 mg/m2 with or without IFN-alpha2 at 2 x 106 IU/m2 three times per week, followed by a second randomization between IFN-alpha2 maintenance (2 x 106 IU/m2 three times weekly) versus observation in treatment-naïve patients with follicular lymphoma (FL). Five hundred eighty-one patients were randomized to either CPA (n = 293) or CPA plus IFN-alpha2 (n = 288). One hundred five responding patients were randomized to observation and 99 to maintenance IFN-alpha2. With a median follow-up of 11.5 years, the median event-free and overall survival (OS) for CPA induction alone were 2.5 years (95% CI 2.2, 3.0) and 9 years (95% CI 7.7, 10.2), compared to 2.4 years (95% CI 2.1, 3.1) and 8.4 years (95% CI 7.5, 11.1) for the combination arm (p = NS). Patients with a partial response (PR) and randomized to observation had the worst outcome (event-free survival (EFS) 1.8 years versus 3.9 years; p = 0.002). Patients with a PR randomized to IFN-alpha2 had a similar EFS to compared to patients with complete response (CR), but this did not translate into a survival advantage. Myelosuppression was increased in IFN-alpha2-containing arms. Despite the small benefit in EFS in patients with PR randomized to IFN-alpha2 maintenance, we conclude that the addition of low dose IFN-alpha2 did not significantly improve the response rate, duration of response, event-free, or OS obtained with single-agent daily oral CPA in patients with previously untreated FL.

Follicular lymphoma: a historical overview

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

Pulmonary Sarcoidosis Induced by Interferon-α Therapy

Recombinant interferon-alpha (IFN-alpha) is being increasingly used in the treatment of chronic hepatitis C. It has been recently recognized that IFN-alpha can induce the development of sarcoidosis, presumably through its ability to stimulate the TH1 immune response. IFN-associated sarcoidosis is histologically similar to de novo sarcoidosis and is characterized by tightly compact epithelioid non-necrotizing granulomas. IFN-induced sarcoidosis may be unsuspected clinically, as the most common side effects of IFN-alpha simulate the symptoms of sarcoidosis. It is therefore important for pathologists to be aware of this association and encourage clinicians to carefully review the medication history in cases of pulmonary non-necrotizing granulomatous inflammation where there is a history of hepatitis C, as discontinuation of IFN-alpha can ameliorate the symptoms of sarcoidosis.

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Medical management of melanoma

The treatment for malignant melanoma has undergone significant changes over the past few decades, with biological therapy playing an increasingly important role and replacing the traditional cytotoxic agents as the first-line therapy for this disease, both in advanced disease and adjuvant settings. Despite the developments of new modalities of therapy for melanoma, the outcome for patients with advanced disease remains poor. This article discusses the clinical studies that have shaped our current management of melanoma, both in the adjuvant setting, and in the metastatic setting. Additionally, successes and failures of clinical trials will be discussed, as they will guide the strategic development of future studies in the management of this aggressive disease.

Diffuse hypertrichosis in the course of hepatitis C treatment by IFN-alpha and ribavirin

A 32-year-old man suffered from hemophilia and hepatitis C. Treatment by interferon-alpha (IFN-alpha) and ribavirin was prescribed. After 6 months, the patient noted a diffuse hair growth, whereas he was beardless before treatment. This hypertrichosis was treated by laser therapy. No hypertrichosis is known in patients with hemophilia or viral hepatitis. Ribavirin has not been described as an inducer of hair growth. IFN-alpha is known to induce telogen effluvium, but some cases of hypertrichosis of the eyelashes or eyebrows have been reported. In this patient, the hypertrichosis is probably caused by IFN.

Phase II study of fludarabine combined with interferon-alpha-2a followed by maintenance therapy with interferon-alpha-2a in patients with low-grade non-hodgkin's lymphoma

Randomized trials suggest improved disease-free survival in low-grade non-Hodgkin's lymphoma (LGNHL) when interferon is combined with multiagent chemotherapy. This phase II trial was conducted to investigate the feasibility of combining fludarabine monophosphate (fludarabine) and IFN in a regimen for treatment of LGNHL. Twenty-one patients were evaluable. Median age was 55 years, and patients had been treated with an average of 1.7 chemotherapy regimens before enrollment. Patients received 25 mg/m2 of fludarabine intravenously on days 1 through 5 followed by 2 x 10(6) U/m2 of interferon-alpha-2a subcutaneously on days 22 through 26. Cycles were repeated every 4 weeks with delays and dose modifications for significant cytopenias. Patients were restaged after cycles 4 and 8, and those with at least a partial response to therapy were given maintenance therapy consisting of 2 x 10(6) U/m2 interferon-alpha-2a subcutaneously three times per week for 6 months. The overall response rate was 76% with a 25% complete response (CR) rate. Overall response rates were 75% (3/4 with 2 CR's) for chemotherapy-naive patients and 76% (13/17 with 3 CR's) for previously treated patients. Median time to progression was 12 months, and currently two patients are without evidence of progression at a median follow-up of 55 months. Grade III or greater toxicities included neutropenia (39%), anemia (17%), thrombocytopenia (5%), fevers/chills (5%), and fatigue (5%). Fludarabine and interferon can be effectively and safely combined in a regimen with significant activity against LGNHL. A modification of this regimen may be suitable for further study.

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

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

Final analysis of the ECOG I-COPA trial (E6484) in patients with non-Hodgkin's lymphoma treated with interferon alfa (IFN-alpha2a) plus an anthracycline-based induction regimen

The Eastern Cooperative Oncology Group (ECOG) performed a prospectively randomized study (E6484) evaluating the use of interferon alfa 2a (IFN-alpha2a) in patients with aggressive low-grade or with intermediate-grade non-Hodgkin's lymphoma (NHL) accruing close to 300 patients between 1985 and 1988. Patients were eligible for study if they had bulky or symptomatic low-grade lymphoma or defined intermediate-grade subtypes. Of 291 patients enrolled, 249 were eligible for analysis. All patients were randomized to receive a four-drug cytotoxic chemotherapy regimen including cyclophosphamide, doxorubicin, vincristine and prednisone in 4-week cycles with or without IFN-alpha2a in addition (COPA vs I-COPA). Treatment was given for up to 8-10 months. This report, at a time when the median follow-up among survivors has reached 12 years, updates the analysis of time to treatment failure (TTF), duration of disease-free survival (DFS), and overall survival. Patients randomized to receive IFN-alpha2a had a prolonged TTF (P= 0.008; median 2.4 vs 1.6 years). DFS for those patients who had complete responses was also longer if IFN-alpha2a had been given (P = 0.035; median 2.7 vs 1.8 years). There was a clinically but not a statistically significant prolongation of overall survival by IFN-alpha2a (P= 0.107; median 7.8 vs 5.7 years). There were fewer deaths over time due to lymphoma in patients receiving IFN-alpha2a (67 vs 80 deaths). A subset analysis, based on disease histology (low-grade, follicular, intermediate-grade), revealed a significant prolongation of TTF in patients receiving IFN-alpha2a with either low-grade (P = 0.002; median 2.4 vs 1.6 years) or follicular (P= 0.01; median 2.5 vs 1.7 years) NHL but not intermediate grade (P = 0.622; median 2.3 vs 1.6 years) NHL. This analysis, performed approximately 12 years after closure of the study to accrual, supports the addition of interferon alfa to an induction cytotoxic chemotherapy regimen including cyclophosphamide and doxorubicin in the treatment of follicular NHL.

Antibody therapy of lymphoma

The availability of rituximab and the possible imminent availability of two new radiolabelled monoclonal anti-CD20 antibodies (Yttrium-90 (90Y)-ibritumomab and Iodine-131(131I)-tositumomab) have captured much attention in the treatment of lymphoma. The chimeric monoclonal anti-CD20 antibody, rituximab has truly heralded a new era for the treatment of lymphoma and human malignancies. The full potential of antibody-based therapy to improve the outcome in patients with B-cell non-Hodgkin's lymphoma has yet to be defined, but recent data suggests that the combination of chemotherapy plus rituximab may significantly improve outcome for patients with aggressive lymphoma over chemotherapy alone. Highly promising data are also emerging for the use of rituximab in combination with chemotherapy in other types of lymphoma. New advances in antibody therapy, driven by new technologies and defining novel antigen targets, offer the promise of more effective tumour specific therapies. Combinations of antibodies, either conjugated with radioisotopes or unlabelled, used with chemotherapy are likely to provide definitive advances in the treatment of lymphoma in the immediate future.

Effectiveness of interferon-alfa and mid-cycle chemotherapy added to an anthracycline-based regimen in the treatment of aggressive non-Hodgkin's lymphoma

Interferon-alfa in combination with cytotoxic chemotherapy has been shown to be effective in treating certain types of non-Hodgkin's lymphoma (NHL) (1). However, there is no published data on upfront induction treatment of aggressive NHL with IFN-alfa containing regimens. Studies have also shown that one can overcome regrowth resistance by administering mid-cycle agents which slow tumor proliferation between courses of cytotoxic therapy (2). Based on this, we treated 32 consecutive patients between 1/93 and 9/96 with a regimen containing cyclophosphamide 750 mg/m2, mitoxantrone 12 mg/m2, and teniposide 60 mg/m2 IV on day 1 with prednisone 100 mg PO given on days 1-5. On day 15, patients received vincristine 1.4 mg/m2 (2 mg max.) and bleomycin 10 units/m2 IV. Interferon-alfa-2b 5x10(6) units/m2 SQ was administered on days 22-26. The median age was 55 (range 26-83), M:F ratio was 2.5:1, and the median International Prognostic Index was 2. 38% of patients had stages I-II and 62% had stages III-IV disease. Fifty-nine percent of the patients achieved a complete response, 22% a partial response, and 19% had progressive disease. The overall survival (OS) was 81% and the progression free survival (PFS) was 56% at 4.3 years. There were no severe (grade IV) hematologic, flu-like, GI and infectious toxicities from IFN-alpha. Leukopenia was the main severe toxicity related to the chemotherapy regimen (days 1-15), but not IFN-alpha. Severe infection secondary to the chemotherapy regimen occurred in one patient. Interferon-alfa-2b and mid-cycle chemotherapy added to an anthracycline based regimen is effective induction treatment for patients with aggressive NHL. The OS and PFS using this regimen, based on regrowth resistance, appears to be at least as or more effective than CHOP therapy for this group of patients. Severe toxicities were rare.

Meta-analysis to assess the efficacy of interferon-alpha in patients with follicular non-Hodgkin's lymphoma

The authors wanted to determine whether adding interferon-alpha (IFN-alpha) to chemotherapy regimens, in either induction or maintenance settings, provides additional survival benefits in follicular non-Hodgkin's lymphoma (NHL). A meta-analysis was performed based on published data from randomized controlled clinical trials involving nine separate study populations. Patients receiving IFN-alpha (in either induction or maintenance therapy) had significantly increased 5-year and progression-free survival rates at 3 and 5 years compared with concurrent controls. The advantages of IFN-alpha therapy were most marked in studies using anthracycline-containing induction chemotherapy; in these studies, patients who received IFN-alpha had approximately 20% increased progression-free survival rates compared with controls and a lesser survival advantage. The available literature did not allow a determination of the relative benefit of IFN-alpha in induction or maintenance treatments for NHL or a determination of the optimum duration of IFN-alpha treatment. Although questions remain about its optimal use. IFN-alpha appears to prolong survival time in patients with follicular NHL.

A prospective randomized study of Chop versus Chop plus alpha-2B interferon in patients with intermediate and high grade non-Hodgkin's lymphoma: the International Oncology Study Group NHL1 Study

The addition of a brief alpha interferon regimen to each CHOP induction cycle, plus one year of alpha interferon thrice weekly maintenance therapy, has no early effect on response rates or survival in patients with Intermediate or High grade cell NHL.

BACKGROUND

The CHOP (Cyclophosphamide, Adriamycin. Vincristine, Prednisone) regimen is the most widely used first-line therapy for patients with Intermediate or High Grade (IG/HG) non-Hodgkin's lymphoma (NHL). Alpha 2b interferon (INF) enhances response rates and improves survival in low-grade NHL. The International Oncology Study Group (IOSG) conducted a prospective randomized study comparing CHOP alone or combined with INF in patients with IG/HG-NHL. The primary study aim was to compare the objective response rates in these patient cohorts.

PATIENTS AND METHODS

Patients with a confirmed diagnosis of measurable NHL of International Working Formulation (IWF) groups D to H histology were randomized to receive CHOP alone or CHOP with 5Mu INF s.c. for 5 days on days 22 to 26 of each 28 day cycle with INF 5 million units (Mu) given three times per week subcutaneously for 52 weeks in those patients who responded to CHOP plus INF.

RESULTS

The overall response rates were equivalent in both groups: CHOP alone (214 patients) 81% (complete 55%, partial 26%); CHOP plus INF (221 patients) 80% (complete 54%, partial 26%). At 36 months, the actuarial survival rate was equivalent in both groups.

CONCLUSIONS

There is no apparent early advantage in terms of response or survival conferred by adding the study INF regimen to CHOP therapy for patients with IG/HG-NHL.

Follicular lymphomas--a review of treatment modalities

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

An unusual adverse effect of interferon: hypertrichosis of the eyelashes

Hypertrichosis of the eyelashes is a rare adverse effect of interferon-alpha treatment. We present a 21-year-old man with chronic renal failure and hepatitis B virus (HBV) infection who developed hypertrichosis of the eyelashes as a complication of IFN-alpha therapy. The patient was a candidate for living related renal transplantation and was given IFN-alpha 15 million units per week for HBV DNA positivity. After 6 months of therapy, HBV DNA positivity persisted, and the dose of IFN was increased to 30 million units per week. At the end of the first half of the second 6 months of therapy, the patient suffered from bilateral hypertrichosis of the eyelashes.

Second-generation interferons for cancer: clinical targets

IFNs were the first new therapeutic products resulting from recombinant DNA technology. IFNs were also the first human proteins effective in cancer treatment. There is however much to be discovered which will lead to new clinical applications. Areas which represent major research challenges for full understanding and application of the IFN system are: (i) the diversity of the IFN family; (ii) the role of induction; (iii) molecular mechanism of action; (iv) cellular modulatory effects; (v) advantages of combinations, and (vi) identification of new therapeutic indications. This review will emphasize the diversity of the IFN family and chemical modifications which will result in second-generation IFNs. Pre-clinical and clinical findings form the basis for new therapeutic directions in chronic myelogenous leukemia, lymphomas, myelomas, melanoma, urologic malignancies, primary brain tumors, and ovarian carcinoma.

Low-dose oral use of human interferon-alpha in cancer patients

In a double-blind placebo-controlled trial, 57 adult subjects with disseminated malignancies were given orally low doses of recombinant human interferon-alpha (rHuIFN-alpha) at 0.05 IU, 0.5 IU, or 5.0 IU/kg body weight. The objective was to determine the efficacy of orally administered rHuIFN-alpha on appetite stimulation and/or weight loss prevention in anorectic cancer patients. Almost two-thirds (64%) of the subjects given 5.0 IU/kg reported an increase in appetite or body weight after 5 weeks in contrast to only 29% of the placebo-treated subjects. However, at the end of the 91-day trial, no significant differences in appetite enhancement or weight gain were noted between these two groups. Additionally, the 5.0 IU/kg treated group experienced half as many deaths as the control group by the conclusion of this 91-day trial.

Ocular complications with high-dose interferon alpha in chronic active hepatitis

PURPOSE

Interferon alpha, which is used to treat various systemic disorders, has many reversible side-effects involving various organ systems. In this study, chronic active hepatitis patients undergoing interferon alpha therapy were followed with regard to the ocular side-effects.

METHODS

Thirty-six patients with chronic active hepatitis undergoing subcutaneous interferon alpha therapy for 1 year were enrolled. Complete ocular examination and photographic documentation were performed at baseline of the therapy and monthly thereafter. Fisher's exact chi-squared test and Mann-Whitney U-test were employed in the statistical evaluation of the results.

RESULTS

Trichomegaly was noted in 2 (6%) patients. Fifteen patients (42%) were found to have retinopathy with cotton wool spot formation and splinter haemorrhages.

CONCLUSIONS

These findings emphasise the need to monitor these retinal complications, which may result in loss of vision in patients receiving interferon alpha therapy.

Non-Hodgkin's lymphoma

OBJECTIVES

To review the etiology, epidemiology, classification, diagnosis, staging, prognosis, treatment, and nursing implications of non-Hodgkin's lymphoma.

DATA SOURCES

Research studies, review articles, and book chapters pertaining to non-Hodgkin's lymphoma.

CONCLUSIONS

Non-Hodgkins's lymphomas are a heterogeneous group of lympho-proliferative disorders, increasing in frequency, for which therapy ranges from supportive to curative.

IMPLICATIONS FOR NURSING PRACTICE

An understanding of the variety of presentations and treatments of non-Hodgkin's lymphomas will enable the oncology nurse to assist patients and their families to cope with the disease, make treatment-related decisions, and optimize the patient's quality of life.

Acquired hypertrichosis lanuginosa: case report and review of the literature

Acquired hypertrichosis lanuginosa is a rare cutaneous disorder usually associated with internal malignancy that consists of the development of abnormal hair growth of the lanugo type, often confined to the skin of the face and neck, although other areas also may be involved. We report on a 66-year-old woman with a metastatic ductal infiltrating carcinoma of the breast who developed growth of fine lanugo type hair on her face and progressive growth of the hair of eyebrows and eyelashes. We review the literature on this uncommon paraneoplastic cutaneous disorder emphasizing the pathogenic mechanisms that have been proposed to explain the striking overgrowth of lanugo type hair.

The role of interferon as maintenance therapy in malignant lymphoma

Interferon (IFN) is a biologic response modifier that has been employed in the treatment of malignant lymphomas with various degrees of success. In patients with low-grade lymphomas, IFN alone induced complete remissions in 17-62% of the patients. When used in combination with chemotherapy, prolongation of remission duration and survival has been reported. The best results have been reported when IFN was used as maintenance therapy in patients with minimal residual disease or complete remission. When used as maintenance treatment toxicity was mild with less than 5% of the patients discontinuing IFN treatment, and late side-effects have not been reported. The results obtained with IFN in patients with intermediate and high-grade lymphomas are disappointing. Complete remissions were observed in less than 10% of the patients and duration of remission and survival did not exceed 12 months. In contrast, promising results have been reported when IFN was used as maintenance treatment following bone marrow transplantation. In conclusion, IFN should be considered as part of the therapeutic process in patients with low-grade lymphomas, and in particular as a maintenance treatment following induction chemotherapy.

Interferon-alpha does not cause significant cardiac dysfunction in patients with chronic active hepatitis

The cardiac adverse effects of interferon (INF) treatment have been reported recently in various clinical trials of INF. In this study, the cardiac effects of recombinant INF-alpha treatment were evaluated prospectively in a group of patients with chronic active viral hepatitis (CAH). Sixteen patients with CAH type B, 14 patients with CAH type C and one patients with CAH type D were included in this study, and 4.5, 3 and 9 MU of recombinant INF-alpha-2a was administrated three times a week to these patients, respectively. The durations of treatment were 6 months for CAH type B and C, and 12 months for type D. The cardiac status of all patients was evaluated and monitored with a detailed medical history, physical examination, electrocardiography (ECG), telecardiography, echocardiography and heart rate variability tests at the beginning of the study and at the first and sixth months of INF therapy and also 6 months after ceasing the therapy. The clinical evaluation of patients before the treatment revealed that three had hypertension, one had a past medical history of myocardial infarction, one had a prosthetic mitral valve replacement and another had left hemiblock in her ECG record. No significant changes and adverse effects were detected in clinical examination and cardiovascular tests of all patients, either in pre-existing cardiovascular diseases, during therapy and after stopping the treatment. The cardiac adverse effects of INF reported in previous studies are questionable and we conclude that it can be used safely in CAH patients. Therefore, it should be kept in mind that fever and tachycardia may occur during the first and second weeks of INF therapy and patients with high risk for cardiac disease should be monitored closely in this period of treatment.

Inflammatory markers in bronchoalveolar lavage fluid of standardbred racehorses with inflammatory airway disease: response to interferon-alpha

Protein and eicosanoid concentrations and procoagulant activity were determined in bronchoalveolar lavage fluid (BALF) from 32 Standardbred racehorses with inflammatory airway disease (IAD) and 6 control horses. Total protein, albumin and immunoglobulin G (IgG) concentrations were high (P < 0.05) in the BALF from horses with IAD, a finding consistent with exudation of plasma protein into the airway. Immunoglobulin A (IgA) concentrations also were increased (P < 0.05) which may signify local immunoglobulin production. Difference was not detected in prostaglandin E2 and 6-ketoprostaglandin F1 alpha concentrations in BALF of IAD-affected and control horses. Procoagulant activity was identified in the majority (66%) of BALF samples from IAD-affected horses and was not detected in control horses. Natural human interferon-alpha (nHulFN alpha) (placebo, 50, 150, or 450 units) was administered orally for 5 days to IAD-affected horses in a double-blind, randomised block design. Total protein, IgG, and IgA concentrations in BALF were reduced (P < 0.05) 8 days after administration of 50 u and 150 u nHuIFN alpha, and 15 days after administration of 50 u nHuIFN alpha. Procoagulant activity and albumin concentrations in BALF were lower 8 days after administration of 50 u nHuIFN alpha. Oral administration of low-dose nHuIFN alpha appeared to ameliorate these parameters of lower respiratory tract inflammation in Standardbred racehorses with IAD.

Regrowth resistance as a likely significant contributor to treatment failure in drug-sensitive neoplastic diseases

Attempts to improve the effectiveness of therapy for neoplastic diseases have largely focused on increasing the cytotoxic efficacy of therapy. While this approach is logical, there is another approach, based on the concept of regrowth resistance, which offers an alternate means of improving treatment outcome. The term "regrowth resistance" refers to the reduction in treatment efficacy resulting from the regrowth of neoplastic cells between courses of therapy or even between doses of radiation therapy. Regrowth resistance is likely to play a significant role in determining the outcome of treatment in rapidly proliferating neoplasms. A reduction in the rate of tumor regrowth would increase the net effectiveness of cytotoxic therapy and would also inhibit the development of resistance to cytotoxic therapies.

Serum beta(2)-microglobulin and serum thymidine kinase are independent predictors of progression-free survival in chronic lymphocytic leukemia and immunocytoma

Chronic lymphocytic leukemia (CLL) and immunocytoma (IC) are remarkably heterogeneous with regard to their clinical course. The current staging systems can distinguish prognostic subgroups, but do not seem to predict the risk of disease progression of an individual patient with sufficient accuracy. Given the increase of treatment options for CLL and IC, additional parameters are needed to decide which patients may benefit from early or intensified treatment. It has been shown that two biochemical markers, serum beta 2-microglobulin (s-beta 2M) and serum thymidine kinase (s-TK), might identify CLL and IC patients at high risk of disease progression. Therefore, the prognostic value of these two serum parameters was compared with a panel of several established prognostic factors in a prospective clinical trial. 113 patients with CLL and 41 patients with IC (mean age +/- SD 63.9 +/- 10.7 years) were included. The following parameters were determined: histopathological diagnosis (IC vs. CLL), age, sex, performance status (Karnofsky index), B symptoms, peripheral blood lymphocyte count, platelet count, blood hemoglobin, serum lactate dehydrogenase (s-LDH), s-beta 2M, s-TK, serum creatinine, number of lymph node areas involved, prior therapy, and the time from diagnosis to inclusion in the study. Univariate analyses showed that nine parameters (Karnofsky index, peripheral blood lymphocytosis, platelet count, blood hemoglobin, lymph node areas involved, pretreatment, s-LDH, s-beta 2M, and s-TK) significantly predicted progression-free survival. In a Cox regression model, only four of these parameters provided independent prognostic information on progression-free survival: 1. s-beta 2M, 2. Karnofsky index, 3. platelet count, and 4. s-TK. The results show that s-beta 2M and s-TK independently predict progression-free survival in patients with CLL and IC, and suggest that these prognostic factors may allow an improved prediction of progression-free survival, particularly in early disease stages.

Treatment strategies for early-stage chronic lymphocytic leukemia: can interferon-inducible MxA protein and tumor necrosis factor play a role as predictive markers for response to interferon therapy?

The potential benefit of interferon (IFN)-alpha therapy in early-stage B cell chronic lymphocytic leukemia (B-CLL) patients is still under discussion, and no assays are available to distinguish potential responders from nonresponders. Herein we analyzed the usefulness of serum tumor necrosis factor (TNF, a cytokine released by CLL cells) and MxA protein (an intracellular marker for biologic activity of endogenous IFN) concentrations as predictive measurements for evolution and response to IFN therapy in early-stage CLL patients. TNF levels and MxA expression were determined at diagnosis in 21 CLL patients. A statistically significant correlation was found between low TNF levels and MxA expression and between high TNF levels and no measurable MxA expression. The patients were then randomized to receive IFN-alpha or no therapy and were evaluated for response and evolution. When response to IFN-alpha therapy was considered, it became apparent that early-stage CLL patients with higher TNF levels and no measurable MxA expression were more likely to benefit from IFN therapy, whereas those patients with lower TNF levels and MxA expression could be considered CLL candidates for longer survival without therapy. More patients have to be tested to strengthen the value of MxA expression and TNF concentrations for subsequent response to IFN-alpha therapy.

Changes in airway inflammatory cell populations in standardbred racehorses after interferon-alpha administration

Natural human interferon-alpha (nHuIFN alpha) was administered to actively training Standardbred racehorses with inflammatory airway disease (IAD). Inflammatory airway disease was characterized by poor exercise performance and inflammation and exudate in the upper and lower airway. Placebo, 50, 150, or 450 units(U) of nHuIFN alpha was administered orally for 5 consecutive days to eight horses per treatment group in a double-blind, randomized block design. Response to nHuIFN alpha was monitored by semiquantitative endoscopic examination score and cytologic examination of bronchoalveolar lavage fluid (BALF) performed at baseline (Day 1), Day 8 and Day 15 after initiation of nHuIFN alpha administration. Neutrophil, macrophage, lymphocyte, and nucleated cell counts in BALF were lower (P < 0.05), compared with BALF cell counts in placebo-treated horses 8 days after administration of 50 U and 150 U nHuIFN alpha, and 15 days after administration of 50 U nHuIFN alpha. Neutrophil, lymphocyte and nucleated cell counts were lower than cell counts from placebo-treated horses, 8 days following administration of 450 U nHuIFN alpha. The proportion CD4-, CD5-, and CD8-positive lymphocytes in BALF was not affected by administration of nHuIFN alpha. Oral administration of low-dose nHuIFN alpha reduced inflammation of the lowest respiratory tract in Standardbred racehorses with IAD.

Low-grade lymphomas: new entities and treatment concepts

Therapy for patients with low-grade lymphomas has never been standardized. Recently, new entities have been described which are included in the REAL classification, and whether these entities should be regarded as separate diseases is not yet clear. Regardless, three new developments in the management of patients with low-grade lymphomas deserve special attention for treatment programs in the future. First, it appears that patients with stage I, II, and III low-grade lymphomas may enjoy very prolonged disease-free intervals after treatment with combination chemotherapy and radiation therapy programs. Although investigators disagree on prognostic factors, new features, such as beta 2-microglobulin appear to predict results better than any other feature, and future studies should address this prognostic factor in assessing their results. Second, for patients with advanced stage disease, administration of interferon as maintenance therapy prolongs the disease-free interval, and use of this drug should be further investigated. Finally, molecular studies using PCR for bcl-2 may be clinically relevant in detecting residual disease in patients with follicular lymphomas, and future studies should focus on the value of eliminating the residual disease from blood and marrow.

Cytokines in the pathophysiology and treatment of chronic B-cell malignancies. A review

Chronic B-cell malignancies are characterized by accumulation of transformed B cells of low proliferative index in lymphatic and extralymphatic tissues. Cytokines do not appear to play a role in the primary step of transformation. However, proliferation as well as inhibition of apoptosis of malignant B cells can readily be explained by cytokine effects. Clinical trials of interferons (IFN) and interleukin-2 alone or in combination have been performed in patients with hairy cell leukemia (HCL), CLL, and low- and intermediate-grade non-Hodgkin's lymphoma. While IFN alpha became standard therapy of HCL, responses in other entities were variable, ranging from 0 to 70% in selected populations. Combination of IFN and cytotoxic chemotherapy in general revealed no additional benefit as compared to chemotherapy alone. Perspectives for future clinical testing of cytokines in low-grade B-cell lymphomas are discussed.

Alpha-interferon and corticosteroids as initial treatment in small cleaved-cell lymphoma

Small cleaved-cell lymphoma (SCCL) is a non-Hodgkin's lymphoma of low clinical grade, highly responsive to radiation and cytotoxic therapy in its early stages, but ultimately fatal as disease progresses and becomes resistant to therapy. This study reports favourable results using recombinant alpha interferon (alpha IFN) and corticosteroids (CS) in five previously-untreated patients with advanced SCCL. Complete response (CR) was seen in three, excellent partial responses (PR) in the other two, with good patient tolerance. Some possible neurotoxicity was observed. As a strategy to minimise or delay cytotoxic exposure in these patients, it appears to have merit.