Long-term outcome and sequelae in aggressive lymphoma patients treated with the LNH-80 regimen

Sexual dysfunction in lymphoma survivors: a scoping review

BACKGROUND

Lymphoma and cancer-related treatment can cause many complications, including sexual dysfunction, a common symptom experienced by lymphoma survivors during the disease trajectory and survivorship.

AIMS

A scoping review was performed to determine the current state of knowledge about sexual dysfunction in lymphoma survivors and identify knowledge gaps and implications for future research.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO were searched to identify all primary peer-reviewed research articles published in the English language that were pertinent to sexual dysfunction in lymphoma survivors. The framework of Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews Checklist were used to assess and synthesize the available evidence on sexual dysfunction in lymphoma survivors.

OUTCOMES

This review provided supportive evidence that sexual function in lymphoma survivors is a major ongoing area of concern.

RESULTS

Thirty eligible articles published from 1979 to 2023 were appraised in this review. Most of the studies (73.33%) used a cross-sectional design. Using the Methodological Index for Non-Randomized Studies, more than half of the publications (53.33%) achieved a C quality ranking. The reviewed studies revealed that sexual dysfunction was a prevalent symptom experienced by lymphoma survivors, with predictors such as age, gender, sex hormones, stage of disease, and types of cancer treatment.

CLINICAL IMPLICATIONS

Healthcare providers need to consistently perform routine assessment of sexual function and provide adequate treatment options.

STRENGTHS AND LIMITATIONS

The reviewed studies document the problem of sexual dysfunction and offer potential areas of improvement for clinical practice. However, in the majority of the studies, longitudinal data were not obtained which could provide valuable insights on sexual functioning in lymphoma survivors.

CONCLUSION

Despite many years of research on sexual function in lymphoma survivors, substantial gaps in knowledge regarding sexual issues in this population remain.

IMPLICATIONS FOR PRACTICE

Healthcare providers should routinely assess sexual function of survivors and provide treatment options. Psychosexual interventions should be tailored for the needs of cancer survivors. Sexual function education is essential for all oncologists and should be included in the care pathway from diagnosis until survivorship.

Fertility status among women treated for aggressive non-Hodgkin's lymphoma

In young women treated for intermediate-high-grade non-Hodgkin's lymphoma with CHOP (cyclophosphamide, adriamycin, oncovine and prednisone), there is insufficient data concerning gonadotoxicity or the need for fertility-preserving measures. The aim of the present study was to evaluate the fertility status in the first complete remission of women who were treated for aggressive non-Hodgkin's lymphoma. A cohort of 36 women with aggressive non-Hodgkin's lymphoma in first remission, who were treated in five university-affiliated hospitals in Israel, was evaluated. All women were aged younger than 40 years at diagnosis and received frontline protocols, including cyclophosphamide and adriamycin, mostly CHOP. Menstrual cycle characteristics, as well as pregnancies before the diagnosis, during treatment and in first complete remission, were evaluated. The patients' mean age at the diagnosis was 28 +/- 7 years (range 17 - 40 years). All patients were treated with chemotherapy, although 10 patients received additional radiotherapy. Follow-up time at first complete remission was 84 +/- 48 months. Before diagnosis, all patients had menstrual cycles, which were regular in 31 (86%). Three patients received gonadtropin-releasing hormone analogs, whereas nine received contraceptive pills together with cytotoxic treatment. During treatment, 18 patients (50%) had amenorrhea, six (17%) had irregular menstrual cycles, and 12 (33%) continued their regular cycles. All but two women resumed menses in the first complete remission, and these were regular in 22 (61%) patients. In 63% of patients, the menstrual cycle recovered within 3 months of the discontinuation of chemotherapy. Eighteen patients (50%) became pregnant during the first complete remission. There was no significant difference between those patients who received fertility-preserving measures versus the remainder concerning regular menstrual cycles recovery or pregnancies. The two patients who developed amenorrhea were 40 years old at the time of diagnosis. In conclusion, the rate of gonadal dysfunction is very low among young, CHOP treated, non-Hodgkin's lymphoma female patients. Fertility-preserving techniques are not needed for women aged younger than 40 years and should probably be reserved for those who are at high risk for gonadal toxicity.

Strategies for improving outcomes with 14-day anthracycline-based regimens in patients with aggressive lymphomas

Among the strategies developed to improve results in patients with diffuse large B-cell lymphoma, increasing the dose of CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) regimen (dose-intense regimen) and decreasing the duration of cycles (dose-dense regimen) or doing both had been proposed before the rituximab era. With granulocyte colony-stimulating factor support, both regimens are feasible without severe hematologic toxicities. Randomized studies have shown better results than with standard CHOP with longer survivals. However, the addition of rituximab to CHOP (R-CHOP) has also dramatically improved the results without increasing the toxicity. Whether the addition of density or intensity to R-CHOP will continue to improve the results are not known, and preliminary results might challenge this hypothesis. The future benefit for patients with adverse prognostic parameters might not come from dose-dense or dose-intense CHOP-like regimens but from the addition of another drug to R-CHOP.

Fertility preservation in female oncology patients

Survival rates for patients treated for the majority of childhood and young adult cancers have improved dramatically in recent years. Despite the high probability of survival, and often good quality of life in female survivors, until recently the concept of fertility preservation has not been seen to be an important component of the overall management of these patients. Over the last few years, various protection and preservation strategies have been developed, which may address potential reproductive concerns. Gametes or embryos may be frozen prior to potentially gonadotoxic cancer therapy, and ovarian tissue may be frozen and stored, with several pregnancies described after subsequent grafting. There is also increasing interest in the possibility of ovarian protection using gonadotrophin-releasing hormone analogues during chemotherapy, despite the lack of randomised controlled trials. Additionally, there are reports of novel protective strategies, including therapeutic alteration or manipulation of the sphingomyelin pathways. This review summarises methods of fertility protection and preservation currently available, as well as the emergence of promising new strategies.

The impact of conventional and high-dose therapy for lymphoma on fertility

The impact of chemotherapy on gonadal function is an important issue for younger patients surviving lymphoma. This article reviews the effects on fertility of conventional and intensive-dose chemotherapy regimens with or without radiation therapy. In general, conventional dose regimens such as ABVD (doxorubicin/bleomycin/vinblastine/decarbazine) and CHOP21 (cyclophosphamide/doxorubicin/vincristine/prednisone) are not sterilizing, but data are limited on the effects of newer aggressive regimens such as BEACOPP (bleomycin/etoposide/doxorubicin/cyclophosphamide/vincristine/procarbazine/prednisone), CHOP14, and CHOP/etoposide. Infertility after myeloablative transplant conditioning is common but not invariable. The role of prechemotherapy gonadotrophin-releasing hormone agonists and antagonists for the prevention of gonadal damage is under evaluation. In addition, new techniques for sperm and oocyte retrieval offer the prospect of improved fertility after sterilizing treatment. Management guidelines for patients undergoing nonmyeloblative and myeloablative therapy are presented, addressing additional issues such as contraception during and after the administration of cytotoxics and the importance of gynecologic and endocrine follow-up in determining the need for short- and long-term hormone replacement therapy.

Long-term results of dose density therapy in patients with aggressive lymphoma

To evaluate the long-term outcome of dose density chemotherapy in the treatment of aggressive lymphoma, we analyzed 142 patients with untreated aggressive lymphoma. Chemotherapy was an eight-drug regimen given in weekly intervals in two prospective trials. The median observation period was 8 years; the longest follow-up was 13 years. Overall survival at 8 years was 0.583. The 8-year survival of patients < or =60 years was significantly better than that of older patients, namely 0.713 vs 0.304 (p=0.000000697). This excellent survival of patients aged < or =60 years was identical for high-risk and high-intermediate-risk patients compared with low-risk and low-intermediate-risk patients in the age-adjusted international prognostic index (IPI). The excellent long-term results of the CEOP/IMVP-Dexa regimen (cyclophosphamide, epirubicin, vincristine, and prednisone/ifosfamide with systemic mesna, methotrexate, etoposide, and dexamethasone) for patients aged < or =60 years suggest that this regimen might be superior to the standard CHOP regimen (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and needs to be tested in comparison to high-dose regimens and novel approaches including antibody treatment.

Therapy-related acute promyelocytic leukemia

PURPOSE

To analyze patient cases of therapy-related acute promyelocytic leukemia (tAPL), occurring after chemotherapy (CT), radiotherapy (RT) or both for a prior disorder, diagnosed during the last 20 years in three European countries.

PATIENTS AND METHODS

The primary disorder and its treatment, interval from primary disorder to tAPL, characteristics of tAPL, and its outcome were analyzed in 106 patients.

RESULTS

Eighty of the 106 cases of tAPL were diagnosed during the last 10 years, indicating an increasing incidence of tAPL. Primary disorders were predominantly breast carcinoma (60 patients), non-Hodgkin's lymphoma (15 patients), and other solid tumors (25 patients). Thirty patients had received CT alone, 27 patients had received RT alone, and 49 patients had received both. CT included at least one alkylating agent in 68 patients and at least one topoisomerase II inhibitor in 61 patients, including anthracyclines (30 patients), mitoxantrone (28 patients), and epipodophyllotoxins (19 patients). Median interval from primary disorder to tAPL diagnosis was 25 months (range, 4 to 276 months). Characteristics of tAPL were generally similar to those of de novo APL. With treatment using anthracycline-cytarabine-based CT or all-trans-retinoic acid combined with CT, actuarial survival was 59% at 8 years.

CONCLUSION

tAPL is not exceptional, and develops usually less than 3 years after a primary neoplasm (especially breast carcinoma) treated in particular with topoisomerase II-targeted drugs (anthracyclines or mitoxantrone and less often etoposide). Characteristics and outcome of tAPL seem similar to those of de novo APL.

Late lethal events in patients with diffuse large B cell lymphoma: a review of 714 patients treated in a single centre

Presence of late lethal events has been recognized as a complication in patients with malignant lymphoma. We reviewed 714 cases of patients treated during 1975-1995 with a long term follow-up (>4 years) in an attempt to identify all late events secondary to malignant lymphoma, either to the treatment or those which are unrelated. Forty-three patients died, and of these 21 (2.8%) were secondary to relapse and tumor progression; deaths associated with second neoplasm and cardiac events were increased 9.6 fold and 26.4 fold respectively compared to the general population. The risk factors for these complications did not differ from those in previous reports and included alkylating agents and/or radiotherapy for second neoplasms and anthracycline therapy and radiotherapy for cardiac toxicity. Moreover, 10 patients died secondary to non-related events. Nevertheless, at 10 years overall survival was 94% (95% confidence interval (CI): 82% to 98%) and event free survival was 97.1% (95% CI: 81% to 98%), for these patients. Thus, second events, fatal in most cases, will be considered as an expected risk in the treatment of patients with malignant lymphoma. The proposed modifications of therapy many indeed be useful to avoid or diminish these complications in the future.

The management of adult aggressive non-Hodgkin's lymphomas

Aggressive non-Hodgkin's lymphona include diffuse large B-cell lymphoma, anaplastic large cell lymphona, and different peripheral T-cell lymphomas. An international prognostic index has been developed including age, serum LDH, performance status, and extranodal involvement. For localized aggressive lymphoma, the preferred treatment is 3-4 CHOP and radiation therapy, with a cure rate of 70-80%. For disseminated aggressive lymphoma, current regimens have a cure rate of less than 40%. Innovative strategies, including dose escalation, autologus stem cell support, new drugs, and immunotherapy are being explored to improve these results.

Mechanisms of action and resistance to tubulin-binding agents

Tubulin binding agents constitute an important class of antimitotics and are widely used for the treatment of solid tumours an haematopoietic malignancies. These compounds, currently represented by the vinca alkaloids and the taxanes, differ from most of the other clinically useful antimitotics in that their target is not nucleic acids, but the mitotic spindle, which is an essential component of the mitotic machinery. Recent data on the mechanisms of action of and mechanisms of resistance to tubulin binding agents are presented. The importance of microtubule dynamics is emphasised, in particular in relationship to the usefulness of drug combinations. Concerning the reported resistance mechanisms, an emerging body of data show that altered microtubule structure may be involved in reduced sensitivity to these compounds. Promising new molecules, including those derived from marine organisms are described.

Importance-satisfaction discrepancies are associated with health-related quality of life in five-year survivors of endocrine gastrointestinal tumours

BACKGROUND

Little is known about the health-related-quality of life (HRQoL) of patients with endocrine gastrointestinal tumours. In this study, HRQoL was investigated in long-term survivors of endocrine GI tumours.

PATIENTS AND METHODS

A questionnaire including the EORTC QLQ-C30 and ratings of importance of and satisfaction with a variety of HRQoL aspects was mailed to patients with carcinoid tumours (n = 64), or endocrine pancreatic tumours (EPT, n = 55). Median time since diagnosis was 120 months (range 60-360). The majority of patients (77 of 119) had ongoing treatment.

RESULTS

The EORTC QLQ-C30 ratings suggest that in spite of a long disease duration and treatment, patients perceived their HRQoL as relatively good. There were no major differences in HRQoL ratings between patients with carcinoid tumours and those with EPT. Patients whose ratings of importance was higher than their ratings of satisfaction with a specific HRQoL aspect also evidenced a low HRQoL for that aspect.

CONCLUSIONS

The results indicate that survivors of endocrine GI tumours enjoy a relatively good HRQoL and suggest that importance > satisfaction discrepancies identify patients with a low quality of life.

Mechanisms of action of and resistance to antitubulin agents: microtubule dynamics, drug transport, and cell death

PURPOSE

To analyze the available data concerning mechanisms of action of and mechanisms of resistance to the antitubulin agents, vinca alkaloids and taxanes, and more recently described compounds.

DESIGN

We conducted a review of the literature on classic and recent antitubulin agents, focusing particularly on the relationships between antitubulin agents and their intracellular target, the soluble tubulin/microtubule complex.

RESULTS AND CONCLUSION

Although it is widely accepted that antitubulin agents block cell division by inhibition of the mitotic spindle, the mechanism of action of antitubulin agents on microtubules remains to be determined. The classic approach is that vinca alkaloids depolymerize microtubules, thereby increasing the soluble tubulin pool, whereas taxanes stabilize microtubules and increase the microtubular mass. More recent data suggest that both classes of agents have a similar mechanism of action, involving the inhibition of microtubule dynamics. These data suggest that vinca alkaloids and taxanes may act synergistically as antitumor agents and may be administered as combination chemotherapy in the clinic. However, enhanced myeloid and neurologic toxicity, as well as a strong dependence on the sequence of administration, presently exclude these combinations outside the context of clinical trials. Although the multidrug resistance phenotype mediated by Pgp appears to be an important mechanism of resistance to these agents, alterations of microtubule structure resulting in altered microtubule dynamics and/or altered binding of antitubulin agents may constitute a significant mechanism of drug resistance.

Second neoplasms following high-dose chemotherapy and autologous stem cell transplantation for malignant lymphomas: a report of six cases in a cohort of 171 patients from a single institution

High dose chemotherapy with autologous stem cell transplantation (ASCT) is increasingly used in the treatment of patients with lymphoma. As previously shown with conventional treatments, second neoplasms are emerging as a long term complication of the procedure. In this study, we investigate the incidence of second neoplasm in a cohort of 171 patients treated with BEAM or BEAC regimens for Hodgkin's disease (n = 62) and non-Hodgkin's lymphomas (n = 109) followed up for a median of 52 months post ASCT. Six patients developed six second malignancies 12 to 105 months after ASCT: fibrolamellar carcinoma of the liver, malignant fibrous histiocytoma, pancreatic carcinoma, squamous cell carcinoma of the lung, invasive carcinoma of the vulva and acute myelogenous leukemia. The cumulative actuarial risk for developing second malignancy is 16.7% (95% confidence interval: 5.9-39.3%) 13 years after transplant. The age-adjusted incidence of cancer in the study group is 4.1 times higher than that of primary cancer in the general population. These data confirm that ASCT recipients are at increased risk of later malignancies. This complication adds significant morbidity and mortality to the transplant process and therefore, needs to be taken into account in long term evaluation of new strategies which involve early intensification in the treatment of lymphomas.

Risk of relapse and clinico-pathological features in 103 patients with diffuse large-cell lymphoma in complete response after first-line treatment

Patients with diffuse large-cell lymphoma (DLCL) achieve a complete response (CR) in most cases, but at least one-third of them eventually relapse. Such an event occurs most frequently within 2 yr from CR achievement. The aim of the present study was to analyse the risk and pattern of relapse of patients with DLCL in CR. One hundred and three patients with DLCL (53 male/50 female; median age: 55 yr) in CR after doxorubicin-containing first-line treatments were included in the study. Main clinicobiological characteristics at diagnosis and at relapse were analysed. Uni- and multivariate studies were performed. Forty-one patients (40%) eventually relapsed, in 27 cases within 2 yr from CR and 14 thereafter. Histological subtype was the same at diagnosis and at relapse in all the early relapsing patients and in 8 of 10 late relapsing patients with available biopsy. The most important variables at diagnosis for predicting relapse were advanced stage (p<0.01) and bone marrow infiltration (p=0.05), with stage (I-II vs. III-IV) (p=0.009; relative risk=2.28) being the only predictive variable in the multivariate analysis. No differences were found according to the treatment given. The second CR rate obtained in the late relapsing patients after salvage therapies was higher that in early relapsing (50% vs. 37%). Median survival from relapse was 1.4 yr for patients early relapsing and it was not achieved for those with late relapses (p=0.09). Late relapse is a quite common event in DLCL lymphomas, with those patients achieving more frequently a second CR and having better survival than early relapsed patients.

In vivo biological response following low-dose interleukin-2 in complete remission B-cell non-Hodgkin's lymphoma patients. Italian Lymphoma Study Group (GISL)

The aim of the present study is to verify whether recombinant interleukin-2 (rIL-2) at low doses is well tolerated in aggressive lymphoma in complete remission (CR), and if there may be a biological justification for its use as a remission-maintenance therapy able to reduce the percentage of relapses. We treated 6 patients with B-cell non-Hodgkin's lymphoma (B-NHL) in CR following PM-Cytabom with rIL-2 3 IMU s.c. x 5 d per wk, every other wk for 8 wk. Our results show that this treatment provokes statistically significant changes in the absolute number of lymphocytes, eosinophils, CD25+ and CD122+ cells and soluble IL-2 receptors; these doses, however, are not sufficient to modify CD3+, CD16+ and CD56+ cell values or natural killer and lymphokine activated killer cell activity. Thus these findings do not appear to constitute a biological rationale for the use of rIL-2 at this dose and schedule as a remission-maintenance therapy in B-cell NHL. Nevertheless, the results are a valid basis for further study of the use of the same rIL-2 doses for a longer period of time in combination with other cytokines, in the hope that the biological effects can be augmented without increasing the toxic side effects.

Long-term gonadal toxicity after therapy for Hodgkin's and non-Hodgkin's lymphoma

With the increasing cure rate of patients treated for Hodgkin's and non-Hodgkin's lymphoma, the evaluation of late effects on gonadal function remains an important issue. The gonadal function of relapse-free long-term survivors with high-grade non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD) were studied; 24 of 119 patients with NHL treated between 1980 and 1990 and 66 of 364 patients with HD treated between 1975 and 1990 at Hannover University Medical School, who were younger than 45 years of age and in complete remission at the time of evaluation for at least 24 months after completion of therapy, were included into the analysis. Of 24 patients with NHL, 1/10 women (10%) and only 3/14 men (21%) showed signs of gonadal dysfunction. Three of these four patients had been treated with combined modality therapy followed by maintenance COP chemotherapy, resulting in high cumulative doses of cyclophosphamide (range: 12-43 g). In comparison, 13/26 (50%) women with HD suffered from premature ovarian failure, and 26/40 (65%) men showed signs of gonadal dysfunction with significant FSH elevations. No significant difference in the incidence of gonadal toxicity existed in patients treated with combined modality who received irradiation to either supra- or infradiaphragmatic radiation fields in combination with chemotherapy (70% versus 62%). A comparison of the chemotherapy regimens used in patients with NHL or HD shows that patients from both groups had received comparable median cumulative doses of cyclophosphamide, vincristine, and adriamycin, but only patients with HD had additionally received a median cumulative dose of 13.3 g of procarbazine per patient. A tendency towards a higher incidence of gonadal toxicity with higher cumulative doses of procarbazine received was found in patients with HD. The frequency of gonadal dysfunctions is markedly lower in patients treated for non-Hodgkin's lymphoma than in patients treated for Hodgkin's disease, approximately half of whom will be affected by long-term gonadal toxicity. Although the use of more intensive radiotherapy in patients with HD compared with NHL patients makes the evaluation of the influence of radiotherapy on gonadal toxicity more difficult, the current retrospective analysis raises the concern that, in addition to infradiaphragmatic radiotherapy, the use of procarbazine in regimens for the treatment of HD, like COPP or MOPP, may be a possible explanation for the differences in gonadal toxicity observed between patients with HD and those with NHL. Regimens including procarbazine should be avoided in patients wanting to preserve fertility since alternative chemotherapies with at least equal efficacy are available.

Gonadal function after MACOP-B or VACOP-B with or without dose intensification and ABMT in young patients with aggressive non-Hodgkin's lymphoma

BACKGROUND

The late effects of chemotherapy of aggressive non-Hodgkin's lymphoma on gonadal function are largely unknown.

PATIENTS AND METHODS

In a retrospective study the gonadal function after chemotherapy with MACOP-B or VACOP-B with or without dose intensification and ABMT in first remission was examined in patients with aggressive non-Hodgkin's lymphoma by patient history and determination of hormonal function. Thirty adult patients of age 40 or less at diagnosis who were alive and free of relapse for at least 1 year after completion of chemotherapy were included in the study.

RESULTS

With a median time of 28 months (range 11 to 62 months) after completion of therapy, gonadal dysfunction was found in 1 of 7 female and none of 15 male patients, or a total of 5% of patients treated with chemotherapy alone. Of patients receiving dose intensification and ABMT in first remission, gonadal dysfunction was present in 2/6 (33%) treated with cyclophosphamide, BCNU and etoposide in 3/4 treated with cyclophosphamide and TBI.

CONCLUSIONS

Our data suggest that therapy of aggressive non-Hodgkin's lymphomas with MACOP-B or VACOP-B has little impact on future fertility and that fertility may be preserved in the majority of patients receiving dose-intensification with CBV in first remission.