CHOP-Bleo plus interferon for stage IV low-grade lymphoma

High ten-year remission rates following rituximab, fludarabine, mitoxantrone and dexamethasone (R-FND) with interferon maintenance in indolent lymphoma: Results of a randomized Study

We report a single-centre, randomized study evaluating the efficacy and safety of concurrent fludarabine, mitoxantrone, dexamethasone (FND) and rituximab versus sequential FND followed by rituximab in 158 patients with advanced stage, previously untreated indolent lymphoma, enrolled between 1997 and 2002. Patients were randomized to 6-8 cycles of FND followed by 6 monthly doses of rituximab or 6 doses of rituximab given concurrently with FND. All patients who achieved at least a partial response received 12 months of interferon (IFN) maintenance. Median ages were 54 and 55 years. The two groups were comparable with the exception of a higher percentage of females (65% vs. 43%) and baseline anaemia (23% vs. 11%) in the FND followed by rituximab group. Complete response/unconfirmed complete response rates were 89% and 93%. The most frequent grade ≥ 3 toxicity was neutropenia (86% vs. 96%). Neutropenic fever occurred in 21% and 16%. Late toxicity included myelodysplastic syndrome (n = 3) and acute myeloid leukaemia (n = 5). With 12·5 years of follow-up, no significant differences based on treatment schedule were observed. 10-year overall survival estimates were 76% and 73%. 10-year progression-free survival estimates were 52% and 51%. FND with concurrent or sequential rituximab, and IFN maintenance in indolent lymphoma demonstrated high response rates and robust survival.

Interferon-alpha for maintenance of follicular lymphoma

BACKGROUND

Indolent non-Hodgkin's lymphoma, in particular follicular lymphoma (FL), is characterized by multiple remissions and relapses. Several studies have used interferon-alpha (IFN) to control this disease, both as induction and as maintenance therapy. It is not yet clear whether IFN can be associated with a survival benefit although it may prolong progression-free survival.

OBJECTIVES

To determine the effects of IFN in the maintenance therapy of FL.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2008), MEDLINE (1966 to 2008), DARE (1990 to 2008), SCOPUS (searched December 2008) and Current Contents (1975 to 2008). .

SELECTION CRITERIA

Randomised controlled trials of IFN versus no intervention or placebo, or IFN plus chemotherapy versus chemotherapy alone, in a maintenance setting in patients with non-Hodgkin's FL. Primary outcomes were overall survival and progression-free survival.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse events information from the trials.

MAIN RESULTS

We included eight trials (1563 patients). The drug was IFN alfa-2b in six trials and alfa-2a in two. Trials were heterogeneous in terms of diagnosis of FL, using several classification systems. IFN had been compared with placebo/no intervention in five trials and other chemotherapy in three. The effect of IFN was similar to that of placebo on overall survival (hazard ratio (HR) 0.90, 95% CI 0.61 to 1.34) whereas IFN was more effective when added to chemotherapy (HR 0.68, 95% confidence interval (CI) 0.52 to 0.90). Considering IFN versus all comparators, IFN was effective in prolonging progression-free survival (HR 0.66, 95% CI 0.57 to 0.77) and overall survival (fixed effects HR 0.79, 95% CI 0.67 to 0.94, I(2) = 52%). After adjustment for heterogeneity this statistically significance disappeared (random effects HR 0.82, 95% CI 0.63 to 1.08). Toxicity and patients lost to follow up were significantly higher in the IFN groups.

AUTHORS' CONCLUSIONS

There is evidence that addition of IFN as maintenance therapy for FL improves progression-free survival. A net benefit for overall survival is less evident. In the included studies, IFN was associated with significant toxicities that may have a major impact on a patient's quality of life.

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.

Economic burden of follicular non-Hodgkin's lymphoma

Follicular non-Hodgkin's lymphoma (FNHL), a slow-growing cancer of the immune system, constitutes about 15-30% of all incident non-Hodgkin's lymphoma in developed countries. Its incidence is rising worldwide. Patients can live many years, but FNHL is considered incurable. We systematically reviewed the English-language MEDLINE-indexed and non-indexed economic literature published in the past 10 years on FNHL, identifying 23 primary economic studies. The economic burden of FNHL is significant, but available data are generally limited to retrospective considerations of hospital-based direct treatment costs, with little information available regarding societal cost of illness. Most direct cost information originates from the US, with one estimate of $US36 000 for the per-patient incremental cost of FNHL care during the first year following diagnosis. The most studied treatment is rituximab, which may offer similar overall costs to fludarabine considering higher resource use with fludarabine complications. Nearly all cost-effectiveness models identified by this review evaluated rituximab for relapsed/refractory FNHL responding to chemotherapy induction. Rituximab is supported as a cost-effective addition to standard chemotherapy by two models in the UK and one in the US, as maintenance therapy instead of stem-cell transplant by one UK model, and as maintenance therapy instead of observation alone by one model each in France, Spain and Canada. The UK National Institute for Health and Clinical Excellence updated guidance on rituximab in February 2008, concluding that it is cost effective when added to induction chemotherapy, and when used as maintenance therapy. No studies of per-patient or national indirect costs of illness were identified, with the only study of indirect costs a Canadian survey documenting lost work productivity. Across all study types identified by our review, the most common focus was on the direct costs of rituximab. As new treatments for FNHL come to market, more real-life cost data are imperative to calculate their relative cost effectiveness.

Improvement of Overall and Failure-Free Survival in Stage IV Follicular Lymphoma: 25 Years of Treatment Experience at The University of Texas M.D. Anderson Cancer Center

Purpose

Advanced-stage follicular lymphoma is considered incurable. The pace of improvements in treatment has been slow. This article analyzes five sequential cohorts of patients with stage IV follicular lymphoma treated between 1972 and 2002.

Methods

Five consecutive studies (two were randomized trials) involving 580 patients were analyzed for overall survival (OS), failure-free survival (FFS), and survival after first relapse. A proportional hazards analysis, and subset analyses using the follicular lymphoma international prognostic index (FLIPI) score were performed. Treatment regimens included: cyclophosphamide, doxorubicin, vincristine, prednisone, bleomycin (CHOP-Bleo); CHOP-Bleo followed by interferon alfa (IFN-α); a rotation of three regimens (alternating triple therapy), followed by IFN-α; fludarabine, mitoxantrone, dexamethasone (FND) followed by IFN-α; and FND plus delayed versus concurrent rituximab followed by IFN-α.

Results

Improvements in 5-year OS (from 64% to 95%) and FFS (from 29% to 60%) indicate steady progress, perhaps partly due to more effective salvage therapies, but the FFS data also indicate improved front-line therapies; these observations held true after controlling for differences in prognostic factors among the cohorts. The FLIPI model adds rigor to and facilitates comparisons among the different cohorts. An unexpected finding in this study was a trend toward an apparent FFS plateau.

Conclusion

Evolving therapy, including the incorporation of biologic agents, has led to stepwise significant outcome improvements for patients with advanced-stage follicular lymphoma. The apparent plateau in the FFS curve, starting approximately 8 to 10 years from the beginning of treatment, raises the issue of the potential curability of these patients.

Personalized immunotherapy for the treatment of non-Hodgkin's lymphoma: a promising approach

The efficacy of immunotherapeutic strategies for the treatment of lymphoid malignancies has been demonstrated in recent years. In patients with B-cell lymphomas, particularly indolent lymphoma, the use of passive immunotherapy, such as the anti-CD20 monoclonal antibody rituximab, has made an impressive impact on patient outcome. Personalized immunotherapy, a method that triggers the immune system to mount a response against tumor cells, has shown promising results in early clinical trials in hematologic malignancies. This therapeutic modality appears safe, with the most common adverse events being transient, local reactions at the site of injection. Furthermore, personalized immunotherapy has the potential to generate immunologic memory, which could provide prolonged remission. Currently, 3 large phase III studies are evaluating the efficacy and safety of personalized immunotherapy in patients with follicular lymphoma. It is hoped that the results of these studies will lead to the incorporation of this promising approach into the standard treatment of patients with lymphoma.

Effective Treatment of Indolent Non-Hodgkin’s Lymphomas with Mitoxantrone, Chlorambucil and Prednisone

Since indolent non-Hodgkin's lymphomas (NHL) represent about 35% of all malignant lymphomas and mainly affect elderly patients, availability of a conventional chemotherapy regimen with high efficacy and low toxicity is of clinical importance.

PATIENTS AND METHODS

We retrospectively analysed 13 patients with advanced indolent NHL who were treated with 6-9 cycles of MCP: mitoxantrone 8 mg/m2 (days 1 and 2), chlorambucil 3 x 3 mg/m2 (days 1-5) and prednisone 25 mg (days 1-5) every 4 weeks.

RESULTS

The overall response was 84% (61% complete response, 23% partial response), 1 patient had stable disease and 1 patient experienced progressive disease. Median time to progression was 37 months (95% CI: 20-53) and the median survival has not yet been reached. The main toxicity (66%) was neutropenia (WHO grade III). There was no hair loss and no cardial or neurologic adverse event.

CONCLUSION

In summary, MCP is an effective and well tolerated chemotherapy regimen and is probably an alternative to the more toxic CHOP regimen, especially in older patients.

Molecular response of follicular lymphoma to cyclophosphamide, doxorubicin, vincristine, prednisone C(H)OP or COP-based therapy as measured by polymerase chain reaction evidence of translocation (14;18)(q32;q21)

PURPOSE

Existing data suggest that conventional C(H)OP (cyclophosphamide, doxorubicin, vincristine, prednisone) regimen may not be intensive enough to achieve molecular response, as measured by polymerase chain reaction (PCR) evidence of translocation (14;18)(q32:q21) for follicular lymphoma. This study was undertaken to study the molecular response rate of follicular lymphoma to C(H)OP-based therapy and to analyze prognostic factors for molecular response.

PATIENTS AND METHODS

Twenty patients with pretreatment PCR evidence of t(14;18)(q32; q21) and at least one posttreatment PCR analysis after the initiation of the treatment with C(H)OP with or without radiation therapy constituted the basis for this analysis. The random effects logistic model was used to analyze the data. The following factors were investigated for their relationship to molecular response: gender, age, beta2-microglobulin, use of radiation therapy, Ann Arbor stage, and international Prognostic Index for malignant lymphoma.

RESULTS

Median follow-up was 56 months (range, 23-153 months). A total of 135 PCR results were available, 33 from bone marrow and 102 from peripheral blood. Overall, there was a clear and steady decreasing trend toward loss of PCR positivity with increasing time aftertreatment. By univariate analysis, stage > or = 3, stage = 4, International Prognostic Index > or = 2, and no radiation therapy were adverse factors for molecular response. On multivariate analysis, Ann Arbor stage IV and no radiation therapy were independent risk factors for PCR positivity, both for the peripheral blood data analyzed alone and for all data combined.

DISCUSSION

It is possible to achieve molecular response with C(H)OP with or without radiation therapy in patients with follicular lymphoma. Response rate depends on the Ann Arbor stage and radiation therapy.

Fludarabine, mitoxantrone, dexamethasone (FND) compared with an alternating triple therapy (ATT) regimen in patients with stage IV indolent lymphoma

Treatment for patients with stage IV indolent lymphoma ranges from watchful waiting to intensive chemotherapy and stem cell transplantation. In this trial we compared 2 induction regimens followed by 1 year of interferon maintenance therapy. Fludarabine, mitoxantrone (Novantrone), and dexamethasone (FND) were compared with an alternating triple therapy (ATT) regimen (CHOD-Bleo, ESHAP, and NOPP). Maintenance interferon/dexamethasone was given for 1 year in both treatment arms. Endpoints were comparisons of remission rates, survival, failure-free survival (FFS), molecular response rates, and toxicities. One hundred forty-two patients with previously untreated stage IV indolent lymphoma were evaluable (73 on FND; 69 on ATT). The overall response rates were 97% for FND and 97% for ATT (P =.9). The median follow-up is 5.9 years. The 5-year survival rates were 84% with FND and 82% with ATT (P =.9); the 5-year FFS rates were 41% with FND and 50% with ATT (P =.02). In a multivariate analysis, factors predicting for longer FFS were beta(2)-microglobulin less than 3 mg/L (P =.01) and ATT treatment (P =.03). ATT was associated with a substantially higher rate of grade 3-4 toxicities than FND. In conclusion, both regimens were associated with high rates of response and survival. ATT was associated with substantially longer FFS, but it was more toxic than FND.

Progress and promise in the treatment of indolent lymphomas

In the era of conventional alkylating agent-based chemotherapy, advanced stage indolent lymphoma has been considered incurable. The failure of our traditional therapies to cure these patients, coupled with the indolent course of the disease and the elderly population affected, has fostered a nihilistic attitude about the treatment of these diseases. Twenty years ago, in the absence of interesting alternatives to alkylating agents, judicious use and reuse of alkylators was perhaps the best we could do. There are now many reasons for optimism and excitement in the treatment of these diseases, including the availability of promising agents such as interferon-alpha, the nucleoside analogues, and rituximab. Radioimmunotherapy will also likely play a role in future therapy programs. Allogeneic stem cell transplantation is a high-risk approach that is not an option for all patients, but it has the potential to cure patients, even in the setting of relapse. Mini-allogeneic transplantation may permit an approach to allogeneic transplantation that is better tolerated than standard transplant strategies. In addition to these therapy options, biological insights have provided new options for monitoring patients. Molecular monitoring (polymerase chain reaction for bcl-2) is a stringent measure of short-term treatment efficacy, and one that correlates with durability of remission, i.e., it is a surrogate marker by which to judge treatment efficacy. There used to be a limited number of conventional treatment approaches, which consistently failed. The pendulum has swung. There are now many promising new options. It is time to plan and conduct trials that are geared for success.

Interferon in oncological practice: review of interferon biology, clinical applications, and toxicities

For the past 40 years, various forms of interferon (IFN) have been evaluated as therapy in a number of malignant and non-malignant diseases. With the advent of gene cloning, large quantities of pure IFN became available for clinical study. This paper reviews the biology, pharmacology, and clinical applications of IFN formulations most commonly used in oncology. It then reviews the most common side effects seen in patients treated with IFN, and makes recommendations for the management of IFN-induced toxicity. The major oncological indications for IFN include melanoma, renal cell carcinoma, AIDS-related Kaposi's sarcoma, follicular lymphoma, hairy cell leukemia, and chronic myelogenous leukemia. Unfortunately, IFN therapy is associated with significant toxicity, which can be divided into constitutional, neuropsychiatric, hematologic, and hepatic effects. These toxicities have a major impact on the patient's quality of life, and on the physician's ability to optimally treat the patient. Careful attention to all aspects of patient care can result in improved tolerability of this difficult but promising therapy.

CONCLUSION

a better understanding of IFN biology, indications, side effect profiles, and toxicity management will aid in optimizing its use in the treatment of patients with cancer.

Anthracyclines in haematology: pharmacokinetics and clinical studies

The activity of anthracyclines in the treatment of a wide spectrum of haematological malignancies has long been established. Differences in the pharmacokinetic and pharmacodynamic properties of these drugs have resulted in the selection of individual compounds for particular indications while the recent reformulation of anthracyclines in liposomal preparations seems likely to significantly alter their range of activity and toxicity. The problems related to cumulative cardiotoxicity secondary to anthracycline exposure can be ameliorated by the use of dexrazoxane and a number of agents may prove to have a role in altering their cellular resistance to their cytotoxic actions.

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.

Primary parotid lymphoma: the effect of International Prognostic Index on outcome

Since the reported survival and failure-free survival (FFS) of adults with primary parotid non-Hodgkin's lymphoma (NHL) is variable, we reviewed our experience of untreated adults with primary parotid NHL. Patients were eligible if they presented to the University of Texas M. D. Anderson Cancer Center Cancer between 1980 and 1995 with parotid enlargement and if the diagnosis of lymphoma was verified according the Working Formulation. Medical records were reviewed to determine Ann Arbor Stage (AAS), the International Prognostic Index (IPI) score, response to therapy, relapse, FFS, and survival. We identified 39 untreated adults with primary parotid NHL representing 1% of all lymphomas and 8.6% of all untreated parotid neoplasms. Three patients were excluded because of suboptimal therapy, leaving 36 patients eligible for outcome analysis. Of the 18 patients with low-grade NHL, two were treated with radiotherapy, eight with chemotherapy and radiotherapy, seven with chemotherapy only, and one with antibiotics. The complete remission (CR) rate was 94%, and with a median follow-up of 36 months for surviving patients the survival and failure-free survival (FFS) at 5 years were 94% and 78%, respectively. The 5-year FFS were not statistically different between patients with early (I or II) or advanced (III or IV) AAS (83% and 74%, respectively; p > 0.05) and favorable (0 or 1) or unfavorable (> 1) IPI scores (73% and 100%, respectively; p > 0.05). All 18 patients with intermediate-grade NHL were treated with doxorubicin-based chemotherapy which was followed by radiotherapy in six. The CR rate was 89%, and with a median follow-up of 51 months for surviving patients the survival and FFS at 10 years were 80% and 72%, respectively. In this group 10-year FFS was better in early than in advanced AAS (100% vs 0%, respectively; p = 0.01) and in favorable (0 or 1) than in unfavorable (> 1) IPI scores (86% vs 20%, respectively; p < 0.01). We conclude the the FFS of patients with low-grade NHL is 78% and not affected by AAS or IPI score. The FFS of patients with intermediate-grade NHL appears comparable with that of NHLs of other primary sites, being 86% for those with IPI < or = 1 and 20% for those with IPI 1. Patients with IPI > 1 should be entered on investigational protocols aiming to increase FFS.

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.

Allogeneic bone marrow transplantation for poor-prognosis lymphoma: response, toxicity and survival depend on disease histology

PURPOSE

To evaluate outcomes and identify prognostic factors in allogeneic bone marrow transplantation in patients with end-stage lymphoma.

PATIENTS AND METHODS

Data were retrospectively analyzed of 64 patients (42 men and 22 women) 18 to 48 years of age with recurrent or refractory lymphoma who underwent allogeneic bone marrow transplantation from matched sibling donors (or in 1 case from a one antigen-mismatched relative) between May 1981 and July 1994.

RESULTS

Twelve patients survived free of disease. They were 8 of 15 with low-grade lymphoma (disease-free survival at 2 years 59% +/- 13%); 3 of 25 with lymphoblastic lymphoma (disease-free survival 17% +/- 8%); and 1 of 10 with diffuse small non-cleaved cell lymphoma (disease-free (10% +/- 9%). Survival and disease-free survival of patients with low-grade lymphoma were significantly superior compared to any other subgroup of patients (P <0.01). Only 2 patients with low-grade lymphoma had disease progression (9% +/- 9% actuarial risk at 2 years) as opposed to 5 of 15 with intermediate-grade lymphoma (39% +/- 14%), 9 of 25 with lymphoblastic lymphoma (28% +/- 9%), and 8 of 10 (80% +/- 13%) with diffuse small non-cleaved lymphoma. The actuarial risk for disease progression was significantly lower for patients with low-grade lymphoma than for any other histologic subgroup (P <0.02). It was significantly higher for those with diffuse small non-cleaved cell lymphoma than for other histologic subgroups (P < or = 0.003).

CONCLUSIONS

Allogeneic bone marrow transplantation is an effective procedure in patients with refractory low-grade lymphoma. It results in long-term remissions and should be considered in younger patients with recurrent disease who have a matched sibling donor. The late recurrence in 1 patient indicates the necessity of continued follow-up. A small fraction of patients with end-stage intermediate- and high-grade lymphoma can obtain prolonged disease-free survival, but recurrence and regimen-related toxicity remain major problems. The results could be improved by the development of conditioning regimens with less toxicity and by the use of bone marrow transplantation earlier in the course of the disease.

Interferon alpha 2b as maintenance therapy in low grade malignant lymphoma improves duration of remission and survival

We assessed the efficacy and toxicity of interferon alpha 2b (IFN) as maintenance therapy in patients with low grade malignant lymphoma. Between March 1986 and December 1989, 98 patients with low-grade malignant lymphoma in complete remission after conventional chemotherapy were randomly assigned to received IFN, 5.0 MU three times a week for one year, as maintenance therapy (n = 48), or to receive no treatment (control group, n = 50). In March 1994, the median duration of response had not yet been reached in the patients treated with IFN compared to 46 months in the control group. At 9-years 62% of the patients in the IFN arm remain in first complete remission compared to only 25% in the control group (p <.001). In addition, the median duration of survival has not yet been reached in either the IFN arm compared to 74 months in the control group (p <.001). Quality of life was excellent in both groups and severe side effects secondary to IFN treatment were not observed. All patients completed the planned dose of IFN. We conclude that IFN as maintenance therapy in low-grade malignant lymphoma is an excellent therapeutic option because it improves the duration of remission and survival without producing severe side effects or reducing the quality of life.

Mantle cell lymphomas

MCLs are thought to arise from a subset of B cells that normally express the CD5 antigen and that reside in the mantle zone of secondary lymphoid follicles. Although expression of the CD5 antigen is also seen in small lymphocytic lymphoma and chronic lymphocytic leukemia, MCL differs from SLL/ CLL in several ways. Whereas trisomy of chromosome 12 is the hallmark cytogenetic abnormality of SLL/CLL, the translocation (11;14) (q13q32) is the most frequent karyotypic abnormality in MCL. The histologic pattern of MCL is most frequently diffuse. However, this lymphoma can grow in a unique pattern called 'mantle zone MCL,' indicating that the malignant cells expand the mantle of the follicle and grow around a normal germinal center. If the germinal center is also replaced by the malignant cells, but the follicular architecture remains, the pattern appears nodular. The clinical presentation of MCL is usually only seen with advanced disease stage, particularly in patients with diffuse MCL. The bone marrow is the most frequently affected extranodal site, followed by the gastrointestinal tract. The histologic pattern of disease in the lymph nodes correlates with clinical outcome. Patients with diffuse MCL have poor response to frontline combination chemotherapy including doxorubicin, whereas patients with mantle zone MCL have excellent complete remission rates. The therapeutic response correlates in turn with worse survival outcome for patients with diffuse MCL compared to mantle zone MCL. The few patients with nodular MCL had clinical behavior similar to diffuse MCL. The chemotherapeutic response of diffuse and nodular MCL, however, is quite poor, and we would propose that new investigational approaches be considered in the front-line therapy of these disorders.

Classification and clinical course of low-grade non-Hodgkin's lymphomas with overview of therapy

Low-grade non-Hodgkin's lymphoma (NHL) presents a formidable treatment challenge to oncologists. This review evaluates the various methods of disease and patient management. The natural history of various subtypes of low-grade NHL and the classification according to the National Cancer Institute Working Formulation are discussed in this review. Additionally, the various therapies in use; radiotherapy alone and combined with chemotherapy, chemotherapy with single alkylating agents such as chlorambucil and combination therapies, autologous and allogenic bone marrow transplantation, and therapy with purine analogs, such as chlorodeoxyadenosine and fludarabine. Patient survival in various studies using these treatment modalities are discussed. Treatment options need to be combined with the use of prognostic models, such as the International Index for optimal care of this difficult-to-treat group of patients.

The role of interferon in the therapy of malignant lymphoma

As a single agent, interferon-alpha (IFN-alpha) can induce remissions, mostly partial, in a large fraction of patients with indolent lymphomas, including the low grade B-cell lymphomas and cutaneous T-cell lymphoma. In aggressive lymphomas, IFN has minimal activity, and in Hodgkin's disease the limited available experience suggests only modest activity. In indolent B-cell lymphomas, IFN has been integrated with chemotherapy in several large trials: the majority of these trials indicate a favorable impact on failure-free survival; a survival benefit of IFN has been reported by the French-Belgian group. Updated results are now available from a previously reported trial from the MD Anderson Cancer Center that also indicate an apparent survival benefit when IFN is used in conjunction with chemotherapy in patients with indolent B-cell lymphoma.

Treatment of Waldenstrom's macroglobulinemia with very low doses of alpha interferon

Waldenström's macroglobulinemia (WM) is a differentiated B-cell malignancy which is usually less responsive to standard chemotherapy because of low-proliferating cells. Interferon alpha has been shown to possess a therapeutic action in numerous B-cell malignancies including the early stage of chronic lymphocytic leukemia, multiple myeloma, follicular lymphoma and hairy cell leukemia. Fourteen patients with progressive WM were included in a pilot study using very low dose of interferon alpha-2a (1 Million Units 3 times a week). The mean duration of treatment was 10.3 months (range 2-44). Six of 14 (42%) patients presented an increase in the hemoglobin level (> or = 0.9 g/dL) and 4/14 (28%) had a substantial decrease of the monoclonal component (> or = 20% of reduction). Only two patients presented both types of response, while the others with an increase in the hemoglobin level had a slight decrease in the monoclonal component (MC) (1 patient), a stable MC (1 patient) or a slight increase of MC (1 patient). One additional patient had a 15% decrease of the MC with a stable hemoglobin level. Response was observed within 3 months with a median duration of 6 months. Treatment was stopped for 3 patients because of flu-like symptoms (2 patients), or thrombocytopenia (1 patient). Follow up was possible in 12 patients lasting up to a maximum of 30 months after discontinuing treatment. Seven patients died, including 4 with progressive disease, two of infection and one of cardiac failure. In the view of these results, very low dose of interferon alpha may constitute a new approach for treatment of some cases of WM.

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.

Interferon-alpha for induction and maintenance in multiple myeloma: results of two multicenter randomized trials and summary of other studies

BACKGROUND

Interferon (IFN) treatment trials in multiple myeloma have yielded discordant results regarding response rates, maintenance duration, and survival times. Further randomized trials and global evaluations of available data are urgently needed for clarification.

PATIENTS AND METHODS

256 patients participated in a randomized trial, 125 on IFN + VMCP, and 131 on VMCP alone. 100 patients were randomized to IFN maintenance (n = 46) or were untreated controls (n = 54). Global evaluations are based on 1,518 patients in induction and 924 in maintenance trials.

RESULTS

The induction trial demonstrated a significantly (p < 0.05) lower rate of progressive disease under IFN + VMCP (10.6%) than under VMCP (22.9%), but this benefit was limited to stage I or II patients. Median progression-free survival was longer in the IFN + VMCP arm (23.2 months vs. 15.8 months); median overall survival did not differ significantly (38.9 vs. 30.2 months). The IFN maintenance treatment trial showed significantly superior results in the IFN arm versus controls (median maintenance duration: 17.8 months and 8.2 months (p < 0.01), survival: 50.6 and 34.4 months (p < 0.05), respectively). Previous IFN treatment increased the benefits of IFN maintenance therapy. Adverse effects of IFN during induction were hematologic toxicity, fever, and infections, requiring dose reductions. Toxic effects of IFN maintenance treatment were mild. Global evaluations of randomized trials showed small but significant benefits of combined IFN induction therapy and significantly prolonged maintenance duration and survival under IFN maintenance.

CONCLUSIONS

Presently available data support the use of IFN maintenance treatment because it significantly prolongs maintenance duration and survival. IFN added to induction chemotherapy resulted in minor improvements at the expense of increased toxicity, highlighting the need for better induction regimens.

Treatment of refractory low grade lymphoma with chlorambucil alternating with interferon and radiotherapy

We report the results of a clinical trial of chlorambucil (CB) alternating with interferon alfa 2b (IFN) in previously treated patients with low-grade lymphoma who were refractory to previous treatment. Patients received CB 10 mg/m2, po, daily, days 1-14, alternating with IFN 5.0 MU three times a week days 15-28 (six doses) by six monthly cycles. If partial response was achieved, patients received extended field radiotherapy to sites of nodal residual postchemotherapy disease. Forty-three patients were enrolled into the study, and 30 were evaluable for response and toxicity. Nineteen out of 39 (40%) achieved complete remission and 14 out of 39 (35%) had partial remission, thus the overall response was observed in 83% of the cases. Ten patients with partial response and residual nodal disease received radiotherapy and achieved complete response criteria. The median duration of response has not been achieved, yet, 23 patients remain in complete response after a median follow-up of 98.5 months. Toxicity was mild and 95% of the patients received the planned dose of CB and IFN. These results suggest that combination of CB and IFN and addition of radiotherapy to residual postchemotherapy nodal disease may be effective in patients with low-grade lymphoma without excessive toxicity and adequate quality of life.

Mitoxantrone, chlorambucil and prednisolone in the treatment of non-Hodgkin's lymphoma

The management of low grade lymphoma, both de novo and relapsed disease, is a contentious area in which there has been little real progress in recent years. Regimens which increase the intensity of treatment may accelerate the response but are inevitably associated with greater toxicity. This cannot be justified in a disease whose median survival is between 4 and 10 years and where the median age at presentation is 57. We have assessed the response of 144 patients treated with a combination of mitoxantrone, chlorambucil and prednisolone in a heterogeneous group with lymphoma, both de novo and relapsed disease. In the subgroup with low grade relapsed/refractory disease our results suggest that this combination is clinically effective, low in toxicity and suitable for the outpatient management of this usually elderly patient population.

Cytokine therapeutics: lessons from interferon alpha

Cytokines are soluble proteins that allow for communication between cells and the external environment. Interferon (IFN) alpha, the first cytokine to be produced by recombinant DNA technology, has emerged as an important regulator of growth and differentiation, affecting cellular communication and signal transduction pathways as well as immunological control. This review focuses on the biological and clinical activities of the cytokine. Originally discovered as an antiviral substance, the efficacy of IFN-alpha in malignant, viral, immunological, angiogenic, inflammatory, and fibrotic diseases suggests a spectrum of interrelated pathophysiologies. The principles learned from in vivo studies will be discussed, particularly hairy cell leukemia, chronic myelogenous leukemia, certain angiogenic diseases, and hepatitis. After the surprising discovery of activity in a rare B-cell neoplasm, IFN-alpha emerged as a prototypic tumor suppressor protein that represses the clinical tumorigenic phenotype in some malignancies capable of differentiation. Regulatory agencies throughout the world have approved IFN-alpha for treatment of 13 malignant and viral disorders. The principles established with this cytokine serve as a paradigm for future development of natural proteins for human disease.

Intensive conventional-dose chemotherapy for stage IV low-grade lymphoma: high remission rates and reversion to negative of peripheral blood bcl-2 rearrangement

BACKGROUND

Advanced-stage low-grade lymphoma is characterized by initial responsiveness to many conventional therapies but ultimate relapse. Intensive therapy approaches with non-cross-resistant regimens have not been extensively explored. The polymerase chain reaction (PCR) can be used to monitor for the presence of cells with rearrangement of bcl-2, and provides a sensitive and stringent parameter of disease activity and treatment response that may have clinical utility.

PATIENTS AND METHODS

From 1988 to 1992, 138 evaluable patients were treated with 3 sequential chemotherapy regimens, as well as with interferon alfa 2b (IFN) in combination with corticosteroids. Nineteen patients had serial PCR monitoring for bcl-2 rearrangement.

RESULTS

Among a subset of 58 patients who had an initial phase of IFN plus prednisone, the response rate was 59%, mostly partial remissions (PR). With the chemotherapy program, 65% have achieved complete remission to date, and 30% PR. By PCR analysis, 13 of 19 tested achieved negative status ('molecular remission'), a much higher frequency of molecular remission than has been seen with standard therapies, and these molecular remissions appear to correlate with a lower likelihood of relapse.

CONCLUSIONS

Intensive conventional-dose chemotherapy can achieve high rates of remission, even when monitored by the stringent PCR technique.

Recombinant interferon alfa-2b combined with a regimen containing doxorubicin in patients with advanced follicular lymphoma. Groupe d'Etude des Lymphomes de l'Adulte

BACKGROUND

Interferon alfa and cytotoxic drugs have synergistic effects in patients with non-Hodgkin's lymphoma. In 1986, we designed a clinical trial to evaluate the benefit of concomitant administration of recombinant interferon alfa with a regimen containing doxorubicin in patients with follicular non-Hodgkin's lymphoma.

METHODS

The trial involved 242 patients with advanced low-grade follicular non-Hodgkin's lymphoma selected on the basis of clinical, radiographic, and biologic criteria. All patients were treated with a regimen consisting of cyclophosphamide, doxorubicin, teniposide, and prednisone (CHVP), given monthly for six cycles and then every two months for one year. After randomization, 123 patients also received interferon alfa-2b at a dosage of 5 million units three times weekly for 18 months. The remaining 119 patients received chemotherapy alone.

RESULTS

As compared with the patients treated with CHVP only, the patients treated with CHVP plus interferon alfa had a higher overall rate of response (85 percent vs. 69 percent, P = 0.006), a longer median event-free survival (34 months vs. 19 months, P < 0.001), and a higher rate of survival at 3 years (86 percent vs. 69 percent, P = 0.02). Granulocyte toxicity was greater in the patients treated with CHVP plus interferon alfa than in those treated with CHVP alone. There were no treatment-related deaths. Interferon alfa had to be stopped because of toxic effects (fatigue and hepatitis) in 13 patients (11 percent).

CONCLUSIONS

The addition of interferon alfa to a regimen containing doxorubicin increased the rate of response, event-free survival, and overall survival in patients with advanced follicular non-Hodgkin's lymphoma, without serious toxicity, although some patients were unable to tolerate the side effects.