Prophylactic treatment with miconazole in patients highly predisposed to fungal infection. A placebo-controlled double-blind study

In a placebo-controlled double-blind study the prophylactic value of oral systemic treatment with the antimycotic agent miconazole was assessed in 30 highly predisposed patients receiving intensive cytostatic chemotherapy because of haematological malignancies. Patients colonized with Candida before treatment were not freed from this micro-organism by miconazole treatment. However, only 3 out of 6 initially non-colonized miconazole-treated patients became colonized during the study, against 10 out of 10 placebo-treated patients (p = 0.036). Seven out of 15 patients in the placebo group developed clinical mycosis, against only two out of 15 in the miconazole group. The miconazole-treated patients remained clinically free of mycosis for 252 out of 264 treatment days, while the placebo-treated patients remained free of mycosis for only 263 out or 338 treatment days (p = 0.0001). The results indicate that systemic miconazole treatment protects highly predisposed patients from colonization with Candida and prevents or postpones clinically established candidosis.

Non-Hodgkin's lymphoma subtypes over time in an unselected population of 646 patients: a study of clinico-pathological data and incidence based on a review using the REAL-classification

Biopsies from 646 consecutive unselected cases of non-Hodgkin's lymphoma from a Danish population-based registry were reclassified according to the REAL classification 1) to study the distribution of subtypes over time, and 2) to correlate a number of clinical parameters with the various subtypes. Two cohorts from 1986 and 1992, of 292 and 354 cases, respectively, were studied. From 1986 to 1992 diffuse large B-cell lymphoma showed a change in incidence of + 43.1%, as opposed + 2.5% for all other subtypes combined (p = 0.05), suggesting that the increasing general incidence of non-Hodgkin's lymphoma is due primarily to an increasing incidence of diffuse large B-cell lymphoma. A higher rate of cell proliferation was associated with an increasing chance of having extranodal disease. For the various subgroups there was good agreement between survival and the International prognostic index.

The rise in incidence of lymphomas in Europe 1985-1992

A collaborative study was carried out of the descriptive epidemiology of the lymphomas from seven countries across Europe in the period 1985-1992. Careful attention was paid to sources of information and the data quality in close collaboration with expert histopathologists. The data were classified as non-Hodgkin's lymphoma (NHL) and Hodgkin's disease (HD). An attempt was made to put the data into a modified version of the Revised European American Lymphoma (REAL) classification. We observed an overall rise in total NHL throughout the time period in all European countries but no such trend in HD. The increase in NHL overall being 4.2% per annum, representing an increase of 4.8% in males and 3.4% in females per annum, was only marked in middle and old age. Such increases were observed in all participating areas except in Burgundy. Different countries, however, have different base rates, the rates being highest in Scandinavia and the Netherlands. The analysis by subcategory classification suggested that the increase in NHL was confined to the follicle centre cell type, extranodal B-cell, nodal T-cell and nodal lymphomas not otherwise specified, categories. These new observations present a picture of real increase in case incidence with no obvious explanation. The increases in NHL do not appear to be due solely to better diagnoses. Pending other explanations or refutation, these present a compelling picture of an inexorable rise in incidence of this disease.

Childhood medulloblastoma in Denmark 1960-1984. A population-based retrospective study

Medulloblastoma is a common paediatric brain tumour, located in the cerebellum and in the IV ventricle, surpassed in frequency only by astrocytomas. 180 children below the age of 15 with a medulloblastoma of the posterior fossa were treated in Denmark in the 25-year period from 1960 to 1984 and followed up until the end of 1996, or until death. During the 25 years they accounted for 20% of all intracranial tumours in children in Denmark. All tumours were histologically verified. The mean annual incidence was 6.4x10(-6), decreasing slightly with a factor of 0.12x10(-6) per year. The male/female ratio was 2.1 - twice that of the background population of children (1.05). The 5-year survival rate following diagnosis, surgery and radiotherapy was 23%, and the 25-year survival rate was 16%. The 5-year survival rate was 8% in the first 5-year period of 1960-1964, increasing to 36% in the last period 1980-1984. Presumably the increase in survival depends on many factors, e.g. improved diagnostic methods and neuroanaesthesia, better operative technique (microscope), improvements in radiotherapy and the introduction of chemotherapy. The best predictive factors of a good prognosis were preoperative CSF shunting, radical tumour removal and complete radiotherapy, i.e. irradiation of the brain, tumour bed and spinal cord. The survival rate in the last five-year period was seven times higher than the survival rate found in a comparable Danish study from the years 1935-1959. Most of the children followed Collins law of risk index. The results of treatment in children with medulloblastoma remain unsatisfactory. Accordingly, participation in international prospective studies of multimodal treatment should be encouraged, possibly using chemotherapy prior to surgery.

Long-term oral pamidronate treatment inhibits osteoclastic bone resorption and bone turnover without affecting osteoblastic function in multiple myeloma

This study was performed as a cross-sectional substudy to the Danish-Swedish Pamidronate Study, a randomized placebo-controlled multicentre trial in multiple myeloma. The purpose was to evaluate the biological effects of long-term treatment with oral pamidronate 300 mg daily on bone metabolism by using histomorphometry and analysis of cytokines and biochemical markers of bone turnover. Sixteen patients were included after median 27.5 months of protocolized treatment; 10 patients received active treatment and 6 patients placebo. When compared with placebo, pamidronate treatment was associated with: (a) marked decreased osteoclastic resorption rate (0.86+/-0.59 microm/d vs. 5.7+/-5.0 microm/d, p=0.002), and diminished activation frequency (0.20+/-0.18 yr(-1) vs. 0.72+/-0.55 yr(-1), p=0.014); (b) compensatory reduced volume referent bone formation rate (0.17+/-0.21 yr(-1) vs. 0.71+/-0.54 yr(-1), p=0.007), but unaltered mineral appositional rate; (c) neutral (-0.66+/-5.6 mm) vs. negative (-2.15+/-2.2 microm, p=0.013) bone balance per remodelling cycle; (d) higher trabecular bone volume (21.0+/-6.2% vs. 13.0+/-3.7%, p=0.01); (e) suppressed urinary excretion and serum levels of some of the biochemical markers of bone metabolism; and (f) significant reduction of circulating soluble interleukin-6 receptor (IL-6sR) (25.9+/-4.1 ng/ml vs. 32.1+/-6.6 ng/ml, p=0.04), and (g) a uniform tendency of lower serum and marrow plasma levels of IL-6, IL-1beta, and TNFalpha. Thus oral pamidronate was absorbed in biologically active amounts, and reduced overall bone resorption and bone turnover without impairing osteoblastic bone formation. The observation that cytokine and cytokine receptor levels were reduced extends the possible and potential beneficial actions of bisphosphonates in multiple myeloma.

Failure of oral pamidronate to reduce skeletal morbidity in multiple myeloma: a double-blind placebo-controlled trial. Danish-Swedish co-operative study group

In order to study whether oral bisphosphonate therapy might prevent or reduce skeletal-related morbidity in patients with newly diagnosed multiple myeloma who required chemotherapy, 300 patients were included in a randomized multi-centre trial. Patients were given oral pamidronate at a dose of 300 mg daily, or placebo, in addition to conventional intermittent melphalan/prednisolone (and in some cases alpha-interferon) treatment. With a median treatment duration of about 550d, no statistically significant reduction in skeletal-related morbidity (defined as bone fracture, related surgery, vertebral collapse, or increase in number and/or size of bone lesions) could be demonstrated. Pamidronate treatment also did not have any influence on patient survival or on the frequency of hypercalcaemia. However, in patients treated with pamidronate there were fewer episodes of severe pain (P=0.02) and a decreased reduction of body height of 1.5 cm (P= 0.02). The overall negative result of the study is attributed to the very low absorption of orally administered bisphosphonates in general.

Changing trends in the incidence of non-Hodgkin's lymphoma in Europe. Biomed Study Group

Non-Hodgkin's lymphoma (NHL) is not a uniform disease entity, and in order to investigate the reported changes in incidence we have set up a study in seven population-based cancer registries in Europe. The study is designed to look at changes in the incidence of total NHL and disease subgroups using standard definitions and methodology. The registries are based in Leeds, Dijon, Kuopio, Odense, Florence, Eindhoven, and Ragussa. The classification system we have used is based on the REAL classification and has utility for epidemiological studies. We have used it to convert data sets which have utilized both local cases and the ICD-O classification. In order to improve data reproducibility, CLL/LL, myeloma/MGUS, lymphoblastic disease, and Hodgkin's disease have been excluded because of the difficulty in defining incident cases accurately. The preliminary results of this study show that there is still an upward trend in incidence rate and that in Yorkshire this is 3% per annum in total NHL. The subgroups which are increasing are extranodal and nodal peripheral T-cell lymphoma. Similar increases in incidence have been reported for the other registries. We conclude that there is a continued upward trend in incidence of NHL, the causes of which are uncertain.

CB/CC diffuse lymphoma: a distinct subtype of non-Hodgkin's lymphoma? A study of 1593 patients from a Danish population-based registry. Danish LYFO Study Group

Between 1983 and 1993, 3165 cases of non-Hodgkin's lymphoma (NHL) were reported to the West Danish Lymphoma Registry (LYFO). Out of these, 148 (4.7%) were of the CB/CC diffuse subtype according to the Kiel classification. However, in the new European-American NHL consensus classification (REAL, 1994), CB/CC diffuse lymphoma was categorized as a provisional subtype only. In the LYFO material, death-probability curves show a significantly shorter survival in CB/CC diffuse than in CB/CC follicular. In order to detect further possible differences between CB/CC diffuse and other NHL subtypes, a number of clinical parameters at presentation were analyzed in a subset of five types of lymphoma. This subset included 148 cases of CB/CC diffuse, 435 cases of CB/CC follicular, 667 cases of CB diffuse, 202 cases of CC diffuse, and 131 cases of peripheral T-cell lymphoma. Using logistic regression analysis, significant differences could be demonstrated between CB/CC diffuse and the four other subtypes as regards sex ratio, age distribution, and sites of both nodal and extranodal involvement. These findings indicate that CB/CC diffuse has a distinct clinical phenotype and imply the existence of real biological differences between CB/CC diffuse and other subtypes of lymphoma.

[Therapeutic results in localized ventricular non-Hodgkin's lymphomas. A retrospective study of 106 cases]

One hundred and six cases of localized gastric lymphomas reported to a population-based register of non-Hodgkin lymphomas were analysed retrospectively to identify the optimum primary treatment. Five-year survival was 67%, and no type of treatment showed any superiority. Surgical resection was associated with significantly more unacceptable late complications than radiotherapy. Accordingly, the latter treatment should substitute surgery as the primary local treatment in localized gastric lymphoma.

A retrospective analysis of treatment outcome in 106 cases of localized gastric non-Hodgkin lymphomas. Danish Lymphoma Study Group, LYFO

197 cases of gastric lymphoma were reported to a population-based Danish registry of non-Hodgkin's lymphomas. 106 of these cases were localized, representing stages IE and II1E, and were analyzed retrospectively, using Cox regression analysis. 67 had surgical resection, 51 chemotherapy, and 55 radiotherapy, or combinations thereof. No type of treatment showed any superiority as regards survival (p = 0.13). Overall 5-year survival was 67%. The pretherapeutic presence of fever or S-LDH-elevation had a far more significant influence on survival than histology or any of the treatments or treatment combinations. Surgical resection was associated with a significantly higher risk of late complications than radiotherapy, suggesting that radiotherapy may be preferable to surgery as the primary treatment in localized gastric lymphoma. It could not be determined from the available data whether the addition of chemotherapy to the primary treatment provides any survival benefit.

[The significance of chemotherapy for survival after recurrent breast cancer. A population based study of patients treated in the 1950's, 1960's and 1970's]

In a population-based study survival after recurrence was compared in three cohorts of patients each with a primary diagnosis of breast cancer in either 1959, 1969 end 1979. The use of chemotherapy after recurrence in these cohorts was either none, sporadic or widespread. This allowed a retrospective analysis of the survival impact of chemotherapy. Our data suggest that chemotherapy in recurrent breast cancer prolongs survival by 9.5 months in patients who survive more than two weeks from the start of treatment for their recurrence, given the basic assumption that the natural history of breast cancer and the influence of endocrine therapy have not changed significantly during the 20-year period covered by the study.

Non-Hodgkin's lymphoma of the gastrointestinal tract: a population-based analysis of incidence, geographic distribution, clinicopathologic presentation features, and prognosis. Danish Lymphoma Study Group

PURPOSE

To evaluate incidence, time trends, geographic distribution, clinicopathologic presentation features, and prognostic factors for survival and relapse in gastrointestinal (GI) non-Hodgkin's lymphomas (NHLs).

PATIENTS AND METHODS

Over a 9-year period (1983 to 1991), 2,446 new NHL cases were recorded in a Danish population-based NHL registry (Danish Lymphoma Study Group [LYFO]). Of these, 306 (12.5%) were GI NHL (175 gastric, 109 intestinal, and 22 both sites). LYFO registry data were used for incidence rate (IR) assessment, and time-trend and geographic distribution analysis. Relative risk (RR) values for survival and relapse were identified by multivariate analysis.

RESULTS

The mean annual, age-standardized IRs for gastric and intestinal NHL were 0.71/10(5) and 0.48/10(5) per year, respectively. Age-specific IRs for both localizations showed an exponential increase as a function of age. Time-trend analysis for the period 1983 to 1991 showed stable IRs for both localizations. Intestinal NHL was more frequent in males (male-to-female ratio, 2.0 v 1.3), and had a higher occurrence of disseminated disease, constitutional symptoms, high-grade histology, and T-cell phenotype (10% v 2%). Gastric NHL had more low-grade cases (38% v 19%), and almost all were of the mucosa-associated lymphoid tissue (MALT) type. The cause-specific 5-year survival rate was 63% for gastric NHL and 49% for intestinal NHL. The Musshoff staging system was an excellent discriminator between truly localized (stage I and II1) and disseminated cases (stage II2 to IV), particularly for gastric NHL, for which no survival difference was found between surgically and conservatively stage localized cases.

CONCLUSION

(1) No increase in the incidence of GI NHL was found over a 9-year observation period; (2) nonrandom spatial distribution of new GI NHL cases was observed; (3) factors that significantly increased the risk of death in gastric cases were presence of B symptoms (RR = 3.3), clinical stage is more than II1 (RR = 3.0), age more than 72 years (RR = 2.4), and elevated serum lactate dehydrogenase (s-LDH) level (RR = 2.0); and factors that increased the risk of death in intestinal cases were presence of B symptoms (RR = 3.2), age more than 58 years (RR = 2.8), and clinical stage more than I (RR = 2.1); (4) factors that significantly increased the risk of relapse in gastric cases were male sex and no radiotherapy in primary treatment; and in intestinal cases were T-cell phenotype and no surgery in primary treatment; (5) surgical staging, as opposed to thorough noninvasive staging, did not improve staging accuracy and final outcome in localized gastric NHL.

A re-analysis of available dose-response and time-dose data in Hodgkin's disease

A re-analysis of all available dose-response data on Hodgkin's disease, compiled recently by Vijayakumar and Myrianthopoulos (Vijayakumar, S. and Myrianthopoulos, L.C. An updated dose-response analysis in Hodgkin's disease. Radiother. Oncol. 24: 1-13, 1992), fails to demonstrate any dose-response relationship at doses higher than 32.5 Gy. Thus, in contrast with these authors, we find no evidence that local control will be improved by radiation doses of more than 32.5 Gy. A review of the available data on the time-dose relationship in Hodgkin's disease indicates that overall treatment time, at least up until 7 weeks, is not of major importance. Further, there is some indication that the sensitivity to changes in dose per fraction is low. This allows the fraction size to be selected from considerations of the level of late treatment related morbidity.

[Non-Hodgkin lymphoma in the elderly]

Within a seven year period, 1597 newly diagnosed cases of non-Hodgkins lymphoma (NHL) were included in a Danish population-based NHL-register. Of these, 602 (38%) were aged 70 or older (age range 70-94, median: 76.8) and represented the population defined as "elderly" patients in the present study. Their average annual incidence rate was 35.7/10(5), as compared to 6.6/10(5) for patients aged < 70 (overall annual incidence: 9.5/105). Localised cases (stage I and II) and extranodal manifestations were more frequent among elderly patients. The most common sites of extranodal involvement were stomach (21% of all extranodal cases) and bone marrow (16%). Histologically, follicular centroblastic/centrocytic cases were found to be less frequent (p < 0.01) in elderly patients as compared to their younger counterparts (< 70 years), who on the other hand had a lower occurrence of diffuse centroblastic cases (p < 0.01). Overall seven year survival for the elderly patient population was 35% (median: 1.7 years), and for patients aged < 70 it was 57%. This difference persisted after correction for apparently NHL-unrelated deaths (52% vs. 66% respectively, p < 0.0001). The following poor prognostic factors for elderly patients were identified by multivariate analysis: hepatic involvement, presence of B-symptoms, high-grade histology and elevated s-LDH. The corresponding relative risk values were respectively 2.4, 2.2, 1.9 and 1.6.

The influence of chemotherapy on survival after recurrence in breast cancer--a population-based study of patients treated in the 1950s, 1960s and 1970s

In a population-based study survival after recurrence was compared in three cohorts of patients with a primary diagnosis of breast cancer in 1959, 1969 and 1979, respectively. The use of chemotherapy after recurrence in these cohorts was either none, sporadic or widespread. This allowed a retrospective analysis of the survival impact of chemotherapy. Given the basic assumption that the natural history of breast cancer and the influence of endocrine therapy have not changed significantly during the 20-year period covered by the study, our data suggest that chemotherapy in recurrent breast cancer prolongs survival by 9.5 months in patients who survive more than 2 weeks from the start of treatment for this recurrence.

Acute mucocutaneous toxicity following high-dose hydroxyurea

Three patients with advanced acute myeloid leukemia were treated with oral high-dose hydroxyurea at a dose of 10 g daily for 8-10 days. Severe acute stomatitis developed in all three patients. In addition, two of the patients developed a peculiar acute cutaneous type of toxicity associated with soreness, violet erythema, and edema of the palms and foot soles followed by intense universal hyperpigmentation of the skin. Apparently, the pronounced acute mucocutaneous toxicity was caused by the sustained high daily dose of hydroxyurea, indicating that myelosuppression may not be the dose-limiting toxicity of this drug.

Non-Hodgkin's lymphoma in the elderly. A study of 602 patients aged 70 or older from a Danish population-based registry. The Danish LYEO-Study Group

Within a 7-year period 1,597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Danish population-based NHL registry. Of these, 602 (38%) were aged 70 years or older (age range 70-94, median: 76.8). They represent the population defined as 'elderly' patients in the present study. The average annual incidence rate for this elderly patient population was 35.7/10(5), as compared with 6.6/10(5) for patients aged less than 70 (overall annual incidence: 9.5/10(5)). Localised cases (stage I and II) and extranodal manifestations were found more frequently among elderly patients. The most common sites of extranodal involvement were the stomach (21% of all extranodal cases) and the bone marrow (16%). Histologically, follicular centroblastic/centrocytic cases were found to be less frequent (p less than 0.01) in elderly patients as compared to their younger counterparts (less than 70 years), who in contrast had a lower occurrence of diffuse centroblastic cases (p less than 0.01). Overall 7-year survival for the elderly patient population was 35% (median 1.7 years), and for patients aged less than 70 it was 57%. This difference persisted after correction for apparently NHL-unrelated deaths (52% vs. 66%, respectively, p less than 0.0001). Elderly patients with poor prognosis were characterised by the following features identified in a Cox-regression model: hepatic involvement, presence of B-symptoms, high-grade histology and elevated s-LDH. The corresponding relative risk values were in the order 2.4, 2.2, 1.9 and 1.6.

Interpretation of granulomatous lesions in malignancy

In patients with malignancy the most frequent granuloma-associated conditions are tumor-related sarcoid reactions, sarcoidosis, tuberculosis and other infections. Quite often, the finding of granulomatous lesions in patients with cancer may lead to difficulties of interpretation resulting in inappropriate treatment of both granulomatous disease and malignancy. This problem is reviewed and exemplified by a number of typical case histories. A systematic diagnostic approach must integrate anamnestic, clinical, histomorphological, immunohistological and laboratory information. In addition, prolonged follow-up may be necessary in order to establish the true nature of a granuloma-associated condition.

Clinicopathological features and prognostic factors in extranodal non-Hodgkin lymphomas. Danish LYFO Study Group

In a Danish population-based non-Hodgkin lymphoma (NHL) registry, 1257 newly diagnosed NHL cases were registered over a 5-year period. Of these, 463 (37%) were extranodal. The gastrointestinal tract was the most common site of extranodal involvement (30% of the cases). Histologically, 44% of all extranodal NHL cases had high-grade, 17% intermediate and 27% low-grade features, while 12% were unclassified. The most common histological subtype (Kiel) was the centroblastic diffuse (23% of cases). 50% of all extranodal NHL were localised (stage IE or IIE) and 27% had B symptoms. Site-specific features included a strong age-correlation for thyroid and testes lymphoma (greater than 50 years) and a high prevalence of female cases in thyroid and salivary glands lymphomas (M/F 0.14 and 0.30, respectively). Overall 7-year survival for extranodal NHL was 46% (median 4.9 years). Poor prognosis patients could be identified by the presence of one or more of the following presentation characteristics: age greater than 65 years, B symptoms, high-grade histology, disseminated disease, elevated s-IgA and hyperuricaemia. Relative risk values ranged from 2.1 for age and B symptoms to 1.7 for hyperuricaemia.

Itraconazole treatment of pulmonary aspergillosis in leukaemia patients during a nosocomial epidemic associated with indoor building renovation

During indoor building renovation a nosocomial epidemic of pulmonary aspergillosis occurred in a haematological ward, involving 10 patients with acute leukaemia undergoing intensive chemotherapy. Antifungal treatment included the combination of amphotericin B and 5-fluorocytosine during periods of granulocytopenia, followed by itraconazole after bone-marrow recovery. In five patients, lung aspergillomas disappeared completely, while significant improvement was observed in a further two patients. Itraconazole appeared to contribute significantly to the result, but the drug did not work during granulocytopenic episodes. Air analyses showed increased counts of fungal spores in ward locations with heavy traffic of patients and staff, suggesting the need to identify and avoid risk areas when placing patients undergoing intensive chemotherapy.

Aclarubicin plus cytosine arabinoside versus daunorubicin plus cytosine arabinoside in previously untreated patients with acute myeloid leukemia: a Danish national phase III trial. The Danish Society of Hematology Study Group on AML, Denmark

A regimen of aclarubicin (ACR) of 75 mg/m2 daily for 3 days plus a continuous intravenous infusion of cytosine arabinoside (ara-C) of 100 mg/m2 per day for 7 days was compared with daunorubicin (DNR) 45 mg/m2/day for 3 days plus ara-C for 7 days as first-line chemotherapy of de novo acute myeloid leukemia (AML) in a randomized, nationwide Danish study. A total of 180 patients aged between 17 and 65 years were entered onto the protocol. Patients who achieved complete remission (CR) were given five courses of intensive consolidation therapy consisting of two courses of high dose ara-C, two courses of amsacrine plus etoposide, and one course of DNR plus ara-C. Of 174 evaluable patients, 99 achieved CR. The rate of CR was significantly higher on ACR plus ara-C than on DNR plus ara-C [66% versus 50% (p = 0.043)] and decreased significantly with increasing age. The hematological toxicity was identical for the two regimens. A total of 83 patients entered consolidation therapy. At 4 years, 37% of patients with CR following ACR were still in remission compared with 33% following DNR (p = 0.48), and the total survival at 4 years was 29% versus 20% (p = 0.26). The duration of remission and total survival both decreased with increasing age. ACR plus ara-C seem at least as good or better than DNR plus ara-C as first-line chemotherapy of AML.

Immunohistologic separation of B-cell-positive granulomas from B-cell-negative granulomas in paraffin-embedded tissues with special reference to tumor-related sarcoid reactions

Frozen and formalin-fixed paraffin-embedded tissue sections were studied concurrently in 17 cases of granulomatous lesions of different etiologies using antibodies recognizing either fixation-sensitive or fixation-resistant antigens. In fixed tissues, the antibodies 4KB5 and L26 for B cells and UCHL1 and MT1 for T cells gave results similar to those obtained in frozen tissues with anti-leu-12/leu-14 for B cells and T-3 for T cells. Paraffin-embedded sections from 35 additional cases of granulomatous lesions were studied retrospectively using the same markers. The combined results from all 52 cases show that granulomas can be divided into two main "families" according to the presence or absence of B cells within the granulomas: one is a B-cell-negative family of lesions to which sarcoidosis and mycobacterial infection belong; the other is a B-cell-positive family of lesions to which toxoplasmosis, granulomatous lesions of unknown significance and tumor-related sarcoid reactions belong.

MIME combination chemotherapy in recurrent or refractory lymphoproliferative malignancies. A phase II study

Seventy-two patients with recurrent or refractory malignant lymphoproliferative diseases were treated with MIME combination chemotherapy (methyl-GAG, ifosfamide, methotrexate, etoposide) and concurrent mesna to prevent urothelial toxicity; 41 patients had high/intermediate-grade non-Hodgkin's lymphoma (NHL), 18 low-grade NHL/chronic lymphocytic leukemia (CLL), and 13 Hodgkin's disease (HD). The overall response rates were 56% in high/intermediate-grade NHL, 11% in low-grade NHL/CLL, and 69% in HD respectively. Median survival in the same 3 groups was 7, 2 and 10 months respectively. Neither previous type of response to chemotherapy nor previous amount of treatment predicted the outcome of MIME chemotherapy. Toxicity was modest, hemorrhagic cystitis did not occur, and only one therapy-related death occurred. Although MIME appears to be a safe treatment with considerable activity in recurrent or refractory lymphoproliferative disease very few patients become long-term survivors. However, MIME is well suited for remission induction in patients intended for subsequent autologous bone-marrow transplantation.

Granulomatous lesions of unknown significance in biopsies from lymph-nodes and other tissues: the GLUS-syndrome

Granulomatous lesions of unknown significance (GLUS) have been described primarily in liver and lymph-node biopsies, and the overall frequency of GLUS among all types of granulomatous lesions is approximately 20-25%. Regardless of localization GLUS is characterized by a benign self-healing course. The combination of this clinical picture with a characteristic histomorphologic and immunohistologic pattern appears to justify the proposal of the existence of a special GLUS-syndrome, possibly with a single or a few related etiologies.

Long-term survival and late relapses in acute leukaemia in adults

34 out of 403 apparently unselected adult patients with acute leukaemia referred to a single department from 1970 through 1989 survived more than 3 years. The cumulative rate of relapse after 3 years was 39% in patients with acute myeloblastic leukaemia (AML) and 74% in patients with acute lymphoblastic leukaemia (ALL). The latest relapse was observed 75 months after diagnosis in AML and 98 months after diagnosis in ALL. 65% of the long-term survivors were able to undertake normal physical activity, 26% had decreased activity, and 9% were unable to work. 5-year survival for all patients, whether treated or not, during two successive decades was 16% versus 18% and 5% versus 6%, respectively, for ALL and AML. The departmental results were identical with population-based national results. Only in patients 15-49 years of age with AML was there evidence that more intensive treatment had led to better survival.

Phase III trial of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) versus cisplatin, etoposide, bleomycin and prednisone (CisEBP) for the treatment of advanced non-Hodgkin's lymphoma of high grade malignancy. The Danish Lymphoma Study Group

The trial included 85 previously untreated patients (median age 61 years) with stage III or IV non-Hodgkin's lymphoma (NHL) of the subtypes centrocytic lymphoma, diffuse centroblastic lymphoma, immunocytoma, immunoblastic lymphoma, or unclassified lymphoma of high grade malignancy. The patients were randomized to 9 monthly treatment cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) or CisEBP (cisplatin, bleomycin, etoposide, prednisone). Patients who had failed to achieve even a partial response (PR) after the completion of 2 cycles were switched to the alternative regimen. Complete response (CR) on primary treatment was obtained in 70% (55-83%) of CHOP-treated patients and in 25% (13-41%) of CisEBP-treated patients (p = 0.0004). Secondary CHOP treatment produced CR in 7 (30%) of 24 patients and secondary CisEBP treatment led to CR in 2 (15%) of 14 patients. The median survival was 3.4 years in the CHOP arm and 2.6 years in the CisEBP arm (p = 0.78). Hematologic toxicity was mainly leukocytopenia and anemia in both treatment arms. Non-hematological toxicity was slight, and late toxicity was insignificant. Three treatment-related deaths were noted. We conclude that CHOP induces more remissions than CisEBP in advanced lymphomas of high grade malignancy.

Immunological marker patterns in granulomatous lymph node lesions

The distribution of various types of lymphocytes and macrophages was studied in 19 cases with granulomatous lymph node lesions using 14 monoclonal antibodies. Cases of sarcoidosis, tuberculosis and atypical mycobacteriosis all showed well demarcated granulomas devoid of B-lymphocytes and natural killer cells. In these cases, T-helper: T-suppressor cell ratios were greater than 2 and poor preservation of the normal lymphoid tissue outside the granulomas was seen. In contrast, cases of non-specific lymphadenitis showed less well-demarcated granulomas always containing B-lymphocytes and natural killer cells, with a T-helper:T-suppressor cell ratio less than 1 and good preservation of the normal lymphoid tissue outside the granulomas. Immunological marker studies may be helpful in the differential diagnosis of granulomatous lymph node lesions, as well as in the study of the pathogenesis of such lesions.

Two pregnancy-associated late relapses in acute lymphoblastic leukemia

Late relapses of acute lymphoblastic leukemia occurred in two women in associated with pregnancy, 7 and 17 years, respectively, after the initial diagnosis of leukemia. In both cases and in a similar pregnancy-associated case in the literature relapse was accompanied by the appearance of vacuolization in the leukemic lymphoblasts. In order to explain how late relapses can occur at all and how they may be triggered by endocrine events such as pregnancy, it seems necessary to assume that some leukemic cells are not autonomous and that they may preserve the faculty of normal homeostatic regulation.

Coexistence of sarcoidosis and myeloproliferative disease: a case of sarcoidosis preceding polycythaemia vera with a literature review

A patient with the chronic active type of sarcoidosis developed polycythaemia vera 20 years later. A review of the literature shows that sarcoidosis preceding myeloproliferative disease tends to be of the chronic active variety. The same pattern is observed in associations of sarcoidosis with malignant lymphoproliferative disease and solid tumours, in which sarcoidosis appears to be the underlying cause of the subsequent malignancy.

Coexistence of sarcoidosis and malignant disease: causality or coincidence?

A review of 131 cases of coexistent sarcoidosis and malignancy indicates that this association is not fortuitous: 1) A nonrandom sample of tumor types is observed. 2) The chronic active type of sarcoidosis is involved much more often than the subacute self-healing type. 3) The temporal relationship between sarcoidosis and subsequent malignancy is not a random one, at least not in malignant lymphoproliferative disease, in which sarcoidosis almost invariably precedes malignancy. 4) The observed incidences of malignant lymphoproliferative disease and of lung cancer are significantly higher than expected. The association of sarcoidosis and malignant lymphoproliferative disease is so constant that the existence of a sarcoidosis-lymphoma syndrome is suggested, in which the chronic active type of sarcoidosis appears to be responsible for an increased risk of malignant transformation of lymphoid cells.

Late relapses after treatment for acute lymphoblastic leukemia in childhood: a population-based study from the Nordic countries

Seven late relapses of acute lymphoblastic leukemia occurring 5.5 to 12.3 years after cessation of therapy are reported in 986 patients who had discontinued treatment for leukemia acquired before the age of 15. The study covers patients from the five Nordic countries. Of the 434 patients with ALL who had passed 5 years of follow-up without recurrence, seven have subsequently relapsed so far; an estimated cumulative proportion of 6.9% within the 10 years. In addition, we report a girl 15.9 years old at diagnosis who relapsed 7.3 years after cessation of therapy. These findings confirm that "cure" of acute lymphoblastic leukemia treated in the 1970s cannot be considered definite, even 5 years after discontinuation of therapy.

Distant recurrence in breast cancer. Survival expectations and first choice of chemotherapy regimen

Controversial questions in recurrent breast cancer include the magnitude of the survival benefit of combination chemotherapy and the best choice of first line chemotherapy. Data from the files of the Danish Breast Cancer Cooperative Group (DBCG) show that with current systemic treatment median survival after distant recurrence is 19 months. Since historical data from the pre-chemotherapy era indicate a median survival of 12 months, the survival benefit of standard chemotherapy appears to be around 7 months in the average patient. The DBCG trial 80-R2 is the largest randomized trial of CAF (cyclophosphamide, doxorubicin, 5-fluorouracil) versus CMF (cyclophosphamide, methotrexate, 5-fluorouracil) in recurrent breast cancer. A review of this study and 6 other similar studies shows that CAF is clearly superior to CMF in terms of better tumor shrinkage, prolonged overall time to progression, and decreased need of secondary therapy. The adverse effects of the two treatments are largely comparable, but CAF causes severe alopecia and is more expensive than CMF. On balance, the existing evidence indicates that CAF rather than CMF should be chosen as first line chemotherapy in recurrent breast cancer.