Exposure to pesticides and risk of Hodgkin lymphoma in an international consortium of agricultural cohorts (AGRICOH)

PURPOSE

Some pesticides may increase the risk of certain lymphoid malignancies, but few studies have examined Hodgkin lymphoma (HL). In this exploratory study, we examined associations between agricultural use of 22 individual active ingredients and 13 chemical groups and HL incidence.

METHODS

We used data from three agricultural cohorts participating in the AGRICOH consortium: the French Agriculture and Cancer Cohort (2005-2009), Cancer in the Norwegian Agricultural Population (1993-2011), and the US Agricultural Health Study (1993-2011). Lifetime pesticide use was estimated from crop-exposure matrices or self-report. Cohort-specific covariate-adjusted overall and age-specific (< 40 or ≥ 40 years) hazard ratios (HRs) and 95% confidence intervals (CIs) were estimated using Cox regression and combined using random effects meta-analysis.

RESULTS

Among 316 270 farmers (75% male) accumulating 3 574 815 person-years at risk, 91 incident cases of HL occurred. We did not observe statistically significant associations for any of the active ingredients or chemical groups studied. The highest risks of HL overall were observed for the pyrethroids deltamethrin (meta-HR = 1.86, 95% CI 0.76-4.52) and esfenvalerate (1.86, 0.78-4.43), and inverse associations of similar magnitude were observed for parathion and glyphosate. Risk of HL at ≥ 40 years of age was highest for ever-use of dicamba (2.04, 0.93-4.50) and lowest for glyphosate (0.46, 0.20-1.07).

CONCLUSION

We report the largest prospective investigation of these associations. Nonetheless, low statistical power, a mixture of histological subtypes and a lack of information on tumour EBV status complicate the interpretability of the results. Most HL cases occurred at older ages, thus we could not explore associations with adolescent or young adult HL. Furthermore, estimates may be attenuated due to non-differential exposure misclassification. Future work should aim to extend follow-up and refine both exposure and outcome classification.

Early skeletal muscle loss in adolescent and young adult cancer patients treated with anthracycline chemotherapy

BACKGROUND

Early skeletal muscle loss has been observed in adolescent and young adult (AYA) sarcoma patients undergoing treatment. Identification of individuals within the AYA populace that are at greatest risk of anthracycline-induced skeletal muscle loss is unknown. Moreover, investigations which seek out underlying causes of skeletal muscle degradation during chemotherapy are critical for understanding, preventing, and reducing chronic health conditions associated with poor skeletal muscle status.

METHODS

Computed tomography (CT) scans were used to investigate changes in skeletal muscle of 153 AYA sarcoma and Hodgkin lymphoma patients at thoracic vertebra 4 after anthracycline treatment. Images were examined at three time points during the first year of treatment. In parallel, we used translational juvenile mouse models to assess the impact of doxorubicin (DOX) in the soleus and gastrocnemius on muscle wasting.

RESULTS

Significant reductions in total skeletal muscle index and density were seen after chemotherapy in AYA cancer patients (p < 0.01 & p = 0.04, respectively). The severity of skeletal muscle loss varied by subgroup (i.e., cancer type, sex, and treatment). Murine models demonstrated a reduction in skeletal muscle fiber cross-sectional area, increased apoptosis and collagen volume for both the soleus and gastrocnemius after DOX treatment (all p < 0.05). After DOX, hindlimb skeletal muscle blood flow was significantly reduced (p < 0.01).

CONCLUSION

Significant skeletal muscle loss is experienced early during treatment in AYA cancer patients. Reductions in skeletal muscle blood flow may be a key contributing factor to anthracycline doxorubicin induced skeletal muscle loss.

Advances in the treatment of Hodgkin's lymphoma (Review)

Hodgkin's lymphoma (HL) is a unique B‑cell lymphoproliferative malignancy that has a critical pathogenesis characterized by a sparse population of Hodgkin and Reed‑Sternberg cells surrounded by numerous dysfunctional immune cells. Although systemic chemotherapy with or without radiotherapy, has significantly improved the prognosis of the majority of patients with HL, a subset of patients remains refractory to first‑line therapy or relapse after achieving an initial response. With the increased understanding of the biology and microenvironment of HL, novel strategies with notable efficacy and manageable toxicity, including targeted therapies, immunotherapy and cell therapy have emerged. The present review summarizes the progress made in developing novel therapies for HL and discusses future research directions in HL therapy.

Clinicopathological evaluation of methotrexate-associated lymphoproliferative disorders with special focus on Epstein-Barr virus-positive mucocutaneous lesions

Some patients diagnosed with methotrexate-associated lymphoproliferative disorder (MTX-LPD) develop spontaneous regression upon the discontinuation of MTX, whereas others require chemotherapy. The mechanisms underlying this differential response and the capacity to spontaneously regress are not clearly understood. We evaluated numerous clinicopathological features in 63 patients diagnosed with MTX-LPD, with a special focus on those with Epstein-Barr virus (EBV)-positive mucocutaneous lesions (EBVMCL). The diagnosis of EBVMCL included cases of both EBV-positive mucocutaneous ulcers (EBVMCU) and diffuse gingival swelling associated with proliferation of EBV-positive large B-cells. Of the four subgroups of MTX-LPD, one-year treatment-free survival (TFS) after the discontinuation of MTX was achieved among those with EBVMCL (100%), diffuse large B-cell lymphoma (57%), Hodgkin-like lesions (60%), or classical Hodgkin lymphoma (29%); a significant difference in TFS was observed when comparing the responses of patients with EBVMCL to the those diagnosed with other subtypes. Multivariate analysis revealed predictive factors for prolonged TFS that included EBV-positive lesions and comparatively low levels of serum LDH. Taken together, our study suggests that a diagnosis of EBVMCL is related to the overall clinical outcome after the discontinuation of MTX.

Methotrexate-associated Hodgkin Lymphoma in a Patient with Rheumatoid Arthritis Successfully Treated with Brentuximab Vedotin in Combination with Doxorubicin, Vinblastine, and Dacarbazine (BV+AVD)

A 53-year-old woman had been diagnosed with rheumatoid arthritis (RA) in X-6. She was started on methotrexate (MTX) in X-1. She developed a cough, and chest computed tomography showed abnormalities. In X, MTX was discontinued, but the cough persisted. A lung biopsy revealed a diagnosis of nodular sclerosis classic Hodgkin lymphoma (CHL-NS). She was considered to have "other iatrogenic immunodeficiency-associated lymphoproliferative disorders" (OIIA-LPD), MTX-associated Hodgkin lymphoma (MTX-HL). She received six courses of brentuximab vedotin (BV) in addition to AVD (BV+AVD). A complete metabolic response was obtained, and the RA went into remission. This is the fourth reported case of BV+AVD for MTX-HL.

A case report of Hodgkin lymphoma in a patient treated with ustekinumab for psoriasis

RATIONALE

Ustekinumab is a biological agent that inhibits interleukin 12 and 23 and has been approved for the treatment of moderate and severe plaque psoriasis. There have been case reports that raise concerns about its oncogenic potential. We are the first authors to report a case of Hodgkin lymphoma in a psoriatic patient receiving ustekinumab.

PATIENT CONCERNS

A 22-year-old asymptomatic female patient presented to our department to investigate an enlarged cervical lymph node. Her past history was unremarkable, except for psoriasis since age 13. Two months before presentation the decision to administer Ustekinumab was taken and the patient had already received 3 doses.

DIAGNOSES

During workup a Stage IV Hodgkin lymphoma was discovered.

INTERVENTIONS

Ustekinumab administration was discontinued. The patient received treatment with the ABVD regimen.

OUTCOMES

The patient's disease was refractory to the above-mentioned treatment. Therefore, a more aggressive regimen (BEACOPP escalated) was administered.

LESSONS

Growing postmarketing surveillance data and case reports indicate that further research is warranted in order to elucidate a potential association between Ustekinumab and malignancy.

Nivolumab for Methotrexate-associated Classic Hodgkin's Lymphoma in a Rheumatoid Arthritis Patient

Nivolumab exerts therapeutic activity in patients with classic Hodgkin's lymphoma (CHL) but may cause several types of immune-related adverse events. Some rheumatoid arthritis (RA) patients develop CHL during methotrexate therapy (MTX-CHL); however, the efficacy and safety of nivolumab for these patients remain unclear. A 68-year-old woman was diagnosed with CHL after six years of MTX therapy for RA. The disease did not respond to any type of chemotherapy. Nivolumab was then initiated, and the patient was successfully treated without the reactivation of RA. The reactivation of RA always needs to be considered with the administration of nivolumab.

Investigatin on the Tumor Producing Effect of Isonicotinic Acid Hydrazide in ASW/Sn Mice and MRC Rats

Administration of 0.1% isonicotinic acid hydrazide in drinking water to 9 week old ASW/Sn mice and to 5 week old MRC rats for the remainder of their lifetime resulted in an enhanced incidence of pulmonary tumors in the former species. It rose from 34 to 68% in the females as compared with the controls, while in the males, the treatment did not affect the development of these lesions nor did it increase the incidences of other types of tumors. In rats, the compound was also without any apparent carcinogenic effect.

The possible role of this chemical in tumorigenesis is discussed in light of the obtained results.

Systematic review and meta-analysis of glyphosate exposure and risk of lymphohematopoietic cancers

This systematic review and meta-analysis rigorously examines the relationship between glyphosate exposure and risk of lymphohematopoietic cancer (LHC) including NHL, Hodgkin lymphoma (HL), multiple myeloma (MM), and leukemia. Meta-relative risks (meta-RRs) were positive and marginally statistically significant for the association between any versus no use of glyphosate and risk of NHL (meta-RR = 1.3, 95% confidence interval (CI) = 1.0-1.6, based on six studies) and MM (meta-RR = 1.4, 95% CI = 1.0-1.9; four studies). Associations were statistically null for HL (meta-RR = 1.1, 95% CI = 0.7-1.6; two studies), leukemia (meta-RR = 1.0, 95% CI = 0.6-1.5; three studies), and NHL subtypes except B-cell lymphoma (two studies each). Bias and confounding may account for observed associations. Meta-analysis is constrained by few studies and a crude exposure metric, while the overall body of literature is methodologically limited and findings are not strong or consistent. Thus, a causal relationship has not been established between glyphosate exposure and risk of any type of LHC.

Occupational benzene exposure and the risk of lymphoma subtypes: a meta-analysis of cohort studies incorporating three study quality dimensions

BACKGROUND

The use of occupational cohort studies to assess the association of benzene and lymphoma is complicated by problems with exposure misclassification, outcome classification, and low statistical power.

OBJECTIVE

We performed meta-analyses of occupational cohort studies for five different lymphoma categories: Hodgkin lymphoma (HL), non-Hodgkin lymphoma (NHL), multiple myeloma (MM), acute lymphocytic leukemia (ALL), and chronic lymphocytic leukemia (CLL).

DATA EXTRACTION

We assessed three study quality dimensions to evaluate the impact of study quality variations on meta-relative risks (mRRs): stratification by the year of start of follow-up, stratification by the strength of the reported acute myelogenous leukemia association, and stratification by the quality of benzene exposure assessment.

DATA SYNTHESIS

mRRs for MM, ALL, and CLL increased with increasing study quality, regardless of the study quality dimension. mRRs for NHL also increased with increasing study quality, although this effect was less pronounced. We observed no association between occupational benzene exposure and HL.

CONCLUSIONS

Our meta-analysis provides support for an association between occupational benzene exposure and risk of MM, ALL, and CLL. The evidence for an association with NHL is less clear, but this is likely complicated by the etiologic heterogeneity of this group of diseases. Further consideration of the association between benzene and NHL will require delineation of risks by NHL subtype.

Development of Hodgkin's lymphoma under bexarotene treatment for Sézary syndrome and review of the literature

There are several reports of patients who developed extracutaneous lymphoma after they started bexarotene treatment. The authors report a case in which the initiation of bexarotene therapy for Sézary syndrome was temporally associated with the development of Hodgkin's lymphoma despite improvement in cutaneous signs and symptoms. It is possible that bexarotene may contribute to the development of extracutaneous lymphoma. Although bexarotene therapy may relieve symptoms and signs of cutaneous T-cell lymphoma, careful examination of the lymph nodes during treatment is recommended.

Methotrexate-induced Hodgkin disease in a patient with systemic lupus erythematosus

Methotrexate sodium use in the management of various immunologic disorders has increased--as have the number of reported adverse effects associated with this therapy. While methotrexate has helped combat various autoimmune and cancerous disorders, the paradoxical risk of causing an often fatal malignancy may still occur as a result of the drug's effect on suppressing immune function. We present a case of methotrexate-induced Hodgkin disease in a 48-year-old man with a history of systemic lupus erythematosus (SLE). Discontinuation of methotrexate facilitated Hodgkin disease reversal. In addition, we review other lymphoproliferative hematologic malignancies caused by methotrexate.

Epstein-Barr virus associated Hodgkin lymphoma in a 9-year-old girl receiving long-term methotrexate therapy for juvenile idiopathic arthritis

We describe a case of Hodgkin lymphoma developing in a 9-year-old girl with polyarticular, rheumatoid factor-positive juvenile idiopathic arthritis treated with methotrexate (MTX), prednisone, and naproxen for 5 years. Pathologic and molecular analyses revealed that the Hodgkin cells contained Epstein-Barr virus and the viral DNA was monoclonal. She achieved complete remission after MTX withdrawal, chemotherapy, and radiation. To the best of my knowledge, this is the sixth report of Hodgkin lymphoma in patients with juvenile idiopathic arthritis receiving low dose MTX therapy.

Hodgkin lymphoma, multiple myeloma, soft tissue sarcomas, insect repellents, and phenoxyherbicides

OBJECTIVE

The objective of this study was to determine if there is an additional risk of developing Hodgkin lymphoma, multiple myeloma, or soft tissue sarcoma as a consequence of exposure to a combination of phenoxyherbicides, rubber gloves, DEET (N, N-diethyl-m-toluamide), and sunlight compared with each of the individual chemicals.

METHODS

This was a population-based study of men with specific cancers and age, province-matched control subjects.

RESULTS

No additional risk from these combinations of exposures of developing these three types of tumor was found in contrast to non-Hodgkin lymphoma.

CONCLUSIONS

The mechanisms by which phenoxyherbicides contribute to the risk of multiple myeloma and non-Hodgkin lymphoma may be different.

Association between personal use of hair dyes and lymphoid neoplasms in Europe

Hair dyes have been evaluated as possibly being mutagenic and carcinogenic in animals. Studies of the association between human cancer risk and use of hair dyes have yielded inconsistent results. The authors evaluated the risk of lymphoid malignancies associated with personal use of hair dyes. The analysis included 2,302 incident cases of lymphoid neoplasms and 2,417 hospital- or population-based controls from the Czech Republic, France, Germany, Ireland, Italy, and Spain (1998-2003). Use of hair dyes was reported by 74% of women and 7% of men. Lymphoma risk among dye users was significantly increased by 19% in comparison with never use (odds ratio (OR) = 1.19, 95% confidence interval (CI): 1.00, 1.41) and by 26% among persons who used hair dyes 12 or more times per year (OR = 1.26, 95% CI: 1.00, 1.60; p for linear trend = 0.414). Lymphoma risk was significantly higher among persons who had started coloring their hair before 1980 (OR = 1.37, 95% CI: 1.09, 1.72) and persons who had used hair dyes only before 1980 (OR = 1.62, 95% CI: 1.10, 2.40). Personal use of hair dyes is associated with a moderate increase in lymphoma risk, particularly among women and persons who used dyes before 1980. Specific compounds associated with this risk remain to be elucidated.

[Environmental pollution from dioxins and soft tissue sarcomas in the population of Venice and Mestre: an example of the use of current electronic information sources]

OBJECTIVE

Estimating the potential carcinogenic risk associated with exposure to dioxins generated by industrial emissions and urban incinerators.

DESIGN

We conducted a geographical investigation on the relationship between Soft Tissue Sarcomas (STS) and other tumours, and estimated levels of exposures to dioxins. Estimates ofthe population's exposure were derived from a historical analysis of emissions of dioxins and other pollutants, conducted by the Province of Venice in all the Venetian area in 1980-1990. Cancer cases were selected from two electronic pathology databases of Venice and Mestre, computerized since 1987. All STS diagnoses were revised in order to improve the quality of the cases in the study and cases of Kaposi sarcoma were excluded from the analysis. The 198 remaining STS--Hodgkin's lymphoma, non-Hodgkin' lymphoma and subjects with at least one cancer--were linked to the registry of residents and mapped according to the pollutant level estimates using GIS techniques. The same procedure was applied to cases of non-Hodgkin's lymphoma (n=822), Hodgkin's lymphoma (n=142) and to 25.568 cases of all cancer at other sites, with microscopic confirmation for comparison.

SETTING

Venetian AULSS 12.

RESULTS

Risks for STS (measured as Standardized Incidence Ratios SIR) did not show any trend related to categories of dioxin pollution. Among women, a statistically significant increased SIR of 1.69 was estimated for the highest category of exposure. The corresponding SIR for Hodgkins lymphoma was 1.94 (I.C. 1.08-1.19). No major excesses were estimated for other cancer sites.

CONCLUSION

Overall, no consistent association between cancer risk and estimated exposure to dioxins was detected in the population under study However, a statistically significant excess of STS among women in the highest exposure category allows for the possibility of a role of environmental exposure.

Reversible Epstein-Barr Virus-Negative Lymphadenopathy and Bone Marrow Involved by Hodgkin's Lymphoma in a Rheumatoid Arthritis Patient Undergoing Long-term Treatment with Low-Dose Methotrexate: A Case Report and Review of the Literature

We report a case of spontaneous regression of Epstein-Barr virus (EBV)-negative methotrexate-associated lymphadenopathy occurring with Hodgkin's lymphoma in the bone marrow of a 48-year-old woman with rheumatoid arthritis. Following 10 years of treatment with low-dose methotrexate, the patient developed pancytopenia, hypercalcemia, and elevated levels of liver enzymes over the course of 2 months. A computed tomography scan of the abdomen revealed splenomegaly and enlarged abdominal lymph nodes. A bone marrow biopsy demonstrated cellular marrow with 2 paratrabecular granuloma-like lesions composed of histiocytes, fibroblasts, small lymphocytes, a few plasma cells, and scattered CD30(+)CD15(+) Hodgkin's cells, including a classic Reed-Sternberg cell. The results of EBV studies of the bone marrow were negative. Within a month from withdrawal of methotrexate treatment, the patient's symptoms and the abnormalities in the laboratory results had regressed completely. A positron emission tomography scan failed to detect lymphadenopathy. Twelve months later, the patient remains free of symptoms.

Epidemiologic studies of chrome and cancer mortality: A series of meta-analyses

We used 49 epidemiologic studies based on 84 papers published since 1950 to develop an array of meta-analyses relating exposure to chrome-six compounds with 10 causes of death. Most exposures occurred in occupational settings. Studies were assessed for quality, and for control of smoking or economic status if they related to lung or stomach cancer. There was no excess mortality from all causes combined among chrome-exposed persons. A minimal excess of cancer (SMR=112), overall, was due primarily to an excess of lung cancer (SMR=141) but the SMR was 112 among the better-quality, smoking-controlled studies. The overall SMR for stomach cancer was 113 but it was 82 among the studies that were controlled for economic status. Findings were unremarkable for the six other cancers evaluated: prostate, kidney, and central nervous system cancer and leukemia, Hodgkin's disease and other lymphatohematopoietic cancer. This series of meta-analyses indicates that chrome-six is a weak cause of lung cancer and is not a cause of any of the other seven forms of cancer evaluated.

Hodgkin lymphoma in temporal association with growth hormone replacement

The association between growth hormone (GH) replacement and malignancy has long been debated. We report a case of Hodgkin lymphoma that developed in temporal association with the initiation of GH replacement in a 57-year-old woman with panhypopituitarism secondary to a non-secretory pituitary macroadenoma. Treatment of her pituitary tumor included transphenoidal surgery, external beam radiation, Bromocriptine and Cabergaline therapy. In addition to replacement steroid, thyroid and sex hormones, she insisted on GH replacement. Approximately 2 years after GH initiation, the diagnosis of Hodgkin lymphoma was made. Although the exact contribution of GH to the development of Hodgkin disease in our patient is unclear and a causal effect cannot be concluded, the temporal association is suggestive, and warrants reporting as part of ongoing surveillance for potential complications of GH replacement.

Personal use of hair dyes and hematolymphopoietic malignancies

In the context of a population-based case-control study in Italy, the authors investigated the possible association between the personal use of hair dyes and non-Hodgkin's lymphoma (NHL), leukemia, multiple myeloma, and Hodgkin's disease. They collected all incident cases of hematolymphopoietic malignancies; the control group was formed with a random sample of the general population. Overall, the authors interviewed 2,737 research subjects and 1,779 control subjects. Among women, the authors found no association between ever using hair dyes and the risk of hematolymphopoietic malignancies. However, for permanent hair dyes, the authors observed a slightly increased risk of lymphocytic leukemia (odds ratio [OR] = 1.3; 95% confidence interval [CI] = 0.8-2.2) and of follicular subtypes of NHL (OR= 1.3; 95% CI = 0.8-2.0). Women who used black hair dye colors were at an increased risk of developing leukemia (OR = 1.9; 95% CI = 1.0-3.4), in particular chronic lymphocytic leukemia (OR = 3.0; 95% CI = 1.1-7.5). In spite of the lack of information on the timing and frequency of hair dye use and the imprecision of the ORs, associations were suggested between leukemia and permanent black hair dye use and follicular NHL and the use of permanent hair dyes.

Successful treatment of extranodal Hodgkin's lymphoma in a patient with longstanding hairy cell leukemia

Purine analogs, particularly pentostatin and cladribine, are highly effective in hairy cell leukemia (HCL). Both of these drugs induce responses in approximately 80-95% of patients. However, it is not yet determined if treatment with these drugs can induce second malignancies. Hodgkin's lymphoma is very rare as a second malignancy and there are only 3 reported cases concerning the association of this lymphoma with HCL. We describe a patient with longstanding HCL in complete remission after cladribine, in whom extranodal Hodgkin's lymphoma appeared 8 years after the diagnosis of HCL. Magnetic resonance imaging revealed diffuse intra-osseal neoplastic infiltration of the corpora of the whole spinal column and extra-osseal propagation from the fifth thoracic vertebra into the spinal canal with spinal cord compression. Histological and immunohistochemical analysis of the extradural tumor, which was completely excised, disclosed nodular sclerosis Hodgkin's lymphoma with typical Reed-Sternberg cells that were positive for CD30, CD15, bcl-6, Ki67, p53, EBV LPM-1 and IgG, and negative for CD45, CD20, DBA44, kappa, lambda light chains and IgM. In addition, immunohistochemical analysis of the bone marrow in 1999 showed infiltration with positivity for IgM and negative for kappa light chains and IgG. These findings (expression of different immunoglobulins and light chains on the cells) suggest an independent origin of these 2 B-cell neoplasms. After neurosurgery the patient received 6 courses of the MP-ABVD protocol and achieved a complete remission, which has lasted 16 months thus far.

Do steroids increase lymphoma risk? A case-control study of lymphoma risk in polymyalgia rheumatica/giant cell arteritis

BACKGROUND

Recent studies indicate increased risks of malignant lymphomas among individuals treated with corticosteroids, but have not taken into account the underlying reasons for steroid use, so the increased risks might be attributable to the underlying disease or concomitant treatments other than steroids. Polymyalgia rheumatica (PMR) and temporal arteritis (giant cell arteritis, GCA) are common inflammatory conditions treated with steroids as single immunosuppressive therapy, but data on lymphoma risk in GCA/PMR are limited.

OBJECTIVE

To assess the risk of lymphoma associated with steroid treatment of GCA/PMR.

METHODS

The association between GCA/PMR and malignant lymphomas (overall, and separately for non-Hodgkin lymphoma, Hodgkin lymphoma, and chronic lymphatic leukaemia) was examined in a nationwide, population based, case-control study of 42,676 lymphoma cases and 78,487 matched population controls, using prospectively recorded data on lymphomas from the Swedish cancer register 1964-2000 and data on pre-lymphoma hospital admissions for GCA/PMR from the Swedish inpatient register 1964-2000. Odds ratios (OR) associated with a pre-lymphoma hospital admission for GCA/PMR were calculated using conditional logistic regression.

RESULTS

153 lymphoma cases and 345 population controls had a history of GCA/PMR, resulting in an overall OR for malignant lymphomas of 0.81 (95% confidence interval, 0.67 to 0.98). The OR varied little with lymphoma type, sex, age, and calendar period. The OR for GCA was 0.67 (0.48 to 0.98) and for PMR, 0.83 (0.67 to 1.04).

CONCLUSIONS

Treated GCA is not associated with increased lymphoma risks, which suggests that even at considerable cumulative doses, steroids may not appreciably increase lymphoma risk.

Hormone replacement therapy and risk of lymphomas and myelomas

The relation between post-menopausal hormone replacement therapy (HRT) and lymphoid neoplasms was analysed using data from a case-control study conducted in northern Italy between 1983 and 1992. Cases included 26 incident, histologically confirmed, post-menopausal female patients of Hodgkin's Disease (HD), 145 non-Hodgkin's lymphomas (NHL) and 65 multiple myelomas (MM), between 45 and 79 years of age. The control group comprised 361 women (age range 45-79 years) admitted to the same network of hospitals for acute, non-neoplastic conditions. The multivariate odds ratio (OR) for ever HRT users was 0.7 [95% confidence interval (CI) 0.2-2.8] for HD, 0.7 (95% CI 0.3-1.4) for NHL, and 0.2 (95% CI 0.1-1.0) for MM. No clear pattern of association was found for duration or recently of use. Despite the relatively small number of cases, due to the rarity of the disease, and the low frequency of HRT use in this population, these findings provide additional information for any global risk-benefit assessment of HRT use.

Occupational risk factors for selected cancers among African American and White men in the United States

OBJECTIVES

This study examined occupational risks for non-Hodgkin's lymphoma, Hodgkin's disease, and soft-tissue sarcoma among African American and White men.

METHODS

Race-specific multivariate logistic regression analyses were conducted using data from a large US population-based case-control study.

RESULTS

Significant occupational risks were limited to African Americans; chromium was associated with non-Hodgkin's lymphoma (odds ratio [OR] = 3.9, 95% confidence interval [CI] = 1.2, 12.9) and wood dust was associated with Hodgkin's disease (OR = 4.6, 95% CI = 1.6, 13.3) and soft-tissue sarcoma (OR = 3.7, 95% CI = 1.6, 8.6).

CONCLUSIONS

Race-specific occupational risk factors for cancer were evident only among African American men. This may reflect racial disparities in levels of exposure to occupational carcinogens.

Exposure to animals and selected risk factors among Canadian farm residents with Hodgkin's disease, multiple myeloma, or soft tissue sarcoma

Exposures to farm animals has been associated with certain rare cancers. Simultaneously, using the same methodology and control group, we conducted a six-province incident, population-based study of Hodgkin's disease (HD), multiple myeloma (MM), and soft tissue sarcoma (STS). Farm residence or work was reported by 38% (n = 119) of HD, 45% (n = 178) of MM, 43% (n = 156) of STS cases and 45% (n = 673) of controls. We conducted conditional logistic regression analyses and report odds ratios (OR(adj)) and 95% confidence intervals. After adjustment for covariates, exposure to farm animals had minimal effect on risk. The independent risk factors after adjustment for covariates were a family history of cancer (MM, STS), occupational uranium exposure (HD), professional driving (MM), and personal previous cancer (MM) or shingles (HD, MM).

Hodgkin's type of Richter's syndrome in familial chronic lymphocytic leukemia treated with cladribine and cyclophosphamide

Second malignancies are frequent complications in patients with chronic lymphocytic leukemia (CLL). Hodgkin's disease (HD) has been observed in approximately 0.5% of the patients with CLL and is known as Hodgkin's type Richter's syndrome (H-RS). We present a 64-year-old male patient with a familial history of CLL who developed H-RS in abdominal lymph nodes 6 years after CLL diagnosis and 18 months after treatment with cladribine (2-CdA) and cyclophosphamide. HD was diagnosed by fine needle aspiration. The disease was refractory to treatment with two courses of CHOP and three courses of ABVD chemotherapy. In the current literature we found case reports of only 6 patients with H-RS who were treated with fludarabine (FA) before transformation, and, to our knowledge the presented patient is the first to develop H-RS after treatment with 2-CdA combined with cyclophosphamide. He is also the first published patient with familial CLL in whom this complication developed.

Review of 2,4-dichlorophenoxyacetic acid (2,4-D) epidemiology and toxicology

The scientific evidence in humans and animals relevant to cancer risks, neurologic disease, reproductive risks, and immunotoxicity of 2,4-D was reviewed. Despite several thorough in vitro and in vivo animal studies, no experimental evidence exists supporting the theory that 2,4-D or any of its salts and esters damages DNA under physiologic conditions. Studies in rodents demonstrate a lack of oncogenic or carcinogenic effects following a lifetime dietary administration of 2,4-D. Epidemiologic studies provide scant evidence that exposure to 2,4-D is associated with soft tissue sarcoma, non-Hodgkin's lymphoma, Hodgkin's disease, or any other cancer. Overall, the available evidence from epidemiologic studies is not adequate to conclude that any form of cancer is causally associated with 2,4-D exposure. There is no human evidence of adverse reproductive outcomes related to 2,4-D. The available data from animal studies of acute, subchronic, and chronic exposure to 2,4-D, its salts, and esters show an unequivocal lack of systemic toxicity at doses that do not exceed renal clearance mechanisms. There is no evidence that 2,4-D in any of its forms activates or transforms the immune system in animals at any dose. At high doses, 2,4-D damages the liver and kidney and irritates mucous membranes. Although myotonia and alterations in gait and behavioral indices are observed after overwhelming doses of 2,4-D, alterations in the neurologic system of experimental animals are not observed with the administration of doses in the microgram/kg/day range. It is unlikely that 2,4-D has any neurotoxic potential at doses below those required to induce systemic toxicity.

Lymphomas in rheumatoid arthritis patients treated with methotrexate: a 3-year prospective study in France

A national prospective study was designed to collect all cases of lymphoma appearing in patients with rheumatoid arthritis (RA) treated with methotrexate (MTX) throughout France over a period of 3 years. A total of 25 cases of lymphoma were recorded, 18 cases of non-Hodgkin lymphoma (NHL), 3 of which were associated with the presence of Epstein-Barr virus (EBV) in lymphoma cells, and 7 cases of Hodgkin disease (HD), 5 of them associated with EBV. Among the 8 patients who were treated by MTX withdrawal alone, 3 underwent remission, but 2 of them had a relapse, the third patient with clonal EBV-associated large granular lymphocytes T-cell NHL remaining alive in complete remission. The estimated annual incidence rate of NHL in RA patients treated with MTX was 33.3.10(-5) (0-80.5) among men and 16.7.10(-5) (0-33.3) among women. There was no significant excess with the French population as a comparison: the standardized mortality ratio (SMR) adjusted for age and sex was 1.07 (0.6-1.7). The estimated annual incidence rate of HD among men and women was, respectively, 27.8.10(-5) (0-70.1) and 2.8.10(-5) (0- 9.6). The incidence of HD was significantly increased compared with the French incidence, with an SMR adjusted for age and sex of 7.4 (3.0-15.3; P <.001). Thus, this 3-year prospective study indicated that, whereas the risk of NHL was not significantly increased in RA patients treated with MTX, the incidence of HD appeared to be higher in these patients compared to the French population.

Hodgkin's disease in a child with sickle cell disease treated with hydroxyurea

Hydroxyurea (HU) is an oral drug that ameliorates the clinical course of sickle cell anemia by increasing the levels of fetal hemoglobin and decreasing the adhesion of red cells to endothelium. Although HU has minimal short-term toxicity, few data are available about the long-term safety and the potential risk for carcinogenesis or leukemogenesis. An 8-year-old child with sickle cell/beta 0-thalassemia who received HU treatment for painful crises is described. Six months after the initiation of the HU treatment he developed Hodgkin's disease, lymphocyte predominance subtype. Chemotherapy induced a complete remission. After discontinuation of chemotherapy the painful crises recurred and bone marrow transplantation was decided at the age of 12 years. Two years after the bone marrow transplantation, the child is in complete remission without painful crises. Although the authors suggest that the development of Hodgkin's disease is a coexisting event, questions arise about the safety of HU treatment in childhood.

Use of hair dyes, hematopoietic neoplasms, and lymphomas: a literature review. II. Lymphomas and multiple myeloma

We review studies on hair dyes and lymphomas and multiple myeloma (MM). A computerized literature search for the years 1966 through 1996 was conducted. Data were extracted using a standardized form that recorded study design, study population, type of cases, comparison group, sources of data on personal exposure to hair dyes, method of data collection, type of exposure data collected, covariates, and results. This review identified 10 epidemiologic studies published in the English literature that examined personal use of hair dyes and lymphomas or MM. These studies include three evaluations of Hodgkin's disease, five of non-Hodgkin's lymphoma (NHL), two of lymphomas with type not specified, and six of MM. For Hodgkin's disease, one case-control study reported some positive associations with use of permanent hair dyes, whereas two cohort studies found no associations with ever use of hair dyes. For NHL and MM, several evaluations suggest associations with use of permanent dyes, particularly with duration, frequency, age at first use, and dark colors. However, these associations are not consistent within and between studies. For lymphomas with type not specified, one study was superseded by a more recent report with NHL specific data and a second study was limited by small numbers of exposed subjects. At this time, it is not possible to determine if the inconsistent associations between permanent hair dyes and NHL and MM reflect sampling variability or differences in methods between studies. Because an appreciable fraction of the population has potential exposure to permanent hair dyes, elucidation of such issues may be warranted with studies that include adequate numbers of exposed subjects and that elicit information on personal use of hair dyes over time.

Poor clinical outcome of patients with Hodgkin's disease and elevated interleukin-10 serum levels. Clinical significance of interleukin-10 serum levels for Hodgkin's disease

Interleukin (IL)-10 is a pleiotropic cytokine with potent inhibitory effects towards T(H)-1 cells. IL-10 inhibits secretion of IL-2 and interferon (IFN)gamma by T cells and downregulates major histocompatibility complex antigens. A variety of tumor cells secrete IL-10, which can inhibit growth of tumor-specific cytotoxic T cells. IL-10 expression has also been detected in B-cell lymphomas and Hodgkin's disease (HD), and it has been suggested that the cytokine is involved in the pathogenesis of these tumors. We analyzed levels of IL-10 in pretreatment sera of 64 patients with HD and healthy controls using a sensitive enzyme-linked immunosorbent assay. Patients with biopsy-proven HD were enrolled in trials of the German Hodgkin Study Group (GHSG). Elevated IL-10 levels were detected in the sera of nine patients with HD (14.1%) (range 4.5-225.6 pg/ml with a mean of 61.5 pg/ml). IL-10 was not detectable in a control population of healthy volunteers (n =90). Multivariate analyses revealed a significant correlation between elevated IL-10 levels and higher age (over 45 years) but not with any other factors defined by the international prognostic factor score. Patients with elevated IL-10 levels had a significantly lower freedom from treatment failure rate as detected in univariate and multivariate tests. Thus, IL-10 may serve as an independent prognostic factor for HD patients.

Hodgkin's disease and B cell lymphoproliferation in rheumatoid arthritis patients treated with methotrexate: a kinetic study of lymph node changes

We describe 2 patients with seropositive rheumatoid arthritis treated with methotrexate (MTX) who developed Hodgkin's disease (HD) and non-Hodgkin's lymphoma. Followup allowed a lymph node biopsy at 4 different time points in 1 patient and at 2 in the other. In the first patient, the steps included a long history of benign follicle hyperplasia, a polymorphic diffuse B cell lymphoproliferation, and finally HD unassociated with Epstein-Barr virus (EBV). In the second patient, a polymorphic diffuse lymphoproliferation was followed by a monomorphic large B cell lymphoproliferation associated with EBV. The cytogenetic analysis showed a monoclonal proliferation associated with the same chromosomal abnormalities found in 1 of the clones observed in the initial biopsy. These 2 cases illustrate the complexity of the role of MTX in the outbreak of such manifestations.

Incidence rates of lymphomas and environmental measurements of phenoxy herbicides: ecological analysis and case-control study

The authors conducted an ecological study of the distribution of malignant lymphomas in a rice-growing area in northern Italy. They considered data on concentrations of phenoxy herbicides in soil and water and found the highest incidence of non-Hodgkin's lymphoma in subjects who lived in an area where 2,4-dichlorophenoxyacetic acid and 2,4,5-trichlorophenoxyacetic acid existed in very high concentrations. During 1985-1988, the incidence of non-Hodgkin's lymphoma in males in the most-polluted municipalities was twice as high as was noted for the remaining less-polluted territories. During 1991-1993, non-Hodgkin's lymphoma was higher by 60%. The authors also conducted a population-based case-control study. They found an association between employment of women in rice-growing jobs (particularly as rice weeders) and risk of non-Hodgkin's lymphoma (odds ratio=1.9; 95% confidence interval=0.6, 6.0). Work in rice fields was correlated strongly with residence in polluted areas. The authors did not detect an association between area of residence or occupation and incidence of Hodgkin's disease.

[An Italian multicenter case-control study on malignant neoplasms of the hematolymphopoietic system. Hypothesis and preliminary results on work-related risks. WILL (Working Group on Hematolymphopoietic Malignancies in Italy)]

A multicenter case-control study was conducted in Italy in twelve areas covering a population of 7 million persons with the aim of verifying the hypothesis of an association between exposure to herbicides and to organic solvents and occurrence of lymphoma, leukaemia and multiple myeloma. 3420 cases were recruited in a three-year period (1991-1993), through periodical surveys in the main hospitals in each area. A random sample of the general population (2317 subjects) constitutes the control group. Cases and controls were face to face interviewed by trained personnel. A questionnaire was used asking about personal habits, residential and occupational history, past health status. Preliminary analyses, concerning a total of 1388 cases and 1718 controls, focused risks by occupation. Elevated risks of non Hodgkin's lymphoma (OR: 1.7; IC 95%: 0.92-3.02; based on 28 exposed cases), and of multiple myeloma (OR: 3.6; IC 95%: 1.51-8.63; based on 9 exposed cases) were shown for welders. Among female hairdressers there were elevated risks of non Hodgkin's lymphoma (OR: 1.8; IC 95%: 0.76-4.30; based on 8 exposed cases), multiple myeloma (OR: 3.3; IC 95%: 0.77-14.15; based on 3 exposed cases) and Hodgkin's disease (OR: 2.0; IC 95%: 0.93-4.47; based on 16 exposed cases).

Hodgkin's disease, pharyngeal cancer, and soft tissue sarcomas in Danish paper mill workers

Several studies have indicated an increased cancer risk among paper mill workers, based on rather few cancer cases. The authors studied cancer incidence in a large historical cohort of 14,362 Danish paper mill workers, employed at any time between 1943 and 1990, and followed up until December 31, 1993. Men had an increased risk of pharyngeal cancer (15 observed (obs), standardized incidence ratio (SIR) 1.99, 95% confidence interval (CI) 1.11-3.29). With two additional cases among women, 11 of 17 cases were located in the tonsils. Men also had an increased risk of Hodgkin's disease (18 obs, SIR 2.01, 95% CI 1.19-3.18). Women had an increased risk of soft tissue sarcomas (nine obs, SIR 2.33, 95% CI 1.06-4.43), with a high risk among female paper sorters (eight obs, SIR 3.98, 95% CI 1.71-7.84). The study thus supports some studies' observations of an increased risk of Hodgkin's disease in paper mill workers. The detailed reporting of cancer cases in paper mill workers have furthermore revealed a risk of pharyngeal cancer together with a risk of soft tissue sarcomas in paper sorters.

Hodgkin's lymphoma in systemic onset juvenile rheumatoid arthritis after treatment with low dose methotrexate

We describe the occurrence of malignant lymphoma as a possible complication of immunosuppression associated with low dose methotrexate (MTX) therapy for juvenile rheumatoid arthritis (JRA). A 6-year-old girl with systemic onset JRA who had received low dose MTX therapy for 16 months developed diffuse peripheral lymphadenopathy and enlargement of the lymph nodes in the mediastinum, hilum of the lungs, and liver. Lymph node histology disclosed mixed cellularity Hodgkin's lymphoma; the neoplastic cells were positive for CD30 and CD15, but negative for Epstein-Barr virus RNA or EBV latent membrane protein. After chemotherapy, the girl had complete remission of her disease lasting for 18 months; however, the disease relapsed and autologous peripheral stem cell transplantation was performed. Although the occurrence of lymphoma may be associated with autoimmune diseases, our observations suggest that in pediatric patients, the increasing use of low dose MTX therapy for JRA may be an additional factor for the development of lymphoproliferative disease.

Case-control study of cancer risk in tetraethyl lead manufacturing

A case-control study was conducted to investigate the relative risk of cancer detection among Du Pont employees who worked in a tetraethyl lead (TEL) manufacturing area. The study's objective was to determine whether the employees' risk of developing or dying from cancer was associated with occupational exposure to TEL. All malignant neoplasms detected in the active and pensioned employee population during the period 1956-1987 were studied. TEL exposure was estimated by the following measures: ever employed in the TEL area, years of employment in TEL, TEL exposure rank, and the TEL cumulative exposure index. TEL manufacturing exposed employees to both organic and inorganic lead compounds. Because the underlying data did not permit the exposure assessment to distinguish between organic and inorganic lead, the TEL exposure measures reflect exposure to the TEL manufacturing process itself. The effects of latency, cigarette smoking habits, and exposures to other known or suspected carcinogens at the plant were also assessed. A strong association was observed between exposure to the TEL manufacturing process and rectal cancer (the odds ratio was 3.7 with 90% confidence limits of 1.3-10.2 for the analysis of ever/never exposed to TEL). An exposure-response relationship was noted with a fourfold elevation in the odds ratio at the high-very high cumulative exposure level. These patterns were even more pronounced after assuming a 10 year latency. Similar results were obtained for cancers of the sigmoid colon. These findings suggest that exposure to the TEL manufacturing process may have played a causal role in the colorectal cancer experience at the plant. This position is supported by the graded exposure-response relationships, the consistency of the results across exposure measures, the specificity of the health outcome (i.e., colorectal cancer), and the strength of the association. However, the evidence for causality is not compelling. This is the first report of an association between TEL manufacturing and colorectal cancer, and the evidence is compatible with a wide range of causal (i.e., indirect vs. direct acting; initiating vs. promoting) and noncausal (i.e., statistical and methodological bias; coincidence) interpretations.

Hodgkin's disease in association with hexavalent chromium exposure

During an epidemiological study assessing cancer risk in a small isolated population exposed to excessive amounts of hexavalent chromium, we noted two patients with Hodgkin's disease after exposure for many years and after a long latency period. The study population demonstrated an observed risk between 65 and 92 times that of reported risks for non-exposed US populations. Although malignant lymphoma, as well as many other malignancies, has clearly been associated with hexavalent chromium exposure, no reports have yet specifically mentioned Hodgkin's disease. We herein report Hodgkin's disease specifically in two individuals so exposed. Although this may be a chance occurrence, clinicians should be aware of the potential association between hexavalent chromium exposure and Hodgkin's lymphoma.

Hodgkin's disease and lymphoproliferations resembling Hodgkin's disease in patients receiving long-term low-dose methotrexate therapy

Recently, it has been shown that patients with rheumatologic diseases who are treated with methotrexate can develop immunosuppression-associated lymphoproliferative disorders. Although a variety of lymphoproliferations have been described in the setting of methotrexate therapy, only rare cases of Hodgkin's disease (HD) have been reported. In this study, we provide a more complete characterization of the spectrum of lymphoproliferations that resemble HD or show features diagnostic of HD that occur in patients receiving long-term low-dose methotrexate therapy. Eight patients were receiving methotrexate for various disorders. Four cases were considered to represent lymphoproliferations resembling HD; the other four cases were diagnosed as HD because they showed diagnostic morphologic and immunophenotypic features. All three patients with lymphoproliferations resembling HD on whom follow-up was available experienced tumor regression with methotrexate withdrawal or with methotrexate withdrawal and steroids; none of these three patients required further therapy. All three patients with HD on whom follow-up was available are alive and free of disease following chemotherapy or radiation therapy. In two of these patients, the tumor persisted or progressed despite discontinuation of methotrexate with observation; the third patient received chemotherapy at the same time methotrexate was stopped. Our findings indicate that a spectrum of lymphoproliferations resembling HD or diagnostic of HD can occur in patients receiving long-term low-dose methotrexate therapy. Recognition of these lymphoproliferative disorders is clinically important because a subset of these neoplasms will completely resolve with discontinuation of methotrexate, thereby obviating the need for chemotherapy or radiation therapy.