Combined therapy in the treatment of primary mediastinal B-cell lymphoma: conventional versus escalated chemotherapy

Treatment of patients with primary mediastinal B-cell lymphoma (PMBCL) remains controversial. We started a controlled clinical trial to evaluate the efficacy and toxicity of a conventional versus more intensive regimen of combined chemotherapy followed by radiotherapy to the mediastinum with the mantle technique. From 1989 to 1997, 68 patients diagnosed with previously untreated PMBCL, aged 18-65 years and negative for immunodeficiency virus test, were considered candidates to receive either conventional chemotherapy with CEOP-Bleo (cyclophosphamide 750 mg/m(2), vincristine 1.4 mg/m(2), prednisone 40 mg/m(2), epirubicin 70 mg/m(2), and bleomycin 10 mg/m(2)) or mega CEOP-Bleo (cyclophosphamide 1000 mg/m(2), epirubicin 120 mg/m(2), vincristine, prednisone, and bleomycin at the same doses) every 21 days for six cycles, followed by radiotherapy to the mediastinum with the mantle technique (35-45 Gy, mean 38 Gy). Complete response (CR) rates were not statistically different: 64% [95 percent confidence interval (CI): 58 percent to 70 percent] for conventional arm vs 81 percent (95 CI: 77-86 percent) in the intensive group (p=0.2). However, failure-free survival (FFS) and overall survival (OS) had statistical differences. At 5 years, actuarial FFS for patients treated with conventional chemotherapy was 51 percent (95 percent CI: 44-59 percent) compared to 70 percent (95 percent CI: 65-76 percent) in the intensive arm (p>0.01). OS rates were also different: 54 percent (95 percent CI: 48-57 percent) vs 70 percent (95 percent CI: 65-76 percent), respectively (p<0.01). Toxicity was mild and no therapy-related deaths were observed. At a median follow-up of 7.3 years, no second neoplasia or acute leukemia has been observed. The international prognostic index was not useful to define clinical risk in this selected group of patients. Multivariate analysis identified pleural and pericardial effusion and chemotherapy regimen as prognostic factors influencing FFS and OS. We feel that patients with PMBCL should be treated with more intensive, but not myeloablative chemotherapy, followed by adjuvant radiotherapy to achieve an improvement in outcome in this setting of patients. Patients with pleural or pericardial effusion are considered at high risk for failure with the actual programs of treatment and probably will be considered for experimental therapeutic approaches.

Treatment of refractory Hodgkin's disease with modified Stanford V program

This study analyzes the results using an Stanford V modified program in the treatment of refractory Hodgkin's disease (RHD). We used cyclophosphamide instead of mechloretamine, and epirubicin instead of doxorubicin to avoid the risk of acute and late side effects associated with this drugs. Seventy-one patients with RHD were treated. All were at an advanced stage at therapy and had associated adverse prognostic factors. The complete response (CR) rate was 84% (60 patients; 95% confidence interval [CI]: 72-91%). At 5 yr, actuarial overall survival (CS) is 71% (95% Cl: 59-78%) and event-free survival (EFS) is 70% (95% CI: 59-79%). Only the duration of the initial complete response (> 12 mo) influenced the duration of EFS and OS. Toxicity was mild. Granulocyte colony-stimulating factor to ameliorate the presence of severe myelosuppression was used only in a few patients. Cardiac function was not affected and, until now, late side effects has not been observed. Thus, the use of this modified Stanford program retains the usefulness of the original scheme both with less frequent and less severe acute and late side effects. A controlled clinical trial in untreated patients comparing the Stanford program with standard chemotherapy is warranted to define the role of this therapeutic option in patients with Hodgkin's disease.

Chemotherapy plus interferon-alpha2b versus chemotherapy in the treatment of follicular lymphoma

The best treatment of follicular lymphoma remains to be determined because the long natural history of follicular lymphoma requires mature data for accurate analysis. Although the goal of primary treatment remains durable remission, the sequential application of effective treatments may also result in a prolongation of median survival time. The use of interferon (IFN) with doxorubicin-based chemotherapy has demonstrated an increase of event-free survival but not in overall survival; however, its acute and late cardiac toxicity limits its use. For this reason, we began a controlled clinical trial to assess the efficacy and toxicity of chemotherapy: COPP (cyclophosphamide, vincristine, prednisone, and procarbazine) + IFN alternating every month for six cycles compared to six cycles of chemotherapy. In an intent-to treat analysis, 55 patients were enrolled (median age 61 years). Most cases (91%) with advanced disease were randomly assigned to chemotherapy + IFN (28 cases) or chemotherapy (27 cases). Complete remission was observed in 16 patients: 59% (95% CI, 53-70%) in the chemotherapy arm compared to 20 patients 71% (95% CI, 58-79%) in the chemotherapy + IFN arm; total responses were 74% and 86%, respectively. At a median follow-up of 60 months, event-free survival was 100% for patients treated with chemotherapy + IFN, which was statistically different from patients treated with chemotherapy 70%. At 7 years, median survival has not yet been reached; 72% of patients chemotherapy + IFN remain alive without disease (95% CI, 59-81%), which is not statistically different from 72% (95%CI, 50-73%) in the chemotherapy arm. Non-hematological toxicity was most frequent and severe in the chemotherapy arm; hematological toxicity was similar in both groups. Thus, it appears that chemotherapy + IFN, as described herein, improves event-free survival but the overall survival rates remain unchanged. The use of COPP appears to be better that anthracycline-based chemotherapy because it avoids the presence of acute and late cardiac toxicity.

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

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

Rituximab in the Treatment of Refractory Follicular Lymphoma - Six Doses Are Better Than Four

Seventeen patients with refractory follicular lymphoma heavily treated with chemotherapy (>2 regimens), radiotherapy, and biological modifiers were enrolled in a pilot study to receive six weekly doses, instead of the more frequent four doses, of monoclonal anti CD20, at a standard dose of 375 mg/m(2). In an intent-to-treat analysis, overall response was 76%, of which 47% (8 patients) were a complete response. With a median follow-up of 33.6 months, 7 complete responders remained alive and free of disease, and 2 partial-response patients remained stable without additional treatment. Actuarial curves showed that at 3 years, 53% of patients should be alive and free of disease. The 4 patients who were failures died secondary to tumor progression. Overall survival at 3 years was 76%. Toxicity was mild; all patients completed the schedule on time and doses. The addition of two doses of anti-CD 20 clearly improved the outcome in a group of patients with refractory follicular lymphoma heavily treated and poor prognostic factors. However, the number is too small to drawn definitive conclusions, and more clinical trials are necessary to determine if four of six doses of anti-CD20 therapy are better in this setting of patients.

Evaluation on a six-dose treatment of anti CD 20 monoclonal antibody in patients with refractory follicular lymphoma

Treatment of refractory follicular lymphoma with monoclonal antibody CD 20 has been proven to be a good therapeutic option. However, most studies used four weekly doses and time to treatment failure (TTF) and overall survival (OS) could be considered very short: 11.0 and 13.6 months respectively. We started a pilot study to evaluate if six infusions at the same doses and schedule could improve the outcome in these patients. Seventeen patients with refractory follicular lymphoma heavily treated with chemotherapy (> 2 regimens), radiotherapy and biological modifiers were enrolled in a pilot study. They received 6 weekly doses, at 375 mg/m2, of monoclonal anti CD 20. In an intent to treat analysis, overall response was 76%, of which 47% (8 patients) were complete response and 5 patients were partial response. With a median follow-up of 28.6 months, 7 complete responders remain alive, free of disease, and 2 partial responses remain stable without additional treatment. Median to TTF has not been reached; yet, actuarial curves showed that at 3 years, 53% of patients are alive. The four patients who were failure died secondary to tumor progression. Overall survival (OS) at 3-year was 76%. Toxicity was mild, all patients completed the schedule on time and doses. The addition of two doses of anti CD 20 clearly improved OS and TTF in a group of patients with refractory follicular lymphoma heavily treated and with poor prognostic factors. However, the number is too short to draw definitive conclusions; more clinical trials are necessary to determine if 4 or 6 doses of anti CD 20 therapy are better in this setting of patients.

High dose chemotherapy with G-CSF in refractory Hodgkin's disease

This study analyzed the long-term results in patients with Hodgkin's disease (HD) who were resistant or refractory to conventional chemotherapy and who were treated with intensive, non-myeloablative chemotherapy with granulocyte colony-stimulating factor (G-CSF) as hematological support. The study population included 86 patients who were treated with combination chemotherapy with high doses: BCNU, 300 mg/m2, on day 1, vincristine 1.4 mg/m2, and bleomycin 10 mg/m2 on days 1, 7, 14 and 21; etoposide 500 mg/m2, i.v., on days 14 and 15; and ifosfamide 4 g/m2, and epirubicin 180 mg/m2, on day 29. G-CSF 5 ug/kg/day, was used to ameliorate severe myelosuppression on days 3 to 13, 16 and 26 and 29 to 38. If a complete response was observed, two cycles of IOPP (ifosfamide 1.5 g/m2, i.v., on days 1 and 8; vincristine 1.4 mg/m2, i.v. on days 1 and 8; prednisone 60 mg/m2, p.o., daily, days 1 to 14 and procarbazine 100 ng/m2, p.o., daily, days 1 to 14 vere given as consolidation therapy. At 8-years, the overall survival rate vas 58% (50 out of 86 patients) being 38 and 76% in patients whose initial complete response was shorter or longer that 12 months, respectively or in 44% of induction failures. Hematological toxicity grade III or IV was observed in all cycles. However hematological recovery was already evident (median on day 13). Only transitory delay in continuing therapy was observed (median 3.9 days). Twenty-two patients developed infection-related granulocytopenia but no therapy related deaths were observed. G-CSF was well tolerated. This study indicates that the hematopoetic growth factor, G-CSF, was sufficient to act as hematological support in patients who received intensive, but non-myeloablative chemotherapy. In our opinion intensive chemotherapy without autologous transplant procedures can be considered in patients with refractory Hodgkin's disease because complete response rate and overall survival times are similar to more aggressive but more toxic regimens.

Maintenance therapy with interferon alfa 2b in Hodgkin's disease

We performed a randomized clinical trial to assess the efficacy and toxicity of interferon alfa 2b (IFN) as maintenance therapy in patients with advanced Hodgkin's disease in complete remission (CR) after conventional chemotherapy. One hundred and thirty-five patients (stage IIIB-IV B) were initially treated with EBVD (epirubicin, bleomycin, vinblastine, dacarbazine). IF CR was achieved they were randomly assigned to receive either maintenance therapy with IFN 5.0 MU three times a week for one year or no further treatment (control group). Clinical and laboratory characteristics at diagnosis were quite similar in both groups. After a median follow-up of 74.3 months (range 49 to 108), 61 out of 68 patients (91%; 95% confidence interval (CI): 76% to 97%) remain in first complete remission in the IFN-treated group compared to 38 out of 67 (58%; 95% CI: 49% to 71%) in the control group (p<.01). Overall survival was also better in the IFN treated group: 62 patients (92%; 95% CI: 82% to 97%) are alive free of disease at 7-years compared to 40 patients (67%, 95%: 55% to 76%) in the control group (p<.01). Toxicity secondary to IFN administration was mild and no dose modification was necessary during treatment. All patients received the planned dose of IFN. This was not an intent-to treat analysis. IFN administration as maintenance therapy was appears to be the only cause of improvement in outcome in these patients. We feel that IFN should be considered as maintenance therapy in patients with advanced Hodgkin's disease because this treatment improves the final outcome without the excessive toxicities of more aggressive therapeutic approaches such as bone marrow transplantation during first CR. We hope that IFN will be considered in future randomized clinical trials in order to define it's role in the treatment of Hodgkin's disease.

Bone marrow protection with amifostine in the treatment of high-risk malignant lymphoma

Based on preclinical and clinical studies which suggested that amifostine can protect against haematological toxicity of cyclophosphamide, we conducted a clinical trial of amifostine and intermediate doses of cyclophosphamide in patients with high-risk malignant lymphoma. 40 patients were enrolled to receive amifostine (910 mg/m2) before cyclophosphamide (1500 mg/m2) for two cycles (10 patients); 20 patients were allocated to receive amifostine/cyclophosphamide only on one cycle (patients were their own control) and 10 patients received cyclophosphamide alone without amifostine protection. Patients who received amifostine had fewer days of severe granulocytopenia (grade III or IV) and infectious episodes, and delay on treatment was minimal. Amifostine was well tolerated; only 2 patients developed transient and mild hypotension. The complete response rate was 72% (29/40). We conclude that amifostine is a good protector against haematological toxicity of cyclophosphamide and did not interfere with tumour response. Clinical trials with increasing doses of cytotoxic drugs or combination chemotherapy are needed to define the role of this myeloprotector agent in the treatment of patients with malignant lymphoma.

Intensive brief chemotherapy with hematopoietic growth factors as hematological support and adjuvant radiotherapy improve the prognosis in aggressive malignant lymphoma

An intensive brief chemotherapy and radiotherapy regimen including high doses of cyclo-phosphamide (5 g/m2), etoposide (1 g/m2), epirubicin (180 mg/m2), and ifosfamide (5 g/m2) administered in a period of 30 days followed by involved field radiotherapy to sites of initial bulky disease was administered to 46 untreated patients with high-intermedium and high-risk malignant lymphoma. G- or GM-CSF were used as hematological support instead of bone marrow transplantation. All patients had more than 3 adverse prognostic factors at diagnosis. Forty-one patients (89%) achieve complete response (33 after chemotherapy and 8 partial responses were converted to complete response after adjuvant radiotherapy). Acturial failure-free survival at 3 years is 83% and 37 of all patients started on therapy remain alive and in first remission at a median of 24.3 months from completion of treatment. Nearly all patients developed granulocytopenia grade IV; only 13 episodes of bacterial infection were documented. Because hematological recovery was very short (mean 13.6 days) no death related treatment and opportunistic infections were observed. Other non-hematological toxicities were scarce and well tolerated. No decrease > 10% was observed in the left ventricular ejection fraction. None have developed clinically evident congestion heart failure or other late side effects. These results showed that G- or GM-CSF can act as hematological support instead of bone marrow transplantation during intensive and brief chemotherapy. These regimens produce higher complete remission rate, and adjuvant radiotherapy will improve the outcome in patients with bulky disease.

Results of a randomized trial of granulocyte colony-stimulating factor in patients with infection and severe granulocytopenia

A study was carried out to investigate the efficacy and toxicity of granulocyte colony-stimulating factor (G-CSF) in the treatment of infection in 119 severely granulocytopenic patients with hematological malignancies after intensive chemotherapy. Patients were assigned randomly to receive either antibiotics alone (ceftazidime, 2 g, i.v., every 8 h + amikacin 7.5 mg/kg, i.v., every 12 h) or the same antimicrobial regimen plus G-CSF (5 micrograms/kg/day, s.c.). Measurements were clinical improvement, eradication of infection and toxicity. Patients who received antibiotics plus G-CSF had more clinical responses (82 versus 60%), less superinfections (6 versus 20%), less mortality (5 versus 15 patients), less days in hospital (median 10 versus 27) and reduced antibiotic usage compared to patients who received only antibiotics. Hematological recovery (granulocytes > 1.0 x 10(9)/l) was also shorter in these patients (12 versus 23 days). Fungal infections occurred only in the group treated with antibiotics alone. Toxicity secondary to G-CSF was absent. We conclude that the addition of G-CSF to broad spectrum antibiotics is useful in selected patients with severe granulocyctopenia after intensive chemotherapy and infection, because if may prove the outcome in these patients.

Biological modifiers (etretinate (changed from etetrinate) and alfa 2a) in the treatment of refractory cutaneous T-cell lymphoma

To assess the efficacy and toxicity of biological modifiers in combination etetrinate, 0.8 mg/kg/day, po and interferon alfa 2a 9.0 MU, three times at week) in the treatment of refractory cutaneous T-cell lymphoma (CTLC) we began a clinical study on 12 heavily treated patients. After 1 year on treatment 10/12 patients (83%) achieved complete response. Two patients were considered failures with disease progression. After a median follow-up of 3 years, seven patients (56%) remained in complete remission. Toxicity was mild. All patients received 93% of the planned dose of etetrinate and interferon. We feel that biological modifiers, as etetrinate and interferons, are agents with limited hematological toxicity even in higher doses. The combination of two agents, with different mechanisms of action, could improve the outcome in patients with refractory CTCL. Controlled trials are necessary to define the roles of this type of therapy as first line of treatment.

GM-CSF instead of hematological support during high-dose chemotherapy for refractory malignant lymphoma

Patients with refractory malignant lymphoma (RML) have a poor prognosis when treated with conventional chemotherapy. The use of high-dose chemotherapy has been limited by secondary myelosuppression. We report the use of intensive and short-duration chemotherapy in patients with RML who received granulocyte-macrophage colony-stimulating factor (GM-CSF) instead of hematological support and salvage with bone marrow transplantation or infusion of peripheral blood stem cells. Thirty-one patients with RML were treated with cyclophosphamide: 7 g/m2, iv on day 1, followed by GM-CSF: 5 micrograms/kg/day, subcutaneously until hematological recovery (granulocytes > 1.8 x 10(9)/L) started on day 2. Methotrexate, 5 g/m2, was also given when the granulocytes and platelets counts were normal, followed by leucovorin rescue. Epirubicin, 180 mg/m2, iv, was given on day 29 if the granulocyte count was normal, and GM-CSF was started on day 30. Complete response was obtained in 21 out of 31 patients (67%) and partial response in 4 more, thus an overall response was achieved in 80% of the treated patients. Time to treatment failure was 24+ months, and the overall survival was 28+ months. Hematological toxicity grade IV, according to the WHO criteria was observed in all cycles, however hematological recovery was already evident on day 13 +/- 2. Eleven patients developed infection related to the treatment, but no therapy related death was observed. GM-CSF was well tolerated with minimal toxicity. Is evident that GM-CSF can act as hematological support after high-dose chemotherapy in patients who cannot undergo bone marrow transplantation programs.(ABSTRACT TRUNCATED AT 250 WORDS)

Results of a randomized study of early stage Hodgkin's disease using ABVD, EBVD, or MBVD

From January 1986 to December 1989, 157 previously untreated patients, with Hodgkin's disease stage I or II without bulky disease, were enrolled in a clinical comparative study. The objectives of the study were to compare the efficacy and safety of using epirubicine or mitoxantrone instead of adriamycin in the combination chemotherapy regimen ABVD (adriamycin, bleomycin, vinblastine, and dacarbazine). The complete response rate was better in the patients treated with the ABVD or EBVD regimens compared to the MBVD arm. Also, differences in overall survival and relapse-free survival were better in the patients who received ABVD or EBVD compared to the MBVD regimen. Hematological, gastrointestinal and cardiac toxicity were similar in the three groups. Dose intensity, delays and complications were also similar in the three groups. The mitoxantrone-containing regimen was found to have less efficacy in comparison to the other regimens tested in the present study in patients with favorable stage I or II Hodgkin's disease.

Effect of granulocyte colony-stimulating factor in patients with diffuse large cell lymphoma treated with intensive chemotherapy

We investigated whether Granulocyte colony-stimulating factor (G-CSF) could prevent myelotoxicity or accelerate hematopoietic recovery after intensive chemotherapy in previously untreated patients with diffuse large cell lymphoma (DLCL). Forty-two patients were included in a prospective clinical trial in which alternating chemotherapy ESAP (etoposide, Solu-Medrol, cytosine arabinoside, cis-platinum), m-BECOD (low doses methotrexate, bleomycin, epirubicin, cyclophosphamide, vincristine, dexamethasone), MVPP-Bleo (mitoxantrone, vincristine, prednisone, procarbazine, bleomycin) were administered by 9 cycles. Each cycle was followed by 10 days of G-CSF (5 micrograms/kg/day) started five days after chemotherapy compared to a control group which received chemotherapy without G-CSF support. Leucocytes and granulocytes were significantly higher in patients receiving G-CSF compared to the control group. The total number of days of leukopenia (WBC counts below 2.0 x 10(9)/L and absolute granulocytes below 1.0 x 10(9)/L) were longer in the patients without G-CSF compared to those who received G-CSF (14.1 days versus 1.9 days). Delays in treatment were most frequent in the control group: 38% versus 4% in all cycles. Infection episodes occurred in 41 out of 168 cycles (25%) in the control group compared to 7 out of 172 (4%) in the G-CSF arm. Complete response was achieved in 12 out of 22 (54%) in the control group compared to 16 out 20 (80%) in the patients who received G-CSF. Toxicity secondary to G-CSF was mild. G-CSF can be administered safely to patients with DLCL and results in improved hematologic recovery after intensive chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Randomized study for the treatment of adult advanced Hodgkin's disease: epirubicin, vinblastine, bleomycin, and dacarbazine (EVBD) versus mitoxantrone, vinblastine, bleomycin, and dacarbazine (MVBD)

Seventy patients with previously untreated advanced Hodgkin's disease and without bulky disease were entered in a prospective randomized clinical trial comparing epirubicin in combination with vinblastine, bleomycin, and dacarbazine (EVBD) with a regimen containing mitoxantrone, vinblastine, bleomycin, and dacarbazine (MVBD). Both groups were comparable for the variables of age, sex, stage, and presence of B symptoms and histology. Thirty-one (88%) of EVBD-treated patients achieved a pathologically documented complete remission (CR) compared to the 24 cases (68%) of the MVBD-treated group. After a median follow-up of 36 months, duration of CR is better in the EVBD-treated patients with an actuarial 5-year duration of CR of 80%, statistically different to the MVBD group: 53% (P < 0.01). Both regimens showed the same gastrointestinal toxicity, but the patients treated with the MVBD regimen shown most and severe hematological and cardiac toxicities. Also, biochemical alterations in hepatic test were observed in these patients. The alternative use of epirubicin in combination chemotherapy appears to be as effective in advanced Hodgkin's disease without bulky disease, with reduced clinical toxicity. Mitoxantrone containing regimen was not found to have an equivalent efficacy and clinical toxicity was most frequent and severe. We felt that mitoxantrone could be consider a second-line drug in the treatment of advanced Hodgkin's disease.

Value of serum beta 2 microglobulin as an indicator of early relapse in diffuse large cell lymphoma

In patients with diffuse large cell lymphoma treated with chemotherapy the presence of high levels of serum beta 2 microglobulin has been considered as a bad prognostic factor. Until now, attempts to detect early relapse in patients with diffuse large cell lymphoma have been sparse. To address this issue we began a prospective clinical trial to evaluate the role of different clinical, laboratory and radiographic tests in the detection of early relapse in non-Hodgkin's lymphoma (NHL). Only serum beta 2 microglobulin levels had clinical significance and 26 of 53 patients (49%) had abnormal levels, 3 to 23.1 months (mean 8.5 months) before evident relapse. Elevated serum lactic dehydrogenase (LDH) levels and beta 2 microglobulin were observed in six patients and all relapsed, suggesting that the combination of these two tests should be considered in future prospective clinical trials in order to define the utility of both tests to detect early relapse. This information may allow us to begin chemotherapy when the tumor mass is still low thereby making the probability of achieving a long second remission more likely.

Maintenance therapy with interferon alfa 2b in patients with diffuse large cell lymphoma

Forty-eight consecutive patients with diffuse large cell lymphoma (DLCL) in complete remission (CR) after conventional chemotherapy were enrolled in a prospective clinical trial. The maintenance therapy was a random either nothing or interferon alfa 2b (IFN) 5.0 MU three times a week for one year. The median duration of CR in the patients treated with IFN has not been reached. After five years 60% of patients remain in CR compared to the control group who had a median CR of 40 months (p < 0.001). Actuarial five-years survival in the IFN treated patients was 88% compared to 42% in the control group (p < 0.001). Maintenance therapy with IFN has been beneficial in patients with DLCL with improvement of duration of CR and survival without the excessive toxicity of most common third generation regimen chemotherapy. We felt that IFN could be explored in most controlled clinical trials in patients with DLCL in CR after conventional chemotherapy.

[The role of radiotherapy in the early stages of Hodgkin's disease]

The outcome of treatment for a first relapse in early stages (IA and IIA) of Hodgkin's disease after primary radiotherapy was analyzed in 86 patients. They received total nodal radiotherapy (TNR) as the primary treatment. Survival was used as the major endpoint. Median follow-up was 13.1 years. Duration of first complete remission was 60% for patients in stage IA and 39% for patients in stage IIA (p < .01). At 10-years, the survival for patients in stage IA was 78% and only 55% for patients in stage IIA (p < .01). A risk factor analysis showed that the presence of stage IIA and bulky disease (adenopathy > 7 cm) were associated with a worse prognosis. We believe that the use of TNR as initial treatment in early stages of Hodgkin's disease should be considered in patients in stage IA and without bulky disease. Patients in stage IIA and risk factors, such as bulky disease, should be treated with more aggressive therapeutic regimens.

Beta 2 microglobulin level as an indicator of prognosis in diffuse large cell lymphoma

We report results of our investigation of prognostic factors for patients with diffuse large cell lymphoma (DLCL) who were entered on the same treatment protocol and who had known pretreatment serum beta 2 microglobulin levels. Serum beta 2 microglobulin, bone marrow involvement, performance status and lactic dehydrogenase (LDH) levels were associated with a poor prognosis in univariate analysis. However, only beta 2 microglobulin remained of prognostic significance in a multivariate analysis with statistical differences at different cut off levels. We believe that beta 2 microglobulin levels accurately separate patients into low-, intermediate- and high-risk patients. It is concluded that serum beta 2 microglobulin is the most significant prognostic factor currently available for DLCL and should be incorporated in the initial staging in order to provide a basis for designing the therapeutic approach in these cases.

[Prognostic importance of beta-2-microglobulin in multiple myeloma]

Beta 2 microglobulin is a low molecular weight protein found on the surface of all nucleated cells: it is the light chain of the HL-A histocompatibility complex. The increased levels of serum beta 2 microglobulin in patients with multiple myeloma have been associated with a poor prognosis. Pretreatment levels of serum beta 2 microglobulin were estimated in 70 previously untreated patients with multiple myeloma. In a multivariate analysis, serum beta 2 microglobulin levels and stage were the most significant prognostic factors for survival independent of other risk factors associated with a worse prognosis. There was a clear difference in survival duration observed between the patients with a high pretreatment level of beta 2 microglobulin and stage III (none alive at 5 years) compared with patients with normal levels and stage I (80% alive at five years) (p less than .001). We conclude that pretreatment-beta 2 microglobulin level is one of the most useful prognostic factors in patients with multiple myeloma.

[Comparative study of high doses vs conventional doses of cytosine arabinoside combined with cisplatin and dexamethasone in patients with refractory lymphoma]

Forty-three patients with advanced malignant lymphoma resistant to previous chemotherapy were randomized in two groups: one received a high dose versus a low-dose cytosine arabinoside, in combination with dexamethasone and cisplatinum. Ten of 24 patients (41%) in the low-dose regimen achieved response: six complete remission (CR) and four partial remission (PR), compared with 5 of 19 (30%) (three CR and two PR). Survival was better in the low dose regimen: 39 versus 23 weeks. Toxicity was most frequent and severe in the high dose schedule. These results suggests that the use of cytosine arabinoside and cisplatinum is useful in the treatment of refractory lymphoma, and that the low-dose would be a better alternative than a high dose.

Growth and development of children of mothers treated with chemotherapy during pregnancy: current status of 43 children

To evaluate the potential teratogenicity of modern cancer treatment, 43 children born to mothers with hematological malignancies (18 with non-Hodgkin lymphoma, 14 Hodgkin disease, seven acute leukemia, and four with chronic granulocytic leukemia) who received chemotherapy during some portion of their pregnancy, including 19 of these 43 who received chemotherapy during the first trimester, were examined for physical health, growth, and development. Immunological, hematological, and cytogenetic status also were evaluated. The children's ages ranged from 3 to 19 years. The children had a careful history and physical examination to detect any abnormal symptoms or signs and the mother's previous chemotherapy was carefully documented. In all of the children studied, physical, neurological, psychological, hematological, immune function, and cytogenetics were normal. These results suggest that chemotherapy can be administered during pregnancy, even during the first trimester, because it is not hazardous to the fetus; nevertheless, this study is inadequate in size to exclude the possibility of teratogenesis, and more reports are necessary to define the best treatment from cancer during pregnancy.

[Preinduction in the treatment of patients with malignant lymphoma]

Prospective clinical study of ninety-eight patients with untreated malignant lymphoma were randomly assigned to be treated wether with combined chemotherapy: cyclophosphamide, hidroxidaunil adriamycin, vincristine, prednisone and bleomycin (CHOP-Bleo) or with two low-dose of methotrexate as preinduction regimen and the same chemotherapy: CHOP-Bleo. The number of early deaths afterwards the group was less with preinduction, also more of them had complete remission, it lasted longer and survival was better than in the group just treated with conventional chemotherapy. Toxicity, secondary to preinduction chemotherapy. Toxicity, secondary to preinduction regimen was acceptable, while it was similar in both groups receiving conventional chemotherapy. Supported on these results it is considered that the use of preinduction regimen, as herein described, is useful in patients with malignant lymphoma and should be applied for the therapeutic approach of these neoplasms.

Prognostic value of serum beta 2 microglobulin in primary gastric lymphoma

Sixty-eight previously untreated patients with primary gastric non-Hodgkin's lymphoma (NHL) available for analysis, were entered in a study in which the prognostic significance of serum beta 2 microglobulin levels were evaluated. The serum beta 2 microglobulin was the most significant prognostic factor. Patients with high levels (greater than 3.5 micrograms/mL) had a relapse-free survival (RFS) of 36 months, while the median RFS has not been reached in patients with normal levels (p less than 0.001). The 5-year survival was 80 per cent for patients with normal levels, statistically significant when compared to patients with high levels: 38 per cent (p less than 0.001). Serum beta 2 microglobulin should be included in the initial staging of patients with primary extranodal NHL and patients with high levels should be treated more aggressively.

Randomized study for the treatment of advanced Hodgkin's disease: MOPP vs. LOPP

Between January 1983 and December 1984, 83 patients with advanced Hodgkin's disease were entered in a prospective randomized trial comparing MOPP (mechlorethamine, vincristine, procarbazine and prednisone) with a regimen containing chlorambucil (Leukeran), vincristine, prednisone and procarbazine (LOPP). Both groups were comparable for the variables of age, stage, symptoms, histology and sites of involvement. Seventy percent of LOPP-treated patients achieved a complete remission compared to 65% of the MOPP-treated group. After a median follow-up of greater than 48 months, there is no statistical difference between the two treatment groups in survival or relapse free-survival. The LOPP combination was better tolerated with significantly less side effects. The drug regimen LOPP appears to be as effective as MOPP in producing complete remission and long term survival in patients with advanced Hodgkin's disease.

[Solitary plasmacytoma. A retrospective analysis of 15 cases]

Solitary plasmocytoma is a rare plasma cell disorder as compared with multiple myeloma. In order to evaluate their relationships, the clinical findings in 51 patients with solitary plasmocytoma were analyzed. The median follow-up was 7.8 years (range 3 to 14). Twenty patients (39%) developed multiple myeloma in a average of 3.8 years. The risk factors associated with the development of multiple myeloma were an initial abnormal electrophoresis (M peak), age (less than 40 years) and an increase in beta-2-microglobulin. Although radiotherapy remains the initial treatment of solitary plasmocytoma, a careful evaluation should be performed in order to consider chemotherapy in selected patients with high risk of developing multiple myeloma.

[Alkaline phosphatase as a prognostic factor in Hodgkin's disease]

Serum alkaline phosphatase level have been studied in 102 patients a the onset of Hodgkin's disease who were staged by laparotomy. Elevated phosphatase was observed in 34 cases who had a worse relapse free survival (RFS): 63 months versus 93 months in patients with normal level (p less than 0.001). Also, overall survival was affected by elevated phosphatase, because patients with this finding had a 10-year survival of 42 percent compared with 70 percent of patients with normal level. We felt that patients with elevated serum alkaline phosphatase should be considered in advanced stage, even other studies remain normal and therapeutic options would considered the use of chemotherapy.

Non-Hodgkin's lymphomas and pregnancy: presentation of 16 cases

Chemotherapy and obstetric care of 16 pregnant patients with non-Hodgkin's lymphoma are reported in this paper. All patients received chemotherapy during the various trimesters of pregnancy, including 8 cases during the first trimester, and there was no evidence of congenital malformations in any offspring. Fifteen babies are alive, healthy, and at a normal level of growth 3 to 11 years after birth. Eight mothers who achieved complete remission are alive and free of disease, 4 to 9 years after delivery, without maintenance treatment and would be considered cured. On the basis of the present study it was concluded that pregnancy is not a contraindication for treatment of non-Hodgkin's lymphomas, cytotoxic drugs do not necessarily cause congenital malformations, and long-term remission can be achieved in these mothers.

[Granulocyte-macrophage colony-stimulating factor in the treatment of secondary bone marrow suppression in patients with lymphoma. Preliminary report]

Four patients with severe myelosuppression secondary to chemotherapy for advanced malignant lymphoma were treated with human granulocyte macrophage colony-stimulating factor (GM-CSF) at dose of 10 micrograms/kg/day. The number of absolute granulocytes increase in all patients in the first 3 days after the treatment was begun. Normal values were observed after 5 days on treatment. No toxicities resulted from the treatment. The results demonstrate the utility of GC-CSF in restoring normal granulocytes counts in patients undergoing intensive chemotherapy.

Group risk classification of non-Hodgkin's lymphoma

Between 1980 and 1982, 162 patients with non-Hodgkin's lymphoma were treated with cyclophosphamide, adriamycin, vincristine and prednisone (CHOP) or CHOP plus bleomycin. At the moment when the patient were diagnosed all clinical characteristics were evaluated according to a multiple regression analysis model, which has the following three factors associated to bad prognosis: a quick clinical evolution (less than three months) bone marrow infiltration and high levels of lactate dehydrogenase (LDH). The Cox model of analysis also agreed that a quick clinical evolution and the high levels of LDH were bad prognosis factors. These two factors were associated with poor complete remission and short survival rates. A mathematical model was built based on the last two factors. Five groups of patients were observed with increasing risk of a poor response and a short survival rates, which allowed us to identified three prognostic groups with clear differences in both the duration of remission and survival. These groups were low, moderate and high-risk. Results analysis in this paper have important clinical implications for the design of the prospective clinical trials in patients with malignant lymphoma.

[Long-term results in the treatment of lymphomas using polychemotherapy (CHOP)]

The long-term results achieved with CHOP chemotherapy in 131 patients with non-Hodgkin's lymphoma of diffuse histological pattern and in advanced stages were analysed. The mean age of the patients was 49 years. Complete remission was achieved in 68 cases (60 %). There was good tolerance in general terms, without any lethal complications. The median survival was 27 months; 28 patients (25 % of the whole series) are alive and disease-free after 10 years, so they can be considered as cured. High lactate-dehydrogenase levels, bulky tumoural mass and high degree of histological malignancy were identified as poor-prognosis factors. CHOP chemotherapy appears as a useful means of treating non-Hodgkin's lymphoma, as shown by the number of patients achieving long lasting remission and by the tolerance. Nevertheless, this treatment is of less value in patients with poorer prognosis, in whom other regimens must be borne in mind.

[Prognosis determination in patients with malignant lymphoma]

One hundred and eight patients with malignant lymphoma were evaluated for pretreatment characteristics as potential predictors of response and survival. Age, sex, lymphocytes, lactic dehydrogenase, clinical evolution, histology, stage and initial symptoms provided the basis for a prognostic classification. The results show that the classification gives good information as the survival curves are clearly separated into three prognostic groups. Implications of the classification in therapy planning are briefly discussed.