Stage I-II follicular lymphoma. Treatment results for 76 patients

Treatment and prognosis of stage I follicular lymphoma in the modern era - does PET matter?

Follicular lymphoma (FL) is the most common subtype of indolent non-Hodgkin lymphoma. Patients with stage I disease are usually treated with radiotherapy (RT). In previous studies, mostly from the pre positron emission tomography-computed tomography (PET-CT) era, the 5 year progression-free survival (PFS) and overall survival (OS) rates of stage I disease were 60-80% and 80-93%, respectively. This study retrospectively evaluated the outcome of stage I FL which was treated with involved field RT in the PET-CT era between 2002 and 2015. Ninety-one patients were enrolled. Five year PFS and OS rates were 73% and 97%, respectively. Relapse occurred in 19 (21%) patients, 74% occurring outside the radiation field. In conclusion, PET-CT staging of clinical stage I FL may contribute to the improved prognosis in patients treated with RT compared to historical cohorts, possibly due to better identification of "genuine" stage I disease.

Disparities in Receipt of Radiotherapy and Survival by Age, Sex, and Ethnicity among Patient with Stage I Follicular Lymphoma

Background

Radiotherapy (RT) is a first-line treatment option for stage I follicular lymphoma (FL). We studied disparities in receipt of RT and survival among patients with stage I FL.

Methods

Adult patients (age ≥18 years) with stage I FL, as the first primary cancer, diagnosed between 1992 and 2007 were identified using Surveillance, Epidemiology, and End Results (SEER) 18 database. Study population was divided into various subgroups based on age, sex, race, and marital status. Factors associated with receipt of RT and survival, among patients receiving RT, was evaluated using regression analysis and Cox PH modeling, respectively. SEER*Stat was used to compute 1- and 5-year RS for various subgroups and compared using Z score.

Results

Of the total 7315 patients (median age: 64 years), 2671 (36.5%) received RT. African-Americans, older age group, and single and separated/divorced/widow marital status predicted omission of RT. The 1- and 5-year RS were significantly better in patients receiving RT. In multivariate analysis, male sex, age <60 years, Caucasian race, and married marital status were found to be independent predictor of better RS among patients receiving RT (P < 0.0001).

Conclusion

This study showed that 36.5% patients with stage I FL received RT. Survival rates were significantly better for patients who received RT.

Early stage follicular lymphoma, current management and controversies

PURPOSE OF REVIEW

In this article, we focus on the epidemiology, outcomes, and treatment options of early stage follicular lymphoma.

RECENT FINDINGS

Radiation therapy has been the predominant treatment for patients with early stage follicular lymphoma for decades. It is associated with a 10-year progression-free survival of 45-60%, thought to represent cures in this otherwise incurable disease with conventional modalities. Limiting the radiation field and dose does not diminish outcomes. On the contrary, the addition of chemotherapy does not benefit this patient population as a whole. The use of polymerase chain reaction for Bcl-2 gene rearrangements to detect molecular disease, however, may identify patients with early occult disseminated disease, who are at risk for relapse and would benefit from the addition of systemic therapy. For patients in whom radiation would be too toxic or prefer to not have radiation, observation is a reasonable alternative and a proportion of patients observed do not require therapy for a number of years. Despite the potential cures achieved by radiation therapy, a minority of patients in the United States receive such therapy; the majority are instead observed or treated with chemoimmunotherapy.

SUMMARY

Patients with early stage follicular lymphoma enjoy excellent outcomes following definitive radiation therapy, many of whom may even be cured. The addition of other therapies has not enhanced cure rates but identifying patients at greatest risk for disease relapse may change this paradigm. Despite the proven success of radiation, the majority of early stage follicular lymphoma patients in the United States do not receive radiation.

Has the time to come leave the "watch-and-wait" strategy in newly diagnosed asymptomatic follicular lymphoma patients?

BACKGROUND

Historically, the median overall survival for follicular lymphoma (FL) has been considered to be 9-10 years, and no treatment had ever prolonged this time period. Studies conducted more than 20 years ago demonstrated that treating patients with asymptomatic FL at the onset of the disease did not increase their survival, and that almost 20% of these patients did not need any treatment in the first 10 years of follow-up. Based on these facts, most clinical practice guidelines recommend active surveillance policies for patients with asymptomatic FL.

DISCUSSION

The introduction of antiCD-20 monoclonal antibodies, over the last 15 years, has significantly increased the median survival rate to above 14 years. This improvement was achieved before the combination of rituximab and chemotherapy regimens became extensively used in patients with symptomatic disease. Therefore, this increase in survival may currently be more significant. At present, several clinical trials have evaluated low-toxicity therapies that prolong progression-free periods, among which rituximab monotherapy, radioimmunotherapy or the combination of rituximab with bendamustine are the most relevant. Unfortunately, these clinical trials have included only patients with symptomatic FL. The results of a recently reported clinical trial show that treatment with single-agent rituximab prolongs progression-free survival rates, time to new treatment and the quality of life of asymptomatic patients, as compared with the active surveillance strategy. Longer follow-up of these results and data regarding overall survival are awaited before this treatment can be recommended as the standard initial therapy.

SUMMARY

There are different therapeutic possibilities for asymptomatic FL patients, but no data are currently available to indicate which option is the best. Patients need to understand the risks and benefits of observation versus treatment before a final decision can be made. For patients who want active treatment the administration of four weekly rituximab doses should be considered.

Follicular lymphoma: a historical overview

Lymphoma was first described in 1862 and follicular lymphoma in 1925. Initially considered a benign disorder, and named Brill - Symmers disease after the authors of the original papers, it was rapidly recognized as a malignancy with a variable but often indolent course. Most of its clinical features were described by the early 1940s. Despite discussion about its cell of origin, and in contrast to many other lymphoma subtypes, follicular lymphoma could always be accurately recognized and diagnosed using light microscopy morphological features. B-cell origin was demonstrated in the 1970s and the important role of t(14;18) and bcl-2 gene rearrangement in the pathogenesis of follicular lymphoma was established shortly thereafter. The etiology of follicular lymphoma, the reason for marked geographic variation in its incidence, the role of alternative molecular pathways in its pathogenesis, and the cause for its variable clinical behavior all remain unknown. Several observations suggest an important role for the normal immune response in regulating the clinical behavior of follicular lymphoma. From the earliest descriptions, radiation therapy was shown to be very effective in follicular lymphoma, but not curative. Combination chemotherapy was tested in the 1970s, but despite high rates of response, there was only minimal impact on survival. Interferon combined with anthracycline based chemotherapy was the first treatment to improve survival, but was not widely adopted in the USA. Randomized studies have shown an impact of autologous transplantation on progression free survival. Allogeneic transplantation is a curative therapy, but is too toxic for widespread application. Targeted therapies, particularly rituximab have revolutionized the treatment of follicular lymphoma. A convergence of technological and biological advances will likely lead to further dramatic progress in the next decade. For the first time consistent improvements in survival of follicular lymphoma are reported.

Follicular lymphomas

Follicular lymphomas constitute approximately 30% of all non-Hodgkin lymphomas. These lymphomas are characterized by at least partially follicular growth pattern, but diffuse areas may be present. The proportions of follicular or diffuse areas vary also from case to case, which seems to be associated with prognosis. Follicular lymphomas should not be divided into distinct subtypes, but rather shows a continuous gradation in the number of large cells. On the bases of this grading, three groups have been defined: grades 1-3. There is a consensus that grade 3 follicular lymphomas, namely grade 3b, should be discriminated from lower-grade cases. The cells of follicular lymphomas express surface immunoglobulin, more frequently IgM+/-IgD>IgG>IgA, B-cell-associated antigens, CD10+/-; they are CD5-, CD23-/+, CD43-, and CD11c-. Follicular lymphomas express bcl-2 proteins, which is useful in distinguishing reactive from neoplastic follicles. t(14;18) is present in 70-95% of follicular lymphomas, involving rearrangement of bcl-2 gene. Clinical behavior of follicular lymphomas is heterogeneous and differs according to the histologic grade and extension of disease. Moreover, the evaluation of these malignancies is conditioned by therapeutic decision, which is also determined by main prognostic factors. The International Prognostic Index for aggressive lymphomas is not optimal for follicular lymphomas. Conversely, the Italian Lymphoma Intergroup Index and, more recently, the Follicular Lymphoma International Prognostic Index (FLIPI), designed in pre-rituximab era, seem to correlate well with outcome. Several active therapeutic approaches from the "wait and watch" strategy to the allogeneic transplantation are available for management of patients with follicular lymphoma. Therapeutic decision is mostly conditioned by patient's characteristics, stage, histologic grade, tumor burden, and risk-predicting factors.

Chemotherapy plus Rituximab versus chemotherapy alone for B-cell non-Hodgkin's lymphoma

BACKGROUND

Rituximab has been shown to improve response rates and progression free survival when added to chemotherapy in patients with indolent and mantle cell lymphoma. However, the impact of R on overall survival (OS) when given in combination with chemotherapy (R-chemo) has remained unclear so far.

OBJECTIVES

We thus performed a comprehensive systematic review in this group of patients to compare R-chemo with chemotherapy alone with respect to OS. Other endpoints were overall response rate (ORR), toxicity and disease control as assessed by measures such as time to treatment failure (TTF), event free-survival (EFS), progression free-survival (PFS) and time to progression (TTP).

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE, EMBASE and conference proceeding from 1990 to 2005.

SELECTION CRITERIA

Only randomised controlled trials (RCT) comparing R-chemo with chemotherapy alone in patients with newly diagnosed or relapsed indolent lymphoma and mantle cell lymphoma (MCL) were included.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed the study quality. Number needed to treat (NNT) were calculated to facilitate interpretation.

MAIN RESULTS

Seven randomised controlled trials involving 1943 patients with follicular lymphoma, mantle cell lymphoma, or other indolent lymphomas were included in the meta-analysis. Five studies were published as full-text articles, and two were in abstract form. Patients treated with R-chemo had better overall survival (hazard ratio [HR] for mortality 0.65; 95% confidence interval (CI) 0.54 to 0.78), overall response (relative risk of tumour response 1.21; 95% CI 1.16 to 1.27), and disease control (HR of disease event 0.62; 95% CI 0.55 to 0.71) than patients treated with chemotherapy alone. R-chemo improved overall survival in patients with follicular lymphoma (HR for mortality 0.63; 95% CI 0.51 to 0.79) and in patients with mantle cell lymphoma (HR for mortality 0.60; 95% CI 0.37 to 0.98). However, in the latter case, there was heterogeneity among the trials (P 0.07), making the survival benefit less reliable.

AUTHORS' CONCLUSIONS

The systematic review demonstrated improved OS for patients with indolent lymphoma, particularly in the subgroups of follicular and in mantle cell lymphoma when treated with R-chemo compared to chemotherapy alone.

Primary follicular lymphoma of the cervix uteri: a review

Primary non-Hodgkin's lymphoma of the cervix is a rare disease, of which a subgroup of follicular lymphoma constitutes only 8.5%. There is not an established treatment protocol neither for primary cervical lymphoma nor for its follicular subgroup. We presented a case with Ann Arbor stage IEA (Extra-nodal involvement and absence of weight loss, fever, night sweat) primary follicular lymphoma of the cervix. She was treated with chemotherapy followed by pelvic radiotherapy. Upon relapse with a nodal neck mass, she was treated with rituximab alone. She remained well for 23 months after rituximab. In the 39 months of follow-up, there was no evidence of disease. In the light of our case, we reviewed the reported cases of primary follicular lymphoma of the cervix while discussing their treatment protocols and the cases of primary cervix lymphoma treated with rituximab.

Stage I/II follicular lymphoma: spread of bcl-2/IgH+ cells in blood and bone marrow from primary site of disease and possibility of clearance after involved field radiotherapy

Stage I/IIA follicular lymphoma (FL) is considered a localised disease that can be adequately treated with radiotherapy alone. Bone marrow (BM) and peripheral blood (PB) involvement in FL was investigated by polymerase chain reaction (PCR) in a series of 24 consecutive patients with histologically revised diagnosis and treated with involved field radiotherapy. Despite the limited stage, Bcl-2/IgH+ cells were found at diagnosis in PB and/or BM of 16 patients (66.6%). After treatment, in 9/15 Bcl-2/IgH positive evaluable patients, a disappearance of Bcl-2/IgH+ cells was observed, which persisted after a median follow-up of 43.5 months (range 11-70) in all but one patient. Quantitative PCR demonstrated the feasibility of clearing PB and BM Bcl-2+ cells after local irradiation of the primary site of the disease only when the basal number of lymphoma cells was <1:100 000. Patients with Bcl-2/IgH+ cells at diagnosis or after treatment had a higher likelihood of relapse. Thus, despite a negative BM biopsy, the majority of localised FL Bcl-2/IgH+ cells were found in the PB and BM. Lymphoma cells can reversibly spread from the affected lymph node to PB and BM and, in a proportion of cases, durably disappear after irradiation. The possibility of a persistent lymphoma cell clearance is proportional to the amount of cells detected at presentation by quantitative PCR.

Immunochemotherapy With Rituximab and Overall Survival in Patients With Indolent or Mantle Cell Lymphoma: A Systematic Review and Meta-analysis

BACKGROUND

Addition of the anti-CD20 monoclonal antibody rituximab to chemotherapy (R-chemo) has been shown to improve response rates and progression-free survival in patients with indolent or mantle cell lymphoma. However, the impact of R-chemo on overall survival is unclear. We performed a comprehensive systematic review and meta-analysis to examine the efficacy of combined immunochemotherapy using R-chemo compared with the identical chemotherapy alone with respect to overall survival in patients with advanced indolent lymphoma or mantle cell lymphoma.

METHODS

Medical databases and conference proceedings were searched for randomized controlled trials published from January 1990 through December 2005 that compared R-chemo with chemotherapy alone in patients with newly diagnosed or relapsed indolent lymphoma or mantle cell lymphoma. We included full-text and abstract publications. Endpoints were overall survival, disease control, overall response, and toxicity. A fixed-effects model was assumed in all meta-analyses. For binary data, the relative risk was used as an indicator of treatment effect, and the Mantel-Haenszel method was used to pool relative risks. Statistical tests for heterogeneity were one-sided; statistical tests for effect estimates were two-sided.

RESULTS

Seven randomized controlled trials involving 1943 patients with follicular lymphoma, mantle cell lymphoma, or other indolent lymphomas were included in the meta-analysis. Five studies were published as full-text articles, and two were in abstract form. Patients treated with R-chemo had better overall survival (hazard ratio [HR] for mortality = 0.65; 95% confidence interval [CI] = 0.54 to 0.78), overall response (relative risk of tumor response = 1.21; 95% CI = 1.16 to 1.27), and disease control (HR of disease event = 0.62; 95% CI = 0.55 to 0.71) than patients treated with chemotherapy alone. R-chemo improved overall survival in patients with follicular lymphoma (HR for mortality = 0.63; 95% CI = 0.51 to 0.79) and in patients with mantle cell lymphoma (HR for mortality = 0.60; 95% CI = 0.37 to 0.98). However, in the latter case, there was heterogeneity among the trials (P = .07), making the survival benefit less reliable.

CONCLUSION

In patients with indolent or mantle cell lymphoma, R-chemo is superior to chemotherapy alone with respect to overall survival.

Follicular lymphoma with extensive gastrointestinal tract involvement: follow-up by capsule endoscopy

Follicular lymphoma with gastrointestinal tract involvement is rare. We describe the case of a young woman with follicular lymphoma with multiple nodular lesions involving segments of the proximal jejunum and terminal ileum. The presenting symptom was chronic diarrhea. The diagnosis was made by endoscopy with histologic examination of the mucosal lesions of the proximal and distal small intestine, immunohistochemical staining, and molecular analysis. The initial spread and pattern of the small bowel involvement, as well as treatment response, were evaluated by videocapsule endoscopy. The application of molecular analysis along with immunophenotypic evaluation has made it possible to precisely diagnose follicular lymphoma. In the present case, the use of capsule endoscopy improved the evaluation of the extent of small bowel involvement prior to and following treatment.

Evolving role of radiation therapy for hematologic malignancies

Radiation therapy continues to play a paramount role in the therapy of hematologic malignancies, whether as definitive therapy, as consolidation after chemotherapy, as part of bone marrow transplantation protocols, or in palliation. During the past 2 decades, significant advances in radiation therapy have occurred, including the evolution of involved-field irradiation and the adoption of conformal radiation administration. It is hoped that modern techniques will reduce the long-term sequelae associated with radiation-based treatments.

Sub-clinical dissemination of follicular lymphoma in normal sized lymph nodes may not be detected by radiologic staging: a case of disseminated follicular lymphoma detected in nodal clearance as part of therapy for cutaneous melanoma

Patients with localized follicular lymphoma are potentially curable; however, the failure rate for local treatment suggests that a proportion of apparently localized disease is being under-staged. We report a case of incidentally diagnosed follicular lymphoma found in association with a stage II malignant melanoma, with immunohistochemical evidence of disseminated lymphoma in radiologically and clinically benign regional lymph nodes. This case provides some evidence to the cause of treatment failure in patients with clinically localized follicular lymphoma, and is a histologically proven example of the association between melanoma and lymphoma.

Follicular lymphoma in early stages: high risk of relapse and usefulness of the Follicular Lymphoma International Prognostic Index to predict the outcome of patients

BACKGROUND AND OBJECTIVES

Patients with follicular lymphoma (FL) in advanced stages are currently deemed incurable with standard treatments. However, FL is considered to be eradicable in the small group of patients presenting with localized disease. The objective of this study was to analyze the clinical features and the outcome of a series of patients with FL in early stages with a long follow-up.

PATIENTS AND METHODS

A total of 48 patients (25m/23f; median age: 50 yr) diagnosed consecutively with FL in Ann Arbor stage I (25 cases) or II (23) at a single institution with a median follow-up of 9.5 yr were included in the study. Main biological and clinical characteristics at diagnosis, including Follicular Lymphoma International Prognostic Index (FLIPI) were analyzed; treatment and response were assessed and analyzed for prognosis.

RESULTS

The histologic subtypes were: FL type I, 20 cases (42%); type II, 24 (50%); type III, three (6%); and unclassifiable, one (2%). Distribution according to FLIPI was: low risk (36 cases) and intermediate risk (five cases). Treatment mainly consisted of combination chemotherapy (CHOP in 34 cases) plus involved-field radiotherapy in 26 cases. Forty patients (89%) achieved a complete response (CR), three (7%) a partial response, and two (4%) were non-responders; the remaining three patients did not receive therapy. No initial variable predicted CR achievement. About 57% of the patients in CR eventually relapsed with a relapse risk of 46% at 10 yr. Intermediate-risk FLIPI predicted failure-free survival. Histologic transformation was observed in six patients with a 10-yr risk of transformation of 13%. Twelve patients died during follow-up, in two cases as a result of unrelated causes. Overall survival (OS) at 10 yr was 79%. The FLIPI was the sole variable predicting OS.

CONCLUSIONS

Although the majority of patients with localized FL achieve CR, the risk of relapse is high. The FLIPI is of prognostic value in these patients.

Annual report to the nation on the status of cancer, 1975-2001, with a special feature regarding survival

BACKGROUND

The American Cancer Society (ACS), the Centers for Disease Control and Prevention (CDC), the National Cancer Institute (NCI), and the North American Association of Central Cancer Registries (NAACCR) collaborate annually to provide updated information regarding cancer occurrence and trends in the U.S. This year's report features a special section on cancer survival.

METHODS

Information concerning cancer cases was obtained from the NCI, CDC, and NAACCR and information concerning recorded cancer deaths was obtained from the CDC. The authors evaluated trends in age-adjusted cancer incidence and death rates by regression models and described and compared survival rates over time and across racial/ethnic populations.

RESULTS

Incidence rates for all cancers combined decreased from 1991 through 2001, but stabilized from 1995 through 2001 when adjusted for delay in reporting. The incidence rates for female lung cancer decreased (although not statistically significant for delay adjusted) and mortality leveled off for the first time after increasing for many decades. Colorectal cancer incidence rates also decreased. Death rates decreased for all cancers combined (1.1% per year since 1993) and for many of the top 15 cancers occurring in men and women. The 5-year relative survival rates improved for all cancers combined and for most, but not all, cancers over 2 diagnostic periods (1975-1979 and 1995-2000). However, cancer-specific survival rates were lower and the risk of dying from cancer, once diagnosed, was higher in most minority populations compared with the white population. The relative risk of death from all cancers combined in each racial and ethnic population compared with non-Hispanic white men and women ranged from 1.16 in Hispanic white men to 1.69 in American Indian/Alaska Native men, with the exception of Asian/Pacific Islander women, whose risk of 1.01 was similar to that of non-Hispanic white women.

CONCLUSIONS

The continued measurable declines for overall cancer death rates and for many of the top 15 cancers, along with improved survival rates, reflect progress in the prevention, early detection, and treatment of cancer. However, racial and ethnic disparities in survival and the risk of death from cancer, and geographic variation in stage distributions suggest that not all segments of the U.S. population have benefited equally from such advances.

Fludarabine Plus Mitoxantrone With and Without Rituximab Versus CHOP With and Without Rituximab As Front-Line Treatment for Patients With Follicular Lymphoma

Purpose

Promising new therapeutic options for follicular lymphoma (FL) include fludarabine plus mitoxantrone (FM) and the mouse/human anti-CD20 antibody, rituximab. We performed a randomized comparative trial of FM with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) front-line chemotherapy with and without sequential rituximab.

Patients and Methods

All previously untreated CD20+ FL patients presenting in 15 Italian cooperative institutions from October 1999 were randomly allocated to FM or CHOP. Following clinical or molecular restaging, patients in complete remission (CR) with bcl-2/IgH negativity (CR−) received no further treatment; those in CR with bcl-2/IgH positivity (CR+) received rituximab, as did those in partial remission (PR) with bcl-2/IgH negativity (PR−) or positivity (PR+); nonresponders (NR subgroup) were off study.

Results

After chemotherapy, the FM arm achieved higher rates of CR (68% [49 of 72 patients] v 42% [29 of 68 patients]; P = .003) and CR− (39% [28 of 72 patients] v 13 of 68 patients [19%]; P = .001). Rituximab elicited CR− in 55 of 95 treated patients (58%). The final CR− rate was higher in the FM arm (71% [51 of 72 patients] v 51% [35 of 68 patients]; P = .01). However, with a median follow-up of 19 months (range, 9 to 37 months), no statistically significant difference was found among the various study arms in terms of both progression-free (PFS) and overall survival (OS).

Conclusion

These results indicate that FM is superior to CHOP for front-line treatment of FL and that rituximab is an effective sequential treatment option. However, they also confirm that this superiority is unlikely to translate into either better PFS or OS.

Limited-stage mantle-cell lymphoma

BACKGROUND

Mantle-cell lymphoma (MCL) is known to have a poor outcome, however, most patients present with advanced-stage disease. Little information is available on limited-stage MCL.

PATIENTS AND METHODS

We retrospectively reviewed clinicopathological information on all patients with limited-stage MCL seen at the British Columbia Cancer Agency since 1984.

RESULTS

Twenty-six patients had low bulk (<10 cm) stage IA (12 patients) or IIA (14 patients) MCL. Initial therapy was involved-field radiation therapy (RT) with or without chemotherapy (CT), 17 patients; CT alone or observation, nine patients. Fifteen patients are alive at a median follow-up of 72 months (range 14-194). Progression-free survival (PFS) at 2 and 5 years was 65% and 46%, and overall survival (OS) 86% and 70%, respectively. Five patients surviving beyond 8 years. Only age and initial use of RT significantly affected PFS. Five-year PFS for patients <60 years of age was 83%, compared with 39% for those aged >/= 60 years, P = 0.04. Patients receiving RT with or without CT (n = 17), had a 5-year PFS of 68%, compared with 11% for those not receiving RT (n = 9, P = 0.002). Receiving RT eliminated the impact of age on PFS (with RT the 5-year PFS was 83% for those aged <60 years and 57% for those >/= 60 years, P = 0.17). Although OS for the whole group was 53% at 6 years, it was 71% for those initially treated with RT, but only 25% for those not given RT (P = 0.13).

CONCLUSION

In our experience, patients with limited-stage MCL had an improved PFS when treated with regimens including RT, with a trend towards improved OS. These results suggest a potentially important role for RT in limited-stage MCL.

Long-term follow-up of a prospective study of combined modality therapy for stage I-II indolent non-Hodgkin's lymphoma

PURPOSE

Standard therapy for patients with stage I-II indolent lymphoma has been involved-field radiation therapy (IF-XRT), which achieves 10-year disease-free survival in 40% to 50% of patients, with many of these patients cured. We investigated the potential for combined-modality therapy to increase the disease-free survival for such patients.

PATIENTS AND METHODS

A total of 102 eligible patients with stage I-II low grade lymphoma (International Working Formulation criteria) were enrolled from 1984 to 1992. Treatment comprised 10 cycles of risk-adapted chemotherapy (cyclophosphamide, vincristine, prednisone, bleomycin [COP-Bleo], and with doxorubicin added for some [CHOP-Bleo]) and 30 to 40 Gy IF-XRT.

RESULTS

The patients' median age was 56 years (range, 28 to 77), with follicular histology in 83%, bulky disease (>/= 5 cm) in 24%, and stage II in 52%. There were no treatment-related deaths and 99% of patients attained complete remission. With a median follow-up of 10 years, the 10-year time to treatment failure and overall survival were 76% and 82%, respectively. For patients with follicular lymphoma, these figures were 72% and 80%, respectively. The only factor associated with treatment failure, for follicular lymphoma patients, was stage-modified International Prognostic Factors Index score (P =.02). None of 17 patients with diffuse small lymphocytic or mucosa-associated lymphoid tissue histology have relapsed. Elevated serum beta2-microglobulin was associated with shorter survival (P <.0001). The 10-year survival after relapse was 46%. There have been two cases of myelodysplasia and 12 other new malignancies, including four arising within radiation fields.

CONCLUSION

With prolonged follow-up, combined-modality therapy with risk-adapted COP-/CHOP-Bleo and IF radiation has attained higher rates of disease control and survival than previously reported with IF-XRT alone. This apparent improvement is being further explored in an ongoing randomized trial.

Primary non-Hodgkin's lymphoma of the bladder with bone marrow involvement

Involvement of the lower urinary tract by advanced non-Hodgkin's lymphoma (NHL) has been reported in up to 13% of cases, but primary NHL of the urinary bladder is very rare. A 35-year-old man was admitted to our hospital with a chief complaint of gross hematuria with left flank pain on April 12, 2001. Cystoscopy revealed an edematous broad-based mass on the left lateral wall of the bladder, and transurethral biopsy showed NHL, diffuse large B-cell type. Abdomino-pelvic CT scan demonstrated left-side hydronephrosis and hydroureter with left proximal ureter infiltration and thickening of the left lateral wall of the bladder with perivesical fat infiltration without lymph node enlargement. Full-scale staging work-up revealed the bone marrow as the solely involved site. The lesions of the bladder and left urinary tract were nearly completely regressed after two cycles of systemic cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy with simultaneous restoration of urinary function.

Primary cutaneous follicle center cell lymphoma and limited stage follicular non-Hodgkin's lymphoma: a comparison of clinical and biological features

Primary cutaneous follicular lymphoma (PCFL) and nodal follicular lymphoma (NFL) are different entities, which, nevertheless, exhibit common features. The aim of this study was to compare the clinico-biological characteristics and the outcome of patients with PCFL and with limited stage NFL. A group of 22 consecutive patients with PCFL presenting with single or multiple cutaneous lesions was compared to a group of 21 patients with limited stage NFL. The median age was 56 and 55 years, respectively. The histologic features were compared, as well as treatment modalities and response. Treatment of PCFL consisted of restricted field radiotherapy (RT), chemotherapy (CHT) and combined modalities (CM) in 12, 5 and 5 cases, respectively. Among the 21 patients with NFL, RT was employed in 13, CHT in 7 and the CM in one patient. The response to treatment was: 17 complete responses, CR (12 RT, 2 CHT, 3 CM), 3 partial responses, PR (1 CHT, 2 CM) and 2 non-responses, NR (2 CHT) in the PCFL group, while in the NFL group 18 patients attained CR (13 RT, 4 CHT, 1 CM) and 3 PR (3 CHT). The relapse rate was 22.7 and 28.5% in PCFL and NFL, respectively (median follow up of 48 and 50 months). The estimated 4 years event free survival (EFS) in the PCFL and NFL patients were 68 and 70%, respectively, (P = 0.83). The estimated 4 years overall survival (OS) in the PCFL and NFL groups were 90% and 100% respectively, (P = 0.254). Among the 22 patients with PCFL, there was a higher incidence of large cells than in NFL, although the differences were not significant (P = 0.08). In conclusion, despite histologic (higher proportion of large cells) and biologic differences, cutaneous and limited stage NFL show similar responses to treatment, with similar relapse rates, EFS and OS.

Management of localized low-grade follicular lymphomas

Long-term follow-up data from Stanford and other centres suggest that 40-50% of patients with clinical stages I and II follicular low-grade lymphoma can be cured by radiotherapy (RT). Relapse generally occurs outside radiation fields and most relapsed patients ultimately die from lymphoma. No randomized data exist to support adjuvant chemotherapy but only one trial of low-intensity chemotherapy was sufficiently powerful to address the question. Nevertheless, data from a large phase-II study from MD Anderson suggest that combined chemotherapy and RT can produce progression-free survival results that are far superior to historical series, with survival at 10 years to be approximately 20% superior to radiation alone. These results have encouraged the development of a joint phase III study by the Trans Tasman Radiation Oncology Group (TROG) and the Australasian Leukaemia and Lymphoma Group (ALLG) in which patients with clinical stage I/II follicular lymphoma are randomized to involved field RT with or without six cycles of cytotoxic chemotherapy. In an era of rapid development in immunological and molecular therapies the potential for improved results with new combinations of more established treatment modalities should not be forgotten. This report reviews the literature on the management of localized low-grade lymphoma and discusses the rationale for the TROG/ALLG study, which began recruitment in early 2000.

Follicular lymphomas--a review of treatment modalities

Follicular lymphoma is the most common low-grade non Hodgkin's lymphoma and represent an homogeneous entity as defined by pathological, molecular and clinical data. This indolent disease is characterised by a slow growth pattern with possible spontaneous regression, is often disseminated but remains incurable with available treatments when disseminated. For localised stages, involved field radiotherapy remains the standard choice but other approaches remain to be investigated. In advanced disease, chemotherapy has been demonstrated to produce high response rates but recent trials with new treatment strategies including interferon and monoclonal antibodies may improve the current situation. In this article, we will review treatment of follicular lymphomas, specially emphasising published phase III trials.

Randomized trial of fludarabine versus fludarabine and idarubicin as frontline treatment in patients with indolent or mantle-cell lymphoma

PURPOSE

A first comparative trial of fludarabine (FLU) alone versus FLU plus idarubicin (FLU-ID) for indolent or mantle-cell lymphomas.

PATIENTS AND METHODS

From September 1995 to July 1998, 199 patients aged 25 to 65 years (median, 54 years) with newly diagnosed stages II to IV indolent or mantle-cell lymphomas (standard risk according to the International Prognostic Index) were enrolled onto a multicenter, 1:1 randomized study. Of the 199 patients who were able to be assessed, 101 were assigned to the FLU group (six monthly cycles of FLU 25 mg/m(2)/d on days 1 through 5) and 98 to the FLU-ID group (six monthly cycles of FLU 25 mg/m(2)/d on days 1 through 3 and idarubicin 12 mg/m(2) on day 1).

RESULTS

In the FLU group, complete response (CR) and partial response rates were 47% and 37%, respectively, whereas in the FLU-ID group, they were 39% and 42%, respectively. In-depth analysis of the CR rate with respect to histologic type showed that FLU seemed to be superior to FLU-ID in treating follicular lymphomas (60% v 40%, respectively), whereas FLU-ID seemed to be more effective than FLU in treating nonfollicular lymphomas (small lymphocytic, 43% v 29%, respectively; immunocytoma, 38% v 23%, respectively; P = not significant), excluding the mantle-cell subset (in which there was no difference between the two groups). No striking differences were observed between the two protocols in terms of overall response or toxicity, which was generally mild. However, with a median follow-up of 19 months, only 29 patients (62%) who received FLU alone have maintained their initial CR, compared with 32 (84%) of those who received FLU-ID therapy (P =.021).

CONCLUSION

Although the FLU-ID regimen may not significantly improve the induction of CR in most indolent-lymphoma patients, our preliminary data do suggest that, with respect to FLU alone, it may be capable of conferring a longer-lasting CR and that it might be superior in terms of CR rate in small lymphocytic and immunocytoma subtypes.

Hodgkin's disease and non-Hodgkin's lymphoma

The development of new classification schemes and prognostic analyses for lymphomas has helped to identify patients at high risk for relapse who may benefit from intensification of primary therapy. Conventional salvage therapy for relapsed follicular or low-grade lymphomas now includes monoclonal antibody therapy. The combination of chemotherapy and monoclonal antibody therapy may improve outcomes for patients with advanced-stage aggressive non-Hodgkin's lymphomas. Confirmatory randomized trials are now in progress. Therapy for Hodgkin's disease continues to evolve toward the most efficacious programs, which also minimize the long-term probability of toxicity. The combination of high-dose chemotherapy and stem cell transplantation is probably the most effective therapy for patients with relapsed or refractory Hodgkin's disease.

Limited stage I and II follicular non-Hodgkin's lymphoma: the Nebraska Lymphoma Study Group experience

The purpose of this study was to evaluate the outcome and prognostic factors of patients with limited stage follicular non-Hodgkin's lymphoma treated prospectively by the Nebraska Lymphoma Study Group (NLSG). Forty previously untreated patients, median age 64 years, with limited stage follicular lymphoma were prospectively treated according to the protocols of the NLSG between January 1980 and December 1990. The follicular large cell type represents 75% of the cases, and 14 of the biopsies also had a diffuse component (composite lymphoma). The initial treatment was radiation therapy (RT) to the involved field in 15 patients, anthracycline-containing combination chemotherapy (CT) in 20, and combined RT and CT in 5. Thirty-seven patients (92.5%) achieved a complete remission (CR). The median follow-up is 120 months (range, 20 to 214). Of the 37 patients achieving a CR, 7 patients are alive in first CR, one died due to sepsis, another because of a myeloproliferative disorder at 77 months following chemotherapy, 6 died because of unrelated causes in first CR. Twenty-two patients relapsed between 1 to 128 months following a CR. The estimated 10-year event-free survival is 21% (95% CI: 7 to 35). Two patients received no or palliative therapy after relapse and both died of progressive disease. Nineteen patients received salvage therapy and 15 achieved a second remission. The median survival after first relapse is 55 months. The estimated 10-year overall survival is 44% (95% CI: 28 to 60). Various factors including sex, histologic subtype, stage, and degree of follicularity do not influence the overall survival or event-free survival. CT with or without RT resulted in a better trend for 10-year event-free survival in stage IA patients compared to RT alone but estimated 10-year overall survival is no different. The overall survival is worse in the > or = 60 age group but this difference is not evident if data is adjusted for cause specific death. In conclusion, limited stage follicular lymphoma has an excellent initial response to radiation therapy or chemotherapy; however the recurrence rate is high and cure is limited.

The impact of radiotherapy dose and other treatment-related and clinical factors on in-field control in stage I and II non-Hodgkin's lymphoma

PURPOSE/OBJECTIVE

To assess local (in-field) disease control, identify potential prognostic factors, and elucidate the optimal radiotherapy dose in various clinical settings of Stage I and II non-Hodgkin's lymphoma (non-CNS).

MATERIALS & METHODS

A total of 285 consecutive patients with Stage I and II non-Hodgkin's lymphoma were treated with curative intent, including 159 with radiotherapy (RT) alone and 126 with combined-modality therapy (CMT). Of these, 72 patients had low-grade lymphomas (LGL), 92 had intermediate or high-grade lymphomas (I/HGL), and 21 had unclassified lymphomas. Clinical and treatment variables with potential prognostic significance for in-field disease control, freedom from relapse (FFR), and absolute survival (AS) were evaluated by univariate and multivariate analyses.

RESULTS

The 5-, 10-, and 20-year actuarial AS rates were 73%, 46%, and 33% for patients with LGL and 64%, 44%, and 18% for patients with I/HGL, respectively. The 5-, 10-, and 20-year actuarial FFR rates were 62%, 59%, and 49% for patients with LGL and 66%, 57%, and 57% for patients with I/HGL, respectively. Significant prognostic factors identified by the multivariate analysis were age, tumor size, and histology for AS; tumor size and treatment for FFR; and only tumor size for in-field disease control. There were 95 total failures, with only 12 occurring infield. Most failures (65%) were in contiguous unirradiated sites. All 4 in-field failures in patients with LGL occurred after RT doses < 30 Gy, although none occurred in 10 patients with small-volume LGL of the orbit treated with doses < 30 Gy. The 8 in-field failures in patients with I/HGL were distributed evenly throughout the RT dose range; 5 occurred in patients treated with CMT, all with tumors > 6 cm, and 4 with less than a complete response (CR) to chemotherapy.

CONCLUSION

Our analysis suggests that the overwhelming problem in the treatment of non-Hodgkin's lymphoma is not in-field failure but, rather, failure in contiguous unirradiated sites. A dose of 20-25 Gy may be sufficient for small-volume LGL of the orbit. A dose of 30 Gy is sufficient for LGL in general, as well as for patients with nonbulky (< or = 6 cm) I/HGL treated with CMT who have a CR. However, patients with I/HGL treated with CMT for tumors > 6 cm and/or without a CR may benefit from doses > or = 40 Gy.

Non-Hodgkin's lymphoma in the elderly: a guide to drug treatment

Adverse events are common in the elderly when they undergo potent chemotherapy and the reasons for this are various. Therefore, chemotherapy for elderly patients with non-Hodgkin's lymphoma (NHL) must differ from that for non-elderly patients. Age is one of the poor prognostic factors for NHL and the main reason for this is reduced antitumour effect due to decreased dose and increased adverse effects. However, many of these elderly patients also die from causes other than lymphoma. The usual approach to the treatment of indolent NHL is to use drugs with few adverse effects such as nucleoside analogs. Multidrug therapy is used for intermediate grade NHL and the most commonly used regimen is CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone). In recent years, many clinical trials have been performed in elderly patients with NHL. The results of these trials indicate that a significantly better prognosis is achieved with anthracycline (cytostatic antibiotics) containing regimens. The elderly population will continue to grow and so it is necessary to establish more effective treatment options for NHL in the elderly.

Non-Hodgkin's lymphoma of the head and neck: a 30-year experience at the University of Florida

BACKGROUND

Outcome in previously untreated patients with non-Hodgkin's lymphoma of the head and neck needed to be assessed.

METHODS

A retrospective review was performed of 79 patients with stage I or II non-Hodgkin's lymphoma of the head and neck treated between 1964 and 1994 with radiotherapy (RT) or combined modality therapy (CMT) at the University of Florida. Freedom from relapse, cause-specific survival, and absolute survival were analyzed by the Kaplan-Meier method. Patterns of failure were defined, and the relationship between dose and infield recurrence was studied. Histology was classified as low grade or intermediate/high grade.

RESULTS

At 10 years, absolute survival for patients with low-grade lymphoma treated with RT was 45%; absolute survival for patients with intermediate/high-grade lymphoma was 41% for those treated with RT and 57% for those who received CMT. Twenty-seven patients had a recurrence of lymphoma after initial treatment. Twenty patients (74%) had recurrences outside the radiation treatment field; 90% of these failures were in predictable sites that would be included in comprehensive lymphatic irradiation fields (Waldeyer's ring, mantle, and whole abdomen). No clear dose response was observed. Multivariate analysis showed that patients with tumors <5 cm in diameter had improved cause-specific survival, absolute survival, and freedom from relapse compared with patients with tumors > or = 5 cm in diameter.

CONCLUSIONS

Patients with non-Hodgkin's lymphoma in the head and neck with tumors > or = 5 cm in diameter appear to have a worse prognosis than those with smaller tumors. The patterns of failure suggest that initial treatment with comprehensive lymphatic irradiation fields could potentially eliminate the majority of treatment failures.

[Role of radiotherapy in the treatment of adult nodal non-Hodgkin's lymphoma]

RADIOTHERAPY OF ADULT NODAL NON HODGKIN'S LYMPHOMA: The role of radiotherapy in the treatment of nodal non-Hodgkin's lymphoma has been modified by the introduction of efficient chemotherapy and the development of different pathological classifications. INTERMEDIATE GRADE OR HIGH GRADE LYMPHOMA: The recommended treatment of early-stage aggressive lymphomas is primarily a combination chemotherapy. The interest of adjuvant radiotherapy remains unclear and has to be established through large prospective trials. If radiation therapy has to be delivered, the historical results of exclusive radiation therapy showed that involved-fields and a dose of 35-40 Gy (daily fraction of 1.8 Gy, 5 days a week) are the optimal schedule. The interest of radiotherapy in the treatment of advanced-stage aggressive lymphoma is yet to be proven. Further studies had to stratify localized stages according to the factors of the International Prognostic Index. LOW-GRADE LYMPHOMA: For early-stage low-grade lymphoma, radiotherapy remains the standard treatment. However, the appropriate technique to use is controversial. Involved-field irradiation at a dose of 35 Gy seems to be the optimal schedule, providing a 10-year disease-free survival rate of 50% and no major toxicity. There is no standard indication of radiotherapy in the treatment advanced-stage low-grade lymphoma. RARE AND NEW ENTITY: For "new" nodal lymphoma's types, the indication of radiotherapy cannot be established (mantle-zone lymphoma, marginal zone B-cell lymphoma) or must take into account the natural history (Burkitt's lymphoma, peripheral T-cell lymphoma) and the sensibility to others therapeutic methods.

[Radiotherapy of follicle center lymphoma. Results of a German multicenter and prospective study. Members of the Study Group "NHL-early stages"]

PURPOSE

Follicle centre lymphoma grade I, II (REAL) or centroblastic-centrocytic lymphoma (Kiel classification) present a well defined clinical entity from a clinical point of view. These lymphomas are not curable by chemotherapy in early or advanced stages. They are treated by radiation therapy in early stages, but up to now the curative potency of radiotherapy has not been confirmed by prospective clinical trials.

PATIENTS AND METHODS

Between January 1986 and August 1993 117 adults with follicle centre lymphoma were recruited from 24 institutions to enter the multicentric prospective, not randomised clinical trial. Patients with histologically proven nodal follicle centre lymphoma of stages I, II and limited III were included. They were treated by a standardised radiotherapy regimen, in stage I by extended field and in stages II and III by total nodal irradiation. Dose per fraction was 1.8 to 2.0 Gy, in the abdominal bath 1.5 Gy up to a total dose of 26 Gy in adjuvant situation and 36 Gy to enlarged lymphoma.

RESULTS

All patients developed a complete remission at the end of radiotherapy. Median follow-up is 68 months. Overall survival of all patients in 86 +/- 3% at 5 and 8 years. Stage adjusted survival at 5 and 8 years was 89% for stage I, 86% for stage II and 81% for III. Patients in stages I and II < 60 years had survival rates of 94% at 5 and 8 years, patients > 60 years 63% (p < 0.0001). Recurrence free survival of all patients is 70% at 5 and 60 +/- 5% at 8 years. The number of recurrences is high with 29% at 5 and 41% at 8 years. All recurrences were seen within 7 years. The probability of localised nodal in-field recurrences is 11% and 22% at 5 and 8 years, respectively. Adverse prognostic factors were identified by multivariate analysis: age > 60 years, treatment breaks > or = 7 days and dose deviations > 20% from prescribed doses. Acute side effects of extended field irradiation were moderate.

CONCLUSIONS

On the basis of these results radiotherapy is a potentially curative therapeutic approach in stages I, II and limited III of follicle centre lymphoma. The optimal technique is total lymphoid irradiation with doses of 30 Gy in the adjuvant situation and 40 to 44 Gy in enlarged lymphomas. The number of local recurrences leads to the assumption, that the extension of radiotherapy to the total lymphoid system might reduce their frequency.

Place of low-dose total body irradiation in the treatment of localized follicular non-Hodgkin's lymphoma: results of a pilot study

PURPOSE

In a first prospective nonrandomized trial, 107 patients with Stage III and IV "low-grade" lymphomas have been treated with a combination of chemotherapy and low-dose total body irradiation (LD-TBI). This study shows that this scheme of LD-TBI was very well tolerated, gave a high response rate (83%), and extended RFS. It incited us to start a pilot study on localized follicular lymphomas.

METHODS AND MATERIALS

From January 1986 through October 1994, 34 patients with previously untreated localized low-grade non-Hodgkin's lymphomas have been included in a prospective trial with LD-TBI followed by radical involved field radiotherapy (IF-RT). Patients received two courses of whole body irradiation of 0.75 Gy in 5 fractions and 1 week separated by a rest period of 2 weeks. After 1 month, patients were reevaluated, and received 40 Gy in 20 fractions, and 4 weeks on initially pathological lymph node areas. Eight patients have been excluded from the study: 4 after histologic review (2 centrocytic, 1 lymphocytic, 1 centroblastic) and 4 patients with Stage IV because of bone-marrow involvement. The remaining 26 patients were 11 men and 15 women, 50 years old median age (mean: 50.2; range: 35-73.5) with clinical Stage I (10 pts), II1 (8 pts), and II2 (8 pts). All patients received the planned treatment.

RESULTS

Clinical tolerance was excellent, and the hematological follow-up shows a mean nadir value of 3.9.10(9)/l (2.1-8.1) for leucocytes, 13.4 g/l (10.8-15.4) for hemoglobin, and 124.10(9)/l (46-216) for platelets, with a median delay of 3.2 months. Of 26 patients, 24 achieved complete remission (CR) after the LD-TBI that was before the IF-RT. All patients, except one, were in complete remission after IF-RT. Nineteen patients remain alive without any evidence of disease, with a median follow-up of 56.2 months. Five patients relapsed; 3 of them died.

CONCLUSION

As delivered, this schedule of LD-TBI give a very high rate of CR in localized follicular non-Hodgkin's lymphoma, with a very good tolerance. It remains to prove that this immediate efficacy has an impact on long-term disease-free survival in such patients, and to understand how the LD-TBI works (direct and/or indirect induction of apoptosis; relationship with t(14;18) translocation and overexpression of bcl-2). These will be the two aims of a new EORTC prospective randomized trial comparing LD-TBI followed by IF-RT vs. IF-RT alone.

Fludarabine-mitoxantrone combination-containing regimen in recurrent low-grade non-Hodgkin's lymphoma

BACKGROUND

The promising results of fludarabine (FLU) in chronic lymphocytic leukemia have prompted its extensive evaluation in low-grade non-Hodgkin's lymphoma (LG-NHL). Its different mechanisms of action make FLU an attractive partner for combination with other cytostatic agents.

PATIENTS AND METHODS

We used a three-drug combination of FLU (25 mg/m2 i.v. on days one to three), mitoxantrone (10 mg/m2 i.v. on day one) and prednisone (40 mg given orally on days one to five) (FMP) to treat 48 patients with recurrent LG-NHL.

RESULTS

Of the 48 patients, 17 (35%) achieved complete responses (CR), 23 (48%) partial responses, while the remaining 8 (17%) showed no benefit from the treatment. The risk of lower CR rate was significantly correlated with the presence of advanced stage (IV) (P = 0.01), the number of previous regimens (> or = 3) (P = 0.006), and the follicular histologic subtype (P = 0.02). The major toxic effects observed were neutropenia and infections; there was only one fatality, due to drug-related side effects.

CONCLUSIONS

These data confirm the significant efficacy of the FMP fludarabine-mitoxantrone combination regimen in obtaining a good remission rate with moderate toxicity in a particular subset of recurrent LG-NHL.

Low dose palliative radiotherapy in low grade non-Hodgkin's lymphoma

The clinical picture of disseminated (stage 3 and 4) low grade non-Hodgkin's lymphoma (NHL) is one of continuing relapse. Management options include observation only in asymptomatic patients, single agent chlorambucil or localised radiotherapy in patients with symptomatic nodal disease. Radiation doses of 25-40 Gray in 10-20 fractions have been the standard approach in low grade NHL, but in 1994 Ganem et al. [Hematol. Oncol. 8: 225-233, 1994] reported the use of low dose radiotherapy (LDRT)--4 Gray in 2 fractions over 3 days--for the palliation of symptomatic disease in patients with disseminated, chemoresistant low grade NHL. We describe here our early experience with this schedule.

Prolonged survival in follicular non Hodgkins lymphoma is predicted by achievement of complete remission with initial treatment: results of a long-term study with multivariate analysis of prognostic factors

Prognostic factors among 200 patients with follicular non-Hodgkin's Lymphoma (NHL) (categories B to D of the Working Formulation) requiring systemic therapy were investigated. In univariate analyses factors that had a favourable influence on survival included complete response to treatment, female sex and age < 60 years, while the presence of B-symptoms was a weakly adverse prognostic factor. In a multivariate analysis only the achievement of CR (chi square = 5.9, p = 0.015) and sex (chi 2 = 5.9, p = 0.015) were significant prognostic factors for survival. Not only was achievement of CR predictive of survival, CR duration > or = 2 years was associated with median overall survival in excess of 6 years. These results suggest that patients who are responsive to first line chemotherapy have a good prognosis and that experimental treatments such as high dose chemotherapy with hemopoetic rescue should be reserved for patients who either fail to achieve CR with initial therapy or who relapse within 2 years of initial treatment.

Is there any place for a wait-and-see policy in stage I0 follicular lymphoma? A study of 43 consecutive patients in a single center

BACKGROUND

A wait-and-see policy (WS) does not appear to modify the long-term prognosis of advanced-stage follicular lymphomas (FL), while irradiation of limited stages sometimes causes complications and does not avert distant relapses. Consequently, we decided to test WS in a selected subset of the localized FL, i.e., patients in complete remission (CR) after the initial lymph node biopsy (stage I0).

PATIENTS AND METHODS

Forty-three previously untreated patients were diagnosed with stage I0 FL and 26 of them were included in the WS. Their median age was 60.3 years; 19 were male and 24 female. All histological slides were reviewed and confirmed the diagnosis of FL. Median follow-up was 6.3 years (y).

RESULTS

Thirteen of the 26 untreated patients are still relapse-free, while six relapsed locally only (median: 4.2 years after diagnosis), and reattained CR with radiotherapy. Seven patients relapsed at distant sites (median: 1 year after diagnosis). No localized relapses were observed in the treated group, but there were 7 distant relapses.

CONCLUSIONS

The use of WS in stage I0 FL did not appear to modify the prognosis of these patients. Furthermore, we observed two distinct patterns of relapse (local and distant) that are difficult to differentiate at onset.

High rate of prolonged remissions following combined modality therapy for patients with localized low-grade lymphoma

PURPOSE

Involved field (IF) radiation can cure as many as 40% to 50% of patients with stage I-II low-grade lymphoma. We sought to improve these results by prospectively evaluating the combination of IF radiation and chemotherapy consisting of 10 courses of cyclophosphamide, vincristine, prednisone, and bleomycin, with doxorubicin added in a risk-adapted manner (COP/CHOP-Bleo).

PATIENTS AND METHODS

From 1984 until December 1992, 91 patients, median age 56 years (range 28 to 77 years), with clinical stage I-II low-grade lymphoma were treated. No patients were excluded on the basis of age or organ function.

RESULTS

A complete response was attained in 99% of evaluable patients. Treatment-related toxicity was mild, and no deaths occurred during therapy. With a median follow-up of 60 months, there have been only 16 relapses. The actuarial freedom from relapse rate at five years is 82% (95% confidence interval 71% to 89%) and at 10 years is 73%. At five years the overall survival rate is 90% (95% confidence interval 81% to 95%) and at ten years it is 82%. Of the clinical features examined, only older age (> 56 years; p = 0.07) was associated with shorter survival. No features examined were predictive of disease relapse.

CONCLUSION

The combination of IF radiation and risk-adapted COP/CHOP-Bleo chemotherapy is well-tolerated, produces a very high rate of complete remission, and with a median follow-up of five years, has produced lower rates of relapse and better overall survival than has been reported for IF radiation alone in patients with clinically-staged I-II low-grade lymphoma.

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

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

Non-Hodgkin's lymphoma

Lymphoid neoplasia is a complex area comprising multiple diseases with varied pathology, treatment, and outcome. The non-Hodgkin's lymphomas are reviewed here. Non-Hodgkin's lymphomas, collectively, represent the sixth most common cancer in the United States as well as the sixth most common cause of cancer deaths. The overall incidence of non-Hodgkin's lymphoma has risen steadily over the past four decades. Although some of this is attributable to human immunodeficiency virus (HIV)-associated lymphoma, HIV-associated disease accounts for only a small part of the increase in lymphoma. As our knowledge of normal as well as neoplastic lymphoid development has expanded on the basis of histopathology as well as adjunct cellular and molecular techniques, multiple classifications have been proposed to take these into account. The clinical relevance to our understanding of non-Hodgkin's lymphoma is the concept that various lymphoid cancers are counterparts of stages of normal lymphoid development. Stages of lymphoid development in terms of cell surface markers and immunoglobulin gene rearrangements have been well characterized. These are particularly applicable to the early B-cell development, which is antigen-independent and occurs in the bone marrow. Diseases correlating with these stages are largely acute lymphocytic and lymphoblastic leukemia/lymphoma and high-grade lymphomas, such as Burkitt's lymphomas. Much has been learned recently about subsequent antigen-dependent B-cell development in secondary lymphoid organs to improve our understanding of the corresponding stages of B-cell neoplasia. Many of these stages correlate with more recently described entities such as mantle cell and marginal zone lymphomas. Histologic study remains crucial in determining the subtype of NHLs, whereas immunohistochemistry, surface phenotype, and molecular studies are useful in selected cases. Although some lymphoma classifications may be better in terms of understanding the lymphoma biology, the working formulation remains useful to guide clinical decision making. Lymphomas classified as low grade are considered incurable with standard therapy when diagnosed, as is usual, at advanced stages. Different subtypes may have different median survivals, but the goal has typically been palliation, whereas experimental approaches are clearly needed. Intermediate and high-grade lymphomas are potentially curable with aggressive combination chemotherapy. Recent evidence suggests that CHOP chemotherapy is as effective as more complex regimens. Still, 40% to 50% of patients are cured. Prognostic factor analysis has allowed separation of subgroups with much better survival in whom CHOP is adequate versus those with much poorer survival in whom experimental approaches are rational. Additional subtypes of lymphomas have been described and characterized since the working formulation was developed, including mucosa-associated lymphoid tissue tumors (MALT-oma), mantle zone lymphoma, anaplastic large cell lymphoma and AILD-like T-cell lymphoma. Approaches to these entities are still being optimized. Newer approaches, including high-dose therapy with stem cell support, biologic agents, and newer chemotherapeutic agents are discussed, as are special situations such as localized lymphoma of certain sites and lymphoma in immunosuppressed patients.

Presenting features, natural history, and prognostic factors in localized non-Hodgkin's lymphomas: analysis of 117 cases from a single institution

Clinical features and prognostic factors were analyzed in a series of 117 patients with localized non-Hodgkin's lymphoma (stage I-II). Median age of the patients was 53 years and 52% were men; 22% had a lymphoma of low-grade histology and one-third presented with extranodal involvement. Eighty percent of the patients achieved a complete response (CR); stage of disease and histology were revealed as the most important factors for response. When analysis was restricted to intermediate/high-grade cases, stage showed a predictive value for response. With a median follow-up of 4.5 years, median overall survival was 12.0 years, with 73% and 62.5% of patients being alive at 5 and 10 years, respectively. Main initial parameters significantly related to a shorter survival were intermediate/high-grade histology, stage II, poor performance status, bulky disease, high serum LDH levels, increased ESR, and advanced International Index. In the multivariate analysis, stage, histology and performance status (PS) were statistically significant. Among intermediate/high-grade lymphoma patients, stage and PS provided prognostic value for survival. Twenty-six patients relapsed after CR; median survival after relapse was 2.7 years. Stage (I vs II) was the only predictive variable for relapse in both the whole series and the intermediate/high-grade subset.

Radiotherapy results in early stage low grade nodal non-Hodgkin's lymphoma

This is a retrospective review of stages I and II low grade nodal non-Hodgkin's lymphoma (NHL) seen at the Royal Marsden Hospital and treated with radiotherapy alone. From January 1970 to December 1989, 58 patients were treated. The Ann Arbor staging system was modified to subdivide stage II into localised and extensive disease, with localised disease representing no more than two contiguous regions. There were 40 stage I patients and 18 stage II patients (eight localised and 10 extensive). Volume of the radiotherapy was involved field only in 30 patients and extended fields in 28 patients. The median dose was 40 Gy in 20 fractions. The pattern of relapse was assessed as being systemic or within the standard volume. Survival and progression-free survival (PFS) were calculated. Prognostic variables of age, histology, stage and radiotherapy volume were analysed by multivariate analysis. The 5- and 10-year PFS for the total group were 59 and 43%, and corresponding OS figures were 93 and 79%. Age less than 60 years was a predictor of improved survival but not for PFS and we found no significance in histology, stage or extent of radiotherapy field for the other variables. All relapses occurred with disease outside the original volume, with three patients also relapsing in-field. Treatment of this disease produced an OS at 10 years of 79%. The plateau on the PFS plot suggested that some patients are cured. Young age was the only prognostic factor found for survival. Relapse is most frequently outside the treated volume. Our current treatment policy for stage I and II low grade NHL is involved field radiotherapy to a dose of 35 Gy in 20 fraction over 4 weeks.