Interferon therapy of non-Hodgkin's lymphoma

New Insights in the Pathogenesis and Therapy of Cold Agglutinin-Mediated Autoimmune Hemolytic Anemia

Autoimmune hemolytic anemias mediated by cold agglutinins can be divided into cold agglutinin disease (CAD), which is a well-defined clinicopathologic entity and a clonal lymphoproliferative disorder, and secondary cold agglutinin syndrome (CAS), in which a similar picture of cold-hemolytic anemia occurs secondary to another distinct clinical disease. Thus, the pathogenesis in CAD is quite different from that of polyclonal autoimmune diseases such as warm-antibody AIHA. In both CAD and CAS, hemolysis is mediated by the classical complement pathway and therefore can result in generation of anaphylotoxins, such as complement split product 3a (C3a) and, to some extent, C5a. On the other hand, infection and inflammation can act as triggers and drivers of hemolysis, exemplified by exacerbation of CAD in situations with acute phase reaction and the role of specific infections (particularly Mycoplasma pneumoniae and Epstein-Barr virus) as causes of CAS. In this review, the putative mechanisms behind these phenomena will be explained along with other recent achievements in the understanding of pathogenesis in these disorders. Therapeutic approaches have been directed against the clonal lymphoproliferation in CAD or the underlying disease in CAS. Currently, novel targeted treatments, in particular complement-directed therapies, are also being rapidly developed and will be reviewed.

[Chemotherapy-Free Treatment of Hematological Neoplasias: Dream or Reality?]

Chemotherapy-Free Treatment of Hematological Neoplasias: Dream or Reality? Abstract. Hematologic neoplasias are a heterogeneous group of diseases based on clonal expansion of immature, dysfunctional blood cell populations. Chemotherapy can achieve long-term remission in some patients, but side effects are often severe and recurrences frequent. The fact that the immune system can have the strongest activity against tumor cells is well-known from the field of allogeneic stem cell transplantation. Accordingly, various immunological therapy approaches to combat malignant diseases have been pursued for a long time. New generations of antibody- and cell-based therapies lead to excellent remission rates; the combination of different technologies culminates today in the combination of the targeted specificity of antibody-like molecules with the efficiency of immune effector cells through the use of genetically modified T cells. Data on long-term remissions and long-term consequences still need to mature in order to finally evaluate efficacy and feasibility, especially of prolonged therapies.

Interferon-alpha-based immunotherapies in the treatment of B cell-derived hematologic neoplasms in today's treat-to-target era

B cell lymphoma and multiple myeloma (MM) are the most common hematological malignancies which benefit from therapeutic monoclonal antibodies (mAbs)-based immunotherapies. Despite significant improvement on patient outcome following the use of novel therapies for the past decades, curative treatment is unavailable for the majority of patients. For example, the 5-year survival of MM is currently less than 50%. In the 1980s, interferon-α was used as monotherapy in newly diagnosed or previously treated MM with an overall response rate of 15-20%. Noticeably, a small subset of patients who responded to long-term interferon-α further achieved sustained complete remission. Since 1990, interferon-α-containing regimens have been used as a central maintenance strategy for patients with MM. However, the systemic administration of interferon-α was ultimately limited by its pronounced toxicity. To address this, the selective mAb-mediated delivery of interferon-α has been developed to enhance specific killing of MM and B-cell malignant cells. As such, targeted interferon-α therapy may improve therapeutic window and sustain responses, while further overcoming suppressive microenvironment. This review aims to reinforce the role of interferon-α by consolidating our current understanding of targeting interferon-α with tumor-specific mAbs for B cell lymphoma and myeloma.

Interferon induced thrombotic microangiopathy (TMA): Analysis and concise review

Interferon (IFN) has been associated with development of thrombotic microangiopathy including thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). We reviewed literature from the earliest reported association in 1993, to July 2016 and found 68 cases. Analysis of this data shows: (1) Mean age at diagnosis was 47 years (95% CI, 44-50). (2) Majority of cases were seen where IFN was used for the treatment of chronic myelogenous leukemia (CML), multiple sclerosis (MS), chronic hepatitis C virus infection (HCV) and one case each for hairy cell leukemia (HCL) and Sezary syndrome. (3) There were no cases reported for polycythemia vera (PV) or lymphoma. (4) Sex distribution was nearly equivalent with the exception in patients with multiple sclerosis where there was female predominance (12 of 16 with reported data). (5) For pooled analysis, the average duration of treatment with IFN before TMA was diagnosed was 40.4 months. (6) Comparative analysis showed that patients with MS required the highest cumulative dose exposure before developing TMA (MS 68.6 months, CML 35.5 months, HCV 30.4 months). (7) Cases of confirmed TTP (where A disintegrin and Metalloprotease with thrombospondin type 1 motif 13: ADAMTS 13 level was measured) showed presence of an inhibitor. (8) In all cases of confirmed TTP, moderate to severe thrombocytopenia was a striking clinical feature at presentation while this was not a consistent finding in all other cases of TMA. (9) Outcome analysis revealed complete remission in 27 (40%), persistent chronic kidney disease (CKD) in 28 (42%) and fatality in 12 patients (18%). (10) Treatment with corticosteroids, plasma exchange and rituximab resulted in durable responses.

Eyelash trichomegaly: review of congenital, acquired, and drug-associated etiologies for elongation of the eyelashes

Eyelash trichomegaly is defined as eyelashes which are found to be of increased length, thickness, and pigmentation. This unique finding can be present at birth as part of a variety of congenital syndromes or as a benign familial trait. There are also acquired conditions and drugs that are known to cause these changes. Case reports and clinical studies in the medical literature concerning eyelash trichomegaly were investigated and summarized to compile a comprehensive review of the etiology of eyelash trichomegaly. Previously published reviews and studies that report on the finding of increased generalized hair growth and which do not specifically mention eyelashes were not included. Trichomegaly of the eyelashes may occur as a key feature among rare congenital syndromes, develop in association with certain acquired diseases, or present as an intended or treatment-related adverse drug effect. Eyelash trichomegaly may be present from birth or manifest later in life in association with acquired diseases or drug therapy. The relevance of this finding may be benign, however eyelash trichomegaly in some individuals can be a symptom for immune dysfunction or a clinical measure of response to drug therapy.

CpG oligodeoxynucleotide-based therapy of lymphoid malignancies

Preclinical and early clinical trials indicate synthetic oligodeoxynucleotides containing unmethylated CG dinucleotides (CpG ODN) have potent immunostimulatory effects. CpG ODN are being explored as immune adjuvants in vaccination strategies and as potential treatments for a wide variety of disorders including cancer and asthma. Therapeutic approaches designed to take advantage of this potent class of agents are based largely on the ability of CpG ODN to activate professional antigen presenting cells (APCs) that express the target receptor - Toll-Like Receptor 9 (TLR9). B-cell malignancies are unique in that the malignant cells themselves express TLR9. CpG ODN can have a direct effect on the malignant B cells and lead to activation induced cell death. CpG ODN also alter the phenotype of target malignant B cells as indicated by upregulation of MHC, immunostimulatory molecules, and antigens that serve as targets for other approaches to lymphoma immunotherapy such as CD20. B cell malignancies are also relatively sensitive to the cytokines that are produced by dendritic cells in response to CpG ODN. Thus, B cell malignancies appear to be uniquely sensitive to CpG ODN because of both the direct and indirect effects the CpG ODN on target cells and the sensitivity of B cell malignancies to an immune response. Preclinical studies support further exploration of the potential of CpG ODN as a component of therapy for lymphoid malignancies. Ongoing clinical trials are exploring the potential of CpG ODN, both alone and in combination with other agents.

Pegylated interferon-induced eyelid and eyebrow trichomegaly during chronic hepatitis C

One of the most common skin and hair growth disorders related to interferon therapy is alopecia. Hypertrichosis has also been reported as a rare side-effect of interferon therapy, especially in eyelashes. Herein is reported a case of eyelid and eyebrow trichomegaly in a patient treated with pegylated interferon and ribavirin for chronic hepatitis C associated with porphyria cutanea tarda.

Activity of interferon-alpha and isotretinoin in patients with advanced, refractory lymphoid malignancies

BACKGROUND

Interferon-alpha (IFN-alpha) and retinoids have shown nonoverlapping toxicity and each has shown antitumor activity in patients with lymphoma. The aim of the current study was to assess the toxicity, safety, and efficacy of IFN-alpha combined with isotretinoin in patients with advanced, refractory lymphoid malignancies.

METHODS

Adults with biopsy-proven advanced lymphoid malignancy were treated. Patients with compromised bone marrow function (platelet counts as low as 30 x 10(9)/L) were eligible. Treatment was comprised of IFN-alpha at a starting daily dose of 3 mega units subcutaneously and isotretinoin orally starting at a dose of 1 mg/kg daily in 2 divided doses.

RESULTS

Forty-four patients were evaluable. Their median age was 57 years (range, 18-82 years). Eighteen patients had advanced cutaneous T-cell lymphoma, 6 patients had peripheral T-cell lymphoma, 14 patients had Hodgkin disease, and 6 patients had a variety of other lymphoid malignancies. Patients with Hodgkin disease had received a median of 6 previous therapies (range, 3-12 therapies) and patients with other lymphoid malignancies had received a median of 4 previous therapies (range, 1-9 therapies). The median duration of treatment was 4 months (range, 0.25-38 months). The overall response rate was 38.6% (complete response in 5 patients [11.3%] and partial response in 12 patients [27.3%]). The median response duration was 3 months (range, 1-95+ months). The most common toxicities were low-grade fever, flu-like symptoms, and fatigue (IFN-alpha effects); dry mouth and skin and hypertriglyceridemia (cis-retinoic acid effects); and thrombocytopenia (which generally occurred in patients with low baseline platelet counts).

CONCLUSIONS

IFN-alpha and isotretinoin combination therapy had antitumor activity and was well tolerated in heavily pretreated patients with lymphoid malignancies.

Cutaneous T-cell lymphoma. New immunomodulators

During the most recent decades, much knowledge has been gained concerning the immunologic and pathologic mechanisms of CTCL. The development of immunomodulators aimed at correcting aberrations in immunology and cellular growth and differentiation reflects this increased understanding. This review of the currently available immune-response modifying drugs shows that recombinant forms of natural cytokines and retinoids can be developed with tolerable toxicity profiles and substantial efficacy. Although milestone drugs such as bexarotene have been approved by the FDA- for treatment of CTCL, other agents such as IL-12 may also have a place in treatment of the disease. Even though unapproved, IFN-alpha may be the most active single immunomodulating agent against CTCL. It seems that further delineation of CTCL cytokine profile changes and immunologic aberrations are key in developing effective immunomodulators that are able to reverse these alterations.

T-cell lymphoma cell lines (HUT102 and HUT78) established at the National Cancer Institute: history and importance to understanding the biology, clinical features, and therapy of cutaneous T-cell lymphomas (CTCL) and adult T-cell leukemia-lymphomas (ATLL)

Efforts at the National Cancer Institute to generate continuous in vitro cultures from patients with mycosis fungoides and the Sezary syndrome, neoplasms with a mature T-helper phenotype, led to the establishment of two cell lines, HUT78 and HUT102. Further characterization of these cell lines led to the identification of the first human retrovirus, HTLV-1, in the HUT102 cells, and the clinical description of the syndrome of HTLV-1 associated acute T-cell leukemia/lymphoma; the serum antibody test to screen for this virus was developed from the serum of the patient from whom the cell line was derived. The HUT78 cell line was pivotal in the identification and characterization of the HIV retrovirus in that a subclone, H9, proved to be permissive for replication of HIV in vitro. Propagation of HIV in vitro in H9 cells allowed for the development of immunological reagents to screen blood supplies for the presence of the virus. Further biologic and molecular studies of these lines have led not only to a better understanding of the underlying diseases but also to the development of rational therapeutic approaches.

Perspectives of cytokine treatment in malignant skin tumors

Cytokines have been tested in the treatment of different skin cancers during the last decade, and treatment schedules have been established or proposed for several malignant skin tumors. Preferentially, the interferons and interleukin-2 were found to be effective in treating skin cancers. Interferons alpha and beta have been approved for the treatment of human immunodeficiency virus (HIV)-associated Kaposi's sarcoma, cutaneous T cell lymphoma, and malignant melanoma in several countries. Interferon alpha was found to be most effective in cutaneous T cell lymphoma with 40%-60% overall responses. When combining interferon alpha with psoralens and ultraviolet A (PUVA) or with retinoids, even higher response rates up to 60%-90% were reported, and long-term remissions have been described. A considerable activity of interferon alpha was found in HIV-associated Kaposi's sarcoma with response rates of 30%-50%. The effectiveness of Kaposi's sarcoma's treatment was further improved by combining interferon alpha and zidovudine. Responses to interferon alpha in metastatic malignant melanoma are rather seldom (10%-15%), but a stabilization of the disease with prolonged survival was reported after interferon alpha treatment. Additionally, interleukin-2 was found to be active in metastatic melanoma, with overall response rates of about 20%, and both biological agents were found to have an additive efficacy in combination. Several combined regimens of interferon alpha, interleukin-2, and polychemotherapy have been described in metastatic melanoma, and overall response rates higher than 50% were found with these combined treatment modalities. Interferon alpha and beta were also intralesionally injected into basal cell carcinomas and other epithelial skin cancers, and complete responses were found in more than 80% of tumors treated. Local applications of interferons and interleukin-2 were likewise found to be effective in the treatment of cutaneous melanoma metastases and cutaneous manifestations of Kaposi's sarcoma. Cytokines and their combination with other treatment modalities has greatly enriched the treatment facilities in malignant skin tumors during recent years, and additional new cytokines will be introduced in skin cancer treatment in near future.

Prognostic factors and survival in non-Hodgkin's lymphomas: the experience of the Istituto Oncologico Romagnolo (IOR)

In an attempt to evaluate natural history, prognostic factors and survival, the data of 340 patients with NHL were collected. 267 patients were evaluable for the analysis of prognostic factors and survival. The tumor samples were reviewed and reclassified according to the Kiel classification. At completion, 180 patients were affected by low-grade (LG)-NHL and 87 patients had high-grade (HG)-NHL. Numerous potential prognostic factors were analysed in univariate and multivariate analyses. Globally 154 patients (57.4%) obtained complete remission (CR) and 65 patients (24.3%) partial remission (PR). The response rate was similar in LG and HG-NHL groups. 5-years survival was 52% for all patients (53% in LG-NHL and 44% in HG-NHL). Median survival was 62 months in LG-NHL and 38 months in HG-NHL (p = n.s.). At the univariate analysis overall survival (OS) in LG-NHL was favourably influenced by age < 65 years (p = 0.004), performance status > 80 (p < 0.02), early clinical stage (p < 0.001), absence of systemic symptoms (p < 0.001), low serum LDH (p < 0.001) and achievement of CR (p < 0.001), while in the HG-NHL only by age (p = 0.005) and achievement of CR (p < 0.001). The multivariate analysis showed early clinical stage, low serum LDH, absence of systemic symptoms and achievement of CR as independent prognostic factors in LG-NHL and only achievement of CR in HG-NHL.(ABSTRACT TRUNCATED AT 250 WORDS)

The interferons in haematological malignancies

Interferons (IFNs) are a family of biological response modifiers with a broad spectrum of action on cellular proliferation as well as immunoregulation. In the last decade, these properties have prompted several investigations of the effect of IFNs on various haematological malignancies. IFNs-alpha have been used most extensively. The response rate is dependent on the type of the disease. The most striking effects have been observed in hairy cell leukaemia and chronic myeloid leukaemia. In both these malignancies the results are well consolidated and indicate that IFNs-alpha have modified the natural history of the disease. Results of IFN therapy in low grade lymphoma, cutaneous T-cell lymphoma and multiple myeloma suggest a beneficial role of IFNs-alpha in the induction, as well as the maintenance, phase. The efficacy of IFNs is now widely confirmed in treating patients with essential thrombocythaemia or polycythaemia vera. However, the role of IFNs in the management of chronic lymphocytic leukaemia and myelofibrosis with myeloid metaplasia is still controversial.

Serum levels of 2',5 oligoadenylate synthetase during interferon therapy in patients with B-cell chronic lymphocytic leukemia

We assayed 2',5 oligoadenylate synthetase (2'5-AS) activity in the serum of eight patients with B-cell chronic lymphocytic leukemia (B-CLL) who were undergoing therapy with alpha interferon (IFN). Mean pretreatment levels of 2'5-AS were normal, but upon treatment the levels rose to higher than normal values. Moreover, the degree of enzyme induction in serum was significantly higher in CLL responders (P < 0.003) whereas no difference was found in non-responders. The lack of serum 2'5-AS induction in non-responder patients might be related to unresponsiveness to treatment with IFN. These results seem to show that the measurement of serum levels of 2'5-AS activity may be a useful tool in monitoring IFN treatment.

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

BACKGROUND

Alpha interferon (IFN) is an effective single agent for patients with low-grade lymphoma, but until 1982 had not been integrated with standard chemotherapy for these patients. Since relapse from complete remission (CR) is the rule for patients with advanced stage low-grade lymphoma, a maintenance IFN schedule was explored for patients in CR.

PATIENTS AND METHODS

From 1982-1987, 127 patients with stage IV low-grade lymphoma were treated with cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-Bleo) for 9-18 mo. (median 13 mo.), followed by interferon alfa-n-1 (Wellferon) maintenance therapy for 24 mo. for CRs.

RESULTS

The overall response rate for the entire treatment program was 73% CR and 23% partial remission. The median follow up was 59 months. At 5 years, survival was 74%, failure-free survival (FFS) 47%, and FFS of CRs 60%. Compared to a group of 96 patients with similar pretreatment clinical features treated with CHOP-Bleo from 1972-1982, this represents a significant improvement for both overall FFS (p = 0.01) and FFS of CRs (P < 0.01). Toxicity from the IFN maintenance was generally acceptable, but even at the modest dose employed in this trial (3 x 10(6) U/m2 three times weekly), dose modification was required in more than 30% of patients, usually because of fatigue.

CONCLUSIONS

The integration of IFN and conventional chemotherapy is feasible and effective. Maintenance IFN prolongs remission duration for patients with stage IV low-grade lymphoma.

Continuous-infusion fluorodeoxyuridine with leucovorin and high-dose interferon: a phase II study in metastatic renal-cell cancer

A total of 25 patients with metastatic renal cancer were treated on a phase II protocol with 5 days of continuous-infusion fluorodeoxyuridine (FUDR), (0.1 mg/kg daily) together with high-dose oral leucovorin (100 mg 4 h) and daily x6 high-dose interferon-alpha 2b (30 x 10(6) IU/m2). Despite the good performance status of the patients and the inclusion of 14 previously untreated patients in the cohort, no response was observed among the 20 evaluable patients. Toxicities included high fever, moderate anemia, transient leukopenia, transient and mild elevations of transaminases, and moderate to severe nausea, vomiting, diarrhea, and mucositis. There were also two episodes each of confusion, fluid retention, and pancreatitis and one episode of increased creatinine levels. During the study three deaths occurred, two of which were possibly therapy-related. Despite previous reports of activity of FUDR in metastatic renal cancer, the present regimen cannot be recommended.

Interferon alpha in lymphoma

A number of studies are currently in progress to evaluate the use of interferon alpha, alone and in combination with conventional chemotherapy in patients with follicular lymphoma. The background to these is reviewed, together with currently available data about the potential role of interferon alpha in cutaneous T cell lymphoma.

Clinical evaluation of treatment with interferon

Interferons (IFNs) are biological response modifiers with antiviral and antitumoral efficacy. They are produced by almost all cells and the IFN system as a whole is an integrated part of body regulation and defence. Exogenous IFN therapy has been used since 1970 and some viral and tumor diseases respond to such therapy. Doses and schedules giving optimal effects are being worked out. IFNs are probably most valuable for the treatment of some chronic viral diseases and their effects on some benign and malignant tumors hold considerable promise for future improved applications.

Clinical effects of interferon therapy with special emphasis on antitumor efficacy

Both natural and recombinant interferons (IFNs) exert antitumor effects in man. Much work has to be done to construct optimal use of the IFN system. Its physiological role is not fully understood. Various IFN effects are described, all of which probably play a role for clinical effectiveness. Doses and schedules are discussed and pharmacokinetics and side-effects described. IFN therapy of benign and malignant tumor disease is pursued as clinical trials. Efficacy on various diseases is reported in the present article. Combination therapy is suggested for the future.