Non-Hodgkin's lymphoma in children

Should children with non-Hodgkin lymphoma be treated with different protocols according to histopathologic subtype?

BACKGROUND

The New York protocol, primarily developed to treat children with high-risk acute lymphoblastic leukemia (ALL), is characterized by early intensive chemotherapy followed by less intensive pulse chemotherapy during maintenance. This study was performed to evaluate the efficacy of this protocol in children with non-Hodgkin lymphoma (NHL), irrespective of histopathologic subtype.

PROCEDURE

From January 1996 to December 2011, 146 newly diagnosed children and adolescents with NHL were treated with the modified New York protocol. Treatment duration was determined according to the stage.

RESULTS

The 5-year failure-free survival (FFS), event-free survival (EFS), and overall survival (OS) rates were 86.7 ± 2.9%, 79.1 ± 3.5%, and 84.7 ± 3.1%, respectively. The 5-year FFS for patients with mature B-cell lymphoma, T-cell and NK-cell lymphoma (T/NK-cell lymphoma), and lymphoblastic lymphoma were 95.4 ± 2.6%, 76.1 ± 7.0%, and 82.1 ± 6.6%, respectively. In multivariate analysis, T/NK-cell lymphoma and non-complete response (non-CR) at the end of induction chemotherapy were associated with a significant increase in treatment failure rate (relative risk [RR], 4.5, P = 0.03, and RR, 5.0, P = 0.002).

CONCLUSION

The protocol appears to be efficacious in the treatment of children and adolescents with NHL, irrespective of histopathologic subtype. Achievement of CR after intensive induction chemotherapy was an important prognostic factor. Early response to treatment may be used to stratify risk groups and modify therapy in children with NHL.

Emerging non-transplant-based strategies in treating pediatric non-Hodgkin's lymphoma

Lymphomas represent the third most common cancer in children and adolescents. The non-Hodgkin's lymphomas comprise a heterogeneous group of tumors, with distinct clinical and pathologic features. Although intensive multi-agent chemotherapy has made non-Hodgkin's lymphoma one of the most curable malignancies in children and young adults, there is room for improvement in treatment, particularly for those with advanced-stage disease and those who relapse after conventional therapy. New approaches are now attempting to reduce the burden of treatment, to focus on novel and more specific biologic targets, and to improve outcomes for patients with advanced-stage disease while reducing the potential for late effects. A comprehensive review of all potential agents is beyond the scope of this review, which will focus on some of the newer strategies for treating non-Hodgkin's lymphoma that are coming into clinical use today.

Non-Hodgkin's lymphoma in children and adolescents

Lymphoma is the third most common cancer in children and adolescents. Non-Hodgkin's lymphomas comprise a heterogeneous group of tumors with distinct pathologic and clinical characteristics. Over the past three decades, significant advancements have been made in the molecular characterization of these disorders. With the use of intensive multiagent chemotherapy, non-Hodgkin's lymphomas are now among the most successfully treated cancers in the pediatric population. Future goals of therapy include reduction of treatment duration for early-stage patients and identification of novel targets and therapeutics for advanced-stage patients.

Advances in therapy for childhood non-B-lymphoblastic leukaemia

The majority of therapeutic gains for patients with ALL have come from prospectively planned clinical trials. Beginning in the 1970s, series of well-designed protocols have produced valuable information that has permitted the development of curative therapy for more than two-thirds of patients. This success emphasizes the importance of controlled, carefully analysed therapeutic studies, which pay dividends for many years by providing a sound basis for future developments. Experienced biostatisticians should be involved early in the development of clinical trials to ensure that research questions can be reliably answered in terms of the size and composition of the patient sample and in terms of accrual time. Despite extensive pre-planning, a protocol may require early termination due to unexpected results that compromise the integrity of the initial design (Rivera et al, 1985). Thus, periodic treatment assessment of the trial is crucial to a successful outcome. Extended follow-up of patients is a requirement in every leukaemia study since relapses may occur many years after diagnosis, especially if patients have a lower risk of treatment failure (Rivera et al, 1979). The quality of long-term survival must also be well documented because all protocols include toxic therapy (Ochs and Mulhern 1988). Every physician treating children with ALL would like to select therapy that is both effective and well tolerated. Unfortunately, this is not always possible when patients have high-risk features. Secondary AML, deaths in remission and fatal organ toxicity (Steinherz, 1991c) are equally devastating complications of current chemotherapy for ALL, and no single protocol can be recommended over any other. Patients with ALL may be equally well served by any of several different protocols. The practice of administering 6MP + MTX alone and usually orally as continuation treatment has been virtually abandoned. Today, most children receive intensified chemotherapy in one schedule or another, including good-risk patients on POG protocols who, although treated largely with antimetabolite-based programmes, receive high-dose chemotherapy during the initial 6 months of treatment. In view of the more favourable results attained with reinduction therapy in recent CCG studies, these investigators also recommend such an approach for children with better-risk ALL. We fully agree. Regrettably, with the success of current regimens for higher-risk ALL, it has not been possible to exclude all toxic agents that may induce serious late complications.(ABSTRACT TRUNCATED AT 400 WORDS)

Optimal therapy for small noncleaved cell lymphoma

Small noncleaved cell lymphoma is now well recognized as a specific subtype of non-Hodgkin's lymphoma with distinctive clinicopathologic characteristics. Initial treatment results in children with endemic Burkitt's lymphoma also indicated a unique sensitivity to cytotoxic chemotherapy; to this day, Burkitt's lymphoma remains one of the few human tumors potentially curable with single-agent chemotherapy. However, the development of effective therapy has proved more difficult in nonendemic SNCL, where presentation with advanced stage and large tumor bulk occurs in most patients. The combination chemotherapy regimens currently considered standard for treatment of large-cell lymphoma have usually produced only transient responses in patients (both children and adult) with SNCL. Recently, several regimens of increased dose intensity have yielded encouraging results both in children and adults. High complete response rates and long-term disease-free survival rates in the 60% range have been reported from several institutions using such regimens. At present, we feel that adults without severe coexisting problems should be treated with high dose-intensity regimens, such as those developed at MD Anderson and Vanderbilt. Routine treatment of these patients with standard lymphoma regimens should be avoided, since the cure rate with this approach has been low. Curative therapy for these patients can be of brief duration, and maintenance therapy is not necessary. Although guidelines are unclear, it seems reasonable at present to include meningeal prophylaxis in the treatment of Stage III and IV patients. Since dose intensity has emerged as an important factor in the curative therapy of SNCL, further exploration of this concept in future clinical trials is critical. The role of growth factors is undefined; if the frequently espoused possibility that growth factors can increase curability by allowing intensification of therapy is to be realized in any human tumor, SNCL leads the list of candidates. The role of early high-dose therapy with bone marrow transplantation is also largely unexplored in SNCL. At the other end of the spectrum, the possibility of administering lesser therapy while maintaining a high cure rate in patients with clinical Stage I SNCL needs further investigation. It is likely that continued clinical investigation will continue to improve therapeutic results in this uncommon but highly distinctive lymphoma.

Results of the LMT81 protocol, a modified LSA2L2 protocol with high dose methotrexate, on 84 children with non-B-cell (lymphoblastic) lymphoma

From May 1981 to June 1989, 84 children with non-B-cell lymphoma (82 lymphoblastic, 1 T-cell immunoblastic, 1 unclassified diffuse lymphoma) were treated in the pediatric department of the Institut Gustave Roussy according to a protocol called LMT81, which was derived from the LSA2L2 protocol of Wollner and modified by the adjunction of 10 courses of high dose methotrexate to improve the CNS prophylaxis. No planned irradiation was performed except in cases of initial tests (2 patients) or CNS (5 patients) involvement and residual mass (2 patients). Sixty patients had mediastinal involvement; for the others, primaries were in the head and neck (7), nodes (2), (sub)cutaneous (4), bone (7), and elsewhere (2). According to Murphy's staging system, there were 2 stage I, 6 stage II, 33 stage III, and 43 stage IV. Among the stage IV patients, 41 had bone marrow involvement, 24 of them with more than 25% blast cells in bone marrow and 19 with blast cells in blood; 7 had CNS involvement. Three patients did not achieve complete remission, 4 died in remission (two measles, one post-transfusion AIDS, one unexplained definitive aplasia) and 13 relapsed at 2 to 29 months (median-13 months). Among the 77 patients without initial CNS involvement, there was only one isolated CNS relapse. With a median follow-up of 57 months (10-106 months), the event-free survival is 75% (SE 2.5) for the 84 patients with a plateau at 29 months, 73% (SE 8) for stage I and II patients, 79% (SE 4) for stage III, and 72% (SE 4) for stage IV patients. Survival was similar in each stage group. Reasons for failure of treatment, however, were different, being toxic deaths in stage II; initial therapy resistance, early relapses, and toxic deaths in stage III; and tumor failures in stage IV. In conclusion, this protocol is efficacious on T and non-T, non-B childhood lymphoma with a low incidence of CNS relapse. A future study will seek to diminish toxicity and long-term sequellae while at least maintaining the same cure rate of patients.

Ovarian tumors in relapsing acute lymphoblastic leukemia: a review of 23 cases

Five cases of relapsing acute lymphocytic leukemia (ALL) presenting as an ovarian tumor have been treated at this institution, representing the largest reported series. In a review of the literature we identified 18 additional cases of ovarian leukemic relapse. Together, these 23 patients form the basis for this report. Abdominal pain is the most common presenting symptom of ovarian leukemia. An abdominal mass is usually palpable, and at least four patients had hydronephrosis. Nine patients had documented bilateral ovarian involvement; however, bilateral disease was not a poor prognostic sign. Most ovarian relapses occurred more than 36 months after the original diagnosis of ALL, with these "late'h relapsers responding more favorably to treatment than "early" relapsers. Definitive statements can not be made from a retrospective review of 23 case reports; however, salpingooophorectomy had no obvious advantage over simple biopsy, and there was no obvious advantage to the routine use of radiation therapy. Most failures in treating ovarian leukemia occurred within 2 years. Most failures were systemic rather than local, illustrating the need for aggressive multiagent systemic chemotherapy. Survival after ovarian leukemic relapse is possible, with eight of the 23 patients alive and in complete continuous remission following the ovarian relapse (median follow-up since relapse, 42 months; range, 2 to 135+ months). With the use of more intensive chemotherapy in recent protocols, the frequency of ovarian leukemic relapses appears to be decreasing. At this institution, no child with ALL diagnosed in the 1980s has subsequently developed an ovarian relapse.

Characterization of a new malignant human T-cell line (PFI-285) sensitive to ascorbic acid

A new malignant human T-cell line-labelled PFI-285-has been isolated from a boy with malignant lymphoma. Morphologically, the cells had characteristics of malignant lymphoid cells. The cells presented surface antigens as early cortical lymphocytes and proliferated non-adherently as single cells, independent of T-cell growth factor (IL-2), in liquid culture. The cells had undetectable levels of receptors for IL-2, were not clonogenic in soft agar, but did form tumors in nude mice. Their establishment and continuous growth in vitro was dependent on the number of cells inoculated and on the growth medium used. Cytogenetic alteration, HTLV-1 or reverse transcriptase activity were not detected. The production of known T-cell derived lymphokines such as IL-2, B-cell growth factor(s), alpha-interferon or granulocyte/macrophage colony stimulating or inhibiting factor(s) was not detected. The cells had 5-8% natural killer (NK)-cell activity against NK-cell sensitive target cells (K562) and were not sensitive for NK cells. A most unusual characteristic was the pronounced sensitivity of the cells to ascorbic acid. Concentrations down to 50 mumol/l killed the cells within hours.

Childhood lymphoma. A clinicopathological and immunohistological study of 58 cases

Fifty-eight cases diagnosed as malignant lymphoma in patients younger than 15 years between 1976 and 1986 in the Kanto area were reviewed and reclassified as follow: 48 non-Hodgkin's lymphomas, 9 Hodgkin's disease and one malignant histiocytosis. Lymphoblastic type consisted of 26 cases or 54.2%; large cell type, 11 cases or 22.9%; Burkitt's type, 7 cases or 14.5%; medium-sized cell type and mixed cell type consisted of 4 cases. There was no follicular lymphoma case. A rare sclerosing mediastinal lymphoblastic lymphoma and diffuse large cell lymphomas with T-zone involvement as well as primary epidural Burkitt's lymphomas were found. Immunohistochemical studies using paraffin sections were performed in 43 non-Hodgkin's lymphomas and phenotypes of 37 cases were determined as follows; T cell origin in 24, B cell origin in 11 and non-T non-B in 2 cases. Of 25 lymphoblastic lymphomas, LCA was positive only in 11 cases. Reed-Sternberg cells and their variants of Hodgkin's disease reacted with anti-Leu M1 antibody in 3 of 8 examined but not with EMA antibody. This study revealed that the survival was related to sites of the primary lesion, regardless of histological type and immunologic phenotypes.

Is cranial radiation necessary for CNS prophylaxis in pediatric NHL?

The records of 95 consecutive children less than or equal to 21 years of age with previously untreated diffuse histology NHL registered in our protocols from 1978 to 1983 were reviewed. Seventy-nine patients were considered eligible for analysis. The histologic subtypes represented included lymphoblastic (LB) 37%; histiocytic (DHL) 29%; undifferentiated (DU) 19%; poorly differentiated (DPDL) 9%; and unclassified (UNHL) 6%. Distribution of the patients according to stage showed Stage I, 0%; Stage II, 11%; Stage III, 53%; Stage IV, 36%. Four different Memorial Hospital protocols for systemic chemotherapy were used (LSA2L2 73%; L10 9%; L17 10%; L17M 8%); however, the IT (intrathecal) chemotherapy was uniform (Methotrexate: 6.0-6.25 mg/M2 per treatment course) and was included in the induction, consolidation, and maintenance phases of all treatment protocols. Cranial radiation was included in the induction, consolidation, and maintenance phases of all treatment protocols. Cranial radiation was not included in the CNS prophylaxis program. The overall median time of follow-up was 43 months. The overall CNS relapse rate was 6.3%, however, the incidence of CNS lymphoma presenting as the first isolated site of relapse in patients in otherwise complete remission (minimum follow-up of 19 months with 97% of patients off treatment) was only 1/58 (1.7%). Our data suggests that IT chemotherapy when given in combination with modern aggressive systemic combination chemotherapy, and without cranial radiation appears to be a highly effective modality for CNS prophylaxis regardless of stage, histology, or bone marrow or mediastinal involvement. Therefore, with the commonly used aggressive combination chemotherapy for the management of all stage diffuse pediatric NHL, and the known increased risk of leukoencephalopathy with combination of cranial radiation and intensive systemic and intrathecal chemotherapy, we believe that cranial radiation may not be indicated for CNS prophylaxis in pediatric NHL.

Bone marrow transplantation in lymphomatoid granulomatosis. Report of a case

Lymphomatoid granulomatosis is an unusual disorder histologically characterized by an angiocentric, angiodestructive mixed cellular infiltrate. The most frequent clinical manifestations are seen in the lungs, the skin, and the central nervous system. Progression to lymphoma may occur, particularly in patients who are anergic. The authors report the case of a boy who had had a splenectomy at 2 years of age for presumed Evan's syndrome, and two episodes of pneumococcal meningitis at 5 and 10 years of age. At 14 years, he had severe respiratory compromise, and a lung biopsy specimen showed lymphomatoid granulomatosis. The liver and bone marrow also were affected. Improvement occurred with multiagent chemotherapy, but he had multiple relapses. A bone marrow transplant was performed using a human leukocyte antigen (HLA) identical mixed lymphocyte culture (MLC) nonreactive brother as the donor. He remains in remission more than 3 years post-transplant. In addition, his abnormal immune function has improved.

Secretory antibodies in IgA-deficient and immunosuppressed individuals

Total levels of IgM and secretory IgM as well as specific antibodies to poliovirus type I antigen, Escherichia coli O antigens, and beta-lactoglobulin were measured in unstimulated and stimulated saliva as well as nasal secretion using an enzyme-linked immunosorbent assay (ELISA). The levels of these antibodies in IgA-deficient adults with and without frequent respiratory infections and children under immunosuppressive therapy for malignant disease were compared to those in normal adults and infants 1-7 months of age. The IgA-deficient adults had significantly higher IgM levels (P less than 0.002) than the normal adults as well as higher levels of IgM antibodies to poliovirus type I (P less than 0.05) and E. coli O antigen (P less than 0.002). There was a less pronounced IgM anti-beta-lactoglobulin compensation. Secretory component (SC)-carrying antibodies against all three antigens were lower than in normal adults. The infants studied had levels of IgM in secretions close to those of the normal adults and significantly lower than those of the IgA-deficient adults (P less than 0.001) but with a higher proportion of SC-carrying IgM. The increase in total IgM and specific bacterial and viral IgM antibodies in saliva above that of the normal adults was significant (P less than 0.001-0.005) for those IgA-deficient individuals without, but not for those with, frequent infections. There was, however, no significant difference between the levels in the two groups of IgA-deficient adults.(ABSTRACT TRUNCATED AT 250 WORDS)

Stage IV non-Hodgkin's lymphoma in children

Twenty-five children with previously untreated stage IV non-Hodgkin's lymphoma (NHL) were studied. At the time of evaluation 16 patients were disease-free (64%), with a median observation time of 23 months. Intensive chemotherapy for childhood NHL provides a better outlook for these patients, including those who would be considered high-risk acute lymphoblastic leukemia (ALL).

Bowel perforation during initial treatment for childhood non-Hodgkin's lymphoma

In the last 5 years we have seen six cases of bowel perforation during initial therapy for childhood non-Hodgkin's lymphoma (NHL). Perforation occurred only in patients with Stage III or IV disease. It occurred in patients without clinically detectable mural disease of bowel. Children who suffered bowel perforation had a worse outcome than those who did not, but two of the six patients described have gone on to long-term disease-free survival more than 2 years from completion of their treatment.

Pediatric Oncology Group experience with modified LSA2-L2 therapy in 107 children with non-Hodgkin's lymphoma (Burkitt's lymphoma excluded)

From September 1976 to August 1979 the Pediatric Oncology Group accessed 145 children to study the effectiveness of modified LSA2-L2 therapy for the treatment of non-Hodgkin's lymphoma (NHL). Burkitt's lymphoma patients were ineligible; E-rosette-positive patients with greater than or equal to 25% blasts in the marrow entered after February 1977 were reported separately. Radiotherapy could be used to treat patients with compressive mediastinal disease at diagnosis and was prescribed for those with residual abdominal disease as demonstrated by second-look surgery on completion of induction chemotherapy. Confirmation of diagnosis by the Pathology Panel and Repository Center for Lymphoma Clinical Trials was mandatory. Diagnostic tissues of 131 patients were reviewed. Among 107 evaluable patients, 91 (85%) achieved complete remission. Differences in response rates among the three major histologic groups (lymphoblastic, undifferentiated, and large cell) were of statistical significance, with response being poorest for diffuse undifferentiated lymphoma (P = 0.03). Failure-free survival did not differ significantly for the three major histologic diagnoses. While response rate was lowest for Murphy Stage III patients (79%), the differences among the stages were not significant. Stage was not a significant prognostic factor for failure-free survival (P = 0.08). The number of patients still at risk and the Kaplan-Meier estimate of percentage of patients remaining at risk after 3 years is: Stage I, 8 (100%); Stage II, 10 (67%); Stage III, 28 (57%); Stage IV, 6 (39%); and greater than 25% blasts, 1 (13%). Stage III failure curves for lymphoblastic disease show continuing stepwise failure through 3 years. Among patients with diffuse large cell and undifferentiated disease, most failures occurred by 8 months. M1 and M2 levels of marrow involvement were not prognostic among children with lymphoblastic disease. The presence of a mediastinal mass was a significant factor contributing to failure in children with lymphoblastic disease without marrow involvement. Leucocytosis greater than 10,000/1, was a significant (P = less than 0.001) factor predicting failure-free survival for patients with large cell lymphoma. The delivery of radiotherapy was not a significant factor in achieving remission. No consistent benefit resulted from using radiotherapy to treat postinduction residual disease demonstrated on second-look exploration. The LSA2-L2 regimen was associated with considerable toxicity, severe or worse in 77% and life-threatening to 40% of these patients. Four died of toxicity. However, therapy was given more easily and safely as investigator experience increased.(ABSTRACT TRUNCATED AT 400 WORDS)

Malignant lymphoma in unusual areas of the head and neck: parapharyngeal space and temporal fossa

Primary malignant lymphomas of the parapharyngeal space are rare and only 28 cases are known to have been reported. No case of malignant lymphoma arising in the temporal fossa has been previously documented. The present paper reports a case of primary non-Hodgkin's lymphoma of the parapharyngeal space in a child and two cases of lymphoma of the temporal fossa in adults. All three cases were diagnosed histopathologically from biopsy specimens as diffuse, B-cell lymphomas. For diagnosis, inspection and bimanual palpation were most important in the parapharyngeal case and the temporal cases required more than one biopsy for the final diagnosis.

Studies on the pathology of non-Hodgkin's lymphoma of childhood. I. The role of routine histopathology as a prognostic factor. A report from the Children's Cancer Study Group

Between April 1977, and August 1980, the Children's Cancer Study Group (CCSG) conducted a clinical trial of childhood non-Hodgkin's lymphoma (NHL), randomizing 256 patients to one of two treatment regimens. A 4-drug regimen (regimen 1, modified cyclophosphamide, Oncorin [vincristine], methotrexate, prednisone [COMP] ) was compared with a 10-drug regimen (regimen 2, modified LSA2-L2). Using the Rappaport classification, the review pathologist diagnosed the 213 evaluable tissue specimens as follows: lymphoblastic (LC), 73; Burkitt's tumor (BT), 40; "undifferentiated" non-Burkitt's type (NB), 67; large cell or "histiocytic" lymphoma (HI), 29; and other types (OT), 4. Concurrence in classification between the review and institutional pathologists was poor when using the above four categories; however, concurrence was 88% between the review pathologist and other hematopathologists, and 99% when classifying the specimens as lymphoblastic or nonlymphoblastic. For patients with nonlocalized disease, this randomized controlled study demonstrated a new important correlation of histopathology with the effectiveness of treatment. When analyzed without stratification into lymphoblastic and nonlymphoblastic types, the two regimens showed identical relapse free survival (RFS) curves for patients with nonlocalized involvement. However, when patients were stratified according to histologic classification, regimen 2 was superior to regimen 1 for patients with lymphoblastic lymphoma, achieving 74% RFS at 30 months compared to 31% for regimen 1 (P = 0.001). Conversely, those with nonlymphoblastic types (BT, NB, HI) treated with regimen 1 had a 58% RFS at 30 months compared to 32% for those treated on regimen 2 (P = 0.01). This study demonstrates that proper, routine histopathologic classification of NHL is the best criterion for choice of therapy in children with nonlocalized involvement. As a result of this study, all patients with nonlocalized disease, diagnosed after August 1980, were no longer randomized but were assigned to the appropriate treatment regimen based on prospective review of histopathology.

LSA2-L2 protocol treatment of stage IV non-Hodgkin's lymphoma in children with partial and extensive bone marrow involvement

Forty-one previously untreated children with Stage IV non-Hodgkin's lymphoma were studied from January 1971 to April 1979. All patients had bulky disease histologically proven to be non-Hodgkin's lymphoma with bone marrow involvement. They were separated into two groups according to the extent of bone marrow involvement. Group IVA included 14 patients with 25% or less lymphoblasts in the bone marrow. Group IVB included 27 patients with more than 25% blasts in the marrow. Their clinical characteristics with regard to age, sex, hemogram, histology, primary site, and blast morphology are compared. All were treated with the LSA2-L2 protocol with radiation therapy to one or more bulky sites of involvement. The disease-free actuarial survival for Group IVA was 64% with a median observation time of 49 months while that for Group IVB was 65% with a median observation time of 66 months. There was no statistical difference in the survival rates between the two groups. Hence, we conclude that the extent of bone marrow involvement does not affect the prognosis in Stage IV non-Hodgkin's lymphoma. It appears that radiation therapy may have contributed to the improved survival in our series. Furthermore, a subset of patients in Group IVB (24/27) who could be considered as high-risk acute lymphoblastic leukemia on the basis of age, initial leukocyte count, hemoglobin, mediastinal mass or T- or B-cell markers showed an improved survival (73% versus 43%) when compared to patients treated with conventional leukemia regimens.

Comparison of morbidity in children requiring abdominal radiation and chemotherapy, with and without total parenteral nutrition

We evaluated the effectiveness of total parenteral nutrition and placing the "bowel at rest," as compared to that of ad libitum food intake, on nutritional status and tolerance to combined chemotherapy and radiotherapy in a randomized, prospective trial in children with previously untreated malignancy requiring abdominal and pelvic irradiation and chemotherapy. Administration of TPN was found to be safe and efficacious in maintaining the children in good nutritional status during combined therapy; one-third of the control patients became malnourished and required TPN. There was no beneficial effect of "bowel at rest" and TPN on the ability of patients to tolerate combined therapies in terms of decreased toxicity; however, use of TPN was associated with improved adherence to chemotherapy schedules. Following termination of TPN or ad libitum food intake, and while receiving chemotherapy, the majority of the children who had previously received TPN lost significant weight. To date there has been no difference in mortality rate between the control and TPN groups. Although we conclude that TPN per se had little beneficial effect beyond that of maintaining good nutritional status, every child undergoing intensive combined therapy should have early and periodic assessments of nutritional status, so that the early signs of malnutrition can be detected, and the adverse effects of malnutrition can be prevented by nutritional replenishment, by TPN, or by other methods.

Childhood non-Hodgkin's lymphoma: long-term results of an intensive chemotherapy regimen

Twenty-nine consecutive children with untreated non-Hodgkin's malignant lymphoma were admitted to Istituto Nazionale Tumori of Milan during the period from 1974 through 1976 and underwent treatment with chemotherapeutic regimens consisting of Adriamycin, Cytoxan, vincristine, and prednisone (two month induction phase) and 6-mercaptopurine, methotrexate, Adriamycin, vincristine, and prednisone (maintenance phase). Each patient, regardless of clinical stage of histologic subgroup, was given the same chemotherapy. The complete response rate was 66%. Due to the high incidence of recurrence of the initial bulky lymphomatous mass and of spread to the central nervous system (CNS), local radiotherapy was given to ten children and CNS prophylaxis (brain radiotherapy + intrathecal methotrexate) to 11 children. After a follow-up period in excess of 40 months, there were five disease-free survivors (17%). Each patient who had a relapse died from the disease. The main reason for first treatment failure was relapse at the level of the primary bulky tumor site or spread to the CNS. This type of CNS prophylaxis did not prevent relapse at this site.

Acute myeloblastic leukemia following non-Hodgkin lymphoma in an adolescent. A report of a case with preleukemic syndrome, and review of the literature

Reports of acute nonlymphoblastic leukemia occurring after successful treatment of Hodgkin and non-Hodgkin lymphoma (NHL) are appearing with increasing frequency. Two years after completion of LSA2-L2 therapy for stage III, poorly differentiated lymphocytic lymphoma, a 16-year-old boy developed a preleukemic state characterized by a refractory macrocytic anemia with excess blasts, dyshematopoiesis, abnormal cluster:colony ratio on in vitro bone marrow culture, and acquired deficiencies of erythrocyte pyruvate kinase, triose phosphate isomerase, and adenylate kinase. Four months later acute myeloblastic leukemia was evident. The RNA index determined by flow cytofluorometry was increased. Four marker chromosomes were found and involved complex translocation of chromosomes 11 and 17 (t11;l17) in 100% of the cells, and chromosomes 4 (t4q;4) in 10% of the cells. A thorough literature search uncovered four other reports of acute nonlymphoblastic leukemia occurring in children treated for NHL and a total of 58 cases in the adult and pediatric age groups. Over 50% of the patients had AML, were mean over 50 years of age, and were treated with radiotherapy and chemotherapy. It is anticipated that additional cases of second malignancies will be reported in this population of patients whose outlook for the curability of the primary malignancy is 75%.

Primary malignant tumors of the stomach in children

Primary malignant tumors of the stomach are rare in children. During the years 1952--1977, eight children were seen at Childrens Hospital of Los Angeles with primary malignant tumors of the stomach. The patients were between the ages of 20 mo and 17 hr and included 5 males and 3 females. The series consisted of 3 malignant lymphomas, 2 adenocarcinomas, 2 leiomyosarcomas, and 1 rhabdomyosarcoma of the stomach. Three patients are living and five are dead. Clinical histories, treatment and pathologic findings are described along with a review of the literature and recommendations for the management of primary gastric malignancies in children.

Improved prognosis in children with intra-abdominal non-Hodgkin's lymphoma following LSA2L2 protocol chemotherapy

Thirty-five consecutive, previously untreated patients with intra-abdominal non-Hodgkin's lymphoma (IANHL), seen between January 1971 and June 1978, were entered on the LSA2-L2 protocol. Six patients had Stage II disease, 23 Stage III and six Stage IV. The prevalent histologic types were diffuse lymphocytic poorly differentiated (13 patients) and diffuse undifferentiated (13 patients) followed by diffuse histiocytic (5 patients) and diffuse lymphoblastic (2 patients). All patients received LSA2-L2 protocol chemotherapy. Three of 4 patients with gross residual disease following initial surgery, who were seen prior to 1974, received radiation therapy during induction chemotherapy; there were no survivors among these 3 patients. Our treatment plan was revised in 1974 to include a "second-look" laparotomy during the third week of induction chemotherapy for all patients with gross residual intra-abdominal disease following their initial surgery. The disease-free actuarial survival for the total group of 35 patients is 72%. Fifteen of the 26 surviving patients are off therapy and have shown no evidence of recurrence or metastases (median observation time 26 + months). Fifteen of 26 patients seen after 1973 underwent the second laparotomy and only two were found to have residual disease. The LSA2-L2 protocol has significantly improved the disease-free survival rate of children with IANHL, even with widespread intra-abdominal and extra-abdominal disease at diagnosis. Further, the "second-look" laparotomy in patients with large unresectable disease at presentation has proved a useful method of unequivocal evaluation of response, thus eliminating unnecessary extensive abdominal irradiation in many of these children.

Non-Hodgkin's lymphoma in children: a progress report on the original patients treated with the LSA2-L2 protocol

This report is a follow-up of the initial group of 39 children with non-Hodgkin's lymphoma treated with the LSA2-L2 protocol as previously reported in Cancer (37:123--134, 1976). The disease-free actuarial survival is 73%. All surviving patients are off therapy and have shown no evidence of recurrence with a median observation time of 70+ months. Their survival times range from 56+ to 88+ months from diagnosis. An analysis of successes and failures is discussed and modifications in the role of radiation therapy and surgery in the multidisciplinary management of children with non-Hodgkin's lymphoma are advocated. The results in the present series indicate that the LSA2-L2 protocol has substantially improved the prognosis for children with non-Hodgkin's lymphoma. We have concluded that age, sex, primary site (perhaps with the exception of primary skeletal), and histology are not of prognostic significance. The amount of bulky widespread disease at initial presentation, early and aggressive therapy, and the achievement of a complete remission status within 1--2 months from onset of therapy are the most important prognostic factors.

Childhood non-Hodgkin Malignant lymphomas: a clinicopathologic retrospective study

Between 1968 and 1975, 44 evaluable children under 16 years of age with the histologic diagnosis of non-Hodgkin malignant lymphoma (ML) were treated at the Istituto Nazionale Tumori of Milan. Histologic diagnoses were reclassified as follows: 13 lymphoblastic (others) ML, 15 convoluted cell type lymphoblastic ML, 9 Burkitt type ML, and 7 immunoblastic ML. Only 36% of the patients had stage I and II disease. At diagnosis 25% showed malignant cells in the bone marrow smears. Bone marrow infiltration was particularly frequent in the convoluted cell type lymphoblastic ML and in the lymphoblastic (others) ML subgroups. Burkitt type ML frequently was associated with abdominal lesions and subsequently a high incidence of central nervous system involvement. Patients with stage I and II ML were encountered mostly in the immunoblastic ML subgroup. After 1973 more intensive chemotherapy plus radiotherapy seems to have slightly improved the survival of the patients, except in the Burkitt type ML Subgroup.

Childhood leukemia and lymphoma: correlation of clinical features with immunological and morphological studies

Malignant cells from 49 children with lymphoid neoplasms other than Hodgkin disease were evaluated by surface marker and morphologic studies. We classified the patients into three groups: 36 patients (74%) with acute lymphocytic leukemia; 7 (14%) classified as convoluted lymphocytic lymphoma/leukemia; and 6 (12%) with small noncleaved follicular center cell lymphoma/leukemia. Diffuse marrow involvement was present at diagnosis in some patients in the latter two groups, but their clinical course was not characteristic of the patients with acute lymphocytic leukemia. Male predominance, poor prognosis, and high incidence of central nervous system disease characterized patients in the convoluted lymphocytic and follicular center cell lymphoma/leukemia groups. Clinical presentation in these two groups differed. Proliferations of convoluted lymphocytes were associated with mediastinal masses and proliferations of follicular center cells with intraabdominal tumors. The high incidence of CNS disease in children with neoplasms of convoluted lymphocytes and follicular center cells suggests that these processes have a predilection for the CNS and that patients with them may benefit from CNS prophylaxis.

The role of radiation therapy in the treatment of pediatric non-Hodgkin's lymphomas

Between 1971 and 1976, 64 patients less than 18 years of age with non-Hodgkin's lymphoma were treated at Boston's Children's Hospital Medical Center-Joint Center for Radiation Therapy. A multimodality approach was used, consisting of radiation therapy (3500--4500 rad), surgery, and chemotherapy. Since 1973, all patients have received a regimen initially comprising Adriamycin, Prednisone, 6-Mercaptopurine, Vincristine, and L-Asparaginase. Methotrexate was substituted for Adriamycin following a cumulative total dose of 450 mg/m2. The 5-year actuarial survival for all patients was 61% while relapse-free survival was 54%. The actuarial and relapse-free survival for patients presenting with localized disease was 75% and 72%, respectively. Median follow-up was 40 months and all relapses occurred within 24 months of initial therapy. A multidisicplinary approach, such as the current regimen, offers a good prognosis for this disease.

Primary lymphosarcoma of the larynx in a child

A 4 7/12-year-old Caucasian female with a history of "croup-like symptoms" and persistent airway obstruction, was found to have a primary lymphosarcoma by biopsy at the time of laryngoscopy and bronchoscopy. No metastatic disease was found. After an induction course of vincristine, prednisone and local irradiation, she received CNS prophylaxis with intrathecal methotrexate and cranial irradiation. Maintenance therapy, administered over a 2 3/4 year period, consisted of cyclophosphamide, methotrexate, and 6-mercaptopurine. Excluding the diagnostic evaluation, she was hospitalized only once for the management of suspected sepsis, gastrointestinal ulceration and severe bone marrow depression. Since discontinuing treatment 27 months ago, she has remained free of disease.

Non-Hodgkin's lymphoma in children: an analysis of 122 cases from Argentina

One hundred twenty two children with non-Hodgkin's lymphoma were studied from January 1966 to December 1975. The first group (1966-1972) did not receive an uniform treatment. The second group (1973-1975) entered in a G.A.T.L.A. protocol consisting of: vincristine-prednisone plus surgery and/or radiotherapy as induction treatment, craniocervical radiotherapy and intrathecal methotrexate as CNS preventive treatment and anti-leukemia (6-mercaptopurine, methotrexate and vincristine-prednisone pulses) or anti-lymphoma (COPP) treatment as maintenance, in a randomized trial. Comparison of survival of the two groups are as follows: series 1966-1972, 22% and 20% at 12 and 24 months of evolution, respectively, and series 1973-1975, 33% and 26% at 12 and 24 months, respectively. After 2 years of complete remission we have not seen any relapse. We conclude that 1) this disease is highly malignant and must be treated with more intensive chemotherapeutic treatment, and 2) there is no difference between antileukemia or anti-lymphoma maintenance treatment, as yet.

The team approach to the management of pediatric cancer

The last 20 years have witnessed remarkable improvements in the prognosis of children with many forms of malignant disease. The reasons for these improvements relate not only to the development of better drugs and more effective radiotherapy, but also to the multidisciplinary approach involving surgeon, chemotherapist, radiotherapist and immunotherapist in providing optimum treatment for the child with a particular cancer. In this paper, the changing role of the pediatric oncologist, surgeon and radiotherapist in improving the management of pediatric cancer is discussed.

Staging in childhood non-Hodgkin's lymphoma. What are its benefits? How extensive should it be?

A review of published reports of the management of childhood non-Hodgkin's lymphoma was undertaken to determine the extent to which a staging procedure should be implemented and the benefits which could be derived. A variety of clinical, radiographic, surgical, and laboratory investigations were performed by different investigators. Overall, similar results were obtained for the different stages. The utility of the individual studies was not defined in any single review. However, it appeared that bone marrow biopsy was superior to bone marrow aspirates, staging laparotomy was generally not required, and lymphangiography did not constitute a routine staging procedure. Staging permitted identification of patients with primary sites at high risk for the development of central nervous system disease or failure. The reviews did not specify the minimum number of procedures to be performed. It is concluded that each patient should receive individual consideration, and diagnostic evaluation should consist of a series of tests sequentially performed and interrupted whenever sufficient information has been assembled for institution of therapy.

Increased survival in childhood acute nonlymphocytic leukemia after treatment with prednisone, cytosine arabinoside, 6-thioguanine, cyclophosphamide, and oncovin (PATCO) combination chemotherapy

One hundred-sixty-three children with acute nonlymphocytic leukemia (ANLL) were treated with a multiple-drug induction program (PATCO) consisting of prednisone (PDN), cytosine arabinoside ((Ara-C), 6-thioguanine (6-TG), cyclophosphamide (CPM), and Oncovin (VCR). Ninety-six, 59%, obtained a remission. Remission was maintained with daily 6-TG and four-day pulses of Ara-C and CPM with a single dose of VCR every 28 days. The median duration of remission was 11.5 months. Certain prognostic factors affected induction rate and remission duration. Initial white blood count (WBC) was a significant factor in achieving a remission, whereas age, sex, and type of ANLL had no effect. Initial WBC, age, and sex had a significant effect on remission duration, but type of ANLL had no effect. Relapsing patients were treated with daunomycin and 5-azacytidine. The reinduction rate was 53% with a median second remission duration of 190 days. Overall survival for the 163 patients is 55.4% at 12 months, 31.5% at 24 months, 21.4% at 36 months, and 19% at 48 months.