Intensive combination chemotherapy with vincristine, adriamycin and prednisolone (VAP) in the treatment of diffuse histology non-Hodgkin's lymphoma. (A report of 89 cases with extensive disease from the Manchester Lymphoma Group)

A randomised study of bolus vs continuous pump infusion of ifosfamide and doxorubicin with oral etoposide for small cell lung cancer

One hundred and fifty-nine previously untreated patients with small cell lung cancer (SCLC), who were not eligible for intensive chemotherapy, were entered into a randomised study of intravenous (i.v.) doxorubicin and ifosfamide (with mesna) and oral etoposide. The i.v. drugs were given either by bolus therapy or by a continuous infusion (CI) pump over 7 days via a central venous line. Therapy was given for 6 weeks only. On weeks 1, 3 and 5 IV doxorubicin 35 mg m-2 was given with 5 days of oral etoposide 100 mg m-2 daily. On weeks 2, 4 and 6 IV ifosfamide 5 g m-2 was given with equidose mesna. The overall median survival was 25 weeks for patients in the bolus arm and 30 weeks for the CI therapy (P = 0.45). The overall response rate was 64% (18% complete response-CR) and 69% (30% CR) respectively (P = 0.13). The median WHO score for haematological toxicity was 4 for bolus therapy and 3 for CI therapy (P = 0.0007). Despite a trend for less supportive care for patients on CI therapy there were no significant differences in the use of i.v. antibodies and blood or platelet transfusions. There were fewer treatment delays due to myelotoxicity in the CI arm (P = 0.04). The median WHO score for non-haematological toxicity was 2 in both treatment groups. There was significantly less nausea (P = 0.037) but more mucositis (P = 0.01) in the CI arm. Weekly chemotherapy using CI treatment was as effective as bolus therapy. It was well accepted by patients. The assessment of quality of life in a subgroup of patients showed a statistically significant reduction in anxiety and depression for both groups of patients during therapy.

Treatment of relapsed Hodgkin's disease using a weekly chemotherapy of short duration: results of a pilot study in 20 patients

Twenty patients with relapsed Hodgkin's disease have been treated with a weekly regimen of chemotherapy (VAPEC-B) comprising Adriamycin 35 mg/m2 i.v. weeks 1, 3, 5, 7, 9, 11; cyclophosphamide 350 mg/m2 i.v. weeks 1, 5, 9; etoposide 100 mg/m2 p.o. daily for 5 days, weeks 3, 7, 11; vincristine 1.4 mg/m2 i.v. weeks 2, 4, 6, 8, 10; bleomycin 10 mg/m2 i.v. weeks 2, 6, 10 and prednisolone 50 mg p.o. daily weeks 1-5, 25 mg p.o. daily weeks 6-11. All had previously received an Adriamycin containing combination and in nine cases this was for relapse following MVPP. In all but one case relapse occurred less than one year after the completion of previous treatment and in 14 cases, disease recurred within 24 weeks. Thirteen patients had extra-nodal involvement. Following six weeks of treatment 14 patients had responded (6 CR; 4 CR, uncertain; 4 PR), four had stable disease, one had progressed and one had died of sepsis. Fourteen patients proceeded to high dose cyclophosphamide and BCNU with autologous bone marrow rescue and seven of these are progression free between 4 and 156 weeks later. High dose therapy was not possible in five patients, three of whom achieved CR. Of these, two (one with bulky nodal disease and skin infiltration; one with extensive bone marrow involvement) are alive and relapse free without further treatment at 95 and 114 weeks. Overall, the regimen was well tolerated but haematological toxicity was moderate or severe in ten patients and four were admitted to hospital for treatment of suspected or confirmed septicaemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic factors in high and intermediate grade non-Hodgkin's lymphoma

An analysis of prognostic factors has been performed on 260 patients with high and intermediate grade non-Hodgkin's lymphoma (NHL) treated over an 11-year period between 1975 and 1986. The overall 5-year survival rate was 50% with a median follow-up of 72 months. Over 20 clinical, radiological and laboratory parameters have been studied, including variables reported to be important indicators of prognosis in previous series, and these variables have been subjected to univariate and multivariate analysis. Attainment of complete remission (CR) was the most important predictor of overall survival, low serum lactate dehydrogenase (LDH), limited stage disease and a high serum albumin were also independently associated with prolonged survival in multivariate analysis. After removing remission status from the model, Ann Arbor clinical stage became the most significant pre-treatment prognostic indicator. Sixty-five per cent of patients achieved CR, and a discriminant analysis showed that failure to attain CR was associated with advanced stage disease, constitutional symptoms, increasing patient age, a low serum albumin and the presence of bulk disease. Advanced clinical stage and an elevated serum LDH predicted independently for a poor relapse-free survival, and reduced overall survival following CR. There was no significant correlation between histological subtype in the Kiel classification and prognosis. This study confirms the prognostic significance of remission status and Ann Arbor clinical stage, and illustrates additional factors including serum levels of albumin and LDH, which serve to enhance the pre-treatment prognostic evaluation of patients with unfavourable histology NHL.

A new approach to the treatment of advanced high-grade non-Hodgkin's lymphoma--intensive two-phase chemotherapy

A total of 110 patients with high-grade non-Hodgkin's lymphoma (NHL) not previously treated by chemotherapy or by radiotherapy at more than one site of disease underwent a regimen comprising an intensive 6-week initial, induction phase using vincristine, adriamycin, methotrexate, and prednisolone (VAMP) followed by the non-cross-resistant combination cyclophosphamide, etoposide, and vindesine (EEE). The median age of patients was 54 years, the majority having stage IV disease. The median follow-up was 34 months and all patients have completed treatment. The overall complete remission (CR) rate for all patients was 68%. The initial phase of treatment produced a CR rate of 49%. The full regimen was completed by 87 patients, and of these, 66 (76%) achieved CR. Of those achieving CR, 72% were relapse-free, on an actuarial basis, at 2 years. Overall 2-year survival was 53%, with a median survival of 31 months. The survival of older patients and those with lymphoblastic histology was comparable to that of other groups. The survival prospects of patients with stage IV disease was not as good as that of other patients, with a significant trend to shorter survival in patients with more advanced disease. Toxicity was predictable and manageable for both phases of the regimen, although it was more severe for the initial phase. Dose-limiting toxicities were neutropenia and mucositis. This regimen is active in the treatment of advanced high-grade NHL with acceptable toxicity. These results have encouraged us to continue the study of weekly chemotherapy, which we will compare with standard cyclical chemotherapy in a prospective, randomized trial.

Chromosomal evidence of a common stem cell in acute lymphoblastic leukemia and chronic granulocytic leukemia

A patient with acute lymphoblastic leukemia (ALL) was found, at the time of diagnosis, to have an unusual Philadelphia chromosome (Ph1) with a satellite marker. The disease evolved into the chronic phase of chronic granulocytic leukemia (CGL), with persistance of the marker. Two months later, the patient died of ALL.

A multivariate analysis of factors affecting survival in patients with high-grade histology non-Hodgkin's lymphoma

One hundred and eleven patients with advanced-stage, high-grade histology non-Hodgkin's lymphoma were studied over a 7-yr period and were treated with one form of chemotherapy and radiotherapy. Multivariate analyses were carried out to identify factors which could predict a favourable prognosis. A complete response, low serum LDH and absence of clinical evidence of liver involvement were associated with long-term survival. The presence of 'B' symptoms, bone marrow involvement, low serum albumin and male sex predicted a reduced chance of achieving a complete remission. For those patients who achieved a complete response, the subdivision of histologies, particularly according to the Kiel classification, was the only significant factor predictive of prolonged relapse-free and overall survival. This confirms the importance of identifying different histological subgroups of lymphoma when considering treatment planning.

Oral acyclovir prophylaxis against herpes simplex virus in non-Hodgkin lymphoma and acute lymphoblastic leukaemia patients receiving remission induction chemotherapy. A randomised double blind, placebo controlled trial

Forty-one patients receiving remission induction chemotherapy with vincristine, adriamycin and prednisolone (VAP) for high grade lymphoma or acute lymphoblastic leukaemia were entered into a double blind, placebo controlled trial of oral acyclovir prophylaxis against herpes simplex virus (HSV) infection. The dose of acyclovir was 200 mg four times daily for the duration of chemotherapy (six weeks). Of the 40 evaluable patients, 20 were randomised to each arm. Prophylactic oral acyclovir significantly reduced the incidence of clinical HSV infection from 60% on placebo to 5% acyclovir (P less than 0.001), and the incidence of viral isolates from 70% on placebo to 5% on acyclovir (P less than 0.001).

Phase II study of Amsacrine in refractory lymphomas. A report of the EORTC early clinical trials group

Forty-three patients with advanced measurable lymphoma, progressive after conventional therapy, were entered into a phase II study of m-AMSA 90-120 mg/m2 every 3 weeks. Five patients were ineligible and response could not be evaluated in four patients. For HD there were two partial responses (14%), lasting 6 and 41 weeks, in 14 evaluable patients. Among 20 evaluable patients with NHDL three (15%) achieved partial remission, but duration of response could not be evaluated. One patient with diffuse histiocytic lymphoma died of infection at 4 weeks, a second with lymphoblastic lymphoma was given high-dose steroids commencing at 6 weeks, and the third patient with nodular poorly differentiated lymphocytic lymphoma refused further treatment after one course. Leucopenia was more marked in patients with NHDL (WBC nadir X 10(9)/l, median 2.2, range 0.2-4.3) than in HD (WBC nadir X 10(9)/l, median 2.8, range 0.85-7.2), as was thrombocytopenia. There was one toxic death and one life-threatening infection, both secondary to myelosuppression. Non-haematological toxicity was mild. m-AMSA has marginal activity in previously treated lymphomas and causes considerable myelosuppression.

Serum beta 2-microglobulin in patients with non-Hodgkin's lymphoma

Eighty-one patients with non-Hodgkin's lymphoma had serum beta 2-microglobulin (beta 2M) estimated at presentation. A significant association was found between beta 2M levels and stage of disease (P less than 0.001), presence of hepatomegaly (P less than 0.001) and bone marrow involvement (P less than 0.05). No association was found between the level of beta 2M and histological group, presence of splenomegaly, lymph-node masses greater than 5 cm in diameter, lymphocyte count or the presence of systemic B symptoms. Pretreatment levels of beta 2M did not help predict response to treatment and achievement of a complete remission, the length of remission obtained or survival.

The role of abdominal computed tomography in lymphoma following treatment

Two hundred and six patients with biopsy-proven lymphoma, 74 with Hodgkin's disease and 132 with non-Hodgkin's lymphoma had abdominal computed tomography for assessment of remission status (108 patients) or for investigation of relapse (98 patients). In 43 patients with diffuse large cell lymphomas scanned at a time of apparent complete remission CT was abnormal in 21. Sixteen of these patients have relapsed and died. Only one patient has relapsed in the group who have normal CT scans. This difference was significant (p=0.00001). This difference was not seen in nodular lymphomas. There were very few patients with Hodgkin's disease in whom the CT scan was abnormal and there is a suggestion that many abnormalities following treatment may represent inactive Hodgkin's disease or fibrosis only. CT played a major role in diagnosing the full extent of relapse in both non-Hodgkin's lymphoma and Hodgkin's disease. Over 50% of the abnormal sites detected by CT would not have been shown by any other non-invasive investigation. Five patients with treated Hodgkin's disease who had "B" symptoms only suggesting relapse were all shown by CT to have extensive intra-abdominal disease.

New approaches to the management of patients with non-Hodgkin's lymphoma of high-grade pathology. First Gordon Hamilton-Fairley memorial lecture

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