The management of adult aggressive non-Hodgkin's lymphomas

Prognostic value of comorbidity for auto-SCT eligibility and outcome in relapsed or refractory aggressive non-Hodgkin's lymphoma

Salvage reinduction therapy followed by high-dose chemotherapy (HDCT) and auto-SCT is the treatment of choice for fit patients with refractory or relapsed aggressive non-Hodgkin's lymphoma (NHL). We assessed the prognostic value of comorbidity at the time of relapse to predict receipt of auto-SCT and outcome. We analyzed 156 consecutive NHL patients, referred to our center between 1999 and 2007 for salvage reinduction therapy, followed by HDCT and auto-SCT. Comorbidity according to the hematopoietic SCT comorbidity index was scored at relapse and directly before HDCT and auto-SCT. Primary end points were actual receipt of auto-SCT and survival. At relapse, comorbidity scores of 0, 1-2 and ≥3 were found among 64 (41%), 62 (40%) and 30 (19%) patients, respectively. Ultimately, 95 patients received auto-SCT. Higher comorbidity scores at relapse were associated with significantly less chance of receiving auto-SCT and with inferior OS, independently from secondary age-adjusted International Prognostic Index (sAAIPI) scores. For transplanted patients, OS rates at 5 years were 62, 30 and 17% for relapse comorbidity scores of 0, 1-2 and ≥3, respectively. In patients with relapsed NHL, comorbidity at relapse is associated with receipt of auto-SCT and subsequent survival independently from the sAAIPI.

Ifosfamide, Epirubicin and Etoposide (IEV) Regimen as Salvage and Mobilization Therapy for Refractory or Early Relapsing Patients with Aggressive Non-Hodgkin's Lymphoma

The prognosis of early relapsing or refractory aggressive non-Hodgkin's lymphoma (NHL) is still poor. Effective salvage therapy should be able to induce high response rate as well as to mobilize hematopoietic precursors. A combination of ifosfamide, epirubicin and etoposide (IEV) was given to 28 patients with refractory or relapsing high grade NHL (4 lymphoblastic lymphoma and 24 large cell lymphoma). All patients were evaluated for response. After 2 courses of IEV, the overall and complete response rate were 64% and 39%, respectively. All patients were controlled for mobilization of peripheral blood stem cells, which was successful in 26 out of 28 (93%). Overall, 25 out of 26 patients proceeded to autologous stem cell transplantation (ASCT). Toxicity was mild, with no occurrence of severe persisting extra-hematologic side-effects. Following the entire therapeutic program, including IEV and ASCT, median progression free survival has not yet been reached and 21 patients are alive (18 in continuous complete remission) after a median follow-up of 18 months. Our results demonstrate that treatment with IEV regimen is effective in refractory or relapsing aggressive NHL, resulting in a high percentage of successful stem cell mobilization and feasibility of ASCT.

Modulation of radiosensitivity in Chinese hamster lung fibroblasts by cisplatin

The effects of cisplatin exposure time, concentration, and irradiation sequence on the sensitivity of Chinese hamster lung fibroblasts (V79) to gamma-ray exposure were examined. Based on clonogenic cell survival, the cisplatin concentrations corresponding to 50% cell survival (EC(50)) for exposure times of 1 h to 7 days followed a 2-phase exponential decay and ranged from 28.26 +/- 3.32 to 1.53 +/- 0.24 micromol/L, respectively. When cells were treated at EC(50) for exposures of less than 4 h and irradiated immediately, cisplatin inhibited the effect of radiation. Exposures of 4-6 h did not affect radiosensitivity. For exposures of 8-12 h, radiosensitization was observed, which disappeared at 14 h and reappeared for much longer cisplatin treatments. At the lowest achievable EC(50) (1.53 micromol/L), radiosensitization was observed if irradiation was delayed for 1-8 h. This enhancement in radiosensitivity disappeared for irradiation delays of 10-12 h, but reappeared when irradiation was delayed for 14-18 h. These data demonstrate that the mode of interaction between cisplatin and gamma-irradiation depends on the concentration and exposure time of cisplatin, as well as on the timing of irradiation after cisplatin administration. Consideration of changes in cell cycle kinetics may contribute to the improvement of treatment outcomes in adjuvant chemoradiotherapy involving cisplatin.

Therapeutic results in patients with relapsed diffuse large B cell Non-Hodgkin's lymphoma achieving complete response only after autologous stem cell transplantation

Forty patients with relapsed diffuse large B cell lymphoma (DLBCL) autografted in partial response (PR) (n = 23) or in refractory relapse (RR) (n = 17) achieved complete remission (CR) after autologous stem cell transplantation (ASCT). Salvage treatment consisted of ifosphamide, epirubicin and etoposide (IEV) in 33 patients and Cisplatinum, ARA-C and dexamethasone (DHAP) in 7 patients. All PR and 8 RR patients were conditioned with BEAM, while 9 RR cases received the BCV regimen. There were no significant differences between the two groups as age, serum LDH, duration of CR1 and IPI at relapse are concerned. Relapse rate after ASCT was 39% in PR group as opposed to 88% in RR group (p = 0.003). Median relapse free survival from ASCT was 6 months for RR patients as opposed to 34 months for PR patients (p = 0.003); median overall survival from ASCT was 10 months for RR subset as opposed to not reached for RR subgroup (p = 0.001). These data demonstrate that CR achieved after ASCT in DLBCL patients who are refractory to previous salvage therapy does not result in long-term disease control. Alternative preparative regimens, allogeneic SCT and/or monoclonal antibodies in the post-ASCT phase should be considered for RR patients despite CR achievement.

The comparison of spontaneous LDH release activity from cultured PBMC with sera LDH activity in non-Hodgkin's lymphoma patients

Based on the fact that lactate dehydrogenase (LDH) enzyme is a very sensitive indicator of the cellular metabolic state, aerobic or anaerobic direction of glycolysis, activation status, and malignant transformation, in this study we compared values of the spontaneous LDH release from circulating PBMC with sera LDH activity in 53 different subtypes of non-Hodgkin's lymphoma (NHL) patients. Results shows that serum LDH was significantly (p < 0.05) elevated in comparison to the range values only in the advance clinical stage (III and IV) in all investigated subtypes of NHL according to The Working and REAL classification. On the other hand, the spontaneous LDH release from cultures PBMC is significantly (p < 0.01) elevated in early and advanced stage in all investigated forms of NHL in comparison to healthy controls. Based on consideration that an increase in spontaneous LDH release appears before elevated sera LDH activity, we conclude that determination of spontaneous LDH release by microassay from cultured cells together with other findings may help in the diagnosis of NHL patients, especially in patients with early stage of disease.

Autologous bone marrow transplant in a patient with sickle cell disease and diffuse large B-cell lymphoma

As the life expectancy of patients with homozygous sickle cell anemia (SCA) improves, SCA care providers are confronted with diseases of the adult SCA population rarely seen before. We report here a 40-year-old woman with SCA who developed diffuse large B-cell non-Hodgkin's lymphoma (NHL) that was treated with eight cycles of chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, prednisone, and etoposide (CHOPE), without complete remission. She subsequently underwent high-dose cyclophosphamide and total-body irradiation followed by autologous bone marrow transplantation (BMT). To reduce the risk of sickle cell crisis precipitated by G-CSF, she underwent hypertransfusion to maintain a low % hemoglobin S throughout her treatment course. Although she has required iron chelation therapy and shows no sign of modification of her underlying SCA, she remains in remission from NHL 12 years posttransplant. To our knowledge, this is the first reported case of autologous BMT in a patient with SCA. Our patient illustrates that SCA in itself does not preclude autologous stem cell transplantation for lymphoma in selected patients, and this report should encourage others to consider autologous BMT in adults with SCA where it represents a lifesaving therapy for malignant diseases.

Towards whole-organ modelling of tumour growth

Multiscale approaches to modelling biological phenomena are growing rapidly. We present here some recent results on the formulation of a theoretical framework which can be developed into a fully integrative model for cancer growth. The model takes account of vascular adaptation and cell-cycle dynamics. We explore the effects of spatial inhomogeneity induced by the blood flow through the vascular network and of the possible effects of p27 on the cell cycle. We show how the model may be used to investigate the efficiency of drug-delivery protocols.

Bilateral hearing loss during vincristine therapy: a case report

Vincristine sulfate is a chemotherapeutic agent used in different cancer therapies. It is also the first choice of treatment for peripheral T-cell lymphoma with cyclophosphamide and adriamycin. Sudden hearing loss during vincristine therapy is a very rare event. This is a case of a 16-year old girl who developed sudden bilateral hearing loss related to vincristine therapy.

Dexamethasone, Cytarabine, and Cisplatin (DHAP) Regimen for Refractory or Relapsed Lymphomas

The increasing complexity of cancer chemotherapy makes it mandatory that pharmacists be familiar with these highly toxic agents. This column reviews various issues related to the preparation, dispensing, and administration of cancer chemotherapy, both commercially available and investigational.

[Intraoral non-Hodgkin's lymphoma. Presentation of 4 clinical cases]

The non-Hodgkin lymphomas (NHL) represent an heterogeneous group of malignancies of lymphoreticular histogenesis. In most cases, they initially arise within lymph nodes but so-called extranodal lymphomas are also found. The NHL has low incidence in the oral cavity. It may involve bone and/or soft tissues as a primary or secondary manifestation. We present a review of the literature and four clinical cases of intraoral NHL. The first couple of cases are primary forms, the third one is associated to HIV infection and the last one is an oral presentation as a component of more widely disseminated disease.

Treatment of human immunodeficiency virus-related lymphoma

In newly diagnosed human immunodeficiency virus (HIV)-positive patients with non-Hodgkin's lymphoma (NHL), standard lymphoma regimens yield approximately a 50% complete response (CR) rate and an overall median survival of < or = 9 months. Treatment results of relapsed patients are extremely poor. Regimens that appear more effective than standard therapy have usually been investigated only in patients with relatively high CD4 counts. An exception is a regimen consisting of a continuous 96-hour infusion of cyclophosphamide, doxorubicin, and etoposide (CDE). A 62% CR rate was achieved in 21 patients with a median CD4 count of 87/microL, and the median overall survival was 18 months. In another study of 25 patients, didanosine (ddI) was added to CDE and was shown to cause less myelosuppression without compromising efficacy. Other studies suggest that highly active antiretroviral therapy (HAART) can be combined with intensive chemotherapy regimens, with improved efficacy attributed to less frequent dosage reduction of chemotherapeutic agents. More recently, autologous and syngeneic bone marrow transplantation have been explored in a handful of patients with acquired immunodeficiency syndrome (AIDS)-related NHL with promising results. Data on whether widespread use of HAART decreases the incidence of HIV-positive NHL are conflicting. Some clues from recent studies suggest we are close to an answer: (1) protease inhibitors significantly improve survival of HIV-positive patients with NHL; (2) only one of eight recent cases of HIV-positive men with NHL received HAART compared with greater than 70% of HIV-positive men free of NHL; and (3) no prior HAART independently predicted for AIDS-related NHL development. On the other hand, Hodgkin's disease may be increasing in frequency in HIV-positive patients as the incidence of NHL declines. It is hypothesized that more effective reconstitution of the immune system with HAART may facilitate the inversion of these incidences. Future prospective studies will hopefully answer these questions.