Non-Hodgkin's lymphoma in the elderly. A study of 602 patients aged 70 or older from a Danish population-based registry. The Danish LYEO-Study Group

BR vs. R‑miniCHOP in unfit patients with B‑cell non‑Hodgkin lymphoma: A randomized, two‑center, cohort study

The aim of the present study was to compare the efficacy and safety between the bendamustine plus rituximab (BR) regimen and rituximab combined with low-dose doxorubicin, cyclophosphamide, vincristine and prednisone (R-miniCHOP) in the treatment of 'unfit' patients with diffuse large B-cell lymphoma (DLBCL) and follicular lymphoma grade 3B (FL3B). Patients, >70 years of age with DLBCL or FL3B, defined as unfit according to Comprehensive Geriatric Assessment, were included in the present study. All patients received 4-6 cycles of a BR or R-miniCHOP regimen at a three-week interval. The objective remission rate (ORR) and adverse reactions were evaluated between the two groups. A total of 35 patients, recruited between January 2020 and December 2021, were included in this prospective study. The median age was 74 years (range, 70-82 years). The ORR in the BR group was similar to that in the R-miniCHOP group (73.3 vs. 75.0%; P=0.606). However, the BR group exhibited a lower incidence of leukopenia than the R-miniCHOP group (20.0 vs. 60.0%; P=0.037). The univariate analysis revealed that the ORR was influenced by the serum β2 microglobulin level. The BR regimen showed equivalent efficacy but more improved safety compared with R-miniCHOP in unfit patients with DLBCL and FL3B. The BR regimen may be considered as an alternative treatment in these subgroups of patients.

The efficacy and cardiac toxicity of different-dose pegylated liposomal doxorubicin in elderly patients with diffuse large B lymphoma

OBJECTIVES

In order to explore the impact of pegylated liposomal doxorubicin (PLD) dose intensity on survival outcomes of newly diagnosed elderly patients with diffuse large B-cell lymphoma (DLBCL), we performed a retrospective study to compare the efficacy and adverse effects of RCEOP (70 mg/m² ), RCdOP (20-30 mg/m² ) and RCDOP (30-45 mg/m² ). The optimal PLD dose of patients with different clinical characteristics of subgroups was explored to provide a clue for the selection of clinical PLD dose.

METHODS

A total of 335 DLBCL patients (60-85 years old) who were newly diagnosed and completed at least four cycles of RCE(D)OP were selected. The patients were mainly divided into RCEOP (126 cases) (epirubicin 70 mg/m² ), RCdOP (151 cases) (PLD 20-30 mg/m² ) and RCdOP (58 cases) (PLD 30-45 mg/m² ). The effects of different doses of PLD on clinical efficacy, cardiotoxicity and prognosis of patients were retrospectively analyzed. Subgroup analysis was performed to compare the clinical characteristics of different subgroups.

RESULTS

Our study showed that PLD and epirubicin had similar efficacy (overall survival (OS) p = 0.776; progression-free survival (PFS) p = 0.959). RCDOP (30-45 mg/m² PLD) group had a higher complete remission (CR) rate of 75.9% compared with RCdOP (20-30 mg/m² PLD) group (P D vs. d = 0.018). In the overall population, there was no significant difference in survival between RCDOP and RCdOP groups (OS P D vs. d = 0.661; PFS P D vs. d = 0.212). In patients with underlying cardiovascular diseases, the PFS of the RCDOP group was significantly better than the RCdOP group (p = 0.043). Meanwhile, patients in the RCDOP group tended to have a better prognosis than those in the RCEOP group (OS: RCDOP vs. RCEOP p = 0.054, PFS: RCDOP vs. RCEOP p = 0.053). There was no significant difference in the incidence of cardiotoxicity and other adverse events among the three groups. For the low-risk (age-adjusted-International Prognostic Index = 0/1) old patients without cardiovascular disease, RCdOP was considered a better strategy in OS (p = 0.020).

CONCLUSION

In the general population, the CR rate in the RCDOP group was significantly higher than that in the RCdOP group (p = 0.018). For elderly DLBCL patients with cardiovascular disease, the effect benefit brought by the PLD dose was more obvious, and the PFS of the RCDOP group was significantly better than that of the RCdOP group (p = 0.043). Full dose of PLD is an efficient alternative in the treatment of patients with preexisting cardiovascular diseases.

Tendencias de la incidencia y la mortalidad de los linfomas en Cuba

Antecedentes: En Cuba, los linfomas se han incluído tradicionalmente entre Ias localizaciones de câncer más frecuentes. Objetivos: Se describió el comportamiento de la incidência y la mortalidad de los linfomas entre 1976 y 1990, de acuerdo a Ias principales variables epidemiológicas; edad, sexo y variedad histológica. Método: Se incluyeron todos los casos reportados al Registro Nacional de Câncer entre 1976 y 1990. Los casos fueron agrupados en Ias dos categorias diagnosticas clásicas: Enfermedad de Hodgkin y Linfomas no Hodgkinianos y de acuerdo al momento de reporte, en tres períodos quinquenales. Eueron calculadas Ias tasas específicas para los grupos de edad y Ias tasas estandarizadas a la población mundial. Resultados: Una marcada masculinidad fue encontrada en ambas categorias diagnosticas tanto en la incidência como en la mortalidad. La incidência tanto en la Enfermedad de Hodgkin como en los Linfomas no Hodgkinianos ha tenido un comportamiento ascendente en el tiempo. Um aumento de la tendencia, tanto de la incidência como de la mortalidad, se observa para el grupo de edad de 65 anos y más, mientras que la disminución de la mortalidad está clara para el grupo de 0 - 14 anos.

Diffuse large B-cell lymphoma: A consensus practice statement from the Australasian Lymphoma Alliance

Diffuse large B-cell lymphoma (DLBCL) is the most common lymphoma subtype, accounting for 30-40% of lymphoma diagnoses. Though aggressive, cure is achievable in approximately 60% of cases with primary chemo-immunotherapy, and in a further substantial minority by salvage therapy and autologous stem cell transplantation. Despite promising activity in early phase clinical trials, no intensified or novel treatment regimen has improved outcomes over R-CHOP21 in randomised studies. However, there remain several areas of controversy including the most appropriate prognostic markers, CNS prophylaxis and the optimal treatment for patients with high-risk disease. This position statement presents an evidence-based synthesis of the literature for application in Australasian practice. This article is protected by copyright. All rights reserved.

Outcomes of diffuse large B-cell lymphoma in elderly patients-real-world experience from a middle-income country setting

Background

Diffuse large B-cell lymphoma (DLBCL) is the commonest subtype of lymphoma in the elderly and poses unique challenges in this group of patients. There is a need for more information on real-world outcomes across economic disparities.

Methods

Electronic Medical Record of 3,087 lymphomas (>18 years) were evaluated retrospectively, of which 842 (27%) patients were ≥65 years. Two hundred and twelve patients who were ≥65 years received first line treatment for DLBCL between May 2011 and Dec 2016. Demography, clinical features, associated co-morbidities, first line treatment outcomes and hospital costs were analysed. Patients were followed up till March 2020.

Results

The median age at presentation was 71 years. Gender ratio was 2.5:1. 38% patients presented with early-stage disease, 37% with low and low-intermediate International prognostic index, 49% with nodal disease. One or more co-morbidities were present in 58%. The commonest extra nodal site was gastro-intestinal (29%). Two-thirds of the patients presented with non-Germinal centre B subtype. The overall response (OR) to treatment was 72.5%. Patients who received anthracycline-based therapy (n = 124) and rituximab-based therapy (n = 159) had a median progression free survival (PFS), not reached and 47.0 months, respectively, versus 10 months and 7.9 months, respectively, for patients receiving non-anthracycline and non-rituximab therapies. At a median follow-up of 24 months, the 5-year overall survival and PFS are 44% and 41%, respectively, for the entire cohort.

Conclusions

DLBCL is a curable lymphoma in elderly patients with standard anthracycline and rituximab-based therapies. Improvement in outcomes largely depends on social and financial support to complete the scheduled treatments.

Low-dose trofosfamide plus rituximab is an effective and safe treatment for diffuse large B-cell lymphoma of the elderly: a single center experience

Background

Rituximab plus combination chemotherapy with cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) is broadly accepted as standard for the treatment of diffuse large B-cell lymphoma (DLBCL). Nevertheless, there is sparsely data concerning the management of elderly patients.

Methods

We performed a retrospective study of treatment with rituximab and low-dose trofosfamide in elderly patients (≥ 75 years) with DLBCL who were not suitable for R-CHOP or R-CHOP-like regimens or who did not consent to aggressive treatment. The choice regarding the qualification for R-CHOP or R-CHOP-like regimen was left to the estimation of the treating physicians.

Results

Eleven patients with a median age of 83 years (range, 75–90 years) were included. The age-adjusted international prognostic index was low risk in one patient, low-intermediate in four patients, high-intermediate in three patients, and high risk in 3 patients. All patients were evaluable for response. Five patients (45%) achieved a complete response, three (27%) a partial response, one (9%) stable disease, and two (18%) progressive disease. The estimated 1-yr overall survival was 54.5%, and the estimated 1-yr progression-free survival 45.5%, however, three patients (27%) were alive without evidence of disease at 16–20 months from start of treatment. Main toxicity was leukopenia (36% grade III or IV), whereas grade III/IV non-hematological adverse events did not occur.

Conclusions

Due to its potency and low toxicity, trofosfamide/rituximab might represent an alternative therapy for DLBCL of elderly patients not suitable for R-CHOP. This observation, however, should be confirmed in a larger patient population within a prospective clinical trial.

Prognostic effect of Ki-67 expression in rituximab, cyclophosphamide, doxorubicin, vincristine and prednisone-treated diffuse large B-cell lymphoma is limited to non-germinal center B-cell-like subtype in late-elderly patients

This study evaluated the effect of age and cell of origin on the prognostic significance of Ki-67 labeling index (Ki-67 LI) on overall survival (OS) of diffuse large B-cell lymphoma (DLBCL) in a cohort of 697 patients treated with rituximab plus cyclophosphamide, doxorubicin, vincristine and prednisone (R-CHOP). Multivariate analysis revealed no prognostic significance of high Ki-67 LI (≥ 85%) for OS. However, on subgroup analysis, high Ki-67 LI was significantly associated with poor OS in late-elderly patients (aged ≥ 70 years) (p = 0.021) and non-germinal center B-cell-like (GCB) subtype (p = 0.015). In particular, high Ki-67 LI was associated with a poor prognosis in late-elderly patients with non-GCB subtype. No correlation was observed in young adults (aged < 60 years) or early-elderly (aged 60-70 years) patients or GCB subtype. The present study shows that high Ki-67 LI is a risk factor for poor OS in the late-elderly age group and non-GCB subtype in patients with DLBCL treated with R-CHOP.

Should the cut-off values of the lymphocyte to monocyte ratio for prediction of prognosis in diffuse large B-cell lymphoma be changed in elderly patients?

OBJECTIVES

A recent study suggested a prognostic role for the peripheral blood absolute lymphocyte/monocyte ratio (LMR) at diagnosis of diffuse large B-cell lymphoma (DLBCL). Here, we investigated the significance of LMR in DLBCL patients in relation to advanced age.

METHODS

We examined the prognostic impact of LMR in 603 DLBCL treated with rituximab plus CHOP, using the receiver operating characteristic curve analysis for optimal cut-off values, and performed a subgroup analysis according to age.

RESULTS

In elderly groups (age ≥ 70), absolute monocyte count was significantly increased, whereas LMR was significantly decreased compared to younger groups. Patients under 70 yr of age with LMR < 3.04 had significantly lower overall survival (OS) and progression-free survival (PFS) compared to those with LMR ≥ 3.04 (P < 0.001 for both). However, in elderly patients (age ≥ 70), there was no significant difference in OS between patients' LMR levels using the 3.04 cut-off value (P = 0.059). Therefore, a new LMR cut-off value of 2.36 was selected in elderly patients, having observed that elderly patients with LMR < 2.36 had significantly lower OS compared to those with LMR ≥ 2.36 (P = 0.021). In multivariate analysis, LMR remained a significant prognostic factor for OS (P = 0.004) or PFS (P < 0.001).

CONCLUSIONS

We suggest the use of a different cut-off value of LMR in elderly patients to distinguish high-risk from low-risk groups.

Application of the BIOMED-2 standardized primer system for the diagnosis of primary gastric B-cell non-Hodgkin's lymphoma

Primary gastric B-cell non-Hodgkin's lymphoma (B-NHL) has a similar morphocytological presentation to severe chronic gastritis, which complicates the pathological diagnosis of this disease. To investigate the practicality and utility of the BIOMED-2 standardized primer system for the diagnosis of primary gastric B-NHL from endoscopic biopsy specimens, we selected 65 cases of archived paraffin-embedded primary gastric B-NHL specimens as well as 27 cases of severe chronic gastritis samples to serve as a negative control group. The positivity rates of immunoglobulin heavy chain (IgH) gene rearrangements detected by the BIOMED-2 standardized primer system for the two groups were 86.4% and 12.0%, respectively, which are significantly different (p < 0.05). Importantly, the combined detection of the five groups of the IgH primer system increased the detection rate of B-NHL. These findings indicate that the BIOMED-2 standardized primer system is suitable for formalin-fixed and paraffin-embedded (FFPE) specimens and is valuable as a secondary diagnostic tool for primary gastric B-NHL as well as the differential diagnosis of severe chronic gastritis.

R-split-CHOP chemotherapy for elderly patients with diffuse large B-cell lymphoma

OBJECTIVES

Chemoimmunotherapy with cyclophosphamide, doxorubicin, vincristine, prednisolone, and rituximab (R-CHOP) is the standard of care for patients with diffuse large B-cell lymphoma (DLBCL). However, management of elderly patients is challenging as critical comorbidities often account for increased number of treatment-related complications.

PATIENTS AND METHODS

In the past 8 yrs, we have treated elderly patients with a full-dose R-CHOP regimen by splitting the administration of cyclophosphamide and doxorubicin over 2 days (R-split-CHOP) to reduce peak plasma level. Here, we retrospectively analyzed the results of 30 patients with newly diagnosed DLBCL.

RESULTS

The overall response rate was found to be 87%, the overall survival probability after 3 yrs was 60.6% (95% CI, 42.1%-79.0%), and the progression-free survival probability was 49.7% (95% CI, 30.4%-68.9%). Grade 3/4 infectious complications were reported in 30% of patients, yet no treatment-related deaths occurred.

CONCLUSION

We suggest that R-split-CHOP could be a valuable option to safely administer full-dose-intensity R-CHOP to elderly patients at risk of treatment-related complications.

Sarcopenia is an independent prognostic factor in elderly patients with diffuse large B-cell lymphoma treated with immunochemotherapy

Approximately 25-35% of patients with diffuse large B-cell lymphoma (DLBCL) are older than 70 years. The aim of this study was to investigate the prognostic impact of depletion of skeletal muscle (sarcopenia) in elderly patients with DLBCL. This retrospective analysis included 82 patients with DLBCL older than 70 years and treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, Oncovin, prednisone) or R-miniCHOP. Sarcopenia was measured by the analysis of stored computed tomography (CT) images at the L3 level at baseline. The surface of the muscular tissues was selected according to the CT Hounsfield unit. This value was normalized for stature in order to calculate the lumbar L3 skeletal muscle index (LSMI, in cm(2)/m(2)). The mean age of the population was 78 years. According to the defined cut-offs for LSMI, 45 patients with DLBCL were considered sarcopenic. Sarcopenic patients displayed a higher revised International Prognostic Index (R-IPI) compared with patients without sarcopenia, and were older, with a mean age of 80 years and 77 years, respectively (p = 0.006). With a median follow-up of 39 months, the 2-year overall survival in the sarcopenic population was 46% compared with 84% in the non-sarcopenic group (HR = 3.22; 95% CI = 1.73-5.98; p = 0.0002). In a multivariate analysis, sarcopenia remained predictive of outcome (p = 0.005). Sarcopenia is a relevant and predictive factor in elderly patients with DLBCL treated with rituximab plus chemotherapy.

Long-term results of pirarubicin versus doxorubicin in combination chemotherapy for aggressive non-Hodgkin's lymphoma: single center, 15-year experience

Pirarubicin is an analog of doxorubicin. Few studies have compared the long-term outcomes of patients receiving pirarubicin-based THP-COP and doxorubicin-based CHOP in the treatment of non-Hodgkin's lymphoma (NHL). We retrospectively compared the efficacy and safety of these two regimens in 459 previously untreated aggressive NHL patients admitted to Sun Yat-Sen University Cancer Center from 1987 to 2003. For initial treatment, 205 patients received the THP-COP regimen, and 254 patients received the CHOP regimen. The patients' characteristics were well balanced. The groups did not differ in the complete remission rate (THP-COP, 57.1% vs. CHOP, 57.0%; P = 0.998) or response rate (THP-COP, 82.9% vs. CHOP, 81.5%; P = 0.691). At a median follow-up of 95.7 months, the 8-year survival rates were also similar (overall survival: THP-COP, 55.8% vs. CHOP, 56.7%; progression-free survival: THP-COP, 47.3% vs. CHOP, 43.5%; lymphoma-specific survival: THP-COP, 51.2% vs. CHOP, 48.5%). The THP-COP group had fewer cases of alopecia (P < 0.001) and gastrointestinal toxicities (P = 0.015). A tendency toward decreased arrhythmia (P = 0.075), especially in elderly patients (P = 0.030), was found. In combination chemotherapy for aggressive NHL, pirarubicin has comparable efficacy to doxorubicin and has a lower incidence of alopecia, gastrointestinal toxicities, and arrhythmia. Further studies are warranted to confirm these results.

Evolution of R-CHOP therapy for older patients with diffuse large B-cell lymphoma

Non-Hodgkin's lymphoma is the fifth most common malignancy in adults in the USA. This disorder is especially relevant in the elderly patient population, as the median age of patients with this disorder is 65 years. Almost half of these disorders in older patients are of a diffuse large B-cell (DLBCL) subtype. The therapy of DLBCL has undergone a renaissance in the past decade, with the addition of rituximab to standard regimens, such as cyclophosphamide- doxorubicin-vincristine-prednisone (CHOP). Over this time, there have been several large Phase III treatment trials in which the CHOP and rituximab-CHOP (R-CHOP) regimens have been prospectively compared, including three trials confined to the elderly patient population. In these trials, it has been demonstrated repeatedly that the addition of rituximab results in an improved outcome, with higher response rates and prolongation in parameters including progression-free, event-free, disease-free and overall survival. In addition, this regimen has been well tolerated, even in older patients. Based upon these data, the R-CHOP regimen has now been established as the standard for initial therapy of DLBCL in older patients with DLBCL. However, issues still remain with regard to the ideal schedule of R-CHOP administration, specifically the optimal number of cycles of therapy (six vs eight), as well as cycle length (14 vs 21 days).

A phase II study of a THP-COP regimen for the treatment of elderly patients aged 70 years or older with diffuse large B-cell lymphoma

Pirarubicin (tetrahydropyranyl adriamycin: THP) is an anthracycline drug that reportedly has fewer cardiotoxic effects than doxorubicin. A phase II study was conducted in order to determine the efficacy of a treatment regimen incorporating THP, namely THP-COP in the treatment of elderly patients aged 70 years or older with diffuse large B-cell lymphoma (DLBCL). The treatment regimens for Group A (aged 70-79 years, n = 45) and Group B (aged 80 years or older, n = 16) consisted of cyclophosphamide, THP, vincristine, and prednisolone, repeated six times, every 3 weeks. The complete remission rate was 72.1%. The 5-year survival rate was 38.1%. For elderly patients with favourable prognostic factors, the 5-year survival rate was significantly better at 77.9% compared with 15.6% for patients with poor prognostic factors (p < 0.01). Death associated with the treatment regimen was not observed. We conclude that the THP-COP treatment regimen has fewer side effects and is very effective in the treatment of DLBCL in elderly patients, especially those with favourable prognostic factors. The present findings indicate the necessity of future studies investigating a combination therapy comprised of rituximab and THP-COP for the treatment of elderly patients with CD20-positive DLBCL.

Feasibility, efficacy and safety of CHOP-14 in elderly patients with very high-risk diffuse large B-cell lymphoma

OBJECTIVES

The dose-dense CHOP-14 regimen is efficient and safe in elderly patients with diffuse large B-cell lymphoma (DLBCL). However, no clinical data regarding very high-risk patients [age >75 yr and/or performance status (PS) >3] are available. The objective of this study was to evaluate the feasibility, efficacy and safety of CHOP-14 in these patients not eligible for clinical trials.

METHODS

We analyzed 65 patients treated with CHOP-14. Patients were stratified into two cohorts; A: very high-risk (age 60-75 with PS = 4 or age >75; n = 24) and B: standard risk (age 60-75 with PS < or =3 or age <60; n = 41).

RESULTS

Fifty eight percent in cohort A achieved complete response (CR) compared with 80% in cohort B (P = 0.054). The 3-yr event free survival (EFS) was 40% vs. 52% (ns), 3-yr overall survival (OAS) 44% vs. 68% (P = 0.017). Median schedule-erosion was 14 (0-67) (A) vs. 8 (0-44) (B) days (ns) and dose-erosion was confined to vincristine-reduction in both cohorts. Therapy-associated deaths did not differ. However, a significant increase in hospital admission was found in cohort A, where 88% required hospitalization (median 47 d) compared with 68% (median 9 d) in cohort B (P = 0.003). The patients presented with a combination of opportunistic infections, malnutrition and decreasing PS.

CONCLUSIONS

Although the 3-yr OAS in very high-risk DLBCL is encouraging, the high frequency of severe toxicity with infections and malnutrition responsible for increased morbidity during treatment, warrants for careful attention to these very high-risk patients.

Lymphoma in Older Patients

One half of patients newly diagnosed with lymphoma are older than 60 years and a significant proportion of them older than 80 years. Older patients treated for lymphoma may not tolerate the high-dose therapies used in younger patients, usually because of the presence of concomitant diseases. Diffuse large B-cell lymphoma represents more than 60% of all lymphomas seen in older patients. Clinical presentation and prognostic parameters are identical to those described in young patients. However, response rate is usually lower in elderly patients compared with young patients, even if the patients are treated with the cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) regimen. Therefore, event-free and overall survival rates are shorter in elderly patients, even if disease-free survival rates are not really shorter than in young patients. Rituximab added to the CHOP regimen has recently been shown to dramatically improve the survival of these older patients without increasing the toxicity of the treatment. Patients older than 80 years may also be treated with rituximab plus CHOP, except for those having severe organ failure secondary to other diseases. Very few of these older patients may benefit from a salvage treatment after relapse.

Vinorelbine and prednisone in frail elderly patients with intermediate-high grade non-Hodgkin's lymphomas

BACKGROUND

Frail patients with non-Hodgkin's lymphoma (NHL) are generally excluded from clinical trials and not even treated. The aim of this study was to evaluate the efficacy and tolerability of vinorelbine and prednisone in frail elderly patients with NHL.

PATIENTS AND METHODS

Thirty consecutive frail elderly patients were entered in a phase II study with vinorelbine 25 mg/m2 i.v. on days 1 and 8 and oral prednisone 30 mg total dose on days 1-8 for six cycles. Criteria of frailty were age > or =80 years, or age > or =70 years and three or more comorbidities of grade 3 or at least one comorbidity of grade 4 according to the Cumulative Illness Rating Scale (CIRS), or not self-sufficient or the presence of one or more geriatric syndromes.

RESULTS

Of 30 evaluable patients, three (10.0%) achieved a complete response (CR), nine (30.0%) showed a partial response (PR), while 10 presented with stable disease and eight with progressive disease. The median duration of CR was 29 months (range 5-36 months), and the median duration of PR was 1 month (range 1-22 months). Three patients had grade 3 neutropenia and one had grade 4. One grade 4 neurotoxicity was observed. Three patients died because of heart failure within 28 days of therapy, and one patient died after 4 days because of rapid progression. The median overall survival was only 10 months.

CONCLUSION

Vinorelbine and prednisone is a relatively non-toxic combination with modest activity in frail patients with NHL. If initial aggressive chemotherapy has been excluded, this combination could be tried to obtain a temporary palliation.

Treatment of Non-Hodgkin's Lymphomas in Elderly Patients

The roles of evolving treatment strategies for non-Hodgkin's lymphomas (NHL) in elderly patients are still not well defined and their effects on the overall epidemiology of the disease are still not clear. Three questions arise when discussing the management of NHL in elderly patients. First, should older patients be treated with the same regimens usually administered to younger patients? Second, are health outcomes of elderly patients similar to those usually observed in young patients, particularly response rate and overall survival? Third, which strategies should be adopted to improve overall health outcomes? Periodic review of the literature and updated data on the management of NHL in elderly patients may provide an answer to all these queries. In essence, older patients must be treated with the same intensive approaches that are usually reserved for younger patients. The results reported in randomized controlled clinical trials are consistent with the capability of older patients to exhibit overall response rate, event-free survival, and overall survival similar to those observed in their younger counterparts. Combining chemotherapy and monoclonal antibodies seems to be the main optional strategy for better outcomes in elderly patients. In contrast, knowledge concerning the management of indolent lymphomas in elderly patients is still lacking, and available clinical data are limited in this setting, especially in patients with poor prognostic factors who may need an immediate therapeutic intervention.

Factors predicting long-term survival in low-risk diffuse large B-cell lymphoma

The International Prognostic Index (IPI) is widely used for risk stratification of patients with diffuse large B-cell lymphoma (DLBCL). However, even among patients with low-risk disease, according to the IPI a substantial proportion of patients ultimately succumb to their disease. Using mature population-based data from the Danish Lymphoma Group, we analyzed if prognostic clinical pretreatment factors could be identified in patients with low-risk DLBCL. One hundred seventy-seven patients, all with a prognostic profile as favorable as possible according to the IPI and treated with anthracycline-based combination chemotherapy (92%) or loco-regional radiotherapy/surgery (8%) with curative intent were included. The median age was 50 years and 170 achieved complete remission. The median follow-up time was 11 years. Twenty-six patients relapsed, with a median time to relapse of 12.1 months. Overall survival at 5 years and 10 years was 85% and 75%, respectively. Stage II was associated with poor response to treatment (P=0.044). In a multivariate analysis, Stage II (P=0.001) and age >50 years (P=0.043) were independently associated with poor outcome. Patients without these adverse factors had an excellent prognosis, with a survival at 5 and 15 years of 90% and 80%, respectively. In contrast, patients with both adverse factors had poor outcome, with survival at 5 and 15 years of 70% and 29%, respectively (P<0.001). The present data suggest that risk stratification of DLBCL patients with a favorable IPI score can be improved by the simple use of two clinical pretreatment factors.

Prognosis of localized diffuse large B-cell lymphoma in younger patients

BACKGROUND

The International Prognostic Index (IPI) is widely used as a predictive model in diffuse large B-cell lymphoma (DLBCL) patients of all ages and stages. To determine the optimal IPI-based prognostic system at the time of diagnosis in younger patients with limited-stage DLBCL, the authors evaluated the age-adjusted IPI and the recently proposed stage-adjusted IPI, and constructed an IPI-based model adjusted for both age and stage.

METHODS

From the population-based LYFO registry of the Danish Lymphoma Group, 233 patients not older than 60 years with Stage I-II DLBCL treated with anthracycline-based chemotherapy with or without involved-field irradiation were identified. The primary endpoint of analysis was overall survival.

RESULTS

At the end of the observation period, 151 patients were alive with a median follow-up time of 8.3 years. All the variables in the age-adjusted and the stage-adjusted IPI had major prognostic significance (P < or = 0.0001). Log-rank analyses of survival showed highly significant differences between the subgroups in each model (P < 0.0001); however, the stage-adjusted IPI was more powerful (chi-square test = 44.99) than the age-adjusted IPI (chi-square test = 36.27). By using the median age of the cohort (50 years) as a cutoff point, age was found to be a strong prognostic factor (P = 0.0036). An age-/stage-adjusted IPI was constructed, the predictive power of which was equal to the stage-adjusted IPI (chi-square test = 44.16) but with different distribution of patients between the risk groups, making the proposed model better suited to identify poor-risk patients.

CONCLUSIONS

The data from the current study suggest that the proposed age-/stage-adjusted IPI is the superior IPI-based model in predicting outcome in younger patients with localized DLBCL.

Treatment paradigms in aggressive non-Hodgkin's lymphoma in elderly patients

Half of the patients newly diagnosed with lymphoma are > 60 years of age and can thus be defined as elderly. Older patients treated for lymphoma may not tolerate the high-dose therapies used in younger patients, usually because of the presence of concomitant diseases. Diffuse large B-cell lymphoma represents > 50% of all lymphomas seen in elderly patients. Clinical presentation and prognostic parameters are identical to those described in young patients. However, response rate is usually lower in elderly patients compared to young patients, even if the patients are treated with a CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) regimen. Therefore, event-free and overall survival rates are shorter in the elderly patients, even if disease-free survival is not really shorter than in young patients. Rituximab added to the CHOP regimen has recently been shown to dramatically improve the survival of these older patients without increasing the toxicity of the treatment.

Aggressive non-Hodgkin's lymphoma treated at the Institute of Oncology, Istanbul: treatment, outcome, and prognostic factors

In an unselected group of patients with aggressive non-Hodgkin's lymphoma (A-NHL) treated at our institution during a 10-year period (1989-1998), we studied the treatment outcome and influence of possible prognostic factors. Two hundred one patients with A-NHL were analyzed retrospectively with regard to personal, treatment, and disease-specific characteristics. Median age was 55 years (range: 16-87 years) and the male:female ratio was 1.5. During a median follow-up of 26 months, the overall response rate was 74% (complete response 63%, partial response 11%). The 2- and 5-year disease-free survival rates were 49 +/- 3% (mean +/- SEM) and 41 +/- 4%, respectively. In a univariate analysis, the following variables were associated with prognosis in terms of survival: patient age, clinical stage, performance status, B symptoms, erythrocyte sedimentation rate, treatment response, and histologic grade of tumor. In multivariate analyses, patient age, performance status, and treatment response emerged as independent prognostic factors for survival.

Mitoxantrone is superior to doxorubicin in a multiagent weekly regimen for patients older than 60 with high-grade lymphoma: results of a BNLI randomized trial of PAdriaCEBO versus PMitCEBO

A prospective, multicenter, randomized trial was undertaken to compare the efficacy and toxicity of adriamycin with mitoxantrone within a 6-drug combination chemotherapy regimen for elderly patients (older than 60 years) with high-grade non-Hodgkin lymphoma (HGL) given for a minimum of 8 weeks. A total of 516 previously untreated patients aged older than 60 years were randomized to receive 1 of 2 anthracycline-containing regimens: adriamycin, 35 mg/m(2) intravenously (IV) on day 1 (n = 259), or mitoxantrone, 7 mg/m(2) IV on day 1 (n = 257); with prednisolone, 50 mg orally on days 1 to 14; cyclophosphamide, 300 mg/m(2) IV on day 1; etoposide, 150 mg/m(2) IV on day 1; vincristine, 1.4 mg/m(2) IV on day 8; and bleomycin, 10 mg/m(2) IV on day 8. Each 2-week cycle was administered for a minimum of 8 weeks in the absence of progression. Forty-three patients were ineligible for analysis. The overall and complete remission rates were 78% and 60% for patients receiving PMitCEBO and 69% and 52% for patients receiving PAdriaCEBO (P =.05, P =.12, respectively). Overall survival was significantly better with PMitCEBO than PAdriaCEBO (P =.0067). However, relapse-free survival was not significantly different (P =.16). At 4 years, 28% of PAdriaCEBO patients and 50% of PMitCEBO patients were alive (P =.0001). Ann Arbor stage III/IV, World Health Organization performance status 2-4, and elevated lactate dehydrogenase negatively influenced overall survival from diagnosis. In conclusion, the PMitCEBO 8-week combination chemotherapy regimen offers high response rates, durable remissions, and acceptable toxicity in elderly patients with HGL.

Reduced-dose chop therapy for elderly patients with non-Hodgkin's lymphoma

While CHOP therapy is effective for malignant lymphoma, the optimum schedule for elderly patients remains controversial. The present study investigated the usefulness of reduced-dose CHOP therapy for elderly patients. Previously untreated patients aged 65 years or older with intermediate to high-grade non-Hodgkin's lymphoma were given up to 6 courses of reduced-dose CHOP therapy at 3-week intervals. Group A patients were given (5/6) of the standard dose and Group B received 7/12 of the standard dose. Filgrastim was administered when the white blood cell count fell below 2,000/microL. Fifty-seven patients were evaluable and the scheduled therapy was completed in 37. For patients aged from 65 to 79 years and for patients older than 80 years, the complete response rate was 79.5% and 46.2%, overall 3-year survival was 58.2% and 30.4%, and event-free 3-year survival was 49.3% and 44.4%, respectively. Major toxicities (> or = grade 3) included leukopenia in 42 patients and documented infection in 7 patients. Grade 3 cardiac plus renal failure, grade 3 peritonitis due to small bowel perforation, and grade 3 liver dysfunction occurred in 1 patient each. One patient died of toxicity (grade 4 hematological toxicity and pneumonia). In conclusion, it seems that in the elderly patients with non-Hodgkin's lymphoma, response to reduced-dose ((5/6) dose) CHOP therapy is comparable to that for standard CHOP in younger adults, mainly because of improved dose-intensity.

The Influence of advanced age on the treatment and prognosis of diffuse large-cell lymphoma (DLCL)

The incidence of non-Hodgkin's lymphoma (NHL) in elderly patients has increased in recent years. Approximately 36% of elderly patients with NHL are diagnosed with diffuse large-cell lymphoma (DLCL), an aggressive lymphoma subtype. Some authors have suggested that lymphoma in the elderly is intrinsically different from that seen in younger patients. Diffuse large-cell lymphoma, for example, is curable in about 50% of patients younger than 65 years of age but has a significantly lower cure rate in older subjects. Elderly patients with DLCL represent a group that is difficult to treat because of comorbidity, diminished organ functions, altered drug metabolism, and irregular drug clearance rates. These factors must be carefully considered when evaluating treatment options for older patients. The quality of life (QOL) associated with various regimens should obviously be evaluated, though QOL has so far received little attention in clinical trials. Analyses of the results from numerous phase II and phase III trials in patients with advanced aggressive NHL have demonstrated that overall survival is reduced when chemotherapy regimens more toxic than CHOP (cyclophosphamide/doxorubicin/ vincristine/prednisone) are employed, whereas therapeutic regimens that are less toxic are often less effective. CHOP, therefore, may be regarded as the current gold standard of therapy for elderly patients with DLCL. The addition of granulocyte colony-stimulating factors to CHOP chemotherapy is recommended to limit myelosuppression. Intensive chemotherapy followed by autologous stem cell transplantation has recently been extended to patients older than 60 years, with encouraging results, albeit in a highly selected groups of patients. Other promising lymphoma treatments with improved toxicity profiles are being developed. Clinical trials are recommended to determine if these new therapies are safe and active in elderly patients with DLCL.

Cemp, a mitoxantrone containing combination, in the treatment of intermediate and high grade non-hodgkin's lymphoma: an effective and non toxic therapeutic alternative for adult and elderly patients

Here we report the results of a randomised multicenter phase III clinical trial which assesses the therapeutic efficacy and tolerability of a chemotherapy protocol CEMP (cyclophosphamide, etoposide, mitoxantrone and prednisone) in adult and elderly patients with advanced intermediate and high-grade NHL. Between October 1991 and October 1995, 139 patients, aged 55 to 79 years, with diffuse intermediate and high-grade lymphoma, were enrolled. A considerable percentage of patients had clinically aggressive disease: 32.4% had systemic symptoms, 79% had stage III or IV disease, 33.8% had bone marrow involvement, 46% had splenic involvement and 42.5% had increased values of serum lactate dehydrogenate. Complete remission was achieved in 70 of the 139 patients (51.9%) and PR in 12 (16.6%) with an overall response of 68.5%. The overall response survival rate at 6 years was 39%, whereas DFS rate was 48.7% and PFS rate was 28.5%. At four years 49% of the patients were still in CR. Dividing the patients in two groups, under and over 65 years of age, we obtained the same results as far as overall response is concerned. No toxic deaths occurred, neither cardiac, renal nor liver complications happened. CEMP regimen is an effective and safe protocol with good results in elderly people, well comparable to those achieved in younger ones.

CHOP chemotherapy with preemptive granulocyte colony-stimulating factor in elderly patients with aggressive non-Hodgkin's lymphoma: a dose-intensity analysis

This prospective trial was designed to determine the safety and efficacy of full-dose, on-time chemotherapy in elderly patients with aggressive non-Hodgkin's lymphoma. Twenty patients (median age, 71 years; range, 66 to 80 years) were enrolled in a phase II, multicenter trial to receive cyclophosphamide/doxorubicin/vincristine/prednisone (CHOP) supported by granulocyte colony-stimulating factor (G-CSF). CHOP was given in standard doses. Six cycles were planned every 21 days, with G-CSF starting on day 3 and continuing until the absolute neutrophil count was greater than 10,000/microL. Consolidation radiation therapy was permitted. Restaging was performed following cycles 4 and 6. By the age-adjusted International Prognostic Index, four patients were low, 10 were low-intermediate, four were high-intermediate, and two were high risk. Eighteen cases completed all 6 cycles. The average cycle length for all 112 cycles was 21.7 days. The dose intensities (corrected for delay) for each agent were cyclophosphamide 97.3%, doxorubicin 97.3%, vincristine 91.5%, and prednisone 97.3%. Treatment-related complications included grade 4 leukopenia and grade 4 thrombocytopenia in 11.6% and 3.6% of cycles, respectively. Hospitalization for neutropenia and fever was needed for 7.1% of cycles. There was no grade 3/4 cardiac toxicity. No treatment-related mortality occurred. All toxicities were reversible. There were 12 (60%) complete responses, four (20%) gallium-negative partial responses, and four patients (20%) with progressive disease. With a median follow-up of 2.29 years, progression-free and overall survival rates at 2 years are 42% (90% confidence interval: 23%-61%) and 66% (90% confidence interval: 47%-85%), respectively. Using preemptive G-CSF, full-dose CHOP can be administered safely to elderly patients.

The management of adult aggressive non-Hodgkin's lymphomas

Aggressive non-Hodgkin's lymphona include diffuse large B-cell lymphoma, anaplastic large cell lymphona, and different peripheral T-cell lymphomas. An international prognostic index has been developed including age, serum LDH, performance status, and extranodal involvement. For localized aggressive lymphoma, the preferred treatment is 3-4 CHOP and radiation therapy, with a cure rate of 70-80%. For disseminated aggressive lymphoma, current regimens have a cure rate of less than 40%. Innovative strategies, including dose escalation, autologus stem cell support, new drugs, and immunotherapy are being explored to improve these results.

Delivery of full dose CHOP chemotherapy to elderly patients with aggressive non-Hodgkin's lymphoma without G-CSF support

Because of evidence that failure to deliver full dose CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) may compromise the outcome of elderly patients with aggressive non-Hodgkin's lymphoma (NHL), we attempted to deliver full dose CHOP to these patients. The objective of this review was to assess the relative received dose intensity (ARRDI), toxicity and outcome of elderly patients treated with curative intent with CHOP at our centre. Charts were reviewed of all patients > or = 65 years with newly diagnosed aggressive NHL referred to the Toronto-Sunnybrook Regional Cancer Centre (TSRCC) for initial management from 1990-1995 before routine use of G-CSF. Sixty eligible patients were identified. 31 received CHOP +/- radiation (XRT), 9 other curative treatment and 20, palliative treatment. The mean ARRDI calculated on 29/31 patients receiving CHOP was .86; 41%=1.0, 24%=.90-.99, 14%=.75-.89 and 21%=<.75. During 141 cycles of CHOP. 17 (12%) episodes of febrile neutropenia (FN) occurred in 14 (45%) patients and other grade 3/4 toxicity occurred in <10% of patients. There were 3 (10%) toxic deaths. Sixteen (52%) patients required a total of 29 admissions to hospital for FN (59%) or other causes. Of the 31 patients, 16 (52%) achieved a complete remission (CR), 7 (23%) a partial remission-1 (PR-1), 2 (6%) a partial remission-2 (PR-2), 1 (3%) had no response (NR), 2 (6%) had progressive disease and 3 (10%) were not evaluable (NE). The median progression free survival (PFS) and overall survival (OS) were (16+) months and (24.5) months respectively. We found that physician biases resulted in the selection of; younger patients (median 71 vs. 80 years), patients with a better ECOG performance status (> or =2, 13% vs. 50%) and patients with less co-morbid illness (42% vs. 90%) for attempt at curative treatment with CHOP chemotherapy. Age was never the sole reason for offering palliative treatment. In conclusion, a subset of patients over the age of 65 with aggressive NHL, who have a good performance status and minimal co-morbid illness can tolerate full dose CHOP chemotherapy without G-CSF support. Future strategies should emphasize full dose treatment with curative intent with minimization of both hematologic and non-hematologic toxicity. Clinical studies are required to determine whether routine G-CSF support will reduce toxicity or improve outcome in this group of patients.

Intermediate and high grade non Hodgkin's lymphoma in the elderly

Many malignant tumors develop in the later years of life. One of malignancies that frequently occurs in older patients is non Hodgkin's lymphoma (NHL) with a median age at diagnosis over 60 years. The overall incidence of NHL has increased over the past decade and is expected to continue to rise in developed countries. So NHL will be diagnosed more in the future. In this review we discuss epidemiology, etiology, possible differences in tumor characteristics compared with younger NHL patients, treatment and treatment results in elderly NHL patients.

Treatment of non-Hodgkin's lymphoma in the elderly: an update

Recent studies specifically directed toward assessing the outcome of older patients with non-Hodgkin's lymphoma (NHL) indicate that age per se is an important and independent prognostic factor for response and survival. We report a review of the clinical trials of the literature and the Aviano Group experience in the treatment of NHL in the elderly. Prospective studies have addressed therapeutic approaches in these patients. Direct comparison of trial results is difficult since different age limits were set for the inclusion of patients under study. These studies suggest that older patients with aggressive NHL should be treated with curative intent.

Pathological and immunophenotypic features of adult non-Hodgkin's lymphomas by age group

To elucidate age-related differences in non-Hodgkin's lymphoma (NHL), the authors evaluated 950 consecutive, human immunodeficiency virus-negative patients (age range, 15 to 96 years) observed between July 1988 and June 1995 in the same Italian cancer institute. Patients were grouped into six age groups and cross-tabulated by Working Formulation (WF) categories and other newly recognized entities according to the Revised European American Lymphoma (REAL) classification, cell immunophenotype, and nodal or extranodal location. There was a tendency of the low-grade category to increase with increasing age (16.8% in the age group 15 to 34 years to 32.4% in the age group 65 to 74 years), although a subsequent decline was seen at age 75 years or older (23.2%). Also the intermediate-grade category was more frequent in the elderly (46.6% and 49.4% at 65 to 74 years and at 75 years or older, respectively). High-grade category showed compared with low and intermediate grade ones, a significant downward trend with age (X2 for trend = 25.31; P < .001), interrupted in only the oldest age group. The relative excess of low-grade NHL in patients older than 55 years. of age was accounted for by the high proportion of small lymphocytic lymphomas, which, however, somewhat declined at age 75 years or older. Conversely, the relative excess of high-grade NHL below age 35 years chiefly derived from the high percentage (28.4%) of CD30-positive anaplastic large cell lymphomas. B- and T-cell lymphomas accounted for 85.9% and 9.0% of all cases, respectively. B- and T- and non-B, non-T-cell and histiocytic NHL accounted for the remaining 5.1%. A highly significant trend of increase in the proportion of B-cell lymphomas with age increase was noted (X2 for trend = 21.90; P < .001); chiefly attributable to the excess of T-cell (15.1%) and undetermined phenotype (18.6%) in patients younger than 35 years of age. Extranodal location was not significantly related to age groups. Thus, the present study showed some interesting differences in NHL morphology and cell phenotype according to age, avoiding, at the same time, the arbitrariness of patients' dichotomization into elderly and nonelderly.

Treatment of aggressive non-Hodgkin's lymphoma in adults--are we doing any better?

Great improvement in the treatment of patients with aggressive non-Hodgkin's lymphoma (NHL) has been obtained with the introduction of new combination chemotherapy regimens in the 1970s. The hope that there would be further improvement has waned during recent years due to the fact that some controlled studies did not reveal any better results using the new more intensive treatment regimens. This is the reason for the question: are we doing any better?

Effect of granulocyte colony-stimulating factor administration in elderly patients with aggressive non-Hodgkin's lymphoma treated with a pirarubicin-combination chemotherapy regimen. Groupe d'Etudes des Lymphomes de l'Adulte

PURPOSE

Results of a multidrug chemotherapy regimen consisting of cyclophosphamide, pirarubicin, teniposide, and prednisolone (CTVP) plus subcutaneous granulocyte colony-stimulating factor (G-CSF) in elderly patients with aggressive non-Hodgkin's lymphoma (NHL) are reported.

PATIENTS AND METHODS

Between January and December 1992, 46 previously untreated patients older than 69 years with intermediate- and high-grade NHL received cyclophosphamide 750 mg/m2, teniposide 75 mg/m2, pirarubicin 50 mg/m2 day 1, and prednisolone 40 mg/m2 days 1 to 3. G-CSF, 5 micrograms/kg/day, was administered from day 4 up to day 14 or when the absolute neutrophil count reached 5 x 10(9)/l. Six cycles were scheduled every 3 weeks.

RESULTS

Grade 3 or grade 4 neutropenia complicated 22% and 26% of chemotherapy cycles, respectively. Fever or/and clinical infection were observed in 4% and 14% of cycles. One toxic death related to a septic shock occurred. Eight cycles (4%) were delayed with a median duration of 7 days. Administered median dose intensity was 93.5%. Objective response rate was 74% and 46% of the patients achieved a complete response. The 2-year overall survival and event-free survival rates were 47% and 28%.

CONCLUSION

In comparison with a previous group of patients treated with CTVP, G-CSF allows delivery of chemotherapy with a reduced neutropenia-induced morbidity in an outpatient setting in elderly patients with aggressive NHL without modifying response rate or survival.

A retrospective analysis of treatment outcome in 106 cases of localized gastric non-Hodgkin lymphomas. Danish Lymphoma Study Group, LYFO

197 cases of gastric lymphoma were reported to a population-based Danish registry of non-Hodgkin's lymphomas. 106 of these cases were localized, representing stages IE and II1E, and were analyzed retrospectively, using Cox regression analysis. 67 had surgical resection, 51 chemotherapy, and 55 radiotherapy, or combinations thereof. No type of treatment showed any superiority as regards survival (p = 0.13). Overall 5-year survival was 67%. The pretherapeutic presence of fever or S-LDH-elevation had a far more significant influence on survival than histology or any of the treatments or treatment combinations. Surgical resection was associated with a significantly higher risk of late complications than radiotherapy, suggesting that radiotherapy may be preferable to surgery as the primary treatment in localized gastric lymphoma. It could not be determined from the available data whether the addition of chemotherapy to the primary treatment provides any survival benefit.

High grade non-Hodgkins lymphoma in the elderly--12 year experience in the Grampian Region of Scotland

A retrospective examination of patients with high grade non-Hodgkin's lymphoma (HG NHL) presenting in the Grampian Region of Scotland from 1980-1992 was undertaken to determine the disease characteristics and outcome in patients over the age of 60 years at diagnosis. This group of patients was found to account for 68 per cent of HG NHL presenting in this region. No difference in clinical stage or histology was noted compared to their younger counterparts. The elderly had a significantly poorer survival with an increase in lymphoma-related and unrelated deaths. On Cox regression analysis the main survival advantage was conferred by completion of 'radical' treatment; elderly patients who were given 'radical' therapy had a median survival of 50 months compared to median survival of 10 months in the 'non-radical' group. Patients who had a good performance status at diagnosis had also a significant survival advantage. Histology, clinical stage at diagnosis and age over 60 had no independent significant effect on survival. Not all the factors that resulted in 'non-radical' therapy being given are explicable but we conclude that 'radical' therapy is achievable in 50 per cent of patients over the age of 60 years with an effective outcome and should be pursued in the elderly when the condition of the patient allows.

Non-Hodgkin's lymphoma in Saskatchewan. A review of 10 years' experience

BACKGROUND

The incidence and treatment of non-Hodgkin's lymphoma (NHL) have changed in recent years. This study was intended to compare current features with a previous study (1966-1975) and assess the impact of these changes in our jurisdiction.

METHODS

Clinical features and treatment of 547 patients with NHL registered at our center from January 1980 through December 1989 were reviewed, including reassessment of histologic type in each patient. Multivariate analysis of potential pretreatment prognostic factors was performed using the Cox proportional hazards model, and survival was analyzed in relation to treatment outcome.

RESULTS

This review includes virtually all incident cases of NHL in a defined geographic area, representing an average annual incidence of 11.3/100,000 population. The male-to-female ratio was 1.1:1, median age was 65 years (range, 4-92 years). Median survival time (MST) of 482 patients with disease diagnosed antemortem was 4.8 years (95% confidence interval [CI], 3.7-6.1 years), 52% of whom have died. Thirty-nine percent of patients with disease classified by the International Working Formulation (IWF) had low-grade disease (MST, 103 months); 27% had intermediate disease (MST, 62 months), and 30% had high-grade disease (MST, 35 months). Sixteen percent of patients had associated neoplasms: 4 acute leukemias, 35 skin cancers, and 37 miscellaneous solid tumors. Results of radiation therapy (RT), chemotherapy (CT), and combined CT/RT were analyzed. Survival correlated strongly with responsiveness to treatment. Considering all patients treated with CT, anthracycline-containing CT was associated with the highest response rate, and survival time (more than 48 months) may have been affected by the addition of this agent. A survival advantage for patients with bulky Stage I and II disease treated with consolidative RT after CT is suggested, but not for more advanced stage disease. The proportional hazards model identified histologic type, disease stage, patient age, hemoglobin level, lactate dehydrogenase (LDH) level, bulky abdominal disease, and systemic "B" symptoms as significant independent prognostic factors influencing survival.

CONCLUSIONS

The incidence of NHL has increased, and the survival of patients with high-grade disease has improved significantly since the previous study. A high incidence of other associated malignancies was demonstrated in this group of patients with NHL. Recognition of prognostic factors should permit a rational application of innovative treatments for patients in unfavorable prognostic categories.

Non-Hodgkin's lymphoma in elderly patients: a phase II study of MCOP chemotherapy in patients aged 70 years or over with intermediate- or high-grade histology

During the period 1 January 1988 to 31 July 1991, 74 patients were seen with intermediate- or high-grade non-Hodgkin's lymphoma who were aged 70 years or over. Of these 74 patients, 20 were treated with radiotherapy alone, and 46 were judged as suitable for treatment with the chemotherapy regime MCOP (mitoxantrone, cyclophosphamide, vincristine and prednisolone). Involved field radiotherapy (35-40 Gy in 20 fractions over 4 weeks) was given to 14 of the 21 patients with stage IA and IIA disease, and 6 of the 25 patients with stage III and IV disease after completion of chemotherapy. The complete response rate was 63% at the completion of all treatment (6 months), and 39% at 12 months. There were no treatment-related deaths, and the 3-year cause-specific survival was 26% (overall survival 21%). For patients aged 70-75 years, the 3-year cause-specific survival was 34% in comparison to 17% for those patients aged 76-93 years. The chemotherapy was well tolerated by those patients aged 70 years and over, 70% of the patients did not vomit and no patients had significant vincristine neuropathy. There were only four infections associated with neutropenia. All patients completing six cycles had moderate, patchy alopecia. This MCOP regime is suitable for patients aged 70 years and over with intermediate- and high-grade non-Hodgkin's lymphoma. The survival of patients is comparable to that obtained with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisolone) with less apparent toxicity.

Incidence, presenting features and prognosis of low-grade B-cell non-Hodgkin's lymphomas. Population-based data from a Danish lymphoma registry

During the period January 1983 to January 1988 1597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Western Danish population-based NHL registry. Of these, 31% (N = 496) were low-grade NHL (LG-NHL) consisting of (Kiel): 9% lymphocytic (LY), 27% lymphoplasmacytic/-cytoid (IC), 53% follicular centroblastic/-centrocytic (CB/CCf) and 11% unclassifiable low-grade. LG-NHL (age range: 26-94 yrs, median: 64 yrs; M/F ratio: 0.8) had an age-standardised incidence rate (IR) of 2.7/10(5)/yr. Age-specific IR's showed an age-related exponential rise in all subtypes except for CB/CCf. Compared with the intermediate (IG)- and high-grade (HG) group, LG-NHL had more female cases (M/F ratio: 0.79 vs. 1.2; p = 0.0002), a higher frequency of stage III-IV disease (66% vs. 53%; p < 0.00005) and of bone marrow involvement (39% vs. 19%; p < 0.00005). A later revision of all IC cases (N = 132) distinguished 79 non-polymorphic (ICnp) from 25 polymorphic (ICp) cases; 28 cases were differently classified. In 34 LG-NHL patients histologic transformation was verified: CB/CCf to CB diffuse (22 pts) and LY to immunoblastic or CB type (6 pts). The 7-yr survival for LG-NHL was 63% (IG: 48%, HG: 38%; p < 0.00005). A Cox-regression analysis identified the following adverse prognostic factors for survival in LG-NHL: age > 50 with a relative risk (RR) of 3.2, hepatic involvement (RR = 2.1), elevated s-LDH (RR = 1.9), B-symptoms (RR = 1.8) and IC histology (ICnp+ICp) (RR = 1.7).(ABSTRACT TRUNCATED AT 250 WORDS)

Cancer in the elderly

This article reviews geriatric oncology and assesses options for treatment and care of the elderly patient with cancer. The size of the population over 65 years old is defined, with particular reference to the continuing growth of this subsection of the community. The high incidence of many cancers and their associated mortality rates in the elderly are identified and the epidemiology of such diseases in the geriatric population is addressed. Given the discrepancies in incidence and survival rates between patients younger and older than 65 years, the association between tumorigenesis and the aging process is explored. Specific aspects of tumor growth in the elderly are considered. General considerations of therapy for elderly patients with cancer are discussed, including the pharmacokinetics and pharmacodynamics of chemotherapy in those over 65 years old, surgical options, the use of radiotherapy, and overall patient assessment. Next, treatment options for individual cancer states are reviewed, with particular emphasis on newer treatment options designed specifically for the elderly. Sections on cancer screening and supportive care are also included, the latter dealing with aspects of symptom control, quality of life assessment, and the physical and psychologic rehabilitation of the elderly patient with cancer who is undergoing treatment. Conclusions are then drawn as to the extent of the oncological process in those over 65 years old, with particular emphasis on the underdiagnosis and undertreatment of many malignancies in the past. The challenge created by the growing elderly population is underscored and necessary plans of action for oncologists in the future are defined. Such proposals are necessary if inroads are to be made into the unacceptable morbidity and mortality rates borne by our elderly patients with cancer.