Discordant bone marrow involvement in diffuse large-cell lymphoma: a distinct clinical-pathologic entity associated with a continuous risk of relapse

Prognostic value of metabolic tumor volume of extranodal involvement in diffuse large B cell lymphoma

Extranodal involvement predicts poor outcomes of diffuse large B cell lymphoma (DLBCL), but the impact of the metabolic tumor burden (MTV) of extranodal sites using positron emission tomography has not been clarified. This study aimed to assess the impact of extranodal MTV on overall survival (OS). We retrospectively analyzed 145 newly diagnosed DLBCL patients and verified the prognostic impact of each extranodal and nodal MTV. Multivariate Cox hazards modelling using both extranodal and nodal MTV as covariables identified extranodal MTV as a significant factor for OS (hazard ratio [HR] 1.072, 95% confidence interval [CI] 1.019-1.129, P = 0.008), but not nodal MTV. Multivariate Cox modelling using restricted cubic splines demonstrated that the impact of total MTV depends on the MTV of extranodal sites, not of nodal sites. When both the number and MTV of extranodal involvements were used as covariables, extranodal MTV remained a significant predictor of OS (HR 1.070, 95%CI 1.017-1.127, P = 0.009), but the number of extranodal sites did not. Extranodal MTV potentially had a more significant role on prognosis than nodal MTV. When considering prognostic impacts, the MTV of extranodal involvement is significantly more important than the number.

Prognostic Value of Accumulative Expression of COX-2 and p53 in Small and Diffuse Large B Cell Lymphoma

Cyclooxygenase-2 (COX-2) plays an important role in carcinogenesis, which catalyzes the conversion of arachidonic acid into prostaglandins. P53 is a tumor suppressor gene that contributes to apoptosis and cell cycle control. There is functional interaction between p53 and COX-2, which lead to abrogation of apoptosis and progression of malignancy. To assess the relationship between COX-2, p53 expression and the clinicopathololgic features in SLL and DLBCL. We immunohistochemically examined the expression of COX-2 and p53 in non-neoplastic lymphoid cells, lymph nodal low-grade (50 cases of SLL), intermediate and high-grade lymphomas (100 cases of DLBCL) and their corresponding bone marrow specimens. The expression of COX-2 and p53 was absent in the in non-neoplastic lymphoid cells. In contrast, their expression values increased progressively with the advancing grade of lymphoma (p < 0.001). COX-2 expression was significantly associated with advanced disease stage, high-grade lymphomas, and disease relapse and p53 expression. The p53was detected in 64.5% in patients positive for COX-2. The expressions of COX-2 and p53 proteins, were significantly associated with shorter overall-survival and progression free survival. Here we report up-regulation of COX-2and p53 protein expression in SLL and DLBCL indicating their interactive involvement in the pathogenesis of lymphoma. Our data provide a rationale for further investigation of COX-2 expression in lymphomas for potential prognostic, chemopreventive and chemotherapeutic purposes.

Prognostic impact of germinal center B-cell-like and non-germinal center B-cell-like subtypes of bone marrow involvement in patients with diffuse large B-cell lymphoma treated with R-CHOP

The prognostic significances of the germinal center B-cell-like (GCB) and non-germinal center B-cell-like (non-GCB) types of diffuse large B-cell lymphoma (DLBCL) have been reported to be different. We analyzed the effect of the cell of origin (COO) of bone marrow (BM) involvement in patients with DLBCL who were treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) in a single institute.The subtype of BM involvement was evaluated in 633 patients who were diagnosed with primary DLBCL and had been treated with R-CHOP. BM trephine biopsies were analyzed, and immunohistochemical staining of CD20, CD79a, and CD3 was performed. Additional staining of CD10, Bcl-6, and MUM1 was performed to determine the COO based on a previously reported algorithm.BM involvement was present in 81 patients (12.8%). Among them, 30 patients (37.0%) had GCB-type BM involvement and 51 (63.0%) showed non-GCB-type involvement. Kaplan-Meier survival analysis showed that the non-GCB type had the worst progression-free survival (PFS) and overall survival (OS) (P <.001). In multivariate analysis controlled for the International Prognostic Index (IPI) score, non-GCB type was an independent predictor of PFS (P <.004) and OS (P =.042), whereas GCB type was not a prognostic factor independent of the IPI score.Further prognostication based on the COO of BM involvement is a useful indicator of PFS, independent of IPI score. Accurate staging based on the COO should be included in the examination of BM in DLBCL.

Angioimmunoblastic T-cell lymphoma: a prognostic model from a retrospective study

Angioimmunoblastic T-cell lymphoma (AITL) is a distinct subtype of peripheral T-cell lymphoma with unique clinical and pathological features. This study aim to design a prognostic model specifically for AITL, providing risk stratification in affected patients. A total of 115 newly diagnosed AITL patients were retrospectively analyzed. The estimated five-year overall survival (OS) rate for all patients was 45.4%. Multivariate analysis found prognostic factors for survival were bone marrow involvement, number of extranodal sites >1, and performance status >1. We categorized three risk groups: group 1, no adverse factor; group 2, one factor; and group 3, two or three factors. Five-year OS was 86.9% for Group 1, 46.3% for Group 2, and 16.2% for Group 3 (p < .0001). The novel prognostic model balanced the distribution of patients into different risk groups with better predictive discrimination as compared to the International Prognostic Index and Prognostic Index for PTCL, unless otherwise specified.

Concordant bone marrow involvement of diffuse large B-cell lymphoma represents a distinct clinical and biological entity in the era of immunotherapy

In diffuse large B-cell lymphoma (DLBCL), the clinical and biological significance of concordant and discordant bone marrow (BM) involvement have not been well investigated. We evaluated 712 de novo DLBCL patients with front-line rituximab-containing treatment, including 263 patients with positive and 449 with negative BM status. Compared with negative BM disease, concordant BM adversely impacted overall and progression-free survival, independent of the International Prognostic Index (IPI) and cell-of-origin classification. Once BM is concordantly involved, poor prognosis was not associated with the extent of BM involvement. Conversely, patients with discordant BM showed favorable overall survival similar to stage I-II DLBCL. A BM-adjusted IPI, using three parameters: concordant BM involvement, age >60 years, and performance status >1, improves the risk stratification for DLBCL with positive BM. Intensive immunochemotherapy seemingly rendered survival benefit for patients with concordant BM, as did rituximab maintenance for the discordant BM group. Frequently revealing adverse clinical and molecular characteristics, patients with concordant BM demonstrated gene expression signatures relevant to tumor cell proliferation, migration and immune escape. In conclusion, clinical and biological heterogeneity is seen in DLBCL with positive BM but concordant BM involvement represents a distinct subset with unfavorable gene signatures, high-risk clinicopathologic features and poor prognosis.

Prognostic significance of bone marrow infiltration detected by PET-CT in newly diagnosed diffuse large B cell lymphoma

The aim of this study was to examine the prognostic value of bone marrow involvement (BMI) assessed by baseline PET-CT (PET(0)-BMI) in treatment-naïve patients with diffuse large B-cell lymphoma (DLBCL). All patients from a single centre diagnosed as DLBCL between 2005 and 2014 had data extracted from staging PET-CT (PET(0)-CT), bone marrow biopsy (BMB), and treatment records. The PET(3)-CT (PET-CT scan after cycle 3 of immunochemotherapy) was performed on all the patients with PET(0)-BMI positivity (PET(0)-BMI(+)). Of 169 patients, 20 (11.8%) had BMI on BMB, whereas 35 (20.7%) were PET(0)-BMI positive. Among PET(0)-BMI(+) patients, patients with maximum of standard uptake value (SUVmax) of bone marrow (SUVmax(BM)) more than 8.6 were significantly associated with high IPI score (3–5) (P=0.002), worse progression-free survival (PFS) and overall survival (OS) (P=0.025 and P=0.002, respectively). In the 68 stage IV cases, 3-year OS was higher in the patients with negative PET(0)-BMI (PET(0)-BMI(−)) than that with PET(0)-BMI(+) (84.2%±6.5% vs. 44.1%±8.6%; P=0.003), while 3-year PFS only shown a trend of statistic significance (P=0.077) between the two groups. Among the 69 patients of inter-risk of IPI (2–3), patients with PET(0)-BMI(+) had significantly inferior PFS and OS than that with PET(0)-BMI(−) (P=0.009 and P<0.001, respectively). The cut-off value of the decreased percentage of SUVmax(BM) between PET(0)-CT and PET(3)-CT (ΔSUVmax(BM)) was 70.0%, which can predict PFS (P=0.003) and OS (P=0.023). These data confirmed that along with the increased sensitivity and accuracy of identifying bone marrow by PET-CT, novel prognostic values of marrow involvement were found in patients with DLBCL.

Discordant bone marrow involvement in non-Hodgkin lymphoma

A discordant lymphoma occurs where 2 distinct histologic subtypes coexist in at least 2 separate anatomic sites. Histologic discordance is most commonly observed between the bone marrow (BM) and lymph nodes (LNs), where typically aggressive lymphoma is found in a LN biopsy with indolent lymphoma in a BM biopsy. Although the diagnosis of discordance relied heavily on histopathology alone in the past, the availability of flow cytometry and molecular studies have aided the identification of this entity. The true prevalence and clinical ramifications of discordance remain controversial as available data are principally retrospective, and there is therefore little consensus to guide optimal management strategies. In this review, we examine the available literature on discordant lymphoma and its outcome, and discuss current therapeutic approaches. Future studies in discordant lymphoma should ideally focus on a large series of patients with adequate tissue samples and incorporate molecular analyses.

Significance of clinical factors as prognostic indicators for patients with peripheral T-cell non-Hodgkin lymphoma: A retrospective analysis of 252 cases

The aim of this study was to retrospectively analyze the significance of different clinical factors for predicting the prognosis of patients with peripheral T-cell non-Hodgkin lymphoma (PTCL) with a median follow-up of 23 months. A total of 252 PTCL patients admitted to the First Affiliated Hospital of the School of Medicine of Zhejiang University between 2005 and 2011 were retrospectively reviewed. At a median follow-up of 23 months, the overall survival (OS) rate was 23.8%. Our results revealed that the presence of B symptoms (P<0.001), Eastern Cooperative Oncology Group (ECOG) score ≥2 (P<0.001), bone marrow involvement (BMI) (P<0.001), elevated lactate dehydrogenase (LDH) levels (P<0.001), elevated β2-MG levels (P<0.001), Ann Arbor stages III/IV (P=0.007) and International Prognostic Index (IPI) ≥3 (P=0.001) were poor prognostic factors for OS and intensive chemotherapy achieved a better OS outcome compared to the CHOP treatment. In conclusion, elevated LDH and β2-MG levels, B symptoms, Ann Arbor stages III/IV, BMI, high IPIs and high ECOG scores predict an unfavorable prognosis for PTCL patients. Compared to the conventional CHOP regimen, the intensive chemotherapy treatment may improve the prognosis of PTCL patients.

Transformation of Indolent B-Cell Lymphomas

Histologic transformation (HT) to an aggressive lymphoma is a well-described event in the natural history and clinical course of patients with so-called indolent lymphomas. This phenomenon has been studied most extensively in patients with follicular lymphoma and subsequent transformation to a diffuse large B-cell lymphoma, with little literature on HT in nonfollicular lymphomas. Despite a considerable body of information on the pathologic and molecular events associated with HT, its pathogenesis has remained elusive and the molecular information available has not been translated into clinical advances. It remains unclear if there is already a predisposition to HT and whether this can be detected at the time of diagnosis. The rituximab era has been characterized by a significant improvement in the prognosis of patients with B-cell lymphomas, but HT remains one of the most important challenges in the management of patients with indolent lymphoma, the difficulties starting with the diagnosis and definition of HT and ending with the appropriate management and treatment of the event. Going forward, it is crucial to incorporate HT as a major end point in clinical trials and to include patients with HT as subject of such studies if we are to see meaningful progress in the future.

Impact of Concordant and Discordant Bone Marrow Involvement on Outcome in Diffuse Large B-Cell Lymphoma Treated With R-CHOP

Purpose

In diffuse large B-cell lymphoma (DLBCL), prior studies suggest that concordant bone marrow involvement with DLBCL portends a poorer prognosis, whereas discordant bone marrow involvement with small B-cell lymphoma does not. We examined the significance of bone marrow involvement in patients treated in the current era of therapy including rituximab.

Patients and Methods

We performed a retrospective analysis of the prognostic impact of bone marrow involvement in an unselected population of patients with newly diagnosed DLBCL treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone in British Columbia and Auckland, New Zealand, with complete clinical information and evaluable staging bone marrow biopsies.

Results

In total, 795 patients were identified. Six hundred seventy (84.3%) of 795 had a negative bone marrow, 67 patients (8.4%) had concordant and 58 (7.3%) had discordant involvement. Median follow-up was 41 months (range, 1 to 115). Progression-free survival (PFS) was inferior in those with concordant (P < .001) and discordant (P = .019) involvement while overall survival (OS) was inferior in those with concordant involvement (P < .001) only. In a multivariate analysis controlling for the International Prognostic Index (IPI) score, concordant involvement remained an independent predictor of PFS (P < .001) and OS (P = .007). Discordant involvement was associated with older age, elevated lactate dehydrogenase, advanced stage, and increased number of extranodal sites and was not a negative prognostic factor independent of the IPI score.

Conclusion

The negative prognostic impact of discordant involvement is adequately represented by the IPI score, while the risk with concordant involvement is greater than that encompassed by this predictor. The results emphasize the need for accurate staging assessment of bone marrow involvement in DLBCL.

Lymphoma recurrence 5 years or later following diffuse large B-cell lymphoma: clinical characteristics and outcome

PURPOSE Patients with diffuse large B-cell lymphoma (DLBCL) usually relapse early following diagnosis but some relapses happen at 5 years or later. Few data exist regarding clinical characteristics and outcome of these patients. PATIENTS AND METHODS We performed a retrospective analysis of all patients from two centers in Lyon, France, between 1985 and 2003 who had a biopsy-proven relapse 5 years or later following diagnosis of DLBCL. All available biopsies were reviewed and immunohistochemistry was completed. Results Among 1,492 patients with DLBCL, 54 were eligible. At diagnosis, 63% of patients had stage I-II, 82% had low/low-intermediate International Prognostic Index (IPI) score, 65% had extranodal involvement, 24% had an indolent component associated with DLBCL, 57% had germinal center phenotype, and 43% had non-germinal center phenotype. Median time from diagnosis to relapse was 7.4 years (range, 5 to 20.5 years). At time of relapse, 83% had DLBCL histology, and 17% had indolent histology. Having an indolent component at diagnosis was associated with indolent histology at relapse (P = .028). Five-year event free-survival (EFS) was 17% for patients with DLBCL relapse and 61% for patients with indolent relapse (P = .027). Five-year overall survival was 27% for patients with DLBCL and 75% for patients with indolent relapse (P = .029). For DLBCL relapse, 3-year EFS was 56% versus 18% with autologous stem-cell transplantation or not, respectively (P = .0661). CONCLUSION Patients with DLBCL who had a late relapse usually had localized stage, favorable IPI score, and extranodal involvement at diagnosis. The outcome of patients with DLBCL at time of relapse remains poor, and aggressive treatment such as autologous stem-cell transplantation should be pursued whenever possible. Biopsy at relapse is essential because some patients relapse with indolent histology.

Low levels of monoclonal small B cells in the bone marrow of patients with diffuse large B-cell lymphoma of activated B-cell type but not of germinal center B-cell type

BACKGROUND

Multiparameter flow cytometry allows the detection of minor monoclonal B-cell populations. Using this technique combined with morphology, we were struck by the presence of minor populations of small monoclonal B cells in bone marrows of patients with diffuse large B-cell lymphoma in routine diagnostic samples and performed a systematic retrospective study.

DESIGN AND METHODS

Bone marrows of 165 patients with primary diffuse large B-cell lymphoma without histological evidence of concurrent non-Hodgkin's lymphoma were studied by routine microscopy of trephines and smears, immunohistochemistry and multiparameter flow cytometry.

RESULTS

Diffuse large B-cell lymphoma infiltration in marrows was documented in 11 of 165 patients. Morphological examination consistently revealed a higher tumor load than evidenced by flow cytometry. Of interest, only 3 of 119 patients with diffuse large B-cell lymphoma not otherwise specified, the largest subtype, showed marrow infiltration. By contrast, flow cytometry revealed a minor monoclonal B-cell population in 24 of 165 patients, none of whom showed diffuse large B-cell lymphoma infiltration by morphology. Of interest, morphological examination revealed the presence of small B cells in the marrows of those patients. Moreover, 11 of 39 (28.2%) of patients with diffuse large B-cell lymphoma not otherwise specified of ABC subtype and only 3 of 80 (3.7%) with the GCB subtype showed these monoclonal small B cells (P=0.0002). In addition 4 of 8 (50%), 4 of 15 (26.7%) and 2 of 3 (66.7%) patients with primary testicular, primary central nervous system and leg-type diffuse large B-cell lymphoma, respectively, showed monoclonal small B cells.

CONCLUSIONS

Bone marrow infiltration with diffuse large B-cell lymphoma in patients with diffuse large B-cell lymphoma not otherwise specified is rare at diagnosis. By contrast, a high number of diffuse large B-cell lymphoma not otherwise specified of the ABC subtype but not of GCB subtype is associated with monoclonal small B cells in the marrow. Whether these monoclonal small B cells are precursors of diffuse large B-cell lymphoma of the ABC type or arise in a common background that favors clonal B-cell expansion remains to be demonstrated.

Diffuse aggressive B-cell lymphomas

Diffuse aggressive B-cell lymphomas comprise a relatively common and increasingly diverse group of neoplasms. Newer modalities including gene expression profiling and an increasing panel of immunohistochemical markers have contributed to greater accuracy in defining these entities. Attention is paid not only to the neoplastic cells but also to the cellular and stromal milieu in which they proliferate. These distinctions may have therapeutic implications as well, with improved outcome related to newer and sometimes targeted therapies. At the same time there is increasing understanding of the overlap, which occurs in the grey zone between diffuse large B-cell lymphoma and Burkitt lymphoma as well as between diffuse large B-cell lymphoma and Hodgkin lymphoma. This review aims to provide practical insights in the correct identification and differential diagnosis of these lymphomas, with emphasis on the changes that have occurred with the publication of the 2008 World Health Organization updated classification.

Concordant but not discordant bone marrow involvement in diffuse large B-cell lymphoma predicts a poor clinical outcome independent of the International Prognostic Index

In diffuse large B-cell lymphoma (DLBCL), previous studies have suggested that, while concordant bone marrow (BM) involvement confers a poor prognosis, discordant BM involvement does not. Whether this correlation is independent of the non-Hodgkin lymphoma International Prognostic Index (IPI) was previously unknown. We reviewed all DLBCL case histories from 1986 to 1997 at our center with complete staging, IPI data, and follow-up. A total of 55 (11.2%) of 489 patients had BM involvement, including 29 with concordant involvement and 26 with discordant involvement. The 55 patients with BM involvement had a poor prognosis compared with the uninvolved BM group (5-year overall survival [OS], 34.5% versus 46.9%; log-rank P = .019). However, concordant involvement portended a very poor prognosis (5-year OS, 10.3%; P < .001), whereas discordant involvement did not (5-year OS, 61.5%, P value nonsignificant). Compared with the discordant subset, the concordant subset patients were older, had a higher serum lactate dehydrogenase level, and a significantly higher IPI. However, the poor survival associated with concordant BM involvement was independent of the IPI score (P = .002, Cox regression). We conclude that in patients with DLBCL, concordant but not discordant BM involvement confers a very poor clinical outcome. Furthermore, concordant BM involvement is an independent adverse prognostic factor.

Prospective study of bone marrow infiltration in aggressive lymphoma by three independent methods: whole-body MRI, PET/CT and bone marrow biopsy

PURPOSE

Initial lymphoma staging requires bone marrow assessment in aggressive lymphomas. Bone marrow lymphoma infiltration is routinely assessed by bone marrow biopsy (BMB), considered as the "gold standard". The aim of this study was to compare the performance of BMB, whole-body MRI and PET/CT for evaluation of BM infiltration.

METHODS

Patients with newly diagnosed aggressive lymphoma were evaluated by BMB, MRI and PET/CT. Two radiologists, two nuclear medicine physicians and one pathologist independently assessed the results of the three modalities. Bone was considered as involved if BM was positive or if PET/CT or MRI was positive and if there was a resolution of the abnormal image shown on PET/CT or MRI halfway or at the end of therapy.

RESULTS

Both MRI and PET/CT detected bone marrow lesions in the 9/43 patients, but two patients with multiple lesions had more lesions detected by PET/CT compared to MRI. Among these nine patients, two with an iliac crest lesion detected by both MRI and PET/CT had bone marrow involvement with large-cell lymphoma on histological examination. The other seven patients had focal MRI and PET/CT lesions in areas other than the iliac crest, where the blind BMB was done. The other patients had bone marrow without large-cell lymphoma involvement. In all cases, after lymphoma therapy bone marrow involvement regressed on histological examination, PET and MRI.

CONCLUSION

These preliminary results suggest that non-invasive morphological procedures could be superior to BMB for bone marrow assessment in aggressive lymphomas. Ongoing study is underway to validate these results.

Diagnosis and Classification of Malignant Lymphoma and Related Entities in the Bone Marrow Trephine Biopsy

The trephine bone marrow (BM) biopsy is an important diagnostic tool in patients with malignant lymphoma. BM examination can serve to establish or confirm a primary diagnosis of lymphoma or to determine the extent of disease dissemination for staging purposes. BM histology renders information which cannot be gained equally from aspirate material, such as spacial distribution and extent of infiltrates, BM cellularity and fibrosis. Furthermore, cytology including flow cytometric immunophenotyping can give false-negative results in BM involvement by lymphoma due to intralesional fibrosis. In addition to morphological examination, the availability of a broad panel of antibodies suitable for paraffin-embedded tissues, in conjunction with less damaging decalcification procedures, nowadays enables us to perform complete immunophenotyping on BM trephines and allows for classification of lymphoma infiltrates according to established algorithms. Molecular determination of clonality and interphase fluorescent in situ hybridization can be employed selectively to resolve difficult cases. This review describes important diagnostic features of malignant lymphoma in the BM, relevant differential diagnoses, and the proper use of ancillary techniques.

Clinicopathologic Characteristics and Outcome of Diffuse Large B-Cell Lymphomas Presenting With an Associated Low-Grade Component at Diagnosis

Purpose

Some diffuse large B-cell lymphomas (DLBCL) present at diagnosis with associated morphologic features of small B-cell non-Hodgkin's lymphoma (NHL) and may arise from the transformation of a previously unknown indolent low-grade lymphoma. The characteristics and prognosis of these particular DLBCL are not well known.

Patients and Methods

The strict morphologic review of consecutive DLBCL patients diagnosed over 12 years in our department (Hematology Department, Centre Hospitalier Lyon-Sud, Lyon, France) allowed to retrieve 60 DLBCL that could be have occurred from the transformation of marginal zone B-cell NHL (32 patients), follicular NHL (22 patients), and small lymphocytic NHL (6 patients). We compared them to 180 matched patients of de novo DLBCL.

Results

Patients median age was 55 years and presented the following clinical characteristics: poor performance status in 33%, disseminated disease in 97%, more than one extranodal site in 50%, and increased lactate dehydrogenase level in 55%. Complete remission with multidrug chemotherapy regimens was achieved in 60% of the patients, but 48% relapsed: 28% with aggressive and 20% with indolent histology, respectively. Overall survival (OS) and freedom-from-progression rates at 5 years were 57% and 33%, respectively. The matched-control analysis showed that patients with transformed NHL at diagnosis had lower complete response to chemotherapy (P = .004) and higher progression rate (P = .03), whereas no difference was observed in OS (P = .21).

Conclusion

Compared to de novo DLBCL, transformed NHL at diagnosis have similar overall survival but lower complete response to initial treatment and higher risk of indolent relapses.

The prognostic impact of bone marrow involvement in patients with diffuse large cell lymphoma varies according to the degree of infiltration and presence of discordant marrow involvement

BACKGROUND

The prognostic significance of marrow involvement in diffuse large cell lymphoma (DLCL) is controversial. Factors that that have been reported to influence prognosis include the pattern and extent of marrow infiltration and histological discordance between the primary site and the bone marrow.

METHODS

Bone marrow biopsies from 172 patients with newly diagnosed DLCL entered in two consecutive trials of the Australasian Leukaemia and Lymphoma Group were analyzed. Progression-free (PFS) and overall survival (OS) were calculated according to the absence or presence of bone marrow involvement (BMI), the extent of lymphomatous infiltration and the presence of histological discordance between the primary site and the bone marrow.

RESULTS

Of 172 patients with DLCL accrued between 1982 and 1990, who were treated with CHOP or CHOP-like regimens, 47 (27%) demonstrated marrow involvement on examination of multiple levels. Seventy two percent (34/47) of patients had discordant marrow involvement (<50% large cells) and 28 had minimal (<10%) involvement; these latter patients with minimal marrow involvement (<10%) had similar PFS & OS to the 113 patients without involvement. Within the group of 47 patients with marrow involvement, an increasing percentage of BM involvement was significantly associated with an increasing percentage of concordant histology and a decreasing PFS & OS.

CONCLUSIONS

Minimal BMI, seen in the majority of patients with DLCL with marrow infiltration, appears not to influence the PFS & OS. However, an increasing degree of marrow involvement is associated with an increasing component of large cells and a poorer prognosis in DLCL patients, independent of other risk factors.

Bone Marrow Biopsy Involvement by Non-Hodgkin's Lymphoma

To evaluate the features of bone trephine biopsy involvement by non-Hodgkin lymphoma, 450 specimens were evaluated for percentage of marrow involvement, pattern of involvement, presence of germinal centers or follicular structures, and discordance with other involved sites. A subset of 197 cases was evaluated for evidence of concurrent peripheral blood involvement. Follicular grade 1 lymphoma (30.4%) was the most common type to involve the marrow, followed by diffuse large B-cell lymphoma (16.0%), mantle cell lymphoma (9.3%), low-grade B-cell lymphoma, not otherwise specified (8.7%), lymphoplasmacytic lymphoma (8.4%), follicular grade 2 lymphoma (7.1%), and mature T- and NK-cell lymphomas (6.4%). A mixed pattern of infiltration was most common, followed by paratrabecular, nodular, diffuse, and interstitial patterns. Greater than 90% of follicular lymphomas had at least a focal paratrabecular infiltration pattern, but this pattern was also seen with other lymphoma types. Interstitial disease infiltration tended to correlate with lymphoplasmacytic lymphoma but was also not specific. The presence of germinal centers or follicular structures was associated with follicular lymphoma in 88% of cases. Discordance between the bone marrow morphology and other tissue sites was observed in 24.9% of cases and was most often seen with follicular or diffuse large B-cell lymphoma. Peripheral blood involvement by lymphoma was observed in 29% of cases, found in all disease groups except for follicular grade 3 lymphoma. This study highlights the frequency of different lymphoma patterns in the marrow, limitations of primary lymphoma classification on biopsy material alone, and the relative frequency of marrow discordance and peripheral blood involvement by marrow lymphoma.

Long-term follow-up of indolent lymphoma patients treated with high-dose sequential chemotherapy and autografting: evidence that durable molecular and clinical remission frequently can be attained only in follicular subtypes

PURPOSE

To evaluate the prognostic relevance of molecular monitoring of minimal residual disease in indolent lymphomas receiving high-dose sequential chemotherapy and autografting.

PATIENTS, MATERIALS, AND METHODS

A polymerase chain reaction- (PCR-)based strategy was used to evaluate the presence of residual tumor cells in a panel of 70 indolent lymphoma patients: 40 with follicular (FCL), 14 with small lymphocytic (SLL), and 16 with mantle-cell (MCL) lymphomas. They were treated either with first-line (n = 61) or second-line (n = 9) therapy with an intensified high-dose chemotherapy program followed by peripheral-blood progenitor cells autografting. The Bcl-1, Bcl-2, and immunoglobulin gene rearrangements were used as lymphoma-specific markers. Overall, a molecular marker was obtained from the diagnostic tissue in 60 of 70 patients (86%). Results The collection of PCR-negative cells and the achievement of posttransplantation molecular remission (MR) were common in patients with FCL subtype (54% and 70%, respectively), whereas they were not frequent among SLL and MCL (25% and 12.5%, respectively) patients. With a median molecular follow-up of 75 months, an 88% incidence of relapse was observed among patients never attaining MR. In contrast, relapse incidence was only 8% among patients attaining a durable MR (P <.005). At present, 26 patients (20 with FCL and six with non-FCL) are long-term survivors in absence of clinical and molecular disease.

CONCLUSION

Our results indicate that among indolent lymphomas, FCL and non-FCL subtypes show a significantly different behavior in terms of MR achievement, and MR after intensive chemotherapy and autografting is predictive for a prolonged disease-free survival, whereas persistent PCR positivity is associated with a high risk of relapse.

Hodgkin and non-Hodgkin lymphoma involving bone marrow

The role of bone marrow examination in diagnosis and staging of patients with Hodgkin lymphoma, B-non-Hodgkin lymphoma, and T-non-Hodgkin lymphoma is reviewed. Optimal routine and specialized bone marrow examination techniques are discussed. The salient morphologic, immunophenotypic, and genetic features of mature and immature B, T neoplasms and classic Hodgkin lymphoma in bone marrow are delineated, along with recommendations to distinguish these overt neoplasms from non-neoplastic processes.

Optimum trephine length in the assessment of bone marrow involvement in patients with diffuse large cell lymphoma

BACKGROUND

The National Cancer Institute has recommended a bone marrow biopsy length of >/=20 mm for the staging and surveillance of patients with non-Hodgkin's lymphoma. However, there are few published data to support this recommendation, particularly the role of examining multiple levels.

PATIENTS AND METHODS

Bone marrow biopsies from 172 patients with newly diagnosed diffuse large cell lymphoma (DLCL) entered in two consecutive trials of the Australasian Leukaemia and Lymphoma Group were analysed. The original haematoxylin and eosin-stained trephine biopsy and two or more deeper sections cut at 0.1-0.2 mm intervals were assessed with respect to the morphology, extent and pattern of lymphomatous involvement. The rate of positive diagnosis was correlated with the length of the biopsy specimen and the number of sections examined.

RESULTS

Forty-seven biopsies (27%) demonstrated marrow involvement on examination of a mean of four trephine biopsy sections. The rate of positivity increased with the examination of multiple levels and correlated with increasing trephine length but was not dependent on the number of sites sampled. Twenty per cent of biopsies <20 mm in length were positive for lymphoma; this increased to 35% for biopsies >/=20 mm (P = 0.023).

CONCLUSIONS

Morphological bone marrow involvement in DLCL is optimally demonstrated by a 20-mm long trephine biopsy from a single site which is examined at multiple levels (four or more). This obviates the need for bilateral sampling, thereby reducing patient morbidity from the procedure. This study provides evidence to support the National Cancer Institute recommendations regarding trephine biopsy in the staging of DLCL, providing multiple levels are examined.

Discordant bone marrow involvement in diffuse large B-cell lymphoma: comparative molecular analysis reveals a heterogeneous group of disorders

Discordant bone marrow (BM) involvement in patients with a diagnosis of large-cell non-Hodgkin's lymphoma (NHL) is characterized by marrow infiltrates predominantly composed of small lymphoid cell, cytologically compatible with low-grade NHL. Although this phenomenon is well described morphologically, molecular data concerning the relationship of the two lesions are lacking. The aim of the study was to investigate the clonal relationship of discordant lymphoma manifestations by using immunoglobulin heavy chain gene (IgH), as well as bcl-2 rearrangements, as molecular markers. IgH rearrangements were amplified by PCR with consensus primers directed against framework regions 3 or 2 (FR3 and FR2), followed by automated fragment length analysis and sequencing in selected cases. Rearrangements of the bcl-2 gene were identified with primers against the major breakpoint region. Small BM infiltrates were isolated by laser capture microdissection. In addition, immunohistochemistry was performed on paraffin sections using antibodies against CD3, CD10, CD20, bcl-2, bcl-6, p53, and the Ki67 antigen. Paraffin-embedded tissues of 21 cases diagnosed as diffuse large B-cell lymphoma (DLBCL) with discordant BM involvement and no previous history of low-grade B-cell NHL were analyzed. After review of immunohistochemical stains, 5 cases were excluded either as concordant BM infiltrates by large-cell lymphoma with abundant reactive T-cells (2 cases) or as benign, reactive lymphoid infiltrates (3 cases), as confirmed by a polyclonal pattern in the IgH analysis. Of the remaining 16 cases, a common clonal origin was confirmed in 8 cases by the presence of an identical clonal IgH rearrangement or bcl-2 rearrangement. In 4 cases, identification of distinct IgH or bcl-2 rearrangements gave evidence for the presence of two clonally unrelated neoplasms. The remaining 4 cases were not evaluable for technical reasons. Morphological, phenotypical, and molecular findings were compatible with a lymphoma of germinal center origin in the majority of cases. However, in 4 cases, flow cytometric analysis of the BM infiltrates revealed a B-cell chronic lymphocytic leukemia phenotype. Two of these cases were clonally related to the DLBCL and thus represented Richter's transformation. In summary, discordant BM infiltrates in DLBCL represent a heterogeneous group of disorders, encompassing cases with a clonally related, clinically occult small-cell component, as well as cases with two clonally distinct, unrelated B-cell neoplasms presenting synchronously at different locations.

Diffuse large B-cell lymphoma: one or more entities? Present controversies and possible tools for its subclassification

Diffuse large B-cell lymphoma (DLBCL) is the commonest type of lymphoid tumour world-wide. This category was included both in the REAL and WHO Classification aiming to lump together all malignant lymphomas characterized by the large size of the neoplastic cells, B-cell derivation, aggressive clinical presentation, and the need for highly effective chemotherapy regimens. These tumours are detected as primary or secondary forms both at the nodal and extranodal levels, in immunocompetent hosts as well as in patients with different types of immunosuppression. They display a significant variability in terms of cell morphology and clinical findings, which justifies the identification of variants and subtypes. Among the latter, the primary mediastinal one does actually correspond to a distinct clinicopathological entity. Immunophenotypic, tissue microarray and molecular studies underline the extreme heterogeneity of DLBCLs and suggest a subclassification of the tumour, based on the identification of different pathogenic pathways, which might have much greater relevance than pure morphology for precise prognostic previsions and adoption of ad hoc therapies. The more recent acquisitions on the pathobiology of DLBCLs are reviewed in the light of the authors' experience, aiming to contribute to the existing debate on the topic.

Discrepancies in the immunophenotype of lymphoma cells in samples obtained simultaneously from different anatomic sites

Few studies have compared the immunophenotypic profiles of non-Hodgkin lymphoma (NHL) cells obtained simultaneously from different anatomic sites. In the present study, we compared flow cytometry immunophenotypic results in 64 consecutive NHL cases in which aspiration or biopsy of 2 sites was performed within 30 days to assess the potential discrepancy rate. In 14 cases (22%), discordant antigen expression was identified, including 4 (36%) of 11 cases with discordant morphologic features and 10 (19%) of 53 cases with concordant morphologic features in the 2 samples. Discrepancies involved 1 antigen in 10 patients and 2 antigens in 4 patients. Antigens most frequently discrepant included CD5 (n = 4), FMC7 (n = 3), and CD20 (n = 3). We conclude that the immunophenotype of NHL cells is generally stable, yet discrepancies can occur in a subset of patients. Differences in immunophenotype may relate to mechanisms of disease dissemination, influence of the microenvironment, or differential response to therapy.

Follicular large cell lymphoma: long-term follow-up of 62 patients treated between 1973-1981

PURPOSE

Investigators disagree on whether follicular large cell lymphoma (FLCL) behaves like other follicular lymphomas, with no plateau in the survival curve, or as a more aggressive but potentially curable lymphoma. We reported in 1984 results for 62 FLCL patients treated at our institution; the current report updates those results.

PATIENTS AND METHODS

Sixty-two patients referred from 1973-1981, including fifteen (24%) patients with Ann Arbor stage I-II and forty-seven (76%) with stage III-IV FLCL. Seven patients received radiation (XRT) alone, forty patients XRT and chemotherapy, and fifteen patients received chemotherapy alone.

RESULTS

The median follow-up was 14.7 years. The median survival was 5.1 years, with 21% alive at 15 years. The failure-free survival (FFS) at 10 years was 31%. Univariate analysis revealed that age, Ann Arbor stage, and the International Index correlated with survival. Performance status, number of platelets, and LDH correlated with failure-free survival.

CONCLUSIONS

FLCL responds to doxorubicin-based regimens similarly to diffuse large cell lymphoma. Patients with FLCL have the potential for prolonged failure-free survival. Variables that predict the survival in aggressive lymphomas apply as well in this type of lymphoma.

Follicular Large Cell Lymphoma: An Aggressive Lymphoma That Often Presents With Favorable Prognostic Features

It is debated whether follicular large cell lymphoma (FLCL) has a clinical behavior that is distinct from indolent follicular lymphomas, and whether there is a subset of patients who can be potentially cured. We report here our experience with 100 FLCL patients treated at our institution since 1984 with three successive programs. We evaluated the predictive value of pretreatment clinical features, including two risk models, the Tumor Score System and the International Prognostic Index (IPI). With a median follow-up of 67 months, the 5-year survival is 72% and the failure-free survival (FFS) is 67%, with a possible plateau in the FFS curve, particularly for patients with stage I-III disease. Features associated with shorter survival included age ≥60, elevated lactic dehydrogenase (LDH) or beta-2-microglobulin (β2M), advanced stage, and bone marrow involvement. Stage III patients had significantly better survival than stage IV patients (P < .05). By the IPI and Tumor Score System, 80% of the patients were in the lower risk groups; both systems stratified patients into prognostic groups. Patients with FLCL have clinical features and response to treatment similar to that reported for diffuse large cell lymphoma. Prognostic risk systems for aggressive lymphomas are useful for FLCL. A meaningful fraction of patients may possibly be cured when treated as aggressive lymphomas.

Follicular Large Cell Lymphoma: An Aggressive Lymphoma That Often Presents With Favorable Prognostic Features

It is debated whether follicular large cell lymphoma (FLCL) has a clinical behavior that is distinct from indolent follicular lymphomas, and whether there is a subset of patients who can be potentially cured. We report here our experience with 100 FLCL patients treated at our institution since 1984 with three successive programs. We evaluated the predictive value of pretreatment clinical features, including two risk models, the Tumor Score System and the International Prognostic Index (IPI). With a median follow-up of 67 months, the 5-year survival is 72% and the failure-free survival (FFS) is 67%, with a possible plateau in the FFS curve, particularly for patients with stage I-III disease. Features associated with shorter survival included age ≥60, elevated lactic dehydrogenase (LDH) or beta-2-microglobulin (β2M), advanced stage, and bone marrow involvement. Stage III patients had significantly better survival than stage IV patients (P &lt; .05). By the IPI and Tumor Score System, 80% of the patients were in the lower risk groups; both systems stratified patients into prognostic groups. Patients with FLCL have clinical features and response to treatment similar to that reported for diffuse large cell lymphoma. Prognostic risk systems for aggressive lymphomas are useful for FLCL. A meaningful fraction of patients may possibly be cured when treated as aggressive lymphomas.

High-dose therapy for diffuse large-cell lymphoma in first remission

Diffuse large-cell lymphoma (DLCL) is curable by first-line conventional chemotherapy in 50%-60% of patients. High-dose therapy makes no contribution to this group of patients and, if applied indiscriminately as first-line consolidation therapy, is likely to unnecessarily increase overall morbidity and mortality. Instead, recent interest has been directed towards (a) the identification of a group of patients with a poor prognosis, and (b) the intensification of first-line treatment for such patients with high-dose therapy and allied regimens. Many prognostic factors have now been standardised, while studies are progressing in the identification of newer prognostic factors, such as the molecular markers. Multi-centre randomised trials are currently in progress to determine the appropriate level of treatment for prognostic subsets, with the value of high-dose therapy being assessed for those in the worst prognostic groups.

Autologous stem cell transplantation in aggressive non-Hodgkin's lymphoma

High-dose therapy with autologous stem cell transplantation (ASCT) has been widely used in the past decade for treating aggressive non-Hodgkin's lymphoma in situations in which conventional therapy was not likely to cure patients. In patients achieving complete remission (CR), ASCT has been proposed for consolidation in a group of lymphoma patients sharing adverse prognostic factors with a high risk of relapse. Results from pilot studies were encouraging. Analysis of the large randomized LNH87 trial showed an increased survival and disease-free survival advantage for ASCT performed after CR when compared to conventional chemotherapy if patients with two or more adverse factors were included. For patients who do not achieve CR after conventional treatment, but who are still sensitive to chemotherapy, ASCT may improve results. Pilot studies as well as randomized studies offer support for this approach. Intensive treatment with ASCT has been reported in thousands of relapsing lymphoma patients. For those remaining sensitive to salvage chemotherapy at 5 years, a 40% probability of disease-free survival has been uniformly noted. Moreover, these results were confirmed by the randomized PARMA study testing ASCT vs conventional chemotherapy, ASCT is accepted by most centers as the treatment of choice for relapsing lymphoma. For lymphoblastic lymphoma and Burkitt's lymphoma, the role of ASCT in first CR is not well defined, although results from pilot studies and the analysis of registry data support the use of ASCT in lymphoblastic lymphoma with adverse prognostic factors. In conclusion, data supporting the use of ASCT in lymphoma in different settings has been provided by numerous nonrandomized trials. Completed randomized studies clearly demonstrate a benefit for ASCT in most relapsing patients as well as a subset of patients with poor prognosis. The socioeconomic implications of such results must be evaluated, especially since the development of peripheral hematopoietic stem cells will reduce both toxicity and cost.

Incidence and prognostic significance of t(14;18) translocation in follicle center cell lymphoma of low and high grade. A report from southern Sweden

BACKGROUND

The t(14;18)(q21;q32) is the most common recurrent genetic defect in follicle center cell lymphoma (FCC). Conflicting reports exist in regard to a possible prognostic significance for the translocation.

PATIENTS AND METHODS

In a single center, 102 patients with either low-grade (n = 50) or high-grade (n = 52) FCC (Kiel classification) and a median follow-up of 82 months were retrospectively studied to determine survival in relation to t(14;18) as shown by either PCR of the bcl-2 rearrangement in paraffinized tissue or karyotype analysis.

RESULTS

t(14;18) was detected in 30 of 50 (60%) low-grade FCC and in 12 of 52 (23%) high-grade FCC. The presence of the t(14;18) was not related to morphologic bone marrow involvement or other clinical parameters, but it was related to age: in low-grade FCC, patients with t(14;18) were an average of 17 years younger (p = 0.002) than those without the translocation. In the group with high-grade histology, 30% survived beyond 60 months regardless of t(14;18) status (p = 0.92). Patients with low-grade histology and t(14;18) fared better than those without, irrespective of age (p = 0.01). No significant difference in disease-free survival related to t(14;18) was found in either low- or high-grade FCC.

CONCLUSIONS

The incidence of t(14;18) is in accord with that of other European reports. T(14;18) does not define a prognostic subset of high-grade FCC, but is significantly correlated with a better survival in low-grade FCC. The association of t(14;18) with younger age and indolent lymphoma is perplexing in light of recent findings of an age-related increase in t(14;18) in normal subjects.

Discordant morphologic features in bone marrow involvement by malignant lymphomas: use of gene rearrangement patterns for diagnosis

Discordant morphology between lymph node or extra-nodal site and bone marrow (BM) involvement by non-Hodgkin's malignant lymphoma (NHL) is a common occurrence, causing diagnostic difficulties. Additional diagnostic problems are posed by lymphoid aggregates commonly found in the BM of elderly patients, the age group with the highest incidence of lymphoma. Morphologic features are used to distinguish between benign and malignant lesions but no feature is diagnostic and exceptions are numerous. Immunophenotyping is helpful for detecting B cell monoclonality, but it cannot detect T cell monoclonality. Unique B and T cell gene rearrangement patterns, the molecular "signature" of the lymphoma, can be used to detect monoclonal lymphoid populations. Finding the same rearrangement pattern in the BM as in the primary mass is proof of BM involvement by the same clone of malignant cells. We used B/T and Bcl-2 gene rearrangements to help diagnose cases with discordant morphology between primary site and BM. One hundred and seventy-five specimens, obtained from patients undergoing staging or restaging for NHL, were analyzed for B/T cell and Bcl-2 gene rearrangements by multiple restriction endonuclease digestion and Southern hybridization with 32P labeled JH, JK, CT beta, and Bcl-2 probes. Forty-two specimens (24%) from 24 patients showed discordant morphology: of 13 specimens with atypical lymphoid aggregates, only one had B cell gene rearrangement; of 15 specimens with morphologically benign lymphoid aggregates, one demonstrated B cell gene rearrangement; and of 14 specimens positive for NHL with different morphology than the lymph node, 13 were positive for B cell gene rearrangements. Molecular analysis can aid in the diagnosis of NHL, can establish a "baseline" for detection of recurrence, and is useful in monitoring therapy. These data suggest that it is also a tool for the pathologist in cases of discordant morphology between the primary tumor and BM, and should be strongly considered for each site.

Bone marrow metastases. A review

Although bone marrow examination is a common procedure in the evaluation of patients with cancer, its role and contribution have been questioned in recent years. This review deals with the clinical and biologic aspects of metastasis to the bone marrow. The discussion is focused on the common tumor types that involve marrow and the application of newer techniques for tumor detection in the marrow. Therapeutic and prognostic implications of bone marrow metastasis are significant in several clinical settings. The mechanisms by which tumor cells affect marrow function have not been completely defined.

A cooperative study on ProMACE-CytaBOM in aggressive non-Hodgkin's lymphomas

Chemotherapy using cyclophosphamide, doxorubicin, etoposide, cytarabine, bleomycin, vincristine, methotrexate with leucovorin, and prednisone (ProMACE-CytaBOM) for patients with intermediate or high grade non-Hodgkin lymphomas (G, H and K according to the Working Formulation), was tested by the Gruppo Cooperativo Lombardo to confirm the activity of the regimen and to test the feasibility and safety of administering third-generation drug regimen in a cooperative group setting. Among 64 previously untreated patients, aged between 20 and 71 years, 7 had stage IB-IIB, 12 had stage IIIA-B, 45 (67%) had stage IVA-B. There were 44 complete remissions (CRs) (69%) and 14 partial remissions (22%); the difference between patients in stage I-II-III (84% complete remissions) and those in stage IV (62% complete remissions) was statistically significant. The median length of follow up was 20 months (range 1-60 months), with 56% of patients alive at 60 months and 53% of CRs patients free of disease at 60 months. Patients in stage I-II-III have the best survival and disease free survival compared to stage IV, 87% versus 42% and 72% versus 32% respectively (both with high statistical significance). Grade 3-4 (WHO) haematological toxicity was observed in 39% of patients, with 3 septic deaths. Two more patients died with chemotherapy related toxicity (1 stroke and 1 acute renal insufficiency). Administration of ProMACE-CytaBOM is a feasible and safe regimen although it presents moderate toxicity. ProMACE-CytaBOM may represent improved treatment for aggressive lymphomas, in terms of duration of response and survival, but a longer follow up is needed.

Clinical implication and prognostic significance of small lymphoma cells in the peripheral blood and bone marrow of B-cell non-Hodgkin's lymphomas

It seems possible that small lymphoma cells (SLC) may have a role even in aggressive B-cell non-Hodgkin's lymphoma (B-NHL) such as large-cell lymphoma. However, SLC are often difficult to distinguish morphologically from normal or reactive small lymphocytes. In this study, we used a flowcytometric technique (kappa-lambda imaging; KLI) for detection of SLC. Peripheral blood (PB) and bone marrow (BM) samples taken from 41 patients with surface immunoglobulin positive (sIg+) B-NHL were analysed. SLC were detected in about 90% (37/41) of the untreated patients when either PB or BM was analysed by KLI. The presence of SLC correlated well with disease activity. However, a few SLC were present even in the PB (16%) or BM (27%) of the 31 patients who achieved complete remission, indicating that minimal residual disease (MRD) was present. In some cases, the reappearance of SLC in the PB or BM preceded clinical relapse. Furthermore, the initial volume of SLC, particularly in the BM, tended to be related to the prognosis (P = .068). These results suggest that the detection of SLC by KLI may be helpful not only for the screening and clinical staging of sIg+ B-NHL, but also for monitoring disease activity and detecting MRD. Moreover, the volume of SLC in the BM may be a useful predictor of prognosis.

Blood lymphocyte clonal excess in advanced non-Hodgkin's lymphoma. Relation to clinical data and prognosis

BACKGROUND

Increasingly sensitive methods, based on the monoclonal nature of NHL, are used to detect tumour spread and remaining disease. Since the lymphomas are thought to arise due to successive genetic changes, clonal cells in different compartments do not necessarily represent the same disease despite a common clonal origin.

PATIENTS AND METHODS

In 179 patients with advanced NHL, clonal cells in peripheral blood were identified by light chain restriction analysed in flow cytometry, i.e. clonal excess (CE) analysis.

RESULTS

CE was more common in low grade NHL (52%) than in high grade NHL (21%). In patients with a normal lymphocyte count CE was found in 23%. CE was significantly correlated to small cell histology and bone marrow involvement. In high grade NHL CE in peripheral blood was more common in those with discordant small or mixed cell involvement of the bone marrow. CE was significantly related to failure to achieve remission in both histologic subgroups. Survival was not influenced by CE in low grade NHL but in high grade NHL. In multivariate analyses however, CE did not emerge as an independent risk factor but age, B-symptoms and LDH were the major factors.

CONCLUSIONS

The utility of blood CE analyses in clinical praxis has still to be settled and the prognostic value of CE per se seem limited in the current perspective. The existence of CE in high grade NHL might be a clue of different biology as compared to de novo high grade NHL.

Autologous hematopoietic stem cell transplantation in intermediate and high grade non-Hodgkin's lymphoma: a review

High dose therapy with or without hematopoietic stem cell rescue has been widely used in the past decade for treating aggressive Non-Hodgkin's lymphoma. Recent data in high and intermediate grade lymphoma were reviewed. Evidence that dose intensity is a critical factor for remission in poor prognosis lymphoma has been accumulated, although the impact on survival has not been clearly established through randomized studies. Intensive treatment with autologous bone marrow transplantation (ABMT) have been reported in more than 1,000 relapsing patients in non randomized trials. For those who are still sensitive to salvage chemotherapy, at 5 years a 40% probability of disease free survival has been uniformly noted. ABMT is accepted by most centers as the treatment of choice for relapsing lymphoma. Consequently, very few randomized studies testing ABMT vs. conventional chemotherapy such as the PARMA protocol are in progress. In patients achieving complete remission, ABMT has been proposed for consolidation in a group of lymphoma sharing adverse prognostic factors with a high risk of relapse. Results from pilot studies were encouraging. However, interim analysis of the large randomized trial LNH87, did not show at the present time an advantage for ABMT performed after CR when compared to conventional chemotherapy. Such a strategy should be only proposed in prospective studies. For patients who did not achieve CR after conventional treatment, but who are still sensitive to chemotherapy, ABMT may improve the results. Pilot studies as well as recent randomized study are in support of this approach.(ABSTRACT TRUNCATED AT 250 WORDS)