Marginal zone lymphoma international prognostic index: a unifying prognostic index for marginal zone lymphomas requiring systemic treatment

Background

Marginal zone lymphomas (MZL), comprised of three unique but related subtypes, lack a unifying prognostic score applicable to all the patients in need for systemic chemotherapy and/or immunotherapy.

Methods

Patients from the prospective NF10 study (NCT02904577) with newly diagnosed MZL and receiving frontline systemic therapy at diagnosis or after observation were used to train a prognostic model. The primary endpoint was progression-free survival (PFS) from start of treatment. The model was externally validated in a pooled analysis of two independent cohorts from the University of Iowa and Mayo Clinic Molecular Epidemiology Resource and the University of Miami.

Findings

We identified 501 eligible patients. After multivariable modeling, lactate dehydrogenase (LDH) above upper normal limit, hemoglobin <12 g/dL, absolute lymphocyte count <1 × 109/L, platelets <100 × 109/L, and MZL subtype (nodal or disseminated) were independently associated with inferior PFS. The proposed MZL International Prognostic index (MZL-IPI) combined these 5 factors, and we defined low (LRG, 0 factors, 27%), intermediate (IRG, 1-2 factors, 57%) and high (HRG, 3+ factors, 16%) risk groups with 5-y PFS of 85%, 66%, and 37%, respectively (c-Harrell = 0.64). Compared to the LRG, the IRG (Hazard Ratio [HR] = 2.30, 95% CI 1.39-3.80) and HRG (HR = 5.41, 95% CI 3.12-9.38) had inferior PFS. Applying the MZL-IPI to the pooled US cohort (N = 353), 94 (27%), 192 (54%), and 67 (19%) patients were classified as LRG, IRG, and HRG, respectively, and the model was validated for PFS (log-rank test p = 0.0018; c-Harrell = 0.578, 95% CI 0.54-0.62). The MZL-IPI was also prognostic for OS in both the training and the external validation sets.

Interpretation

MZL-IPI is a new prognostic score for use in all patients with MZL considered for systemic treatment.

Funding

The MER was supported by P50 CA97274 and U01 CA195568.

Tumor-Infiltrating Normal B Cells Revealed by Immunoglobulin Repertoire Clonotype Analysis Are Highly Prognostic and Crucial for Antitumor Immune Responses in DLBCL

PURPOSE

Tumor-infiltrating B lymphocytes (TIL-B) have demonstrated prognostic and predictive significance in solid cancers. In this study, we aimed to distinguish TIL-Bs from malignant B-cells in diffuse large B-cell lymphoma (DLBCL) and determine the clinical and biological significance.

EXPERIMENTAL DESIGN

A total of 269 patients with de novo DLBCL from the International DLBCL R-CHOP Consortium Program were studied. Ultra-deep sequencing of the immunoglobulin genes was performed to determine B-cell clonotypes. The frequencies and numbers of TIL-B clonotypes in individual repertoires were correlated with patient survival, gene expression profiling (GEP) data, and frequencies of DLBCL-infiltrating immune cells quantified by fluorescent multiplex IHC at single-cell resolution.

RESULTS

TIL-B abundance, evaluated by frequencies of normal B-cell clonotypes in the immunoglobulin repertoires, remarkably showed positive associations with significantly better survival of patients in our sequenced cohorts. DLBCLs with high versus low TIL-B abundance displayed distinct GEP signatures, increased pre-memory B-cell state and naïve CD4 T-cell state fractions, and higher CD4+ T-cell infiltration. TIL-B frequency, as a new biomarker in DLBCL, outperformed the germinal center (GC) B-cell-like/activated B-cell-like classification and TIL-T frequency. The identified TIL-B-high GEP signature, including genes upregulated during T-dependent B-cell activation and those highly expressed in normal GC B cells and T cells, showed significant favorable prognostic effects in several external validation cohorts.

CONCLUSIONS

TIL-B frequency is a significant prognostic factor in DLBCL and plays a crucial role in antitumor immune responses. This study provides novel insights into the prognostic determinants in DLBCL and TIL-B functions with important therapeutic implications.

Direct-Acting Antivirals as Primary Treatment for Hepatitis C Virus-Associated Indolent Non-Hodgkin Lymphomas: The BArT Study of the Fondazione Italiana Linfomi

PURPOSE

We prospectively treated patients with hepatitis C virus (HCV)-associated indolent lymphomas with genotype-appropriate direct-acting antivirals (DAAs) with the aim to evaluate virologic and hematologic outcomes. No prospective studies in this setting have been published so far.

METHODS

FIL_BArT is a prospective, multicenter, phase II trial that evaluated genotype-appropriate DAAs in untreated HCV-positive patients with indolent lymphomas without criteria for immediate conventional antilymphoma treatment. The primary objective was sustained virologic response, whereas the main secondary objectives were overall response rate of lymphoma and progression-free survival.

RESULTS

Forty patients were enrolled, including 27 with marginal zone lymphoma. Median age was 68 years. Extranodal sites were involved in 14 cases (35%). Main genotypes were 1 in 16 patients and 2 in 21 patients. All patients received genotype-guided DAAs: 17 ledipasvir/sofosbuvir, eight sofosbuvir plus ribavirin, and 15 sofosbuvir/velpatasvir. All patients achieved sustained virologic response (100%). DAAs were well tolerated, with only two grade 3-4 adverse events. Overall response rate of lymphoma was 45%, including eight patients (20%) achieving complete response and 10 (25%) partial response, whereas 16 exhibited stable disease and six progressed. With a median follow-up of 37 months, two patients died (3-year overall survival 93%; 95% CI, 74 to 98) and three additional patients progressed, with a 3-year progression-free survival of 76% (95% CI, 57 to 87).

CONCLUSION

HCV eradication by DAAs was achieved in 100% of HCV-positive patients with indolent lymphomas not requiring immediate conventional treatment and resulted in non-negligible rate of lymphoma responses. Treatment with DAAs should be considered as the first-line therapy in this setting.

Irradiation Fields and Doses in Glioblastoma Multiforme: Are Current Standards Adequate?

Aims and background

The optimum conventional radiotherapy in glioblastoma multiforme patients has not been clearly defined by prospective trials. To better characterize a standard radiotherapy in glioblastoma multiforme, the impact on survival of different fields and doses was analyzed in a retrospective single center series.

Methods

One hundred and forty-seven patients with glioblastoma multiforme, submitted to biopsy only (n = 15), subtotal (n = 48) or total resection (n = 82) and who completed the planned postsurgical radiotherapy, were considered. The median age was 57 years, the male/female ratio 1.5/1, and the performance status ≥70 in 76%. Whole brain irradiation, followed by a boost to partial brain, was used in 75 cases with a whole brain dose of 44–50 Gy (median, 46) and a partial brain dose of 56–70 Gy (median, 60 Gy). Partial brain irradiation alone was used in 72 patients with a dose of 56–70 Gy (median, 61 Gy). Ninety-eight patients received 56–60 Gy (median, 59 Gy) to partial brain whereas 49 patients received 61–70 Gy (median, 63 Gy).

Results

There was an almost significantly longer survival in patients irradiated to the partial brain alone with respect to those also receiving whole brain radiotherapy (P = 0.056). Doses <60 Gy significantly prolonged survival (P = 0.006). Multivariate analysis confirmed that the impact on survival of radiation dose was independent of age, performance status, extent of surgery, field of irradiation and the use of chemotherapy. The extent of irradiation field was not independently related to improved survival.

Conclusions

Our retrospective findings suggest that we reflect on the adequacy of the current standard irradiation parameters. Well-designed prospective trials are necessary to standardize the radiotherapy control group in patients with glioblastoma multiforme to be compared in phase III trials with innovative therapeutic approaches.

Early Chemotherapy Intensification With Escalated BEACOPP in Patients With Advanced-Stage Hodgkin Lymphoma With a Positive Interim Positron Emission Tomography/Computed Tomography Scan After Two ABVD Cycles: Long-Term Results of the GITIL/FIL HD 0607 Trial

Purpose

To investigate the progression-free survival (PFS) of patients with advanced Hodgkin lymphoma (HL) after a risk-adapted treatment strategy that was based on a positive positron emission tomography scan performed after two doxorubicin, vinblastine, vincristine, and dacarbazine (ABVD) cycles (PET2).

Patients and Methods

Patients with advanced-stage (IIB to IVB) HL were consecutively enrolled. After two ABVD cycles, PET2 was performed and centrally reviewed according to the Deauville five-point scale. Patients with a positive PET2 were randomly assigned to four cycles of escalated bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP) followed by four cycles of standard BEACOPP with or without rituximab. Patients with a negative PET2 continued ABVD, and those with a large nodal mass at diagnosis (≥ 5 cm) in complete remission with a negative PET at the end of chemotherapy were randomly assigned to radiotherapy or no further treatment. The primary end point was 3-year PFS.

Results

Of 782 enrolled patients, 150 (19%) had a positive and 630 (81%) a negative PET2. The 3-year PFS of all patients was 82%. The 3-year PFS of those with a positive and negative PET2 was 60% and 87%, respectively ( P < .001). The 3-year PFS of patients with a positive PET2 assigned to BEACOPP with or without rituximab was 63% versus 57% ( P = .53). In 296 patients with both interim and post-ABVD–negative PET who had a large nodal mass at diagnosis, radiotherapy was randomly added after chemotherapy without a significant PFS improvement (97% v 93%, respectively; P = .29). The 3-year overall survival of all 782 patients was 97% (99% and 89% for PET2 negative and positive, respectively).

Conclusion

The PET-driven switch from ABVD to escalated BEACOPP is feasible and effective in high-risk patients with advanced-stage HL.

High Doses of Antimetabolites Followed by High-Dose Sequential Chemoimmunotherapy and Autologous Stem-Cell Transplantation in Patients With Systemic B-Cell Lymphoma and Secondary CNS Involvement: Final Results of a Multicenter Phase II Trial

Purpose

Treatment of secondary CNS dissemination in patients with aggressive lymphomas remains an important, unmet clinical need. Herein, we report the final results of a multicenter phase II trial addressing a new treatment for secondary CNS lymphoma based on encouraging experiences with high doses of antimetabolites in primary CNS lymphoma and with rituximab plus high-dose sequential chemoimmunotherapy (R-HDS) in relapsed aggressive lymphoma.

Patients and Methods

HIV-negative patients with aggressive B-cell lymphoma and secondary CNS involvement at diagnosis or relapse, age 18 to 70 years, and Eastern Cooperative Oncology Group performance status ≤ 3 were enrolled and treated with high-doses of methotrexate and cytarabine, followed by R-HDS (cyclophosphamide, cytarabine, and etoposide) supported by autologous stem-cell transplantation (ASCT). Treatment included eight doses of rituximab and four doses of intrathecal liposomal cytarabine. The primary end point was 2-year event-free survival; the planned accrual was 38 patients.

Results

Thirty-eight patients were enrolled; CNS disease was detected at presentation in 16 patients. Toxicity was usually hematologic and manageable, with grade 4 febrile neutropenia in 3% of delivered courses and grade 4 nonhematologic toxicity in 2% of delivered courses. Four patients died because of toxicity. Autologous stem cells were successfully collected in 24 (89%) of 27 patients (median, 10 × 106/kg); 20 patients underwent ASCT. Complete response was achieved in 24 patients (complete response rate, 63%; 95% CI, 48% to 78%). At a median follow-up of 48 months, 17 patients remained relapse free, with a 2-year event-free survival rate of 50% ± 8%. At 5 years, 16 patients were alive, with a 5-year overall survival rate of 41% ± 8% for the whole series and 68% ± 11% for patients who received transplantation. Systemic (extra-CNS) and/or meningeal disease did not affect outcome.

Conclusion

The combination of high doses of antimetabolites, R-HDS, and ASCT is feasible and effective in patients age 18 to 70 years old with secondary CNS lymphoma, and we propose it as a new standard therapeutic option.

Watchful Waiting in Low–Tumor Burden Follicular Lymphoma in the Rituximab Era: Results of an F2-Study Database

Purpose

Patients with follicular lymphoma (FL) registered in the F2-study and initially managed without treatment were analyzed to describe the presentation and outcome of a watch and wait (W&W) strategy in the rituximab era, to identify parameters for initiating treatment, and to evaluate whether initial W&W could have deleterious effects on treatment efficacy after progression or relapse.

Patients and Methods

Between 2003 and 2005, 120 patients selected from the 1,093 treatment-naive patients with FL in the F2-study cohort were initially managed expectantly (W&W), and 107 patients were assessed. Most of these patients (80%) had disseminated disease with a low tumor burden according to Groupe d'Etudes des Lymphomes Folliculaires criteria.

Results

After a median follow-up of 64 months, treatment was initiated in 54 patients (50%), with a median delay of 55 months for the entire cohort. In a univariate analysis, involvement of more than four nodal areas (hazard ratio [HR], 2.26) and serum albumin less than 3.5 g/dL (HR, 3.51) were predictive of a shorter time to lymphoma treatment initiation. In a multivariate analysis, only involvement of more than four nodal areas remained significant (HR, 2.32). The 4-year freedom from treatment failure (FFTF) rate of W&W patients (79%; 95% CI, 69% to 85%) was not inferior to that of a subgroup of 242 patients from the F2-study cohort with good prognosis characteristics who were initially treated with a rituximab-based regimen (69%; 95% CI, 61% to 76%; P = .103).

Conclusion

In the rituximab era, patients with FL in a selected prognostically favorable group can still be managed with W&W. W&W does not seem to have detrimental effects on FFTF and overall survival rates after treatment.

First-Line Treatment for Primary Testicular Diffuse Large B-Cell Lymphoma With Rituximab-CHOP, CNS Prophylaxis, and Contralateral Testis Irradiation: Final Results of an International Phase II Trial

Purpose

Primary testicular lymphoma (PTL) has poor prognosis with failures in contralateral testis, CNS, and extranodal sites. To prevent these events, we designed an international phase II trial (International Extranodal Lymphoma Study Group 10 [IELSG-10]) that addressed feasibility and activity of conventional chemoimmunotherapy associated with CNS prophylaxis and contralateral testis irradiation. The trial was conducted by the IELSG and the Italian Lymphoma Foundation.

Patients and Methods

Fifty-three patients (age 22 to 79 years) with untreated stage I or II PTL were treated with six to eight courses of rituximab added to cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) every 21 days (R-CHOP21); four doses of intrathecal methotrexate (IT-MTX) and radiotherapy (RT) to the contralateral testis (30 Gy) for all patients and to regional lymph nodes (30 to 36 Gy) for stage II disease.

Results

All patients received R-CHOP21, 50 received CNS prophylaxis, and 47 received testicular RT. With a median follow-up of 65 months, 5-year progression-free survival and overall survival rates were 74% (95% CI, 59% to 84%) and 85% (95% CI, 71% to 92%), respectively. Ten patients relapsed or progressed: two in lymph nodes, five in extranodal organs, and three in the CNS. The 5-year cumulative incidence of CNS relapse was 6% (95% CI, 0% to 12%). No contralateral testis relapses occurred. Ten patients died: lymphoma (n = 6), secondary leukemia (n = 2), heart failure (n = 1), and gastric cancer (n = 1). Grade 3 to 4 toxicities were neutropenia, 28%; infections, 4%; and neurologic, 13%. No deaths occurred as a result of toxicity.

Conclusion

This international prospective trial shows that combined treatment with R-CHOP21, IT-MTX, and testicular RT was associated with a good outcome in patients with PTL. RT avoided contralateral testis relapses, but CNS prophylaxis deserves further investigation.

Re-occurrence of the CD20 molecule expression subsequent to CD20-negative relapse in diffuse large B-cell lymphoma

We report the first case of diffuse large B-cell lymphoma (DLBCL) of the stomach displaying CD20-negative relapse after rituximab-containing treatment and the re-appearance of CD20 expression at the second failure. The loss of CD20 expression in B-cell lymphomas relapsing after rituximab is a well-known phenomenon, but its actual impact in DLBCL is difficult to estimate. This paradigmatic case suggests that CD20-expression reappearance after purging of CD20-positive clones with rituximab might be an underestimated occurrence in B-cell lymphomas. Accordingly, every relapse, whenever possible, should be histologically assessed with diagnostic and immunophenotyping purposes.

Guidelines for the treatment of primary central nervous system lymphomas in immunocompetent patients

The best therapeutic management in primary central nervous system lymphomas remains to be defined because of current knowledge on these malignancies results from small retrospective series with a short follow-up, a limited number of prospective studies with some methodological pitfalls and a single published randomised trial. This review focuses on the current therapeutic approaches, most commonly used drugs, role of intrathecal chemotherapy, and indications for consolidation radiotherapy, providing recommendations for ordinary clinical practice. Some important therapeutic issues, such as the management of meningeal and intraocular lymphomas, as well as the relevance of salvage therapy as a playground for evaluation of new drugs are also analysed. Finally, the main open questions, as well as current and expected investigation trends are discussed.

Therapeutic management of refractory or relapsed primary central nervous system lymphomas

Despite the high rate of complete remission achieved with first-line therapy, 10-15% of immunocompetent PCNSL patients are treatment refractory while 35-60% relapse and die of lymphoma within a few months. In many cases, salvage therapy produces a second complete remission with consequent symptomatic and survival improvement. Due to the heterogeneity of both first and second line therapies employed, the optimal schedule for salvage therapy can not be identified. Nevertheless, some therapeutic guidelines could be suggested. Radiotherapy is an effective option for both previously irradiated and radiotherapy naïve patients. Some authors have been able to minimize the incidence of actinic toxicity by using chemotherapy alone at failure. In patients that have relapsed after receiving high-dose methotrexate (HD-MTX), the same drug again has been successfully employed while HD-cytarabine has been the most widely used cytostatic. Ocular recurrence can be treated with cytarabine or focal radiotherapy. Meningeal relapse can be treated with spinal cord irradiation, intrathecal and/or systemic chemotherapy. Salvage therapy, beyond improving survival, constitutes the selection ground for testing active agents. The addition of other cytostatics to HD-MTX has been empirically based and without a clear survival benefit, but with a higher toxicity. Intriguing preliminary results from small pilot studies are now available with topotecan, rituximab, temozolomide, PCV regimen and HD-chemotherapy supported by autologous or allogeneic peripheral blood stem cells transplantation. Considering its positive effect on survival and the potential improvement in neurological symptoms and quality of life, salvage therapy seems to be a valuable treatment in PCNSL patients. Finally, the inclusion of relapsing or progressive PCNSL patients into second-line prospective clinical trials for testing therapeutic agents should be strongly encouraged.

Immunoreactivity for p27(KIP1) and cyclin E is an independent predictor of survival in primary gastric non-Hodgkin's lymphoma

Our aim was to assess the prognostic implications of the expression of p27(KIP1) and cyclin E in gastric lymphoma. We investigated the prognostic value of the immunoreactivity of these molecules in 92 cases of primary gastric lymphoma: 34 LGMLs, 24 DLCLMLs and 34 DLCLs. p27 was positive in 88% of LGMLs, 71% of DLCLMLs and 32% of DLCLs (p = 0.004); cyclin E was positive in 9%, 33% and 59% of cases, respectively (p < 0.00001). p27/cyclin E immunoreactivity significantly correlated with histologic category, stage and LDH serum level. p27 immunoreactivity was significantly associated with better survival, whereas cyclin E reactivity was significantly related to worse outcome. Five-year CSS was 94% for patients with p27(+)/cyclin E(-) phenotype (n = 42), 79% for p27(+)/cyclin E(+) (n = 14) or p27(-)/cyclin E(-) (n = 16) phenotype and 60% for p27(-)/cyclin E(+) phenotype (n = 16) (p = 0.02). The prognostic role of p27/cyclin E expression was confirmed when analyzed separately within LGMLs and large-cell lymphomas. Immunoreactivity for p27 and cyclin E is an independent predictor of survival in PGLs that may be an adjunctive tool in identifying high-risk patients. It correlates with histologic category, stage and LDH serum level. p27(-)/cyclin E(+) phenotype is associated with worse survival, probably due to a synergistic effect of both cell-cycle defects. The predictive role of these molecules within each histologic group of PGLs deserves to be confirmed in larger series.

Therapeutic outcome according to histologic subtype in 121 patients with malignant pleural mesothelioma

One-hundred and twenty-one cases of malignant pleural mesothelioma (MPM) seen between 1986 and 1999 at the authors' Institution were reviewed. Histotype was epithelial in 88 patients (73%), sarcomatous in 21 (17%) and mixed in 12 (10%). Ninety-one patients received a treatment (38 palliative pleurectomy and no further therapy, 16 palliative pleurectomy followed by chemotherapy, 37 chemotherapy alone), while 30 were referred to supportive care only. Median survival of the whole population was 10.5 months. The 1-, 2- and 3-year survival were 40, 17 and 8%, respectively. Univariate analysis of subgroups showed that poor performance status (PS), non-epithelial histotype, Butchart stage>I and International Mesothelioma Interest Group (IMIG) stage>I were individually associated with lower survival. Patients receiving any therapy survived longer than patients treated with supportive care only (P=0.0004). Treatment modality had an independent prognostic value (P=0.00005), with a survival advantage for patients receiving surgery and adjuvant chemotherapy. Multivariate analysis confirmed the independent prognostic value of PS (P=0.001; HR=2.48) and treatment modality (P=0.003; HR=1.38). The prognostic role of PS (P=0.02) and treatment modality (P=0.01) was confirmed in the subset of patients with epithelial histology. On the contrary, therapy had no impact on survival in patients with sarcomatoid MPM (P=0.74). Despite the predicted bias of a retrospective non-randomized evaluation of treatment-related factors, patients with good PS and epithelial histology seemed to have a survival benefit from surgery or multimodality therapy, as opposite to patients with poor PS or non-epithelial histotype. However, these results must be confirmed in a larger prospective trial with uniform treatment.

Therapeutic management of primary CNS lymphoma in immunocompetent patients

The best therapeutic management in primary CNS lymphomas remains to be defined because of the small size and short follow-up of retrospective series, the methodological pitfalls and limited number of prospective studies, and the paucity of randomized trials. The purpose of this article is to analyze, discuss and summarize the current therapeutic approaches, namely chemotherapy or radiotherapy as exclusive treatment, combined treatment, most commonly used drugs, intrathecal chemotherapy and consolidation radiotherapy and to provide recommendations for ordinary clinical practice. Some important therapeutic issues such as the management of intraocular lymphomas, elderly patients and patients without histological diagnosis, as well as the relevance of salvage therapy as a playground for the evaluation of new drugs are also analyzed. Finally, the main open questions as well as current and expected investigation trends are discussed.

Clinical relevance of consolidation radiotherapy and other main therapeutic issues in primary central nervous system lymphomas treated with upfront high-dose methotrexate

PURPOSE

To evaluate the optimal dose of methotrexate (MTX) and the efficacy of other drugs, intrathecal chemotherapy (CHT), and radiotherapy (RT) in primary brain lymphomas.

METHODS AND MATERIALS

Two hundred eighty-eight immunocompetent patients with histologically documented, previously untreated primary brain lymphomas, receiving CHT containing high-dose MTX (> or =1 g/m(2)) with or without RT were selected from 19 prospective series. The impact on survival of the MTX dose (<3 g/m(2) vs.> or =3 g/m(2)), the main drugs, intrathecal CHT, and combination CHT (mono-CHT vs. poly-CHT) was assessed, according to the intention-to-treat principle. The role of post-CHT irradiation (immediate vs. delayed RT) was evaluated in 119 patients with a complete response to CHT. The whole brain and tumor bed dose (<40 Gy vs. > or =40 Gy) was assessed in 70 irradiated complete responders.

RESULTS

No difference in overall survival (OS) was detected between mono-CHT and combination CHT (p = 0.38). MTX > or =3 g/m(2) (p = 0.04), thiotepa (p = 0.03), and intrathecal CHT (p = 0.03) improved the OS, and nitrosoureas (p = 0.01) correlated with a worse survival. In multivariate analysis, limited to patients receiving MTX > or =3 g/m(2), only the addition of cytarabine improved the OS; nitrosoureas reduced MTX efficacy. Of the 119 complete responders, 70 received immediate RT. A RT dose of > or =40 Gy to the whole brain or tumor bed did not improve OS. The 3-year OS was similar between the immediate and delayed RT groups. In multivariate analysis, RT delay had no negative impact on survival.

CONCLUSIONS

MTX > or =3 g/m(2) seems to improve survival in primary brain lymphoma patients. The efficacy of additional drugs, except for cytarabine, remains unproved. Randomized trials are needed to confirm that RT withdrawal yields no detrimental effect in complete responders.

Effect on local control and survival of electron beam intraoperative irradiation for resectable pancreatic adenocarcinoma

PURPOSE

To assess the impact on local control and survival of intraoperative radiotherapy (IORT) in resectable pancreatic adenocarcinoma.

METHODS AND MATERIALS

The outcome of 127 patients surgically treated with curative intent combined with IORT was compared with the therapeutic results of 76 patients treated with surgery as exclusive treatment.

RESULTS

Operative mortality and morbidity were similar in IORT and no-IORT patients. In 49 patients with locally limited disease (Stage I-II; LLD), IORT (n = 30) reduced the local failure rate and significantly prolonged time to local failure (TTLF), time to failure (TTF), and overall survival (OS) with respect to surgery alone (n = 19). The multivariate analyses, stratifying patients by age, tumor grade, resection margins, chemotherapy, and external-beam radiotherapy use, confirmed the independent impact of IORT on outcome. In patients with locally advanced disease (Stage III-IVA; LAD), IORT had an impact on local failure rate and on TTLF when combined with beam energies of greater than 6 MeV, whereas no effect on TTF and OS was observed.

CONCLUSION

IORT did not increase operative mortality and morbidity and achieved a significant improvement in local control and outcome in patients with LLD. In patients with LAD, beam energies greater than 6 MeV prolonged TTLF.

Combined treatment with high-dose methotrexate, vincristine and procarbazine, without intrathecal chemotherapy, followed by consolidation radiotherapy for primary central nervous system lymphoma in immunocompetent patients

OBJECTIVES

To assess the feasibility and the activity, as well as the efficacy to treat meninges, of chemotherapy (CHT) containing high-dose methotrexate (HD-MTX) followed by radiation therapy (RT), without intrathecal CHT, in patients with primary central nervous system lymphoma.

METHODS

Eligibility criteria were histologically proven diagnosis, disease limited to the CNS, age < or = 70, ECOG performance status < or = 3, HIV-negative and no prior treatment. Thirteen patients (1996-1999; median age 54 years) received two courses of vincristine 1.4 mg/m2 day 1, MTX 3 g/m2 days 3 and 10 and procarbazine 100 mg/m2 days 1-14 every 4 weeks. Patients who achieved a complete remission were referred to RT, those with progressive disease were excluded from further study; all the remaining patients received a third course of CHT followed by RT.

RESULTS

Twelve patients responded to CHT (overall response rate = 92%, complete response rate = 77%): 9 underwent consolidation RT, 3 did not. Two patients experienced severe acute toxicity; lethal pulmonary thromboembolism and transient renal failure. Five patients relapsed: 2 after CHT and 3 after RT. Relapse was local in all cases, with a case of concomitant hepatic involvement. No cases of ocular or meningeal relapse were observed. In contrast to high-dose cytarabine-containing CHT, salvage therapy with temozolomide produced good results. Two patients died of treatment-related neurotoxicity. Six patients are alive with a median follow-up of 17 months, and a 2-year overall survival (OS) of 61%. The median survival of the 9 patients who completed the planned treatment is 25+ months with a 2-year OS of 80%.

CONCLUSIONS

HD-MTX, procarbazine and vincristine followed by RT, without intrathecal therapy, produce similar results with respect to other HD-MTX-containing regimens. These results seem to suggest that adequate meningeal treatment is possible without intrathecal drug delivery, even in CSF-positive patients. Corroborating data from a larger series are, however, necessary. Temozolomide should be tested in relapsed patients in a phase II prospective trial.

Prognostic significance of the histopathologic recognition of low- and high-grade components in stage I-II B-cell gastric lymphomas

The prognostic value of histopathologic features was assessed in 83 patients with stage I-II gastric B-cell lymphomas (PGL). The following histotypes were considered: low-grade mucosa-associated lymphoid tissue (MALT)-type lymphoma (LGML; n = 35), diffuse large B-cell lymphoma with areas of MALT-type lymphoma (DLCLML; n = 20) and diffuse large B-cell lymphoma without areas of MALT-type lymphoma (DLCL; n = 28). Low-grade (LG) and high-grade (HG) components, lymphoepithelial lesions (LEL), size of cells giving rise to LEL, and amount and growth pattern of large cells (LC) were analyzed. Five-year cause-specific survival (CSS) for patients with LGML, DLCLML, and DLCL were 94%, 84%, and 64%, respectively (p = 0.05). LG component or LEL were associated with a significantly longer 5-year CSS, whereas the presence of an HG component, defined as clustered LC greater than 10% of neoplastic population, was significantly related to a shorter survival. Lymphomas with LC disposed in clusters were associated with a worse survival in comparison with cases with scattered LC. The presence of scattered LC 5%-10% appeared irrelevant in LGML. When analysis was limited to DLCLML/ DLCL patients, the presence of LG component or LEL was associated with a significantly longer 5-year CSS, whereas the existence of LEL formed by LC (HG LEL) did not modify survival. Multivariate analysis, adjusted by the main prognostic factors, confirmed the independent and significant association between histopathologic categorization and survival. Age, stage, lactate dehydrogenase (LDH) ratio, thrombocytopenia, and use of chemotherapy had independent prognostic value. In conclusion, histopathologic categorization is an independent prognosticator in PGL. The formation of compact clusters by LC, rather than their amount, is a true prognostic variable. The presence of scattered LC 5%-10% appears irrelevant in LGML. LG component and LEL are favorable predictors in HG lymphomas, helping to identify two subsets of DLCL with different prognosis.

A retrospective analysis of postradiation chemotherapy in 133 patients with glioblastoma multiforme

The impact on survival of postradiation nitrosourea-containing chemotherapy (CHT) in patients with glioblastoma multiforme (GM) was analyzed retrospectively in 133 patients who completed the planned radiotherapy out of 173 observed cases. Thirty-five patients were < 50 years old, 89 were males, 20 had performance status (PS) < 70 and 72 > or = 70. Surgery was followed by radiotherapy in all cases (50-60 Gy in 95 patients, 61-70 Gy in 38 patients). At the end of radiotherapy, 43 patients received CHT, whereas 90 patients did not receive further therapy. At univariate analysis, age < 50 years, feminine gender, subtotal or total resection, radiotherapy doses > 60 Gy, and CHT had an independent prognostic value. Our results suggest that chemotherapy improves 2-year survival rates from 12% to 28% in GM. The sequence of treatment, new drugs, and combinations should be further explored.

Therapeutic management of primary central nervous system lymphoma: lessons from prospective trials

Primary central nervous system lymphomas (PCNSL) are aggressive malignancies, exhibiting one of the worst prognoses among lymphomas. The best treatment modality for PCNSL has not yet been identified. Several therapeutic questions still remain unanswered, and some methodological pitfalls in clinical trials prevent definitive conclusions from being drawn. In this review, certain aspects of trial design as well as emerging therapeutic guidelines are analyzed, and future perspectives are discussed. In the vast majority of prospective trials, general criteria for treatment of aggressive lymphomas were adopted, choosing primary chemotherapy (CHT) followed by radiotherapy (RT) as therapeutic modality. This strategy produced a five-year survival of 22%- 40% in comparison to the 3%-26% reported with RT alone. Systemic high-dose methotrexate (HD-MTX) seems to be the most effective drug, producing a response rate of 80%-90% and a two-year survival of 60%-65%. To date, the addition of other drugs at conventional doses have not consistently improved outcome. With a few exceptions, any regimen without HD-MTX comprehensively performed no better than RT alone. In combined treatment. RT doses should be decided on the bases of response to primary CHT and the number of lesions, and, until definitive conclusions from well-designed trials are available, RT parameters should follow the widely accepted principles used for other aggressive lymphomas. CHT as exclusive treatment, keeping RT for relapses or persistent disease, appears to be an attractive strategy. However, the worldwide experience with this modality is still limited, and corroborating data are needed. Intrathecal CHT still has not found a defined role in PCNSL management. Preliminary data seem to indicate that adequate meningeal treatment with HD-MTX, but without intrathecal CHT, could also be suitable in positive-cerebrospinal fluid patients. Future efforts should be addressed to identify new active drugs and more efficient CHT combinations, to evaluate the efficacy of high-dose CHT supported by autologous peripheral blood stem cells transplantation, and to clarify the impact of RT delay in complete responders, the usefulness of intrathecal CHT, and the best management for elderly patients. The assessment of impact of treatment on neuropsychological functions and quality of life is a mandatory endpoint in clinical trials.

Consolidation radiotherapy to bulky or semibulky lesions in the management of stage III-IV diffuse large B cell lymphomas

BACKGROUND

To assess the impact on survival of consolidation radiotherapy to bulky or semibulky lesions in patients with advanced diffuse large B cell lymphoma (DLCL) in complete remission after primary chemotherapy.

PATIENTS AND METHODS

Ninety-four patients with stage III-IV DLCL and bulky ( > or =10 cm) or semibulky lesions (6-9 cm) in complete remission after primary chemotherapy were reviewed. Forty patients received consolidation radiotherapy to bulky (n = 20) or semibulky lesions (n = 20), while 54 (18 with bulky disease) did not. Twenty-eight patients were irradiated to the involved field and 12 to the extended field with a dose of 30-46 Gy.

RESULTS

In patients with bulky disease, consolidation radiotherapy prevented relapses involving exclusively the bulky area, prolonged time to relapse (TTR) (median 41+ vs. 18 months; p = 0.05) and improved 5-year overall survival (OS) (73 vs. 57%; p = 0.05). Consolidation radiotherapy reduced relapses within the semibulky area, prolonged TTR (median 26+ vs. 20 months; p = 0.01) and improved 5-year OS (59 vs. 41%; p = 0.09) also in patients with semibulky lesions. Multivariate analyses confirmed the independent association between consolidation radiotherapy and survival, and showed that a dose > or =36 Gy was related to a longer OS, while the extension of the radiotherapy field did not modify outcome. No treatment-related deaths were observed. Four patients developed a second malignancy, none of whom had undergone consolidation radiotherapy.

CONCLUSIONS

Consolidation radiotherapy to bulky or semibulky lesions significantly improved the outcome in patients with advanced DLCL in complete remission after primary chemotherapy. Involved-field irradiation with 36-45 Gy made a prolonged disease control possible without either lethal toxicity or a higher incidence of second malignancies.

Diffuse large-cell lymphoma of the testis

PURPOSE

To evaluate clinical outcome of patients with testicular diffuse large-cell lymphoma treated with conventional-dose systemic chemotherapy.

PATIENTS AND METHODS

This study is a retrospective analysis of adult patients with testicular diffuse large-cell lymphoma who were treated with a doxorubicin-based chemotherapy regimen at our institution, the Istituto Nazionale Tumori of Milan. Twenty-nine assessable patients, with a median age of 61 years, were identified. Sixteen patients had limited stage (Ann Arbor stage I/II) disease, whereas 13 patients had a testicular mass and distant organ involvement (Ann Arbor stage IV). Patients were retrospectively classified according to the International Prognostic Index.

RESULTS

After a median follow-up of 82 months, 22 patients presented disease progression and 22 patients had died. Actuarial median time to treatment failure and overall survival were 44 and 41 months for patients with limited stage and 9 and 16 months for patients with advanced stage, respectively. Eight patients failed initial treatment, and 14 patients relapsed from clinical remission after a median disease-free time of 17 months (range, 6 to 98 months). Median survival time after progression of lymphoma was 5 months (range, 0 to 22 months). In nine (41%) of the 22 failing patients, the initial site of relapse was either the CNS or the contralateral testis; the remaining patients experienced relapse in multiple extranodal sites.

CONCLUSION

Poor prognosis of patients with diffuse large-cell lymphoma calls for more effective treatment strategies, such as high-dose chemotherapy programs for younger patients or specifically designed chemotherapy regimens for patients not suitable for high-dose treatment, with the purpose to provide control of both systemic disease and disease of the CNS and contralateral testis. The potential benefit of contralateral testicular irradiation has to be taken into account in the treatment planning.

Therapeutic management of stage I-II high-grade primary gastric lymphomas

The best treatment for primary gastric lymphomas (PGL) has not yet been defined. Eighty-three patients with stage I/II PGL are documented, focusing on prognostic factors, treatment-related morbidity and mortality, and therapeutic outcome. Chemotherapy improved survival in comparison to local treatments, i.e. gastrectomy (n = 15) or gastrectomy and radiotherapy (n = 5). Patients treated with primary chemotherapy and/or radiotherapy (n = 21), with gastrectomy and chemotherapy (n = 26) or with gastrectomy and chemotherapy and radiotherapy (n = 16) showed a similar survival rate. Conservative treatment obtained a 5-year actuarial survival of 82% with a stomach preservation rate of 100%. Two treatment failures and 19 relapses (24%) were observed. Sixty patients (72%) are alive (59 no evidence of disease) at a median follow-up of 58 months. Ten-year actuarial survival is 64%. Local control was influenced by stage, tumor size, depth of infiltration, LDH ratio, and therapeutic modality, while age, stage, LDH ratio, and the use of chemotherapy had independent prognostic value. Because of its efficacy and safety, conservative strategy should be considered as first-line treatment for high-grade PGL. Gastrectomy should be indicated only for urgent cases, in which surgery followed by chemotherapy appears the best choice, followed by radiotherapy in patients with stage II2 disease.

Non-surgical treatment with primary chemotherapy, with or without radiation therapy, of stage I-II high-grade gastric lymphoma

Morbidity, mortality and discomfort related to gastrectomy has led some investigators to treat patients with stage I-II primary gastric high-grade lymphoma (PGL) with a conservative strategy. Here we report a retrospective series of 21 patients with PGL treated with primary chemotherapy alone or followed by radiation therapy and analyze previously reported series, focusing on therapeutic results, treatment-related morbidity and stomach preservation rate. All 21 patients with stage I-II PGL received an initial anthracycline-containing chemotherapy, which was followed by involved field-radiation therapy in 8 cases. Data regarding toxicity, response and relapse rates and survival of this patient group and 14 previously published series, involving 316 patients treated with conservative modality, were also analyzed. In the present series two patients did not complete the planned treatment, while the remaining 19 achieved a complete remission (response rate: 90%). Three patients relapsed, all of whom had been treated with chemotherapy alone. Two patients died of lymphoma, one of sepsis and the other of lung cancer while still relapse-free. The survival rate at 50 months is 81%, and the 5-year actuarial cause-specific survival is 82%. The stomach preservation rate is 100%. Previously reported series showed a response rate ranged between 76% and 100%. Gastrointestinal bleeding was observed in only 3% of cases, while no cases of gastric perforation were reported. Treatment mortality rate was 2.5%. 5-year actuarial survival ranged between 73% and 90% and stomach preservation rate was 97%. Short-term chemotherapy obtained similar results to more prolonged treatment. In conclusion, conservative treatment with primary chemotherapy followed by involved field-radiation therapy should be used for the first-line treatment of patients with stage I/II PGL considering that it is associated with a high response and survival rates, and with an insignificant risk of bleeding or perforation, high stomach preservation rate and good quality of life.

Second-line treatment for primary central nervous system lymphoma

Failure after first-line treatment was reported in 35-60% of immunocompetent patients with primary central nervous system lymphoma (PCNSL). There are currently no reports focusing on salvage therapy. This review analyses prognostic factors and the efficacy of salvage therapy by focusing on data from papers reporting results of first-line treatment in 355 cases. The study group consisted of 173 patients presenting treatment failure. The interval between failure and death (TTD) was compared for age at relapse (< or =60 vs. >60 years), type of failure (relapse vs. progression), time to relapse (< or =12 vs. >12 months) and salvage treatment (yes vs no). Median TTD was similar in younger and older patients (P = 0.09). Relapsed patients had a longer TTD than patients with progressive disease (P = 0.002). Early relapse led to a shorter TTD than late relapse (P = 0.005). Median TTD was 14 months for patients who underwent salvage therapy and 2 months for untreated cases (P<0.00001). A multivariate analysis showed an independent prognostic role for salvage therapy and time to relapse. Age and type of failure had no predictive value. Salvage therapy significantly improves outcome and, possibly, quality of life. As many different treatments were used conclusions cannot be made regarding an optimal treatment schedule.

Therapeutic management with adriamycin-containing chemotherapy and radiotherapy of monostotic and polyostotic primary non-Hodgkin's lymphoma of bone in adults

The best treatment of primary lymphoma of bone (PLB) remains undefined. We reviewed 15 patients with monostotic PLB and 8 with polyostotic PLB. Twenty of the patients were suitable for analysis. All patients but 1 received adriamycin-containing chemotherapy in association with radiation therapy. Radiotherapy for monostotic cases consisted of 40 Gy to long bones, followed by a boost to 45 Gy to bulky lesions or 40-45 Gy to whole flat bones. In cases of polyostotic PLB, bulky sites, fractured lesions, or sites with a high risk of fracture were irradiated with a median dose of 38 Gy. All patients with monostotic disease achieved complete remission (CR): 10 patients were alive and relapse-free at the time of this writing, 1 other patient was alive following a relapse, and 1 patient died while relapse-free. The survival rate for the patients in the study at the time of this writing was 92% at 50 months. Four patients with polyostotic disease achieved CR. Three of them had only two adjacent sites of disease and were treated as cases of monostotic PLB. Two of these 3 patients are alive and relapse-free. Four patients with polyostotic disease achieved PR, relapsed rapidly, and died of progressive disease. The relapse site was invariably the skeleton. The survival rate for patients with polyostotic PLB at the time of writing was 25% at 40 months. No severe late treatment-related toxicity was observed. The treatment of patients with monostotic PLB with adriamycin-containing chemotherapy and whole-bone irradiation with 40 Gy, followed by a boost to 45 Gy to bulky sites, prevented local relapse and produced a more favorable outcome than the use of radiotherapy (RT) alone. Patients with multiple adjacent lesions that can be included within a single radiation field with acceptable toxicity should be treated as cases of monostotic PLB.

Low sensitivity of computed tomography in the staging of gastric lymphomas of mucosa-associated lymphoid tissue: impact on prospective trials and ordinary clinical practice

The natural history and management of gastric lymphomas of mucosa-associated lymphoid tissue (MALTomas) are not completely understood. Most stage I cases are now entered into prospective trials to confirm the excellent results obtained with conservative treatment, whereas current therapeutic policies are based on accumulated experience. The limits of staging work-ups may have a significant impact on prospective trials and ordinary clinical practice. The authors explore the sensitivity of computed tomography scanning in detecting perigastric adenopathy in 20 patients with gastric MALToma treated by gastrectomy. Clinical staging identified 17 patients as having stage I MALTomas and three patients as having stage II1 MALTomas. Histopathologic staging showed that 8 of 17 patients formerly diagnosed with stage I MALToma had perigastric nodal involvement, whereas the three patients with clinical stage II1 were confirmed as such. Computed tomography scanning has low sensitivity in detecting perigastric lymphadenopathy in gastric MALTomas. This leads to understaging, with a significant impact on therapeutic decision, and distorts newly acquired knowledge about the disease's natural history and management, introducing a bias in prospective clinical trials. Endoscopic ultrasonography should be tested as a staging procedure both in prospective trials and in ordinary clinical practice.

Role of dose intensity in conservative treatment of anal canal carcinoma. Report of 35 cases

Chemoradiotherapy (CRT) is considered the standard treatment for anal canal cancer. However, the optimum schedule of therapy has yet to be defined. This study was carried out to evaluate the role of dose intensity (DI) of chemotherapy (ChT) and radiotherapy (RT) on the outcome of patients submitted to CRT. Thirty-five consecutive patients with anal canal carcinoma received a combination of RT (median dose 56 Gy) and ChT (two or more cycles of 5-fluorouracil and mitomycin C). With a median follow-up of 33 months, 83% of patients are alive without evidence of disease and 70% are colostomy-free. Five-year actuarial disease-free survival (DFS) is 74%. Univariate and multivariate analysis was performed to determine the correlation of DFS with various clinical and therapeutic parameters. Our series confirmed the prognostic negative value of a tumor size >4 cm. An average relative dose-intensity (ARDI) >0.8 was related to a better outcome both in univariate and in multivariate analysis; an overall treatment time >70 days was related to a worse DFS in univariate analysis, but these data were not confirmed by the Cox model. RT dose was not associated with DFS. In conclusion, the results of this study seem to suggest an independent prognostic role of ChT DI, as measured by ARDI. The results regarding RT DI are inconclusive, and remain a matter for further trials.

Primary cardiac lymphoma in immunocompetent patients: diagnostic and therapeutic management

BACKGROUND

Primary cardiac lymphoma (PCL) is extremely rare in immunocompetent patients. Different definition criteria have been employed in published series. Prognosis is poor due to diagnostic delay and relevance of the site of disease.

METHODS

Two cases observed at the study institution are reported, with a review of 48 cases published in the literature from 1980 to 1996. Only patients with lymphoma confined to the heart and/or pericardium and those with a single and asymptomatic extracardiac site were considered for analysis.

RESULTS

Eight patients had minimal extracardiac disease. The most common presentation was unresponsive heart failure. Electrocardiography findings were not specific. PCL usually arose in the right chambers as a mass, with or without pericardial effusion (> 80%). Chest X-rays, transthoracic echocardiography, and computed tomography scans are standard in diagnostic workup, but transesophageal echocardiography (TEE) and magnetic resonance imaging (MRI) showed a sensitivity > 90%. Cytology of pericardial effusion was diagnostic in 67% of cases. Thoracotomy was diagnostic in all cases, whereas less invasive procedures had high false-negative rates. Gross resection has no role. Early anthracycline-containing chemotherapy appears to improve survival, whereas the role of radiotherapy has not yet been defined.

CONCLUSIONS

The diagnosis of PCL should be considered in patients with a cardiac mass and/or unexplained refractory pericardial effusion. Adequate diagnostic workup, including TEE and MRI, allows confirmation of the early suspicion of PCL. In the absence of a diagnostic cytology, an open biopsy may be indicated to avoid treatment delay. There is no evidence that PCL should be treated differently from other bulky aggressive lymphomas arising at other anatomic sites.

Primary brain lymphomas in patients with a prior or concomitant malignancy

The increased incidence of second malignancies among cancer survivors is well documented. Thus, differential diagnosis between metastatic spread from a prior malignancy and the occurrence of a new neoplasm should be considered. This is particularly difficult for brain lesions due to their poor prognosis that often discourages diagnostic work-up. In some cases diagnosis of a second primary neoplasm, such as primary central nervous system lymphomas (PCNSL), could change the therapeutic management and the prognosis. About 8% of PCNSL occurs as a second malignancy. Homogeneous and intense tomographic enhancement, deep location of lesions and dramatic response to corticosteroids are suggestive for PCNSL and should be carefully considered before the start of treatment for cerebral lesions. Prognosis and standard management of brain metastases and PCNSL are almost completely different. In addition, while treatment of brain metastases often has a palliative purpose the goal in PCNSL treatment is the cure. Four patients with PCNSL as a second malignancy are reported and literature is reviewed. Diagnosis of PCNSL changes the strategy of treatment which could have a critical therapeutic and prognostic impact.