Survival outcomes in aggressive non-Hodgkin's lymphoma according to the International Prognostic Index

PURPOSE

To retrospectively analyse the disease-free survival (DFS) and overall survival (OS) according to the International Prognostic Index (IPI) risk groups in patients with aggressive non-Hodgkin's lymphoma (A-NHL) treated at the Institute of Oncology, Istanbul University between 1989-1998.

PATIENTS AND METHODS

The records of 201 patients with A-NHL and aged 15 years and over were retrospectively analysed. Features evaluated for potential prognostic importance for DFS and OS included sex, age, tumor stage, performance status (PS), "B" symptoms, bone marrow infiltration, number of extranodal disease sites, size of the largest tumor, histologic grade, erythrocyte sedimentation rate (ESR), and serum levels of lactate dehydrogenase (LDH), albumin and beta2-microglobulin. The International Working Formulation system and the Ann Arbor staging system were used for histologic and staging classifications, respectively. Kaplan-Meier, log-rank and Cox's methods were used for statistical analyses.

RESULTS

Sixty-six percent of the patients were classified in the low risk group; 23% in the low-intermediate risk group; 9% in the intermediate-high risk group; and 2% in the high risk group. The median follow-up was 25.9 months (range 1-150 months). Five-year DFS and OS were 41% and 47%, respectively, in all patients. According to IPI, based on the age, tumor stage, LDH level, PS, and extranodal involvement in the identified 4 risk groups of all patients and all ages, the 5-year DFS and OS rates were 66-51%, 49- 43%, 40-34%, and 0%, respectively. Patients in the lowintermediate and intermediate-high risk groups had a worse survival outcome than low risk patients (p=0.001).

CONCLUSION

The IPI can be used in the selection of appropriate therapeutic strategy for individual patients. IPI is the most acceptable prognostic system, but being not the ideal one, is still being under critical discussion.

Colorectal cancer in young patients: characteristics and outcome

Colorectal cancer is predominantly a disease of the elderly population, but this disease is unusual in patients 40 years of age or under, and controversy persists as to prognosis in this subset of patients. The aim of this study was to determine the clinicopathologic features and their impact on patients survival of colorectal cancer in patients aged 40 years or younger, and to compare them with those of older patients. The records of 466 patients with non-metastatic colorectal adenocarcinoma who were referred between 1991 and 1999 to the University of Istanbul, Institute of Oncology, following curative surgery were retrospectively analysed. The clinicopathologic features of 84 (18%) colorectal cancers (group A; male:female ratio 48:36) which occurred in patients aged 40 years or younger were compared with 382 colorectal cancers in older patients (group B; male:female ratio 194:188). Patient gender, performance status, T stage, N stage, TNM stage, histologic grade, location of tumor, lymphatic invasion, serum levels of LDH and CEA, and survival rates were compared as prognostic factors. There was no statistically significant difference between group A and group B with respect to patient gender, performance status, T stage, N stage, TNM stage, histologic grade, location of tumor, serum levels of LDH and CEA, and survival rates of colorectal cancers. The proportion of lymphatic invasion was present in 27% of patients in group A vs. 12% in group B. With median follow-up of 69 months, the overall 5-year survival rate was 61% in group A and 56% in group B. In the univariate survival analysis according to age groups (group A and B), advanced TNM stage, location of rectal tumor, presence of lymphatic invasion, and presence of high serum LDH and CEA levels are predictors of poorer survival in young patients with colorectal cancer. In the Cox-Regression analysis, location of tumor and TNM stage were determined as independent prognostic factors for survival. This study revealed no difference in clinicopathologic characteristics in patients with colorectal cancer aged 40 years or younger compared with those aged above 40 years. However, in patients aged 40 years or younger, distal location of tumor and advanced stage should be considered as poor prognostic factors for overall survival.

Anemia in oncology practice: relation to diseases and their therapies

Anemia is common in patients with cancer and is a frequent complication of myelosuppressive chemotherapy. In this study, we investigated the incidence and severity of chemotherapy-induced anemia caused by the most common chemotherapy regimens, including the new generation of chemotherapeutic agents, used in the treatment of the major nonmyeloid malignancies in adults. Five hundred fifty-two patients with histologically proven carcinoma originating from breast (n = 165), lung (n = 128), colon (n = 75), ovary (n = 84), and malignant lymphoma (n = 100) were included in this study. Hemoglobin levels for each patient were measured with an automatic counter during both pretreatment and before each chemotherapy cycle during therapy. To document the incidence of anemia, the National Cancer Institute grading system was used. Before chemotherapy, 44% of patients with breast carcinoma had anemia. There was a 16% increase in the incidence of anemia after chemotherapy. Severe anemia was observed in less than 1% of patients. No difference was found in the incidence of anemia between the fluorouracil, doxorubicin, cyclophosphamide (FAC) and cyclophosphamide, methotrexate, fluorouracil (CMF) regimens used in the adjuvant setting. However, single-agent chemotherapy with newer generation caused more anemia when compared with the FAC regimen (p < 0.005). Chemotherapy resulted in a significant decrease in hemoglobin levels when compared with pretreatment values in patients with lung cancer (p < 0.001). During treatment, the increase in the incidence of grade II anemia was associated with a parallel decrease in the incidence of grade I anemia. The incidence of severe anemia did not exceed 15%. The incidence of anemia was equivalent in both patients with small-cell lung cancer and those with non-small-cell lung cancer treated with the etoposide and cisplatin (EP) combination. Seventy-one percent of patients with colon cancer had anemia before initiation of chemotherapy. No difference was observed in posttreatment hemoglobin values compared with pretreatment values. Patients treated with irinotecan and fluorouracil and leucovorin (FUFA) combination showed similar rates of anemia. Incidence of anemia in patients with ovarian cancer at admission was 68%. Chemotherapy resulted in a prominent increase in incidence of anemia, which increased to 91.5%. There was an increase in grade II anemia, which corresponded to the decrease in grade I anemia. Less than 10% of patients developed severe anemia. No difference in the incidence of anemia was observed in patients with ovarian cancer treated with either cisplatin and cyclophosphamide or cisplatin combination. Showing a high incidence of anemia (82%) at presentation, hemoglobin levels in patients with malignant lymphoma were unaltered with chemotherapy. Severe anemia occurred in less than 3% of patients. There was a higher incidence of anemia in patients with non-Hodgkin's lymphoma receiving the cyclophosphamide, epirubicin, vincristine, prednisone (CEOP) regimen in contrast to patients with Hodgkin's lymphoma treated with the doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) combination. There was a prominent decline in the hemoglobin levels with cisplatin-based combinations in contrast to combinations including noncisplatin agents (p < 0.001). In this study, we have observed equivalent rates of treatment-related anemia when compared with previous data in patients with specific tumor types. The incidence of pretreatment anemia was high in various malignancies. The mechanisms underlying the propensity for a higher risk of pretreatment anemia in patients with malignant disorders and its influence on the outcome has to be elucidated by further population-based and molecular studies.