Advanced stages of classical Hodgkin lymphoma - first-line treatment options

BACKGROUND

Advanced stages of classical Hodgkin lymphoma can be cured by the first-line treatment in 80% of patients. Conventional treatment options include ABVD chemotherapy (doxorubicin bleomycin, vinblastine, dacarbazine) or escalated BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, prednisone) are commonly used in advanced stages. The result of interim positron emission tomography allows adjustment of the treatment intensity during chemotherapy and this approach can affect the treatment results and toxicity.

PURPOSE

This review summarizes current options of conventional chemotherapy and implementation of brentuximab vedotin and PD-1 inhibitors in combination with chemotherapy into the first-line treatment.

[Treatment of patients with relapsed/refractory Hodgkin lymphoma]

BACKGROUNDS

This retrospective study evaluated treatment outcomes in patients undergoing autologous stem cell transplantation (ASCT) for relapsed/refractory Hodgkin lymphoma (HL).

PATIENTS AND METHODS

Overall, 194 HL patients treated with ASCT between 2000 and 2009 were analyzed. Survival was calculated using Kaplan-Meier method and differences in survival between subgroups with log-rank test.

RESULTS

Best responses observed after ASCT: 124 complete and 35 partial remissions, 2 patients with stable disease and 33 relapses/progressions. During a median follow-up of 44 months, seventy patients after ASCT progressed/relapsed. Thirty-seven patients received salvage chemotherapy only with or without radiotherapy, 25 underwent allogeneic stem cell transplantation (SCT), 4 the second ASCT and 4 refused treatment. 5-year overall survival after ASCT was 71% and progression-free survival 54%. Median survival of the 70 patients relapsing after ASCT was 16.9 months. Median survival in patients after allogeneic SCT was 31.8 months and 12.4 months in patients treated with other modalities (p = 0.21). Overall mortality was 26.3% (51/194 patients): 13.4% progressions/relapses of HL and 12.9% non-relapse mortality.

CONCLUSION

Efficacy of ASCT was confirmed in 54% progression-free survivors. Median survival after ASCT failure is relatively short. There is a slightly longer overall survival after allogeneic SCT, although not statistically significant when compared to other approaches.

Prognostic significance of absolute lymphocyte count and lymphocyte subsets in lymphomas

Lymphocytopenia is a poor prognostic marker in initial staging of non- Hodgkin lymphomas (below 1.0 x 10(9)/l) and Hodgkin lymphoma (below 0.6 x 10(9)/l) and in relapsed diffuse large B cell lymphoma. Early lymphocyte recovery > or =0.5 x 10(9)/l after autologous and allogeneic stem cell transplantation is a significant predictor of tumor control and survival in lymphomas. Natural killer cells are involved in tumor cell killing and are the only subset of lymphocytes associated with disease outcome in initial staging and after autologous stem cell transplantation in lymphomas. The antitumor effect of various NK cell subsets should be defined.

The biological environment of Hodgkin's lymphoma and the role of the chemokine CCL17/TARC

Hodgkin's lymphoma is a lymphoproliferative disease, which differs in its morphology and therapeutic response from other lymphomas. Neoplastic cells represent only a minor cell population of the tumour, while the major part of the tumour is formed by inflammatory cells. It results from the production of cytokines and chemokines both by neoplastic cells and by inflammatory cells. An important prognostic marker in Hodgkin's lymphoma appears to be the chemokine (C-C motif) ligand 17 (CCL17), also known as thymus and activation-related chemokine (TARC). This chemokine is expressed by many cell types and tissues, and in the case of Hodgkin lymphoma, also by Reed-Sternberg cells. CCL17/TARC binds to chemokine receptors CCR4 and CCR8 and displays chemotactic activity for T lymphocytes and some other leukocytes. The understanding of biological pathways in Hodgkin's lymphoma could be important for monitoring of disease activity and for the development of future targeted therapy.

Inhalation trauma in burns, cytology and biochemical findings

We have followed in a pilot study a group of patients for cytological and biochemical changes of lavage in the upper and lower respiratory system. Into the study patients with respiratory burns confirmed by bronchoscopy and skiagraphy were included. We divided patients according to the Lung Injury Scores (LIS). We obtained the values in our sample group between intubation and last swab (before extubation). Listed are the risk factors, probability of survival, and lung histology results are listed for patients who died.

[Bone changes in multiple myeloma--current etiopathogenic, diagnostic and therapeutic aspects]

Myelomatous bone disease affects about 90% patients with multiple myeloma and solitary myeloma as well. In initial stage it is manifested as osteopenia with osteoporosis or osteolytic foci, pathologic fractures followed by neurologic complications. Ethiopathogenitically a role is played by cytokine interactions with local chemokines produced by myeloma cells and activated stromal and hemopoietic cells (osteoblasts, monocytes, macrophages) resp. From the TNF-alpha family glycoprotein complexes are liberated (RANK-L), which support activation and proliferation or are inhibitory (osteoprotegerins). Similarly in the family TGF-beta several izotypes of antiinflammatory cytokines are known (the most important is TGF-beta 1 and the morphogenetic protein-2), which have a fibrotizing effect in bones, because the produced osteoid is insufficiently mineralized. The effect is a pathologic remodelation of the skeleton. In the diagnosis of multiple myeloma the immunological knowledge is used in the initial diagnosis (immunophenotypization, follow up of TNF-alpha, TGF-beta 1, IL-1, IL-6 etc). Important are also biochemistry values of increased osteoresorption (changes of calcium, parathormone, excretion of collagen fission products, osteocalcin, the bone alkaline phosphatase). In the following part the authors inform about favourable results of long-term treatment with bisphosphonates (Bonefos, Ibandronate) in combination with anti-tumor chemotherapy in 364 patients. During a 15 years observation period median survival of 94 months with a 35% probability of 10 year survival was achieved with a significant decrease of bone complications in 58% compared to 14% in the placebo group.

[Primary hepatosplenic (gamma delta) T-cell lymphoma: clinico-pathologic analysis of 3 cases]

The authors analyze three cases of hepatosplenic (gamma-delta) T-cell lymphoma which is a newly defined unit in the spectrum of primary splenic lymphomas. The first two were diagnosed in sequential biopsies of bone marrow, splenectomic material and the liver of female patients aged 38 and 67 years. In the clinical picture dominated symptoms of progressing splenomegaly, hepatomegaly, haemolytic anaemia and different manifestations of leuco- and thrombocytopenia with expulsion of tumour cells into the peripheral blood. The first patient died after complete remission with signs of heart failure, the second one is surviving for 11 months in partial remission. The third case, a 66-year-old male patient, died suddenly during a 16-day hospitalization on account of diagnosis of hepatopathy and anaemic syndrome, as a result of cardiorespiratory failure. The diagnosis was established only post mortem. In none of the patients signs of affected lymph nodes were present. The authors analyze problems of bioptic diagnosis of the mentioned lymphoma, in particular biopsy of bone marrow in the stage of its initial infiltration. The key to diagnosis is in addition to knowledge of clinical manifestations the typical morphology and intrasinusoid propagation of tumour cells and immunohistochemical evidence of their T-phenotype. The predominance of initial manifestations of haemolytic anaemia calls for differential diagnosis of haemolytic conditions and confirmation of their secondary character.

[Immunophenotyping with flow cytometry in patients with acute leukemia]

The authors evaluate their own results of examinations using a flow cytometer in 72 patients (22 children and 50 adults) with acute leukaemia, incl. 34 acute lymphatic leukaemias and 38 acute myeloid leukaemias during the period between January 1994 and October 1995. At the same time the authors draw attention to the clinical importance in the diagnosis, treatment and prognosis as well as to different findings in children and adults.