Malignant Lymphoma

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Malignant Lymphoma

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Malignant Lymphoma Edited by

BW Hancock MD FRCP FRCR Professor of Clinical Oncology and YCR Director of Cancer Research, The University of Sheffield, UK

PJ Selby MD FRCP Director, ICRF Cancer Medicine Research Unit, St James's University Hospital, Leeds, UK

K MacLennan DM FRCP Professor of Tumour Pathology, ICRF Cancer Medicine Research Unit, St James's University Hospital, Leeds, UK and

JO Armitage MD Professor and Chairman, Department of Internal Medicine, Section of Oncology and Hematology, University of Nebraska Medical Center, Omaha, Nebraska

A member of the Hodder Headline Group LONDON Co-published in the USA by Oxford University Press Inc., New York

First published in Great Britain in 2000 by Arnold, a member of the Hodder Headline Group, 338 Huston Road, London NW1 3BH http://www.arnoldpublishers.com Co-published in the United States of America by Oxford University Press Inc., 198 Madison Avenue, New York, NY10016 Oxford is a registered trademark of Oxford University Press © 2000 Arnold All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronically or mechanically, including photocopying, recording or any information storage or retrieval system, without either prior permission in writing from the publisher or a licence permitting restricted copying. In the United Kingdom such licences are issued by the Copyright Licensing Agency: 90 Tottenham Court Road, London W1P 9HE. Whilst the advice and information in this book are believed to be true and accurate at the date of going to press, neither the authorfs] nor the publisher can accept any legal responsibility or liability for any errors or omissions that may be made. In particular (but without limiting the generality of the preceding disclaimer) every effort has been made to check drug dosages; however it is still possible that errors have been missed. Furthermore, dosage schedules are constantly being revised and new side-effects recognized. For these reasons the reader is strongly urged to consult the drug companies' printed instructions before administering any of the drugs recommended in this book. British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress ISBN 0 340 74207 0 12345678910 Commissioning Editor: Joanna Koster Project Editor: Sarah de Souza Production Editor: James Rabson Production Controller: Fiona Byrne Project Manager: Marian Haimes Typeset in 10/12 pt Minion by Phoenix Photosetting, Chatham, Kent Printed and bound in Great Britain by The Bath Press, Bath

To the memory of Tim McElwain and Mike Bennett for their major contributions to an understanding of the clinical management and pathology of malignant lymphoma

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Contents

Color plates appear between pages 50 and 51 Contributors Preface Foreword

PART 1

1

HISTOPATHOLOGY

4

5

6

7

8

9

3

Hodgkin's disease

KA MacLennan, B Vaughan Hudson, G Vaughan Hudson 3

1

Lymphoma classification KA MacLennan

2

ix xi xiii

9

Follicular lymphoma KA MacLennan

21

Mantle cell lymphoma DD Weisenburger, JO Armitage

27

Diffuse indolent B cell neoplasms KA MacLennan

43

Diffuse aggressive B cell lymphoma KA MacLennan

49

T cell lymphoproliferative disorders AS Jack, SJ Richards, KA MacLennan

55

Extranodal lymphomas PG Isaacson

71

Cytogenetics WG Sanger, BJ Dave, MR Bishop

91

PART 2

PATHOGENESIS

105

10

Hodgkin's disease V Diehl, J Wolf

107

Viruses and malignant lymphoma LM Weiss, KL Chang

115

Molecular biology VI Pappa, BD Young

133

11

12

viii Contents

PART 3

EPIDEMIOLOGY

13

Hodgkin's disease NE Mueller

14

159

161

Non-Hodgkin's lymphoma RA Cartwright

169

PART 4

CLINICAL MANAGEMENT

179

15

Hodgkin's disease: clinical features PWM Johnson, PJ Selby, BW Hancock

16

Imaging of lymphoma K Sandrasegaran, PJ Robinson, A Sprigg

17

421

The way forward BW Hancock, PJ Selby, JO Armitage, KA MacLennan

Index

399

Long-term problems M Henry-Amar

31

385

Infections B Crosse, PJ Selby

30

371

Lymphoma in the elderly PWM Johnson

29

359

Pediatric lymphomas JS Malpas

28

351

Cutaneous lymphomas RT Hoppe, YH Kim

27

331

AIDS-related lymphoma AM Levine

26

325

High-dose therapy PJ Bierman, JM Vose, JO Armitage

25

309

Other low-grade non-Hodgkin's lymphomas JA Radford

24

299

Follicular lymphoma TA Lister, AZS Rohatiner

23

287

Lymphoblastic lymphoma in adults JW Sweeten ham

22

269

Aggressive non-Hodgkin's lymphoma ER Gaynor, Rl Fisher

21

247

Advanced Hodgkin's disease BW Hancock, PJ Selby

20

221

Localized non-Hodgkin's lymphoma SB Sutcliffe, MK Gospodarowicz, MH Robinson

19

205

Localized Hodgkin's disease SB Sutcliffe, AR Timothy, MH Robinson

18

181

437

439

Contributors

James 0 Armitage

Michel Henry-Amar

Department of Internal Medicine, University of Nebraska

Centre Francois-Baclesse, Service de Recherche Clinique,

Medical Center, Omaha, Nebraska, USA

Caen, France

Philip J Bierman

Richard T Hoppe

Department of Internal Medicine, University of Nebraska

Professor of Cancer Biology, Chairman, Department of

Medical Center, Omaha, Nebraska, USA Michael R Bishop National Institutes of Health, National Cancer Institute, Bethesda, Maryland, USA

Radiation Oncology, Stanford University Medical Center, Stanford, California, USA PG Isaacson Department of Histopathology, Royal Free and University College London Medical School, University Street, London, UK

Ray A Cartwright Director, Leukaemia Research Fund, Centre for Clinical Epidemiology, University of Leeds, 30-32 Hyde Terrace, Leeds, UK Karen L Chang Department of Pathology, City of Hope National Medical Center, Duarte, California, USA

Andrew S Jack Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals, Leeds, UK PWM Johnson CRC Department of Medical Oncology, Southampton General Hospital, Southampton, UK Youn H Kim

B Crosse ICRF Cancer Medicine Research Unit, St James's University Hospital, Leeds, UK Bhavana J Dave

Associate Professor of Dermatology, Stanford University Medical Center, Stanford, California, USA Alexandra M Levine Professor of Medicine, University of Southern California

Assistant Professor, Pathology/Microbiology and Pediatrics,

School of Medicine, Norris Cancer Hospital, Los Angeles,

University of Nebraska Medical Center, Omaha, Nebraska, USA

California, USA

V Diehl Department of Internal Medicine I, University of Cologne, Germany

T Andrew Lister Consultant Medical Oncologist, Department of Medical Oncology, St Bartholomew's Hospital, West Smithfield, London, UK

Richard I Fisher

KA MacLennan

Professor of Medicine, Director Division of

Consultant Histopathologist, ICRF Cancer Medicine Research Unit, St James's University Hospital, Beckett Street, Leeds, UK

Hematology/Oncology, Loyola University Medical Center, Maywood, Illinois, USA Ellen R Gaynor Professor of Medicine, Division of Hematology/Oncology, Loyola University Medical Center, Maywood, Illinois, USA

JS Malpas Masters Lodge, Charterhouse Square, London, UK Nancy E Mueller

Mary K Gospodarowicz

Professor of Epidemiology, Harvard School of Public Health, Boston, Massachusetts, USA

Professor of Radiation Oncology, Department of Radiation

VI Pappa

Oncology, University of Toronto, Princess Margaret Hospital,

Second Department of Internal Medicine, Athens University,

Toronto, Ontario, Canada

Evangelismos Hospital, Athens, Greece

Barry W Hancock

JA Radford

YCR Department of Clinical Oncology, Weston Park Hospital, Sheffield, UK

Christie Hospital NHS Trust, Wilmslow Road, Withington, Manchester, UK

x Contributors SJ Richards

John W Sweetenham

Haematological Malignancy Diagnostic Service, Leeds Teaching Hospitals, Leeds, UK

University of Colorado Health Sciences Center, Division of

Martin H Robinson

Adrian R Timothy

YCRC Department of Clinical Oncology, Weston Park Hospital

St Thomas' Hospital, Lambeth Palace Road, London

Medical Oncology, Denver, Colorado, USA

NHS Trust, Sheffield, UK

B Vaughan Hudson

PJ Robinson

The British National Lymphoma Investigation,

Department of Radiology, St James's University Hospital, Beckett Street, Leeds, UK

UCH/Middlesex Hospital, London, UK G Vaughan Hudson

Ama ZS Rohatiner

The British National Lymphoma Investigation,

Medical Oncology Unit, St Bartholomew's Hospital, West

UCH/Middlesex Hospital, London, UK

Smithfield, London, UK

Dennis D Weisenburger

K Sandrasegaran

Department of Pathology and Microbiology, University of

Department of Radiology, Birmingham Heartlands Hospital,

Nebraska Medical Center, Omaha, Nebraska, USA

Birmingham, UK

Lawrence M Weiss

Warren G Sanger

Chairman, Department of Pathology, City of Hope National Medical Center, Duarte, California, USA

Director, Cytogenetics Laboratories, Professor, Pathology/Microbiology and Pediatrics, University of Nebraska Medical Center, Omaha, Nebraska, USA PJ Selby Director, ICRF Cancer Medicine Research Unit, St James's

Jurgen Wolf Department of Internal Medicine I, University of Cologne, Germany Julie M Vose

University Hospital, Beckett Street, Leeds, UK

University of Nebraska Medical Center, Omaha, Nebraska,

A Sprigg

USA

Department of Radiology, Sheffield Children's Hospital, Western Bank, Sheffield, UK

BD Young Imperial Cancer Research Fund, Medical Oncology

Simon B Sutcliffe Vancouver Cancer Center, Vancouver, Canada

Department, St Bartholomew's Hospital Medical College, London, UK

Preface

This book gives fiilly referenced reviews of the many aspects of malignant lymphoma. It is a field where it is of particular importance that the clinician be aware of the variations in histological structure in the lesions with which he or she deals; we hope that the histopathology chapters are intelligible to the clinician, particularly as the most recent classification (Revised EuropeanAmerican Lymphoma/World Health Organisation) is likely to be universally accepted. An understanding of the pathogenesis (particularly the role of viruses and relevance of molecular biological discoveries) and epidemiology is likely to improve treatment strategies, so these subjects are also covered in depth. However,

clinical management, in all its aspects, comprises the major section of the book since it is towards improving the patient's lot that we all strive. We have invited an international panel of distinguished experts in all fields to contribute chapters in the hope that the book will give you a truly global interpretation of current and possible future strategies in understanding, diagnosing and treating this wide spectrum of diseases known collectively as the malignant lymphomas. Barry Hancock August 2000

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Foreword

When the history of oncology research is finally written, the lymphomas will be the tumor group that dominates. As a group these tumors have opened up trails where there were no paths in understanding the biology of cancer, in general, and shown how biology can be effectively linked to cancer management. They have also served as a model for how multidisciplinary teams can coalesce to properly diagnose, stage and treat a group of complex cancers. A number of prominent firsts are associated with lymphomas. Hodgkin's disease was the first hematological malignancy described, followed in a few decades by the lymphocytic lymphomas. They were also the first tumors of a major organ system in adults cured by chemotherapy. Treatments developed for them have led to principles that have had applications in many other cancers as well. For many years, however, the field was plagued by a cacophony of pathology classification systems developed by prominent pathologists the world over. Most relied on empiricism and were not easy to learn and use. Always, it was difficult to match data across systems. A major advance occurred when the Working Formulation was developed because it brought some commonality to the language we used and allowed a more accurate crosscomparison of study results. It was, however, not a very scientific classification. Now we have the Revised European-American

Lymphoma (REAL) classification, which has brought order out of chaos by merging science with clinical practice, and it has brought us this book. The REAL classification was first met with considerable skepticism by lymphoma clinicians who feared it would be too unwieldy for practical use. On the contrary its strong scientific foundation and logical display of the numerous lymphoma subtypes has made it easy to remember and the most efficient lymphoma classification yet devised. So it is appropriate to have a new text on the subject that re-arrays the rich lode of information available to us on lymphomas under the new system. The editors and authors of this text have done just that. The content covers the science well, and distills all the information in a practical way and covers the new entities offered in the REAL classification. It is the judgement of this author that this is the definitive text in the field and, that it will be a necessary and welcome addition to the bookshelf of any physician who sees patients with lymphomas. Now if we can only call them what they are instead of what they are not! Vincent T. DeVita Jr, MD Professor of Medicine and Epidemiology and Public Health Yale University School of Medicine 30 June 2000

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PART

Histopathology

Lymphoma classification Hodgkin's disease Follicular lymphoma

3 9 21

Mantle cell lymphoma

27

Diffuse indolent B cell neoplasms

43

Diffuse aggressive B cell lymphoma

49

T cell lymphoproliferative disorders

55

Extranodal lymphomas

71

Cytogenetics

91

1

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1 Lymphoma classification KAMACLENNAN

Introduction Rappaport classification Lukes and Collins classification Kiel classification National Cancer Institute sponsored lymphoma classification project

3 3 4

Revised Kiel classification Revised European-American lymphoma classification Lymphoma classification project

4

WHO classification

5 6 6 7

References

8

4

INTRODUCTION The classification of the non-Hodgkin's lymphomas has been the subject of considerable controversy over many decades. Our understanding of the immune system has increased dramatically over recent years and thus our appreciation of the complexity of its neoplasms has been heightened. These factors, together with the introduction of new methodologies for the study of malignant lymphoma has greatly expanded the number of distinct entities that we now can recognize. This has inevitably led to terminological confusion, and many clinicians regard lymphoma classification with apprehension and distaste. The clinical management strategies for the treatment of malignant lymphoma still revolve around the concepts of low-grade lymphoma, which are regarded as indolent but incurable, and high-grade lymphomas, which are aggressive but potentially curable. However, embedded within these clinical groupings are distinctive biological entities that have widely varying clinical behavior. In order to understand how far we have progressed in the difficult field of the classification of the non-Hodgkin's lymphomas, it is of some value to review the history of lymphoma classifications briefly. Although earlier reports of lymphoproliferative disease are available, the first detailed study and documentation that malignant lymphoma was a distinctive entity was provided by Thomas Hodgkin's classical paper describing the disease,1 which Samuel Wilks generously gave the eponymous name Hodgkin's disease.2 This was

based upon macroscopic findings alone. In later years microscopic study of tissue from cases of malignant lymphoma was undertaken and the bewildering complexity of neoplasms of the immune system became apparent.3"5 The first classification of the modern era to gain widespread acceptance was proposed by Henry Rappaport.

RAPPAPORT CLASSIFICATION The Rappaport classification (Table 1.1) was submitted for publication as a fascicle of the Armed Forces Institute of Pathology Atlas of Tumor Pathology in 1959 but was not published until 1966.6 The classification paid particular attention to the architecture of non-Hodgkin's lymphoma, believing that there were nodular and diffuse subtypes of each cytological form. Although lacking any precision in terminology or lineage, the Rappaport classification proved extremely useful clinically and persisted for more than 20 years.

Table 1.1 Original Rappaport classification of 1956

1. 2. 3. 4. 5.

Lymphocytic type, well differentiated Lymphocytic type, poorly differentiated Mixed type (lymphocyticand reticulum cell) Reticulum-cell type Hodgkin's type

4 Lymphoma classification

Table 1.2 Original Lukes and Collins classification of 1974

Table 13 Original Kiel classification of 1974

I U cell (undefined cell) type II T eel I types Mycosis fungoides and Sezary syndrome Convoluted lymphocyte ?lmmunoblastic sarcoma (of T cells) ?Hodgkin's disease III B eel I types Small lymphocyte (chronic lymphocytic leukemia; CLL) Plasmacytoid lymphocyte Follicular center cell (FCC) types (follicular, diffuse, follicular, and diffuse and sclerotic) Small cleaved Large cleaved Small non-cleaved Large non-cleaved Immunoblastic sarcoma (of B cells) IV Histiocytictype V Unclassifiable

Low-grade malignancy Malignant lymphoma- lymphocytic (CLL and others) Malignant lymphoma - lymphoplasmacytoid (immunocytic) Malignant lymphoma - centrocytic Malignant lymphoma - centroblastic-centrocyticfollicular; follicular and diffuse; diffuse; with and without sclerosis High-grade malignancy Malignant lymphoma - centroblastic Malignant lymphoma - lymphoblastic Burkitt type Convoluted-cell type Others Malignant lymphoma - immunoblastic

In the 1970s the development of modern immunological concepts of T and B cell lineage impacted on lymphoma classification.7

LUKES AND COLLINS CLASSIFICATION The Lukes and Collins classification (Table 1.2) was developed based on cell lineage and morphological alterations associated with lymphocyte transformation in response to antigenic stimulus. It introduced new terminology to describe the varied cell morphology of follicle center cells, and terms such as cleaved and non-cleaved became widely accepted. Central to the classification was the belief that experienced hematopathologists could discriminate between B and T cell lineage lymphoma with reliability.7"13 In Europe, a similar ideology was used by Karl Lennert and members of the European Lymphoma Club to formulate the Kiel classification.

KIEL CLASSIFICATION The Kiel classification (Table 1.3) achieved popularity in Europe and as its central tenet was the concept that the cytology of lymphoma cells could be used as a grading system to predict clinical behavior. The presence of numerous transformed or blast cells was indicative of aggressive disease. Important in the structure of the Kiel classification was the belief that the nodular lymphomas proposed by Rappaport were the neoplastic equivalent of germinal center B cells. The Kiel classification introduced new terminology for follicle center B cells. Although originally termed germinoblasts and germinocytes as equivalent to the large non-cleaved and

small cleaved cells of the Lukes and Collins classification, this was subsequently changed as the terms centroblast and centrocyte were introduced.14"17 The Lukes and Collins and the Kiel classifications were the most scientifically appropriate classifications that existed in their day.18 However, four other classifications were also in use in the early 1970s. These were the Dorfman classification,19 World Health Organisation (WHO) classification,20 the British National Lymphoma Investigation classification21'22 and the updated Rappaport classification.23 These employed different terminology and had different criteria for diagnosis. It is therefore no surprise that there was a degree of confusion that pertained during this period and caused extreme difficulties in the comparison of therapeutic trials in malignant lymphoma. In an attempt to resolve these difficulties, the American National Cancer Institute sponsored a comparative study of lymphoma classification.

NATIONAL CANCER INSTITUTE SPONSORED LYMPHOMA CLASSIFICATION PROJECT The National Cancer Institute (NCI) lymphoma classification project studied the reproducibility and clinical value of the six major lymphoma classifications that were used in the 1970s. Six pathologists each representing a particular lymphoma classification and six expert hematopathologists who were to use each classification studied 1175 cases of malignant lymphoma accrued at four major oncology institutions (three Northern American and one European: Stanford University, Tufts-New England Medical Center, University of Minnesota Hospitals and the Milan National Tumour Institute). The prognostic significance and reproducibility of each classification was studied. As it transpired there was no significant difference between any of the six classifications in terms of clinical value and reproducibility. An attempt was made to select one classification for

Revised Kiel classification 5

Table 1.4 Working formulation of non-Hodgkin's lymphomas for clinical usage Low grade A. Small lymphocytic Consistent with CLL; plasmacytoid B. Follicular predominantly small cleaved cell Diffuse areas, sclerosis C. Follicular mixed small cleaved and large cell Diffuse areas, sclerosis Intermediate grade D. Follicular predominantly large cell Diffuse areas, sclerosis E. Diffuse small cleaved cell Sclerosis F. Diffuse mixed, small and large cell Sclerosis; epithelioid cell component G. Diffuse large cell Cleaved cell, non-cleaved cell, sclerosis High grade H. Large cell, immunoblastic Plasmacytoid, clear cell, polymorphous epithelioid cell component I. Lymphoblastic Convoluted, non-convoluted J. Small non-cleaved cell Burkitt's, follicular areas Miscellaneous Composite, mycosis, fungoides, histiocytic, extra medullary, plasmacytoma, unclassifiable, other

use world-wide. This was unsuccessful and so, after analysis of survival data, a working formulation of nonHodgkin's lymphomas for clinical usage was proposed (Table 1.4). This recognized three grades of lymphoma, low grade, intermediate grade and high grade, and was proposed, not as a classification, but as a common terminology for reporting lymphoma clinical trials.24 Serious criticisms were levelled at the working formulation, principally by Lukes and Lennert, who regarded it

as biologically imprecise with a division of distinctive entities between different clinical grades, and a lumping together of diverse lymphomas under terms such as diffuse mixed small and large cell and diffuse large cell lymphoma. They expressed the hope that the working formulation would not stifle research into the basic biology of malignant lymphoproliferative disease.24 Although proposed solely as a translational device, the working formulation was quickly adopted in North America as a classification, and during the 1980s and early 1990s became the standard classification. In Europe the working formulation was adopted by some centers, but the Kiel classification became predominant and was the most important in this continent, particularly after it was updated in 1988.25

REVISED KIEL CLASSIFICATION The Kiel classification was extensively updated in 1988 by Stansfeld and colleagues and now introduced clear delineation of B and T cell lymphoma entities.25 The classification was intended for nodal lymphomas and paid little attention to extra nodal disease. The updated Kiel classification (Table 1.5) was criticized for its level of complexity, particularly within the peripheral T cell lymphoma compartment where ten major subtypes were recognized. This was felt to lack clinical relevance and to be poorly reproducible by pathologists.26 The emergence of these two dominant classifications led to a major divergence of terminology between Europe and the United States, which led to difficulties in interpretation of the clinical and pathological literature. In order to resolve these difficulties, a group of 19 expert hematopathologists, who called themselves the International Lymphoma Study Group (ILSG), conducted a series of meetings in an attempt to identify distinct lymphoma entities within the field of lymphoproliferative

Table 1.5 Updated Kiel classification on non-Hodgkin's lymphoma

Low grade Lymphocytic-chronic lymphocytic and prolymphocytic leukemia; hairy cell leukemia Lymphoplasmacytic/cytoid Plasmacytic Centroblastic/centrocytic Centrocytic High grade Centroblastic Immunoblastic Large cell anaplastic Burkitt lymphoma Lymphoblastic Rare types

Lymphocytic-chronic lymphocytic and prolymphocytic leukemia Lymphoepithelioid Angioimmunoblastic Tzone Pleomorphic, small cell Pleomorphic, medium and large cell Immunoblastic Large cell anaplastic Lymphoblastic Rare types

6 Lymphoma classification

disease, which could be reproducibly diagnosed and on which they could establish an acceptable terminology.27

REVISED EUROPEAN-AMERICAN LYMPHOMA CLASSIFICATION In 1994, Harris and co-workers published the Revised European-American Lymphoma (REAL) classification. This classification was a listing of lymphoid neoplasms which were distinctive biological entities and which could be reproducibly diagnosed by hematopathologists (Table 1.6). This listing delineates precursor and peripheral lymphoid neoplasms of both B and T cell lineage as well as including plasmacytoma/multiple myeloma and Hodgkin's disease. The classification is applicable to nodal and extranodal lymphoma alike, and is thus a significant advance on the Kiel classification.27'28 Although fiercely criticized by some when first published, the classification has been broadly accepted and welcomed by hematopathologists world-wide. Criticisms that were levelled at the REAL classification were that it had not been tested for its clinical and prognostic value, and there were no data as to how well it could be applied by hematopathologists.29 In order to study these questions, a group was established under the chairmanship of Professor J.O. Armitage from the University of Nebraska Medical Center at Omaha, which was termed the Lymphoma Classification Project.

LYMPHOMA CLASSIFICATION PROJECT In order to evaluate the recently proposed ILSG classification of non-Hodgkin's lymphoma, a group of five expert hematopathologists visited eight major oncology institutions. The objectives of this study were to determine how well the REAL classification could be applied by expert hematopathologists, and to compare its applicability with the working formulation and Kiel classification to study the clinical value of the classification and to gain some idea of the geographic variability in the incidence of non-Hodgkin's lymphoma. The results of this study showed that the REAL classification could be applied with a high degree of accuracy with an interobserver concordance rate of 85 per cent for the major lymphoma subtypes and an intraobserver concordance rate of 94 per cent when clinically insignificant discrepancies were discounted.30 The REAL classification was a good predictor of survival and failure-free survival. This study has validated the ILSG proposal, and shown the REAL classification to be superior to the working formulation and updated Kiel classification in terms of reproducibility and prognostic significance. The REAL classification and the data generated by the Lymphoma Classification Project have been of great

Table 1.6 Lymphoid neoplasms recognized by the International Lymphoma Study Group B cell neoplasms I Precursor B cell neoplasms: B precursor lymphoblastic leukemia/lymphoma II Peripheral B cell neoplasms 1. B cell chronic lymphocytic leukemia/prolymphocytic leukemia/small lymphocytic lymphoma 2. Lymphoplasmacytoid lymphoma/immunocytoma 3. Mantle cell lymphoma 4. Follicle center lymphoma, follicular Provisional cytologic grades: I (small cell), II (mixed small and large cell), III (large cell) Provisional subtype: diffuse, predominantly small cell type 5. Marginal zone B cell lymphoma Extranodal (MALT type *monocytoid B cells) Provisional subtype: nodal (*monocytoid B cells) 6. Provisional entity: splenic marginal zone lymphoma (*villous lymphocytes) 7. Hairy cell leukemia 8. Plasmacytoma/plasma cell myeloma 9. Diffuse large B cell lymphoma Subtype: primary mediastinal (thymic) B cell lymphoma 10. Burkitt lymphoma 11. Provisional entity: high-grade B cell lymphoma, Burkitt-like T cell and putative natural killer (NK) cell neoplasms I. Precursor T cell neoplasm: T precursor lymphoblastic lymphoma/leukemia II. Peripheral T cell and NK cell neoplasms 1. T cell chronic lymphocytic leukemia/prolymphocytic leukemia 2. Large granular lymphocytic leukemia (LGL), T and NK cell types 3. Mycosis fungoides/Sezary syndrome 4. Peripheral T cell lymphoma, unspecified Provisional cytologic categories, medium-sized cell, mixed medium and large cell, large cell, lymphoepithelioid cell Provisional subtype: hepatosplenic y6 T cell lymphoma Provisional subtype: subcutaneous panniculiticTcell lymphoma 5. Angioimmunoblastic T cell lymphoma (AIL) 6. Angiocentric lymphoma 7. Intestinal T cell lymphoma (*enteropathy associated) 8. Adult T cell lymphoma/leukemia (ATLL) 9. Anaplastic large cell lymphoma (ALCL), CD 30+, T and null-cell types 10. Provisional entity: anaplastic large cell lymphoma, Hodgkin's like Hodgkin's disease I. Lymphocyte predominance II. Nodular sclerosis III. Mixed cellularity IV. Lymphocyte depletion V. Provisional entity: lymphocyte-rich classical Hodgkin's disease

WHO classification 7

value in formulating the forthcoming proposal from the WHO on the classification of hemopoietic neoplasms. WHO CLASSIFICATION The WHO classification, although not yet published, is being developed under the joint auspices of the Society for Hematopathology and the European Association for Haematopathology. A steering committee composed of

Drs C Berard, J Diebold, N Harris, E Jaffe and K Lennert has established ten committees, which are involved in the classification of hematolymphoid malignancy. Although a final version has not been published, the broad outlines of the classification are illustrated in Table 1.7, and the close similarity between the proposed WHO classification and the REAL classification are immediately apparent. It is to be hoped that, with the publication of the WHO classification, a period of stability in lymphoma

Table 1.7 World Health Organisation classification of neoplastic diseases of the hematopoietic and lymphoid tissues B cell neoplasias Precursor B cell neoplasms B cell lymphoblastic leukemia/lymphoma Peripheral B cell neoplasms B cell chronic lymphocytic leukemia/small lymphocytic lymphoma Variant: with monoclonal gammopathy/plasmacytoid differentiation; mu heavy chain disease B cell prolymphocytic leukemia Variant: hairy cell variant Lymphoplasmacytic lymphoma Variant: Waldenstrom's macroglobulinemia; gamma heavy chain disease Mantle cell lymphoma Variant: blastic Follicular lymphoma Grades: Grade 1 (centroblasts comprise <50 per cent of the follicle surface area); Grade 2 (centroblasts comprise >50 per cent of the follicle surface area) Variant: cutaneous follicular lymphoma Marginal zone B cell lymphoma of mucosa-associated lymphoid tissue Variant: alpha heavy chain disease Nodal marginal zone lymphoma ± monocytoid B cells Splenic marginal zone B cell lymphoma (± villous lymphocytes) Hairy cell leukemia Diffuse large B-cell lymphoma Variants: Centroblastic Immunoblastic Tcell or histiocyte rich Anaplastic large B cell Burkitt-like Lymphomatoid granulomatosistype Diffuse large B cell lymphoma, subtypes: Mediastinal (thymic) large B cell lymphoma Intravascular large B cell lymphoma Primary effusion lymphoma in HIV patients/pyotorax related Burkitt lymphoma Variant: with plasmacytoid differentiation (AIDSassociated) Plasmacytoma Variants: Solitary plasmacytoma of bone Extramedullary plasmacytoma

Plasma cell myeloma Variants: Indolent myeloma Smoldering myeloma Osteosclerotic myeloma (POEMS syndrome) Plasma cell leukemia Non-secretory myeloma Systemic light chain disease Primary amyloidosis T cell neoplasias Precursor Tcell leukemia/lymphoma Tcell lymphoblastic leukemia/lymphoma Peripheral T/NKcell neoplasms, predominantly leukemic/disseminated T cell prolymphocytic (T-PLL) T cell large granular lymphocyte leukemia NKcell leukemia Adult Tcell lymphoma/leukemia Peripheral T cell and NK cell neoplasms, predominantly nodal AIL Tcell lymphoma Peripheral T cell lymphoma (unspecified) T-zone Lymphoepithelioid (Lennert) lymphoma ALC lymphoma (T and null cell types) Peripheral T cell and NK cell neoplasms, predominantly extra nodal Mycosis fungoides Sezary syndrome Primary cutaneous CD 30-positive T cell lymphoproliferative disorders Primary cutaneous ALC lymphomas + borderline with lymphomatoid papulosis Subcutaneous panniculitic-like T cell lymphoma NK/Tcell lymphomas, nasal/nasal type Enteropathy-type intestinal T cell Hepatosplenic76Tcell lymphoma Hodgkin lymphoma (Hodgkin disease) Nodular lymphocyte-predominance Hodgkin lymphoma Classical Hodgkin lymphoma Hodgkin lymphoma, nodular sclerosis (Grades I and II) Hodgkin lymphoma, mixed cellularity Classical Hodgkin lymphoma, lymphocyte-rich Hodgkin lymphoma, lymphocyte depletion

8 Lymphoma classification

terminology will pertain, so that prospective data on the clinical behavior of defined lymphoma entities may be accrued.

15. Lennert K, Stein H, Kaiserling E. Cytological and functional criteria for the classification of malignant lymphomata. BrJ Cancer 1975; 31 (suppl 2): 29-43. 16. Lennert K. Malignant lymphomas other than Hodgkin's disease. New York: Springer-Verlag, 1978.

REFERENCES

17. Lennert K. Immunology: morphology and function. Adv Exp Med Biol 1979; 114:1-9. 18. Lennert K, Collins RD, Lukes RJ. Concordance of the Kiel

1. Hodgkin T. On some morbid appearances of the absorbent glands and spleen. Med Chir Trans 1832; 17:68-114. 2. Wilkes Sir S. Cases of enlargement of the lymphatic glands and spleen (or, Hodgkin's disease), with remarks. Guys Hosp Rep 1865; 11: 56-67. 3. Greenfield WS. Specimens illustrative of the pathology of lymphadenoma and leucocythaemia. Trans Path Soc Land. 1878; 29: 272-304. 4. EwingJ. Neoplastic diseases. Philadelphia, London: WB Saunders, 1919. 5. Fox H. Remarks on microscopic preparations made from some of the original tissue described by Thomas Hodgkin, 1832. Ann Med Hist 1926; 8: 370-4. 6. Rappaport H. Tumors of the hematopoietic system, series 1, section III. Washington, DC: Armed Forces Institute of Pathology. 1966. 7. Lukes RJ, Collins RD. Immunologic characterization of human malignant lymphomas. Cancer 1974; 34 (suppl): 1488-503. 8. Lukes RJ, Collins RD. New approaches to the classification of the lymphomata. BrJ Cancer 1975; 31 (suppl 2): 1-28. 9. Lukes RJ, Collins RD. Lukes-Collins classification and its significance. Cancer Treat Rep 1977; 61: 971-9. 10. Lukes RJ, Lincoln TL, Parker JW, Alavaikko MJ. An

and Lukes-Collins classifications of non-Hodgkin's lymphomas. Histopathology 1983; 7: 549-59. 19. Dorfman RF. Classification of non-Hodgkin's lymphomas (letter). Lancet 1974; 2: 961-2. 20. Mathe G and Rappaport H. Histological and cytological typing of neoplastic diseases of hematopoietic and lymphoid tissues. Geneva: World Health Organisation, 1976. 21. Bennett MH, Farrer-Brown G, Henry K, Jell iff e AM. Classification of non-Hodgkin's lymphoma. Lancet 1974; ii: 405. 22. Henry K, Bennett MH, Farrer-Brown G. Morphological classification of non-Hodgkin's lymphomas. Rec Results Cancer Res 1978; 64: 38-56.

23. Nathwani BN, Kim H, Rappaport H, Solomon J, Fox M. Non-Hodgkin's lymphomas: a clinicopathologic study comparing two classifications. Cancer 1978; 41: 303-25. 24. Anonymous. National Cancer Institute sponsored study of classifications of non-Hodgkin's lymphomas: summary and description of a working formulation for clinical usage. The Non-Hodgkin's Lymphoma Pathologic Classification Project. Cancer 1982; 49: 2112-35.

immunologic approach to classification of malignant

25. Stansfeld AG, Diebold J, Noe H, et al. Updated Kiel classification for lymphomas. Lancet 1988; 1: 292-3.

lymphomas: a cytokinetic model of lymphoid neoplasia. In: Clarkson B, et al., eds. Differentiation of normal and

26. Hastrup N, Hamilton-Dutoit S, Ralfkiaer E, Pallesen G. Peripheral T-cell lymphomas: an evaluation of

neoplastic hematopoietic cells. Cold Spring Harbor, NY:

reproducibility of the updated Kiel classification.

Cold Spring Harbor Laboratory, 1978; 935-52.

Histopathology 1991; 18: 99-105.

11. Lukes RJ, Taylor CR, Parker JW. Multi para meter studies in malignant lymphoma based on studies in 1186 cases. Prog Clin Biol Res 1983; 132E: 203-13. 12. Lukes RJ, Taylor CR, Parker JW, Lincoln TL, Pattengale PK, Tindle BH. A morphologic and immunologic surface marker study of 299 cases of non-Hodgkin lymphomas and related leukemias. Am} Pathol 1978; 90: 461-85. 13. Lukes RJ, Parker JW, Taylor CR, Tindle BH, Cramer AD, Lincoln TL. Immunologic approach to non-Hodgkin lymphomas and related leukemias. Analysis of the results of multiparameter studies of 425 cases. Semin Hematol 1978; 15: 322-51. 14. Gerard-Marchant R, Hamlin I, Lennert K, et al. Classification of non-Hodgkin's lymphoma. Lancet 1974; H: 406-8.

27. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 28. Chan JK, Banks PM, Cleary ML, et al. A proposal for classification of lymphoid neoplasms (by the International Lymphoma Study Group). Histopathology 1994; 25: 517-36. 29. Rosenberg SA. Classification of lymphoid neoplasms. Blood 1994; 84:1359-60. 30. Anonymous. A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. Blood 1997; 89: 3909-18.

2 Hodgkin's disease KA MACLENNAN, B VAUGHAN HUDSON AND G VAUGHAN HUDSON

9

Introduction Cell of origin of Hodgkin's disease

10

Mixed cellularity Hodgkin's disease 13 Clinical significance of morphological pattern in Hodgkin's

Lymphocyte-predominant Hodgkin's disease Nodular sclerosis

10 12

disease

14

References

14

Lymphocyte-depleted Hodgkin's disease

13

INTRODUCTION The first descriptions of the disease currently termed Hodgkin's disease are attributed to Thomas Hodgkin1 and the term Hodgkin's disease was generously applied by Sir Samuel Wilkes;2 however, there are several texts describing a similar disease process that antedate both these workers' manuscripts.3'4 These early descriptions of Hodgkin's disease were all concerned with the macroscopic appearances and distribution of affected lymph nodes, spleen and visceral organs as observed at post mortem examination. There thus exists some doubt as to the exact nature of the disease processes being described. Herbert Fox,5 after histological examination of pathological material stored at Guy's Hospital from three of Thomas Hodgkin's original cases, believed two were typical of Hodgkin's disease, and one to be an example of lymphosarcoma or leukaemia; other skilled observers have concurred with this view.6,7 During the latter half of the nineteenth century, many workers undertook histological examination of cases that were felt to be similar to Hodgkin's disease.8'11 There emerged from these descriptions an awareness that the normal structure of the lymph node was replaced by abnormal tissue, often described as fibrous tissue, and the disease was associated with unusual giant cells. In 1898, Sternberg gave a masterful description of these giant cells,12 which 4 years later was followed by the publication of Dorothy Reed's classic paper.13 Following the meticulous histological descriptions of Hodgkin's disease by these early microscopists, terminological confusion was soon to emerge and, by 1933, Walhauser was able to find 52 synonyms for this condition

(an unusually large number even for the field of lymphoreticular pathology).14 This ridiculous state of affairs was only resolved by the widespread adoption of the Jackson and Parker classification" (see below). In the early part of the twentieth century, some workers attempted to correlate the histological appearances of Hodgkin's disease with the clinical course. In 1919, Ewing recognized a rapidly fatal form of the disease characterized by depletion of lymphocytes and a sheetlike growth of pleomorphic mononuclear and multinuclear cells, which he termed Hodgkin's sarcoma.16 Rosenthal, in 1936, observed the inverse relationship between the number of lymphocytes and abnormal reticulum cells;17 he was also able to correlate survival and response to orthovoltage radiotherapy to the histological appearances. Following the work of Rosenthal, Jackson and Parker15'18"20 proposed their classification of Hodgkin's disease. Three histological subtypes were recognized: paragranuloma, granuloma and sarcoma, which showed a good correlation with clinical behavior and prognosis. Unfortunately, the classification proved to be of limited value as the majority of cases were classified as Hodgkin's granuloma15'21 and this subtype showed an extremely variable clinical course.22 These problems were overcome by the widespread adoption of the Lukes and Butler classification and its modification proposed at the Rye conference,23-26 which has remained essentially unchanged for over 20 years, and most pathologists believe they are familiar with the terminology and criteria employed. It is therefore surprising to find high levels of disagreement between pathologists in establishing the diagnosis of Hodgkin's disease and its classification, which may range

10 Hodgkin's disease

from 13 per cent27'28 to a staggering figure of 47 per cent, reported by Symmers.29 The reasons for the difficulties pathologists experience in the diagnosis of HD are not too difficult to understand. Hodgkin's disease is rare and most pathologists will see only a few cases a year. This, combined with the complexity of the histological picture, which may be closely mimicked by a variety of neoplastic and nonneoplastic lymphoproliferative conditions, will lead to errors in diagnosis.

CELL OF ORIGIN OF HODGKIN'S DISEASE There has been considerable controversy over the years about the cellular origin of the putative malignant cell in Hodgkin's disease (HD), the Hodgkin's and ReedSternberg cell (H-RS cell). Many candidates have been proposed that include histiocytes, interdigitating cells, follicular dendritic cells and lymphoid cells of both B and T cell lineage. One significant problem in establishing the lineage of the H-RS cell has been their relative paucity in tissue affected by HD, where they often make up less than 5 per cent of the total cell population. This has led investigators to study Hodgkin's cell lines and cases of HD containing numerous H-RS cells, which may show major differences to typical HD.3031 An early study of a case of H-RS cell-rich nodular sclerosis revealed a clonal immunoglobulin gene rearrangement.32 Although initially controversial, subsequent reports also found immunoglobulin (Ig) gene rearrangements in a percentage of cases. Other workers demonstrated T cell receptor rearrangements of both beta and gamma chains in some cases of HD.33 A novel approach of single cell microdissection of HRS cells was established, which allowed analysis of the Ig gene configuration by polymerase chain reaction (PCR). Initial reports showed clonal Ig gene rearrangement with somatic hypermutation within the H-RS cell population in the vast majority of the cases studied.34 Controversy soon followed with other workers providing dramatically different results despite using very similar methodology. In summary, one group were unable to detect any evidence of Ig gene rearrangement within H-RS cells,35 one group showed polyclonal Ig rearrangement36 and a third demonstrated a mixture of results, with some cases showing no Ig gene rearrangement,37 some polyclonal rearrangement,36 some clonal,38-10 and some mixed polyconal and clonal Ig gene rearrangement.41 These results are clearly incompatible. Evidence is now accumulating that the majority of cases of classical HD have clonal Ig gene rearrangement, with somatic hypermutation clearly identifying the H-RS cells as a neoplastic, germinalcenter-derived B cell. In addition, many cases display 'crippling mutations' such as stop codons within the rearranged Ig genes.42

Similarly controversial results have been found in lymphocyte-predominant nodular HD, with some workers demonstrating somatically hypermutated, clonally rearranged Ig genes, while others have found polyclonal patterns of Ig gene rearrangement within populations of microdissected lymphocytic and/or histiocytic (L & H) cells. Recently, three separate groups have demonstrated clonal Ig gene rearrangements within populations of microdissected L & H cells. These rearrangements are somatically hypermutated but lack the 'crippling mutations' seen in classical HD, and show evidence of continuing antigen selection in an analogous manner to follicle-center-derived non-Hodgkin's lymphomas.43'44

LYMPHOCYTE-PREDOMINANT HODGKIN'S DISEASE For many years, Hodgkin's disease with a predominance of lymphocytes has been recognized as having a more indolent natural history15,17,22,23,25,45-47 than the usual type of HD. Lukes and Butler described a form of HD that contained a spectrum of cytological appearances, which ranged from a predominance of mature lymphocytes to a histiocyte-rich cellular background which they termed lymphocytic and/or histiocytic (L & H) Hodgkin's disease;24 they recognized nodular and diffuse architectural patterns. These cytological and architectural patterns of L & H HD were amalgamated at the Rye conference26 and termed lymphocytic predominance. Lymphocyte-predominant (LP) Hodgkin's disease makes up a variable percentage of cases of HD in large series, depending on the stringency of the diagnostic criteria applied.48 In the British National Lymphoma Investigation (BNLI) series of 4249 cases, LP comprises 5.7 per cent and in the European Organisation for Research and Treatment of Cancer (EORTC)-GELA studies of localized HD (H 8), which include 722 centrally reviewed cases, LP makes up 4 per cent.49 It usually presents with localized, asymptomatic disease and often involves unusual sites, such as the suprahyoid neck, the periparotid lymph nodes and the inguinal region. There is a marked male predominance and patients are usually a decade older than the peak age incidence of the usual type of HD.50 For many years there was a lack of precision in the diagnosis of LP, with many cases of the usual type of HD that displayed a lymphocyte-rich cellular background being included in this category. In a seminal paper published in 1979, Poppema and co-workers51 recognized the cytological similarities between LP nodular HD and a reactive condition affecting germinal centers, termed progressive transformation.52'53 They postulated that LP nodular HD was a distinct form of HD, which arose in

Lymphocyte-predominant Hodgkin's disease 11

the B cell regions of the lymph node and was related to progressive transformation of germinal centers. In order to emphasize the differences between LP nodular and other histological subtypes of HD, they proposed the term nodular paragranuloma, which has been adopted by some workers.

Morphologic features Lymph nodes affected by LP nodular HD are enlarged and can reach significant sizes (up to 5 cm); their cut surface has a uniform fleshy appearance and occasionally residual remnants of lymph node may be observed, which are compressed at the periphery of an expansile tumor mass.54 Microscopically LP nodular HD is characterized by the presence of a macronodular growth pattern, which is expansile rather than infiltrative (Plate 1); nodules do not penetrate the lymph-node capsule or extend into perinodal tissue. Diffuse areas are sometimes seen. Exclusively diffuse LP HD is exceptionally rare in our experience, with the majority of cases being nonHodgkin's lymphomas of peripheral T cell or T cell-rich B cell type.55 The nodules of LP nodular HD often have a 'motheaten' appearance at low power (Plate 2), and are composed of small round or slightly irregular lymphoid cells with admixed large lymphoid cells, epithelioid histiocytes, dendritic reticulum cells and a Reed-Sternberg (RS) cell variant called the L & H or popcorn cell. The lymphocytes within the nodules show a close cytological similarity with mantle zone lymphocytes, which is confirmed by their phenotype. Epithelioid histiocytes may be scattered within the nodules or form loose aggregates; well-formed, sarcoid-like granulomata, if present, are usually seen at the periphery of the nodules and may form encircling rings (Plate 3). The histiocytes bear a close resemblance to those seen in mantle cell lymphoma, and possess an open nuclear chromatin with a single prominent nucleolus and well-defined eosinophilic cytoplasm. The nuclei of follicular dendritic cells are easily identified and multinucleated forms, resembling Warthin-Finkeldy giant cells are common (Plate 4). L & H cells have a characteristic morphology with a large, irregular and often lobulated nucleus with a prominent nucleolus which is often amphophillic and irregular (Plate 5). Classical RS cells are rare and are not essential for the diagnosis of LP nodular HD; in fact, if classical RS cells can be found with ease, the diagnosis of LP nodular HD should be changed to one of mixed cellularity as the clinical behavior of these cases is different from typical LP HD.56 The number of L & H cells is very variable and ranges from scanty to very numerous, making up more than 10 per cent of the cellular composition of the nodules; the latter is often seen in relapses of LP nodular. The number of L & H cells present does not

seem to influence the clinical behavior.50 L & H cells may be confined to the nodules or may spill out into the internodular region of the node. Immunocytochemistry The nodules of LP nodular HD are composed of polytypic small B cells expressing CD 20 and CD 79a57^ (Plate 6) and showing co-expression of IgM and IgD in a similar fashion to mantle zone B cells.61 Within the nodules is a meshwork of follicular dendritic cells (FDCs) revealed by staining for CD 21 and CD 35, and their processes often wrap around the L & H cells (Plate 7). The L & H cells uniformly express a B cell phenotype with strong expression of CD 20 and CD79a62'63 (Plate 8). There is evidence of immunoglobulin synthetic capacity as shown by the presence of J chain within the L & H cells,64 and some workers have shown the presence of kappa-light-chain restriction either by immunocytochemistry65 or by in situ hybridization for light-chain messenger RNA.66,67 The markers of classical H-RS cells, CD 30 and CD 15 are not usually detected on L & H cells68 (though there is some evidence for expression of a heavily sialylated form of CD 15, which is undetectable without prior neuraminidase digestion69). The presence of these markers should prompt consideration of a diagnosis of follicular colonization by classical HD (see below). There is frequent expression of epithelial membrane antigen by L & H cells70 and the presence of EpsteinBarr virus is not usually detectable.48,63,71 Within the nodules are numerous T cells, which express CD 3. Numerous CD 57-positive T cells are also seen and these may form rosettes around the L & H cells (Plate 9). The number of CD 57 cells has proved useful in the differential diagnosis of LP HD and lymphocyterich classical HD (LRCHD). Cases of LP have been shown to have >200 CD 57-positive cells per high-power field compared to an average of 45 CD 57-positive cells per high-power field in LRCHD.48 Non-Hodgkin's lymphoma arising in patients with LP nodular It is now clear from several large studies of patients with LP nodular HD that there is a markedly increased risk of non-Hodgkin's lymphoma (NHL), which ranges from an incidence of 3.8 per cent72 to nearly 10 per cent.73 The lymphomas associated with LP nodular HD may occur simultaneously74-77 or after a period of many years.72,75,78,79 They are usually of B cell lineage72,74,75 and there is some evidence that there may be a clonal relationship between the original LP and the subsequent B cell NHL;79,80 other workers have been unable to confirm this.78 The morphology of these secondary, high-grade B cell lymphomas is variable: some show features typical of diffuse

12 Hodgkin's disease

large B cell lymphoma exhibiting centroblastic or immunoblastic cytology, while others resemble sheets of L & H cells. Since the first recognition of T cell lineage NHL following LP nodular HD,72 subsequent reports have confirmed this association,81'82 and Weisenburger and co-workers have reported the concurrent presentation of T NHL and LP nodular HD.83 These may have a variety of histological patterns but the majority appear to fall within the peripheral T cell lymphoma, unspecified group of the Revised European-American Lymphoma (REAL) classification.84 A single case of composite T and B lineage lymphoma has been described in the setting of LP HD.85

NODULAR SCLEROSIS The presence of fibrosis and the proliferation of fibroblastic cells in HD has been recognized for over a century.10-12,17 The recognition by Smetana and Cohen21 of a sclerosing variant of Hodgkin's granuloma15 and its associated superior survival were among the first steps in the delineation of nodular sclerosis (NS). Lukes and co-workers23-25,86 described the histological features of NS, and stressed the importance of nodularity, lacunar cells and birefringent collagen band formation. Rappaport and colleagues emphasized the unique nature of NS by demonstrating the consistency of this histological pattern in sequential biopsies and from different anatomical locations.87,88

Morphological features Lymph node involvement by nodular sclerosis may be partial or complete. There is usually capsular and intranodal fibrosis, which may impart a firm rubbery texture. The cut surface may have a coarsely nodular appearance and areas of necrosis may be macroscopically apparent. Histologically, capsular thickening is present in the majority of cases (Plate 10) and there is a variable degree of intranodal sclerosis, which may range from occasional thin collagen bands to large areas of collagenous sclerosis that obliterate most of the nodal structure. Nodularity is a constant feature of NS, and may be present partially or throughout the lymph node. NS is associated with a particular H-RS cell variant termed the lacunar cell. The lacunar cell is most obvious in specimens fixed in formalin in whom paraffin processing dissolves the lipid-rich cytoplasm to leave a clear space; specimens fixed in mercuric-based fixatives do not show this helpful artefact. The nucleus of lacunar cells is typically twisted or lobulated with a prominent eosinophillic nucleolus (Plate 11). In recent years there has been considerable confusion over the precise criteria required to diagnose NS and this

has centred around the entity termed cellular phase NS. Lukes86 required the presence of intranodal collagen band formation in association with lacunar cells to establish a diagnosis of NS and recognized a cellular phase in which only a single band of collagen was found in association with the typical • cellular background of NS. Cases lacking collagen band formation were classified as mixed cellularity by Lukes. Other workers have classified cases as cellular-phase NS when lacunar cells are seen in the absence of collagen band formation.87,89 The advantage of adhering to the strict criteria proposed by Lukes and Butler24 is that they do enable pathologists to achieve very high levels of interobserver and intraobserver concordance (97 per cent)90 in the diagnosis of the NS subtype. The cellular nodules of NS show a wide range of cytological appearances ranging from a lymphocyte-rich cellular background with scanty lacunar cells to one of lymphocyte depletion and sheets of lacunar and H-RS cells. This latter pattern may be associated with areas of necrosis. In many cases there are also admixed histiocytes, eosinophils and plasma cells with the lymphocytes and lacunar cells. The cytological diversity of the cellular nodules of NS has prompted workers to develop grading systems for NS, which might correlate with prognosis (reviewed in MacLennan et a/.91). In a series of publications the BNLI proposed a grading system which recognized low-grade (Grade I) and high-grade (Grade II) subtypes of NS. 50,56,90-93 The histologic criteria for this grading system have been published in detail elsewhere90 and are only outlined here. Cases were classified as Grade II NS if more than 25 per cent of the cellular nodules showed lymphocytedepleted cytology. These lymphocyte-depleted nodules are often composed of sheets of mononuclear Hodgkin's and lacunar cells; an appearance that has been termed 'syncytial Hodgkin's disease' by some workers.94'95 Central necrosis and eosinophilic abcess formation within these lymphocyte-depleted nodules is sometimes observed (Plate 12). Also classified as Grade II NS were cases in which more than 25 per cent of the cellular nodules contained numerous pleomorphic H-RS cells in the absence of lymphocyte depletion. The rarest form of lymphocyte-depleted cytology was the bland-appearing fibrohistiocytic variety; if more than 80 per cent of the cellular nodules showed this feature, the case was classified as Grade II NS.93 The adverse prognostic significance of fibroblastic proliferation was also reported by Colby et a/.96 All other cases were graded as Grade I including borderline cases. Using this system significant differences in survival and disease-free survival are seen between the grades of NS (see below). Other workers have confirmed the clinical value of this grading system;97'101 some have not been able to demonstrate a difference in prognosis between the two grades of NS.102'103

Mixed cellularity Hodgkin's disease 13

Immunocytochemistry The phenotype of NS differs from LP nodular HD in that the nodules are composed predominantly of T cells104'105 (CD 3-positive, CD 45 Ro-positive) with a prevalence of CD 4-positive cells centrally and a rim of CD 8-positive lymphocytes at the periphery. The lacunar cells exhibit strong staining for CD 15 in over 80 per cent of cases and this staining is usually membrane and golgi associated; CD 30 is also expressed in the majority of cases106-110 (Plate 13). The expression of lymphoid lineage-restricted antigens on H-RS cells remains controversial with some groups claiming expression of CD 3 in a percentage of cases,111,112 whilst others find expression of B lineage antigens on a small percentage of H-RS cells,113 which may be seen in up to 60 per cent of cases of HD.114 There is variable expression of BCL 6 protein and CD 138.115,116 The significance of these phenotypic differences is unclear but in human immunodeficiency virus (HIV)-associated HD there is a marked predominance of CD 138-positive/BCL 6-negative H-RS cells.117 Some cases of anaplastic large cell lymphoma (ALCL) may display morphological features, which are reminiscent of NSHD particularly the Grade II subtype.118 So close may these similarities be that some workers have introduced the term 'ALCL Hodgkin's like';84 other workers feel that the vast majority of these cases are in fact related to classical HD and have used the term 'malignant lymphoma with features of Hodgkin's lymphoma and ALCL'.119 Immunocytochemistry can be helpful in distinguishing between HD and ALCL; whilst CD 30 is usually expressed by both, CD 15 staining is uncommon in ALCL and, when present, does not exhibit the membrane and Golgi staining characteristic of HD. Leukocyte common antigen (CD 45) is expressed in a percentage of ALCL118 but in our hands has proved of limited value. Recently antibodies to the p80 NPM-ALK fusion protein, generated by the 2;5 translocation,120 have become available,121,122 which stain just over half the cases of ALCL studied; no case of HD was labelled.122 Of interest is the detection of t(2;5) in a minor population of microdissected CD 30-positive cells from cases of classical HD123 and in the peripheral blood of normal individuals.124

LYMPHOCYTE-DEPLETED HODGKIN'S DISEASE Lymphocyte-depleted (LD) Hodgkin's disease is the rarest form of Hodgkin's disease and its frequency appears to be diminishing. It includes two distinctive morphological entities from the Lukes and Butler classification: diffuse fibrosis and reticular HD. It is now clear from various studies that many of the cases formally classified as LD were in fact examples of non-Hodgkin's

lymphomas125 often of anaplastic large cell type or of other HD subtypes, such as the Grade II form of NS.56 In a review of cases from the BNLI, many of the cases that were originally diagnosed as LD HD were reclassified as NHL and the incidence of true LD HD was below 2 per cent in this series. Patients with LD HD tended to be elderly and often presented with advanced symptomatic disease. Bone marrow disease occurred in over 60 per cent of cases.50 There was a low attainment of complete remission with combination chemotherapy and survival was poor.

Morphological features Lymphocyte-depleted Hodgkin's disease has a high frequency of extranodal involvement. In particular, the bone marrow is affected in many cases and may be the site of initial diagnostic biopsy (Plate 14). When lymph nodes are affected, the architecture is completely effaced. The diffuse fibrosis variant is characterized by a hypocellular lymph node often showing areas of geographic necrosis (Plate 15). In the background there is a pink fibrillary appearances of non birefringement fibrosis. Lymphocytes are relatively scanty and bizarre mononuclear and multinuclear Hodgkin's cells are seen. Classical Reed-Sternberg cells are often difficult to find. The reticular subtype of LD HD is characterized by a numerical predominance of H-RS cells. It has been our experience that the majority of cases initially diagnosed as reticular HD represents examples of non-Hodgkin's lymphomas.

MIXED CELLULARITY HODGKIN'S DISEASE In the Lukes and Butler classification, mixed cellularity Hodgkin's disease was used to classify cases of Hodgkin's disease that did not conform to the pathological criteria of LP, NS and LD HD. It thus contained a spectrum of cytological appearances ranging from lymphocyte-rich forms, which contained classical RS cells, to subtypes which showed foci of lymphocyte-depleted cytology not involving the whole lymph node. Many cases of mixed cellularity Hodgkin's disease have similarities to nodular sclerosis, such as focal nodularity and the presence of lacunar cells, but lack sufficient criteria to be diagnosed as NS. Other cases showed distinctive morphological patterns, which often involved alterations in the structure of the germinal center and the marginal zone B cell region.

Morphological features Classical mixed cellularity Hodgkin's disease is characterized by a diffuse architecture, which effaces the nodal

14 Hodgkin's disease

architecture completely. Typically the cytological background contains lymphocytes, macrophages, plasma cells and eosinophils, as well as mononuclear and classical Reed-Sternberg cells that are easy to find (Plate 16). There may be small foci of necrosis but this is much less common than in either NS or LD HD. Some cases may show the presence of lacunar cells or even areas of indistinct nodularity - features that suggest a close association with NS. In the absence of the three essential criteria for the diagnosis of NS (nodularity, intranodal collagen band formation and lacunar cells), these are best classified as mixed cellularity. Some workers prefer to classify these cases with NS features as HD unclassified between mixed cellularity and nodular sclerosis54 and some even put them into the cellular phase of NS. Several striking morphological patterns have been observed in mixed cellularity HD. One such case is inter follicular HD, highlighted by the Stanford Group, which is characterized by florid reactive follicular hyperplasia and an easily overlooked interfollicular infiltrate containing typical mononuclear Hodgkin's cells and RS cells126 (Plate 17). A variant of this form of HD is characterized by a marginal zone hyperplasia where the H-RS cells are seen to sit within a sea of marginal zone B cells. This has been termed HD occurring in monocytoid B cell clusters127 (Plate 18). In some cases of mixed cellularity HD the germinal centers are replaced by large expansile masses of mantle zone lymphocytes within which H-RS cells are readily found. The mantle cell nodules contain an expanded meshwork of follicular dendritic cells and, in many cases, the Hodgkin's cells express B cell antigens in addition to CD 15 and CD 30. Some workers have termed this follicular Hodgkin's disease.128 The term lymphocyte-rich classical Hodgkin lymphoma has been applied to morphological variants of HD characterized by an abundance of small lymphocytes with relatively scanty classical H-RS cells and very few eosinophils and plasma cells. In the REAL classification, LRCHD is a provisional entity84 and it has been formally adopted in the forthcoming World Health Organisation (WHO) classification.119 This histological subtype may be nodular or diffuse. The nodular subtype corresponds closely to the entity of follicular HD described by Isaacson and co-workers128 (Plate 19). The diffuse subtype is characterized by a predominance of small T lymphocytes and shows no evidence of involvement of germinal centers. In some cases of HD there are marked regressive changes within germinal centers that come to resemble the dendritic cell-only germinal centers that are seen in the hyaline vascular variant of Castleman's disease (Plate 20). These are surrounded by H-RS cells, which seem to localize preferentially at the junction of the marginal and mantle zones. The reasons for these different patterns of germinal-center reaction in mixed cellularity HD are

unknown but one might postulate they are related to the pattern of cytokine expression by the H-RS cells. Rare cases with the morphological features of the plasma cell variant of Castleman's disease in association with HD have been described.129

CLINICAL SIGNIFICANCE OF MORPHOLOGICAL PATTERN IN HODGKIN'S DISEASE Many believe that histopathology has little part to play in the prognostic assessment of patients with HD, and that the role of the pathologist is limited to accurate establishment of the diagnosis of HD and documentation of involvement of extranodal sites.130-132 In a series of publications over the past 10 years, the BNLI has documented the value of accurate histopathological classification in HD and shown that there are differences in the clinical presentation, response to therapy, freedom from relapse and overall survival between the different histological subtypes of HD. In addition it has demonstrated that there is clinical value in the subdivision of NS into two prognostic grades.50,56,90-93,133 It can be seen from the cause-specific survival curves from over 4000 patients that there are distinct differences in the rate of death from Hodgkin's disease in the different histological subtypes (Fig. 2.1).

Figure 2.1 Cause-specific actuarial survival curve for 4578 patients with Hodgkin's disease subdivided according to histological type, 1970-97. (Data from the British National Lymphoma Investigation.)

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5. Fox H. Remarks on microscopic preparations made from some of the original tissue described by Thomas Hodgkin, 1832. Ann Med History 1926; 8: 37(M. 6. Symmers WStC. The lymphoreticular system. In: Symmers WStC, ed. Systemic pathology. Edinburgh: Churchill Livingstone, 1978: 784-5. 7. Lennert K. Borderlands of pathological entities. In: Magrath IT, ed. The non-Hodgkin's lymphomas, 2nd edn. London: Arnold, 1997:133-67.

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H. HL-A antigens and Hodgkin's disease. Report on the histological analysis. In: Dausset J, Colombani J, eds. Histocompotability testing, Copenhagen: Munksgaard, 1972:769-71. 28. Miller TP, Byrne GE, Jones SE. Mistaken clinical and pathologic diagnoses of Hodgkin's disease. A Southwest Oncology Group study. Cancer Treat Rep 1982; 66: 645-51. 29. Symmers WStC. Survey of the eventual diagnosis in 600

8. Virchow R. Die Krankhaften Geschwuelste, Vol 2. Berlin: Hircwald, 1864.

cases referred for a second histologic opinion after an

9. Murchison C. Case of lymphadenoma of the lymphatic

Pathol 1968; 21: 650-3.

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system, spleen, liver, lungs, heart, diaphragm, dura mater etc. Trans Path Soc London 1870; 21: 372-89. 10. Langhans T. Das maligne lymphosarkom (pseudoleukaemia). Virchow Arch 1872; 54: 509-37.

30. Drexler HG and Minowada J. Hodgkin's disease derived cell lines: a review. Hum cell 1992; 5: 42-53. 31. Drexler HG. Recent results on the biology of Hodgkin and Reed-Stern berg cells. I. Biopsy material. Leuk

11. Greenfield WS. Specimens illustrative of the pathology

lymphoma 1992; 8: 283-313. 32. Linch DC, Jones HM, Berliner N, et al. Hodgkin-cell

of lymphadenoma and leucocythaemia. Trans Path Soc London 1878; 29: 272-304. 12. Sternberg C. Uber eine eigenartige unter dem Bilde der Pseudoleukamie verlaufende Tuberculose des lymphatischen Apparates.Z. Heilk. 1898; 18: 21-90. 13. Reed DM. On the pathological changes in Hodgkin's disease, with especial reference to its relation in tuberculosis. Johns Hopkins Hosp Rep 1902; 10:133-96. 14. Walhauser A. Hodgkin's disease. Arch Pathol 1933; 16: 522-62, 672-712. 15. Jackson H Jr, Parker F Jr. Hodgkin's disease and allied disorders. Oxford: Oxford University Press, 1947.

leukaemia of B-cell origin. Lancet 1985; 1: 78-80. 33. Griesser H, Feller AC, Mak TW, Lennert K. Clonal rearrangements of T-cell receptor and immunoglobulin genes and immunophenotypic antigen expression in different subclasses of Hodgkin's disease. IntJ Cancer 1987; 40:157-60. 34. Kuppers R, Hansmann ML, Diehl V, Rajewsky K. Molecular single-cell analysis of Hodgkin and Reed-Stern berg cells. Mol Med Today 1995; 1: 26-30. 35. Roth J, Daus H, Trumper L, et al. Detection of immunoglobulin heavy-chain gene rearrangement at

16. EwingJ. Neoplastic diseases. Philadelphia, London: WB Saunders, 1919.

the single-cell level in malignant lymphomas: no

17. Rosenthal SR. Significance of tissue lymphocytes in the

cells. IntJ Cancer 1994; 57: 799-804.

rearrangement is found in Hodgkin and Reed-Sternberg

prognosis of lymphogranulomatosis. Arch Pathol 1936; 21:628-46. 18. Jackson H Jr, Parker F Jr. Hodgkin's disease. I. General considerations. N EnglJ Med 1944; 230:1-8.

36. Ohshima K, Suzumiya J, Mukai Y, et al. Classical Hodgkin and Reed-Sternberg cells demonstrate a nonclonal immature B lymphoid lineage: evidence from a single cell assay and in situ hybridization. Hematol

19. Jackson H Jr, Parker F Jr. Hodgkin's disease. II.

Oncol 1996 14:123-36. 37. Trumper LH, Brady G, Bagg A, et al. Single-cell analysis

Pathology. N EnglJ Med 1944; 231: 35-44. 20. Jackson H Jr, Parker F Jr. Hodgkin's disease. III. Symptoms and course. N EnglJ Med 1994; 231: 636-46. 21. Smetana HF, Cohen BM. Mortality in relation to histologic type in Hodgkin's disease. Blood 1956; 11: 211^4. 22. Jelliffe AM, Thompson AD. The prognosis in Hodgkin's disease. BrJ Cancer 1955; 9: 21-36. 23. Lukes RJ. Relationship of histological features to clinical stages in Hodgkin's disease. AmJRoengenol 1963; 90: 944-55. 24. Lukes RJ, Butler JJ. The pathology and nomenclature of Hodgkin's disease. Cancer Res 1966; 26:1063-81. 25. Lukes RJ, Butler JJ, Hicks EB. Natural history of Hodgkin's disease as related to its pathologic picture. Cancer 1966; 34: 317-44.

of Hodgkin and Reed-Sternberg cells: molecular heterogeneity of gene expression and p53 mutations. Blood 1993; 81: 3097-115. 38. Hansmann ML, Kuppers R. Pathology and 'molecular histology' of Hodgkin's disease and the border to nonHodgkin's lymphomas. Baillieres Clin Haematol 1996; 9: 459-77. 39. Kuppers R, Rajewsky K. The origin of Hodgkin and Reed/Stern berg cells in Hodgkin's disease. Annu Rev /tfW7HA70/1998;16:471-93. 40. Vockerodt M, Soares M, Kanzler H, etal. Detection of clonal Hodgkin and Reed-Sternberg cells with identical somatically mutated and rearranged VH genes in different biopsies in relapsed Hodgkin's disease. Blood 1998;92:2899-907.

16 Hodgkin's disease 41. Hummel M, Marafioti T, Ziemann K, Stein H. Ig rearrangements in isolated Reed-Stern berg eel Is: conclusions from four different studies. Ann Oncol 1996;7(suppl4):31-3. 42. Kanzler H, Kuppers R, Hansmann ML, Rajewski K. Hodgkin and Reed-Sternberg cells represent the outgrowth of a dominant tumour clone derived from (crippled) germinal centre B cells. J Exp Med 1996; 184: 1495-505. 43. Ohno T, Stribley JA, Wu G, Hinrichs SH, Weisenburger DD, Chan WC. Clonality in nodular lymphocyte predominant Hodgkin's disease. N EnglJ Med 1997; 337: 459-65. 44. Marafiota T, Hummel M, Anagnostopoulos I, el al. Origin of lymphocyte predominant nodular Hodgkin's disease from a clonal expansion of highly mutated germinal-center B cells. N EnglJ Med 1997; 337: 453-8. 45. Harrison CV. Benign Hodgkin's disease (Hodgkin's paragranuloma).) Path Bact 1952; 64: 513-18. 46. Lumb G, Newton KA. Prognosis in tumours of lymphoid tissue. Cancer 1957; 10: 976-93. 47. Lennert K, Mohri N. Histologische Klassifizierung und Vorkommen des M. Hodgkin. Internist 1974; 15: 57-65. 48. von Wasielewski R, Werner M, Fischer R, et al. Lymphocyte-predominant Hodgkin's disease: an immunohistochemical analysis of 208 reviewed Hodgkin's disease cases from the German Hodgkin Study Group. Am} Pathol 1997; 150: 793-803. 49. Henry-Amar M, MarnayJ. Personal communication, 1997. 50. MacLennan KA, Bennett MH, Bosq J, et al. The histology and immunohistology of Hodgkin's disease: the relationship to prognosis and clinical behavior. In: Sommers R, Henry-Amar M, Carde P, eds Treatment strategy in Hodgkin's disease. London, Paris: John Libbey, 1990:17-25. 51. Poppema S, Kaiserling E, Lennert K. Nodular paragranuloma and progressively transformed germinal centres: ultrastructural and immunohistologic findings. Virchows Arch B Cell Path 1979; 31: 211-25. 52. Lennert K, Muller-Hermelink HK. Lymphocyten und ihre Funkionsformen - Morphologic, Organisation und immunologische Bedeutung (lecture). Verhandl Anat Gesellschaft 1975; 69:19-62. 53. Muller-Hermelink HK, Lennert K. The cytologic, histologic and functional basis for a modern classification of lymphomas. In: Lennert K, in collaboration with Stein H, Mohri N, Kaiserling E, Muller-Hermelink HK, eds Malignant lymphomas other than Hodgkin's disease. New York: Springer, 1978: 38^1. 54. Neiman RS. Current problems in the histopathologic diagnosis and classification of Hodgkin's disease. Pathol Annu 1978; 13: 289-328. 55. Ramsey AD, Smith WJ, Isaacson PG. T-cell rich-B-cell lymphoma. AmJSurg Pathol 1988; 12: 433-43.

56. Bennett MH, MacLennan KA, Vaughan Hudson B, Vaughan Hudson G. The clinical and prognostic relevance of histopathological classification in Hodgkin's disease. ProgSurg Pathol 1989; 10:127-51. 57. Tiemens W, Visser L, Poppema S. Nodular lymphocyte predominance type of Hodgkin's disease is a germinal centre lymphoma. Lab Invest 1986; 54: 457-61. 58. Hansmann ML, Wacker HH, Radzun HJ. Paragranuloma is a variant of Hodgkin's disease with a predominance of B-cells. VirchowArch (Pathol Anat) 1986; 409: 171-81. 59. Coles FB, Cartun RW, Pastuszak WT. Hodgkin's disease, lymphocyte predominant type: immunoreactivity with B-cell antibodies. Mod Pathol 1988; 1: 274-8. 60. Pinkus GS. Said JW. Hodgkin's disease, lymphocytes predominance type, nodular - further evidence for a Bcell derivation. Am J Pathol 1988; 133: 211-17. 61. Poppema S. Lymphocyte-predominance Hodgkin's disease. Int Rev Exp Pathol 1991; 33: 53-79. 62. Kuzu I, Delsol G, Jones M, Gatter KC, Mason DY. Expression of the Ig-associated heterodimer (mb-1 and B 29) in Hodgkin's disease. Histopathology 1993; 22: 141-4. 63. Mason DY, Banks PM, Chan JKC, et al. Nodular lymphocyte predominance Hodgkin's disease: a distinct clinicopathological entity. AmJSurg Pathol 1994; 18: 526-30. 64. Stein H, Hansmann M-L, Lennert K, Brandtzaeg P, Gatter KC, Mason DY. Reed-Sternberg and Hodgkin's cells in lymphocyte predominance Hodgkin's disease of nodular subtype contain J cha\n.AmJ Clin Pathol 1986; 86: 292-7. 65. Schmidt C, Sargent C, Isaacson PG. L and H cells of nodular lymphocyte predominant Hodgkin's disease showimmunoglobulin light chain restriction. Am J Pathol 1991; 139:1281-9. 66. Hell K, PringleJH, Hansmann M-L, et al. Demonstration of light chain mRNA in Hodgkin's disease .J Pathol 1993; 17:137-43. 67. Stoler MH, Nichols GE, Symbula M, Weiss LM. Lymphocyte predominance Hodgkin's disease: Evidence for k light chain restricted monotypic B cell neoplasm. Am J Pathol 1995; 146: 812-18. 68. Nicholas DS, Harris S, Wright DH. Lymphocyte predominance Hodgkin's disease: an immunohistochemical study. Histopathology 1990; 16: 157-65. 69. Hsu SM, Ho YS, Li PJ, et al.t&H variants of Reed-Sternberg cells express sialyated Leu M1 antigen. AmJ Pathol 1986; 122:199-203. 70. Jack AS, Cunningham D, Soukop M, Liddle CN, Lee FD. Use of Leu M1 and antiepithelial membrane antigen monoclonal antibodies for diagnosing Hodgkin's diseasej Clin Pathol 1986; 39: 267-70. 71. Bosq J, Audouin J, Henry-Amar M, et al. Relationship between EBV infection, clinical, biological and histologic characteristics and response to therapy in

References 17

patients with Hodgkin's disease. In: Proceedings of the Third International Symposium on Hodgkin's Lymphoma. 1995: Abstracts. 72. Bennett MH, MacLennan KA, Vaughan Hudson B, Vaughan Hudson G. Non Hodgkins lymphoma arising in patients treated for Hodgkin's disease in BNLI: a 20 year experience. Ann Oncol 1991; 2 (suppl 2): 83-92. 73. Miettinen M, Franssila KO, Saxen E. Hodgkin's disease, lymphocytic predominance nodular increased risk for subsequent non-Hodgkin's lymphoma. Cancer 1983; 51: 2293-300. 74. Sundeen JT, Cossman J, Jaffe ES. Lymphocyte predominant Hodgkin's disease with coexistent 'large cell lymphoma': histological progression or composite malignancy? Am JSurgPathol 1988; 12: 599-606. 75. Hansmann ML, Stein H, Fellbaum C. etal. Nodular paragranuloma can transform into high-grade malignant lymphoma of B type. Hum Pathol 1989; 20: 1169-75. 76. Whittaker M, Foucar K, Keith T, McAneny B. Letter. Am J Surg Pathol 1989; 13: 715-16. 77. Grossman DM, Hanson CA, Schnitzer B. Simultaneous lymphocyte predominant Hodgkin's disease and large cell lymphoma. Am J Surg Pathol 1991; 15: 668-76. 78. Pan LX, Diss TC, Peng HJ, Norton AJ, Isaacson PG.

lymphocyte predominant Hodgkin's disease. Ann Diagn Pathol 1999; 3: 23-34. 86. Lukes RJ. Criteria for involvement of lymph node, bone marrow, spleen and liver in Hodgkin's disease. Cancer Res 1971; 31:1755-67. 87. Strum SB, Rappaport H. Interrelations of the histological types of Hodgkin's disease. Arch Pathol 1971; 91:127-34. 88. Strum SB, Rappaport H. Consistency of histological subtypes in Hodgkin's disease in simultaneous and sequential biopsy specimens. Natl Cancer Inst Monogr 1973;36:253-60. 89. Dorfman RF. The enigma of Hodgkin's disease: current concepts based on morphologic, clinical and immunologic observations. In: Hanaoka M, Kadin ME, Mikata A, Watanabe S, eds Lymphoid malignancies, immunocytology and cytogenetics. New York: Field and Wood, 1990:167-76. 90. MacLennan KA, Bennett MH, Vaughan Hudson B, Vaughan Hudson G. Diagnosis and grading of nodular sclerosing Hodgkin's disease: a study of 2190 patients. Int Rev Exp Pathol 1992; 33: 27-51. 91. MacLennan KA, Bennett MH, Tu A, etal. Prognostic significance of cytologic subdivision in nodular sclerosing Hodgkin's disease: an analysis of 1156

Nodular lymphocyte predominance Hodgkin's disease:

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eds Malignant lymphomas and Hodgkin's disease:

79. Greiner TC, Gascoyne RD, Anderson ME, et al. Nodular lymphocyte-predominant Hodgkin's disease associated with large cell lymphoma: analysis of Iggene rearrangements by V-J polymerase chain reaction. Blood 1996; 88: 657-66. 80. Wickert RS, Weisenburger DD, Tierens A, Greiner TC, Chan WC. Clonal relationship between lymphocytic predominance Hodgkin's disease and concurrent or subsequent large cell lymphoma of B lineage. Blood 1995:86:2312-20. 81. Tefferi A, Wiltsie JC, Kurtin PJ. Secondary T cell

experimental and therapeutic advances. Dordrecht: Martinus Nijhoff Publishing, 1985:187-200. 92. Bennett MH, MacLennan KA, Easterling MJ, Vaughan Hudson B, Vaughan Hudson G, Jelliffe AM. Analysis of histological subtypes of Hodgkin's disease in relation to prognosis and survival. In: Quaglino D, Hayhoe FGJ, eds. The cytobiology of leukaemia and lymphomas, Serono Publications, Vol. 20, New York: Raven Press, 1985: 15-32. 93. MacLennan KA, Bennett MH, Tu A, Vaughan Hudson B, Vaughan Hudson G. The relationship of histopathology to survival and relapse. A study of 1659 patients. Cancer

82. Rysenga E, Linden MD, Carey JL, Ross CW, Schnitzer B,

1989;64: 1686-93. 94. Strickler JG, Michie SA, Warnke RA, Dorfman RF. The 'syncytial variant' of nodular sclerosing Hodgkin's disease. Am J Surg Pathol 1986; 10: 470-7.

Sawdyk M, Maeda K. Peripheral T-cell non-Hodgkin's

95. Ben-Yehuda-Salz D, Ben-Yehuda A, Polliack A, etal.

lymphoma in the setting of nodular lymphocyte predominance Hodgkin's disease. AmJHaematol 1992; 40: 232-3.

lymphoma following treatment of nodular lymphocyte

Syncytial variant of nodular sclerosing Hodgkin's

predominance Hodgkin's disease. Arch Pathol Lab Med 1995;119:88-91.

disease. A new clinicopathologic entity. Cancer 1990,

83. Delabie J, Greiner TC, Chan WC, Weisenburger DD. Concurrent lymphocyte predominance Hodgkin's disease and T-cell lymphoma. Am J Surg Pathol 1996; 20: 355-62. 84. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92.

65: 1167-72. 96. Colby TV, Hoppe RT, Warnke RA. Hodgkin's disease: a clinicopathologic study of 659 cases. Cancer 1981; 49: 1848-58. 97. Gartner HV, Wherman M, Inniger R, Steinke B. Nodular sclerosing Hodgkin's disease: prognostic relevance of morphological parameters. In: First International Symposium on Hodgkin's Lymphoma, Cologne, 27A, 1987. 98. Jairam R, Vrints LW, Breed WPM, Wijlhuizen TJ, Wijnen

85. Hancock JC, Wells A, Hailing KC, et al. Composite B-cell

TJM. Histological subclassification of the nodular sclerotic

and T-cell lymphoma arising 24 years after nodular

subtype of Hodgkin's disease. NethJ Med 1988; 33:160-7.

18 Hodgkin's disease 99. Wijlhuizen TJ, Vrints LW, Jairam R, et al. Grades of nodular sclerosis (NSI-NSII) in Hodgkin's disease: are they independent prognostic values? Cancer 1989; 63: 1150-3. 100. Ferry JA, Linggood RM, Convery KM, Efird JT, Eliseo R, Harris ML Hodgkin's disease, nodular sclerosis type implications of histologic subdassification. Cancer 1993; 71:457-63. 101. Georgii A, Hasenclever D, Fischer R, etal. Histopathological grading of nodular sclerosing Hodgkin's reveals significant differences in survival and relapse rates under protocol-therapy. Proceedings of the Third International Symposium on Hodgkin's Lymphoma, Kbln, 1995, Abstract 83. 102. Masih AS, Weisenburger DD, Vose JM, Bast MA, Armitage JO. Histologic grade does not predict prognosis in optimally treated advanced stage nodular sclerosing Hodgkin's disease. Cancer 1992; 69: 228-32. 103. Hess JL, Bodis S, Pinkus G, Silver B, Mauch P. Histopathologic grading of nodular sclerosis Hodgkin's disease: lack of prognostic significance in 254 surgically staged patients. Cancer 1994; 74: 708-1714. 104. Borowitz MJ, Croker BP, Metzger RS. Immunohistochemical analysis of the distribution of lymphocyte subpopulations in Hodgkin's disease. Cancer Treat Rep 1982; 66: 667-74. 105. Abdulaziz S, Mason DY, Stein H, Gatter KC, Nash JRG. An immunohistological study of the cellular constituents of Hodgkin's disease using a monoclonal antibody panel. Histopathology 1984; 8:1-25. 106. Pinkus GS, Thomas P, Said JW. Leu M1 - a marker for Reed-Stern berg cells in Hodgkin's disease. AmJPathol 1985;119:244-52. 107. Hall PA, D'Ardenne AJ. Value of CD15 immunostaining in diagnosing Hodgkin's disease: a review of published literature.7 Clin Pathol 1987; 40:1298-304. 108. Hall PA, D'Ardenne AJ, Stansfield AJ. Paraffin section immunohistochemistry. II. Hodgkin's disease and large cell ana plastic (Ki1) lymphoma. Histopathology 1988; 13:161-9. 109. Chittal SM, Caveriviere R, Schwarting R, et al. Monoclonal antibodies in the diagnosis of Hodgkin's disease: the search for a rational panel. AmJSurg Pathol 1988; 12: 9-21. 110. Werner M, Georgii A, BernhardsJ, Hubner K, Schwarze E-W, Fischer R. Characterization of giant cells in Hodgkin's lymphomas by immunohistochemistry applied to randomly collected diagnostic biopsies from the German Hodgkin trial. Haematol Oncol 1990; 8: 241-50. 111. Cibull ML, Stein H, Gatter KC, Mason DY. The expression of the CD3 antigen in Hodgkin's disease. Histopathology 1989;15:597-605. 112. Casey TT, Olson SJ, Cousar JB, Collins RD. Immunophenotypes of Reed-Stern berg cells: a study of 19 cases of Hodgkin's disease in plastic-embedded sections. Blood 1989; 74: 2624-8.

113. Korkolopoulou P, Cordell J, Jones M,et al. The expression of the B-cell marker mb-1 (CD 79a) in Hodgkin's disease. Histopathology 1994; 24: 511-15. 114. Isaacson PG, Ashton-Key M. Phenotype of Hodgkin and Reed-Stern berg cells. Lancet 1996; 347: 481. 115. Carbone A, Gloghini A, Gaidano G, et al. Expression status of BCL-6 and syndecan-1 identifies distinct histogenetic subtypes of Hodgkin's disease. Blood 1998; 92: 2220-8. 116. Carbone A, Gloghini A, Gattei V, et al. Reed-Sternberg cells of classical Hodgkin's disease react with the plasma cell-specific monoclonal antibody B-B4 and express human syndecan-1. Blood 1997; 89: 3787-94. 117. Carbone A, Gloghini A, Larocca LM,etal. Human immunodeficiency virus-associated Hodgkin's disease derives from post-germinal center B cells. Blood 1999; 93: 2319-26. 118. Agnarrson BA, Kadin ME. Ki1 positive large cell lymphoma: a morphological study of 19 cases. AmJ Surg Pathol 1988; 12: 264-74. 119. Stein H. Hodgkin's disease. AmJ Surg Pathol 1997; 21: 119-20. 120. Morris SW, Kirstein MN, Valentine MB, Dittmer KG, Shapiro DN, Saltman DL, Look AT. Fusion of a kinase gene, ALK, to a nucleolar protein gene, NPM, in nonHodgkin's lymphoma. Science 1994; 262:1281-4. 121. Shiota M, Nakamura S, Ichinohasama R, et al. Anaplastic large cell lymphomas expressing the novel chimeric protein p80NPM/ALK: a distinctive clinicopathologic entity. Blood 1995; 86:1954-60. 122. Pulford K, Lamant L, Morris SW, et al. Detection of anaplastic lymphoma kinase (ALK) and nucleolar protein nucleophosphormin (NPM) - ALK proteins in normal and neoplastic cells with the monoclonal antibody ALK1. Blood 1997; 89:1394-404. 123. Trumper L, Daus H, Merz H, etal. NPM/ALK fusion mRNA expression in Hodgkin and Reed-Stern berg eel Is is rare but does occur: results from single-cell cDNA analysis. Ann Oncol 1997; 8 (suppl 2): 83-7. 124. Trumper L, Pfreundschuh M, Bonin FV, Daus H. Detection of the t(2;5)-associated NPM/ALK fusion cDNA in peripheral blood cells of healthy individuals. BrJ Haematol 1998; 103:1138^4. 125. Kant JA, Hubbard SM, Longo DL, Simon RM, DeVita VT, Jaffe ES. A critical appraisal of the pathologic and clinical heterogeneity of lymphocyte depleted Hodgkin's disease, y Clin Oncol 1986; 4: 284-94. 126. Doggett RS, Colby TV, Dorfman RF. Interfollicular Hodgkin's disease. AmJSurg Pathol 1983; 7:145-9. 127. Mohrmann RL, Nathwani BN, Brynes RK, Sheibani K. Hodgkin's disease occurring in monocytoid B-cell clusters. AmJ Clin Pathol 1991; 95: 802-8. 128. Ashton-Key M, Thorpe PA, Allen JP, Isaacson PG. Follicular Hodgkin's disease. Am J Surg Pathol 1995; 19: 1294-9. 129. Maheswaran PR, Ramsay AD, Norton AJ, Roche WR. Hodgkin's disease presenting with the histological

References 19

features of Castleman's disease. Histopathology 1991; 18: 249-53. 130. Torti FM, Dorfman RF, Rosenberg SA, Kaplan HS. The changing significance of histology in Hodgkin's disease. ProcAm Assoc Cancer Res 1979; 20: 401 (C-454). 131. Dorfman RF, Colby TV. The pathologists role in the management of patients with Hodgkin's disease. Cancer Treat Rep 1982; 66: 675-80.

132. Culline S, Henry-Amar H, Diebold J, et al. Relationship of histological subtypes to prognosis in early stage Hodgkin's disease: a review of 312 cases enrolled in a controlled clinical trial. EurJ Cancer 1989; 25: 551-6. 133. Vaughan Hudson B, Vaughan Hudson G, MacLennan KA, Bennet, MM, Jelliffe AM. A retrospective evaluation of radiotherapy as a curative agent in localised Hodgkin's disease. BrJ Cancer 1987; 56: 872.

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3 Follicular lymphoma KAMACLENNAN

Introduction

21

Transformation

Morphology

21

Extranodal disease

Immunophenotype

22

References

INTRODUCTION The first description of the entity now termed follicular lymphoma was provided by Ghon and Roman in 1916,' but it was the publications of Brill et al.2 and Symmers3'4 that brought the entity of follicular lymphoma (FL) to the attention of clinicians and pathologists. Although initially there was confusion as to whether FL was a neoplastic condition, it gradually became clear that it was a distinctive form of low-grade non-Hodgkin's lymphoma. The favorable prognostic significance of a follicular pattern and a superior response rate to radiotherapy of FL were recognized.5 Studies undertaken by Rappaport and co-workers6 delineated histologic criteria for the recognition of FL; however, they felt that an origin from the germinal center was unproven and applied the term nodular lymphoma. Detailed morphologic and ultrastructural studies by Lennert and co-workers7-9 and Lukes and Collins10 clearly identified FL as a germinal center neoplasm. FL is characterized by the neoplastic proliferation of germinal center B cells (both centroblasts and centrocytes) arranged in rounded aggregates which recapitulate the non-neoplastic germinal center. Within the neoplastic follicle are reactive cellular elements, which inhabit the normal germinal center. These are follicular dendritic cells, macrophages and T cells. A description of the cytogenetic and molecular biologic events that occur in follicular lymphoma is provided in Chapters 9 and 12.

MORPHOLOGY Lymph nodes affected by FL are enlarged and usually

22 23 23

show complete effacement of their normal architecture by neoplastic follicles. These are relatively uniform in size when compared to reactive germinal centers and are closely packed with compression of the surrounding lymphoid architecture (Plate 21); this process involves the entire lymph node in the majority of cases.11 The neoplastic follicles show a uniformity in their cellular composition and lack the distinct 'zoning' seen in reactive germinal centers (Plate 22). The mantle zones of the follicles in FL are usually ill-defined and difficult to appreciate,12 a factor associated with an increased mortality rate by some workers.13 Follicular lymphoma may be completely follicular in architecture or may have diffuse areas, which may range from small foci to large expanses; the latter is often seen in association with centroblastic cytology. The prognostic significance of diffuse areas in FL remains unclear and some workers believe they are associated with a decreased median survival.14'15 This area was addressed as part of a larger investigation of lymphoma classification.16 It was found that, if there was unequivocal follicularity within a follicle center lymphoma, the extent of the diffuse area was unimportant prognostically.16 Follicular lymphomas may be associated with intranodal sclerosis either as collagen bands or as fine compartmentalizing fibrosis.17-19 Sclerosis associated with FL often occurs in retroperitoneal and inguinal lymph nodes, and is associated with a more favorable prognosis.17-19 In some cases of FL the neoplastic B cells may develop cytoplasmic vacuolation and resemble the signet ring cells of poorly differentiated adenocarcinoma. This change may affect a minor population of cells or be extensive (Plate 23). The cytoplasmic vacuoles in the signet ring variant of FL may be either clear or associated with pink globules; the former has been associated with

22 Follicular lymphoma

immunoglobulin G (IgG) production and the latter with IgM.20~23 Occasionally large quantities of extracellular eosinophilic material may be found within the follicles.24'25 Other rare variants of FL include cases showing marginal zone differentiation,26-30 rosette formation,31 a 'floral pattern' to the neoplastic follicles,32 epithelioid granuloma formation33'34 and pronounced plasma cell differentiation.35 With the exception of marginal zone differentiation, which is associated with a decreased survival,36 these variants do not affect prognosis. The neoplastic follicles of FL contain a variable composition of centroblasts and centrocytes, which may range from a predominance of centrocytes to rare cases in which the follicles contain sheets of centroblasts. This cytological variability has formed the basis for a series of grading systems for FL. These grading systems employ either a subjective assessment of the percentage of large cells present within the follicles37-40 or by counting the number of large non-cleaved cells per high-power field41 or both.42 Some have used a proliferative index as assessed by automated image analysis of Ki 67 staining in FL to predict prognosis; a high proliferative index also showed a close correlation with grading.43 Although differences in survival can be demonstrated between different grades of FL (Fig. 3.1), they are small and all the methods so far employed suffer from very poor interobserver concordance rates.44,45 Objective evidence of'cure' as evidenced by a plateau in the actuarial survival curve, is not seen for the majority of patients.

IMMUNOPHENOTYPE Phenotypically FL is seen to be composed of rounded aggregates of B cells with similarities to normal germinal center B cells. There is expression of pan-B cell antigens CD 19, 20 and 22, surface immunoglobulin and

Figure 3.1 Actuarial survival of patients subdivided using the Berard criteria into follicular lymphoma small, mixed and large cell types.

expression of CD 10. Antibodies to CD 10 are now available that work in routinely fixed and processed tissue46 (Plate 24). CD 5 and CD 43 are usually negative and there is no nuclear cyclin Dl expression. These are important discriminating features from mantle cell lymphomas.47-52 The neoplastic B cells in FL differ from normal germinal center B cells in the presence of BCL 2 protein within their cytoplasm in up to 85 per cent of cases53"55 (Plate 25). Cases of follicular lymphoma with predominantly large cell cytology express BCL 2 protein less frequently.55 The expression of BCL 2 protein is of practical value in the discrimination of FL from florid follicular hyperplasia as it is not expressed in the B cells of the latter condition. Cell adhesion molecules, such as VLA 4-VCAM and LFA1-ICAM, mediate the interactions between the neoplastic B cells and the follicular dendritic cells (FDCs), and appear to be significant in the retention of a follicular architecture.56-65 Follicular dendritic cells within reactive germinal centers show a degree of heterogeneity in their antigenic profile, in particular expression of CD 21 is restricted to FDCs in the apical light zone.66 As CD 21 is expressed in many examples of FL (Plate 26) this suggests there may be similarities between FL and the light zone of the germinal center. Numerous reactive T cells are also seen scattered within the follicles, which express pan-T cell antigens CD 3 and CD 2. Many are of the helper-subtype expressing CD 4 and show expression of CD 40 ligand.67 Some also express the germinal center T cell-associated marker CD 57.

TRANSFORMATION Transformation of FL into a diffuse, high-grade nonHodgkin's lymphoma is relatively common and is associated with a poor prognosis.68 The frequency of histologic transformation is variable and ranges from around 30 per cent69'70 to an actuarial prediction that 60 per cent of patients will transform.71 Transformation tends to occur early in the course of the disease, and is associated with adverse prognostic factors or failure to achieve complete remission; the rate of transformation shows a tendency to plateau at 6 years.69 Most transformed FLs show histologic features of diffuse large B cell lymphoma with centroblastic cytology.72 The genetic factors involved in transformation are at present unknown, somatic mutations in the translocated bcl 2 gene,73"75 cytogenetic abnormalities at 6q23-26 and 17p,76 and, mutations in p5377'78 or overexpression of p53 protein79 have been identified as possible factors. Rare case of FL may transform into high-grade nonHodgkin's lymphoma with variant histology, sometimes with 'Burkitt-like' features and an aggressive leukaemic course; these are often associated with t(8;14) with deregulation of c-myc, in addition to t(14;18).80-86 Rare

References 23

cases of transformation of FL to CD 30-large cell lymphoma with anaplastic features have been described.87

EXTRANODAL DISEASE

5. Gall EA and Mallory TB. Malignant lymphoma. A clinicopathologic survey of 618 cases. AmJ Pathol 1941; 18: 381-429. 6. Rappaport H, Winter WJ, Hicks. Follicular lymphoma: a re-evaluation of its position in the scheme of malignant lymphoma, based on a survey of 253 cases. Cancer

Follicular lymphoma is typically disseminated at presentation with the involvement of a wide range of organs whose function may or may not be compromised. One of the commonest sites of extranodal disease is the bone marrow, which shows histological evidence of disease in approximately three-quarters of cases.88 The earliest morphological features of bone-marrow infiltration by FL are paratrabecular aggregates of small B cells (Plate 27),89'91 which are admixed with follicular dendritic cells and T cells.54,92-94 More extensive marrow disease shows the presence of neoplastic follicles within the hemopoietic marrow.95 When extensive marrow involvement is present, the normal marrow elements are displaced by sheets of coalescing follicles and normal hemopoietic function may be compromised. Cytologically, small irregular B cells predominate. In the presence of heavy bone-marrow infiltration, FLs may develop a leukemic phase in which cytologically atypical lymphoid cells are found in the peripheral blood; the leukemic cell count may be very high96,97 (Plate 28). The spleen is commonly involved by FL. The lymphoma cells preferentially home in to the white pulp regions98"101 and form expansile white nodules measuring several millimetres in diameter, imparting a miliary appearance to the cut surface (Plate 29). Large tumor masses are not usually seen in the absence of high-grade transformation. Many other organs may be infiltrated by FL, including the liver,95 soft tissues102 and skin.103 In extranodal locations the follicular pattern may be difficult to discern and may require the immunohistochemical demonstration of a follicular dendritic cell meshwork.

1956; 9: 792-821. 7. Lennert K. Germinal centers and germinal center neoplasms. Nippon Ketsueki Gakkai Zasshi 1969; 32: 495-500. 8. Lennert K. Giant follicular lymphoma. Dtsch Med Wochenschr 1973; 98: 335-6. 9. Lennert K, Stein H, Kaiserling E. Cytological and functional criteria for the classification of malignant lymphomata. BrJ Cancer 1975; 31 (suppl 2): 29-43. 10. Lukes RJ, Collins RD. New approaches to the classification of the lymphomata. BrJ Cancer 1975; 31 (suppl 2): 1-28. 11. Nathwani BN, Winberg CD, Diamond LW, Bearman RM, Kim H. Morphologic criteria for the differentiation of follicular lymphoma from florid reactive follicular hyperplasia: a study of 80 cases. Cancer 1981; 48: 1794-806. 12. Crocker J, Jones EL, Curran RC. A quantitative study of the size of benign and malignant lymphoid follicles. 7 Clin Pathol 1983; 36:1055-61. 13. West KP, Potter LJ, Henderson SD, Lauder I. A retrospective study of follicular lymphomas. Histopathology 1989; 14: 629-36. 14. Ostrow SS, Diggs CH, Sutherland JC, Gustafson J, Wiernik PH. Nodular poorly differentiated lymphocytic lymphoma: changes in histology and survival. Cancer Treat Rep 1981; 65: 929-33. 15. Vose JM, Bierman PJ, Lynch JC, et al. Effect of follicularity on autologous transplantation for large-cell non-Hodgkin's lymphoma. J Clin Oncol 1998; 16: 844-9. 16. Anonymous. A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. Blood 1997; 89: 3909-18.

REFERENCES 1. Ghon A, Roman B. Ueber das Lymphosarkom. Frankfurt ZPathol 1916; 19:1-138. 2. Brill NE, Baehr G, Rosenthal N. Generalised giant lymph follicle hyperpalasia of the lymph follicles and spleen: a hitherto undescribed type. JAMA 1925; 84: 668-71. 3. Symmers D. Follicular lymphadenopathy with

17. Bennett MH. Sclerosis in non-Hodgkin's lymphomata. Br J Cancer 1975; 31 (suppl 2): 44-52. 18. Bennett MH, Millett YL Nodular sclerotic lymphosarcoma: a possible new clinico-pathological entity. Clin Radiol 1969; 20: 339^3. 19. Millett YL, Bennett MH, Jelliffe AM, Farrer-Brown G. Nodular sclerotic lymphosarcoma. A further review. BrJ Cancer 1969; 23: 683-92. 20. Kim H, Dorfman RF, Rappaport H. Signet ring cell

splenomegaly: a newly recognised disease of the

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4. Symmers D. Giant follicular lymphadenopathy with or without splenomegaly: its transformation into polymorphous cell sarcoma of the lymph follicles and its association with Hodgkin's disease, lymphatic leukaemia, and an apparently unique disease of the lymph nodes and spleen - a disease entity believed heretofore undescribed. Arch Pathol 1938; 26: 603-47.

PatholWJS; 2:119-32. 21. Harris M, Eyden B, Read G. Signet ring cell lymphoma: a rare variant of follicular lymphoma. J Clin Pathol 1981; 34:884-91. 22. Silberman S, Fresco R, Steinecker PH. Signet ring cell lymphoma. A report of a case and review of the literature. AmJ Clin Pathol 1984; 81: 358-63.

24 Follicular lymphoma

23. Spagnolo DV, Papadimitriou JM, Matz LR, Walters MN. Nodular lymphomas with intracellular immunoglobulin inclusions: report of three cases and a review. Pathology 1982; 14: 415-27. 24. Talerman A, Platenburg HP. Follicular lymphoma with deposits of amorphous hyaline material, y Pathol 1974; 112:27-31. 25. Chittal SM, Caveriviere P, Voigt JJ, et al. Follicular

38. Lukes RJ, Collins RD. Immunologic characterization of human malignant lymphomas. Cancer 1974; 34 (suppl): 1488-503. 39. Henry K, Bennett MH, Farrer-Brown G. Classification of the non-Hodgkin's lymphomas. In: Anthony P and Woolf N, eds. Recent advances in histopathology 10. Edinburgh: Churchill Livingstone. 1978: 275-302. 40. Anonymous. National Cancer Institute sponsored study

lymphoma with abundant PAS-positive extracellular

of classifications of non-Hodgkin's lymphomas:

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summary and description of a working formulation for

26. Chan JK, Ng CS, Hui PK. An unusual morphological variant of follicular lymphoma. Report of two cases. Histopathology 1988; 12: 649-58. 27. Hernandez AM, Nathwani BN, Nguyen D, et al. Nodal benign and malignant monocytoid B cells with and without follicular lymphomas: a comparative study of follicular colonization, light chain restriction, bcl-2, and t(14;18) in 39 cases. Hum Pathol 1995; 26: 625-32. 28. Nathwani BN, Hernandez AM, Deol I, Taylor CR. Marginal zone B-cell lymphomas: an appraisal. Hum Pathol 1997; 28: 42-6. 29. Ree HJ, Leone LA. Prognostic significance of parafollicular small lymphocytes in follicular lymphoma: clinicopathological studies of 82 cases of primary nodal origin. Cancer 1978; 41:1500-10. 30. Schmid U, Cogliatti SB, DissTC, Isaacson PG. Monocytoid/marginal zone B-cell differentiation in follicle centre cell lymphoma. Histopathology 1996; 29: 201-8. 31. Frizzera G, Gajl-Peczalska K, Sibley RK, Rosai J, Cherwitz D, Hurd DD. Rosette formation in malignant lymphoma. Am J Pathol 1985; 119: 351-6. 32. GoatesJJ, Kamel OW, LeBrun DP, Benharroch D, Dorfman RF. Floral variant of follicular lymphoma. Immunological and molecular studies support a neoplastic process. AmJSurg Pathol 1994; 18: 37-47. 33. Kojima M, Nakamura S, Motoori T, et al. Centroblastic and centroblastic-centrocytic lymphomas associated with prominent epithelioid granulomatous response without plasma cell differentiation: a clinicopathologic study of 12 cases. Hum Pathol 1996; 27: 660-7. 34. Naresh KN. Morphological spectrum of follicle center cell lymphomas associated with infiltration of epithelioid histiocytes. Hum Pathol 1997; 28:114-15. 35. Frizzera G, Anaya JS, Banks PM. Neoplastic plasma cells in follicular lymphomas. Clinical and pathologic findings in six cases. Virchows Arch A Pathol Anat Histopathol 1986; 409:149-62. 36. Nathwani BN, Anderson JR, Armitage JO, et al. Clinical significance of follicular lymphoma with monocytoid B-cells. Non-Hodgkin's lymphoma classification project. Hum Pathol 1999; 30: 263-8. 37. Rappaport H. Tumors of the hematopoietic system.

clinical usage. The Non-Hodgkin's Lymphoma Pathologic Classification Project. Cancer 1982; 49: 2112-35. 41. Mann RB, Berard CW. Criteria for the cytologic subclassification of follicular lymphomas: a proposed alternative method. Hematol Oncol 1983; 1:187-92. 42. Jaffe ES, Raffeld M, Medeiros LJ. Histopathologic subtypes of indolent lymphomas: caricatures of the mature B-cell system. Semin Oncol 1993; 20: 3-30. 43. Martin AR, Weisenburger DD, Chan WC, et al. Prognostic value of cellular proliferation and histologic grade in follicular lymphoma. Blood 1995; 85: 3671-8. 44. Metter GE, Nathwani BN, Burke JS, et al. Morphological subclassification of follicular lymphoma: variability of diagnoses among hematopathologists, a collaborative study between the Repository Center and Pathology Panel for Lymphoma Clinical Studies.7 Clin Oncol 1985; 3: 25-38. 45. Nathwani BN, Metter GE, Miller TP, et al. What should be the morphologic criteria for the subdivision of follicular lymphomas? Blood 1986; 68: 837-45. 46. Mclntosh GG, Lodge AJ, Watson P, et al. NCL-CD10-270: a new monoclonal antibody recognizing CD10 in paraffin-embedded tissue. Am J Pathol 1999; 154: 77-82. 47. Banks PM, Chan J, Cleary ML, et al. Mantle cell lymphoma. A proposal for unification of morphologic, immunologic, and molecular data. Am J Surg Pathol 1992; 16, 637^10. 48. Contos MJ, Kornstein MJ, Innes DJ, Ben-Ezra J. The utility of CD20 and CD43 in subclassification of low-grade Bcell lymphoma on paraffin sections. Mod Pathol 1992; 5: 631-3. 49. Isaacson PG. Malignant lymphomas with a follicular growth pattern. Histopathology 1996; 28: 487-95. 50. Swerdlow SH, Zukerberg LR, Yang Wl, Harris NL, Williams ME. The morphologic spectrum of nonHodgkin's lymphomas with BCL1/cyclin D1 gene rearrangements. Am J Surg Pathol 1996; 20: 627-40. 51. Treasure J, Lane A, Jones DB, Wright DH. CD43 expression in B cell lymphoma. J Clin Pathol 1992; 45: 1018-22. 52. Vasef MA, Medeiros LJ, Koo C, McCourty A, Byrnes RK. Cyclin D1 immunohistochemical staining is useful in distinguishing mantle cell lymphoma from other low-

Washington, DC: Armed Forces Institute of Pathology,

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References 25 53. Ashton-Key M, DissTC, Isaacson PG, Smith ME. A comparative study of the value of immunohistochemistry and the polymerase chain reaction in the diagnosis of follicular lymphoma. Histopathology 1995; 27: 501-8. 54. Ben-Ezra JM, King BE, Harris AC, Todd WM, Kornstein MJ. Staining for Bcl-2 protein helps to distinguish benign from malignant lymphoid aggregates in bone marrow biopsies. Mod Pathol 1994; 7: 560-4. 55. Gaulard P, d'Agay MF, Peuchmaur M, etal. Expression of the bcl-2 gene product in follicular lymphoma. AmJ Pathol 1992; 140:1089-95. 56. Lampert IA, Van Noorden S. Acetyl cholinesterase is expressed in the follicular dendritic cells of germinal centres: differences between normal and neoplastic follicles.yPof/70/1996; 180:169-74. 57. Liu YJ, Grouard G, de Bouteiller 0, Banchereau J. Follicular dendritic cells and germinal centers. Int Rev Cytol 1996; 166:139-79. 58. Vyth-Dreese FA, Dellemijn TA, van Oostveen JW, Feltkamp CA, Hekman A. Functional expression of adhesion receptors and costimulatory molecules by fresh and immortalized B-cell non-Hodgkin's lymphoma cells. Blood 1995; 85: 2802-12. 59. Ishii G, Harigaya K, Soeta S, Mikata A. VLA-4-dependent adhesion in follicular non-Hodgkin's lymphomas. Hematol Pathol 1995; 9:155-69. 60. Kuriyama Y, Nakano M, Kawanishi Y, Iwase 0, Kuge S, Toyama K. Significance of VLA-4 and LFA-1 expressions in neoplastic follicle formation and its deterioration in B-cell non-Hodgkin's lymphomas. Leuk Lymph 1994; 13: 123-9. 61. Ree HJ, Khan AA, Elsakr M, Liau S, Teplitz C. Intercellular adhesion molecule-1 (ICAM-1) staining of reactive and neoplastic follicles. ICAM-1 expression of neoplastic follicle differs from that of reactive germinal center and is independent of follicular dendritic cells. Cancer 1993; 71: 2817-22. 62. Gloghini A, Carbone A. The nonlymphoid microenvironment of reactive follicles and lymphomas of follicular origin as defined by immunohistology on paraffin-embedded tissues. Hum Pathol 1993; 24: 67-76. 63. Petrasch S, Kosco M, Schmitz J, Wacker HH, Brittinger G. Follicular dendritic cells in non-Hodgkin lymphoma express adhesion molecules complementary to ligands on neoplastic B-cells. BrJ Haematol 1992; 82: 695-700. 64. Freedman AS, Munro JM, Morimoto C, et al. Follicular non-Hodgkin's lymphoma cell adhesion to normal germinal centers and neoplastic follicles involves very late antigen-4 and vascular cell adhesion molecule-1. S/oo
66. Imal Y, Yamakawa M. Morphology, function and pathology of follicular dendritic cells. Pathol Int 1996; 46: 807-33. 67. Carbone A, Gloghini A, Gruss HJ, Pinto A. CD40 ligand is constitutively expressed in a subset of T cell lymphomas and on the microenvironmental reactive T cells of follicular lymphomas and Hodgkin's disease. AmJ Pathol 1995; 147: 912-22. 68. ArmitageJO, Dick FR, Corder MD. Diffuse histiocytic lymphoma after histologic conversion: a poor prognostic variant. Cancer Treat Rep 1981; 65: 413-18. 69. Bastion Y, Sebban C, Berger F, et al. Incidence, predictive factors, and outcome of lymphoma transformation in follicular lymphoma patients. J Clin Oncol 1997; 15:1587-94. 70. Cullen MH, Lister TA, Brearley Rl, Shand WS, Stansfeld AG. Histological transformation of non-Hodgkin's lymphoma: a prospective study. Cancer 1979; 44: 645-51. 71. Acker B, Hoppe RT, Colby TV, Cox RS, Kaplan HS, Rosenberg SA. Histologic conversion in the nonHodgkin's lymphomas. J Clin Oncol 1983; 1:11-16. 72. Lennert K, Feller AC. Centroblastic-centrocytic lymphoma. Histopathology of non-Hodgkin's lymphomas (based on the updated Kiel Classification). Berlin: Springer-Verlag, 1990. 73. Matolcsy A, Warnke RA, Knowles DM. Somatic mutations of the translocated bcl-2 gene are associated with morphologic transformation of follicular lymphoma to diffuse large-cell lymphoma. Ann Oncol 1997; 8 (suppl 2): 119-22. 74. Matolcsy A, Casali P, Warnke RA, Knowles DM. Morphologic transformation of follicular lymphoma is associated with somatic mutation of the translocated Bcl-2 gene. Blood 1996; 88: 3937-44. 75. Raghoebier S, Broos L, Kramer MH, et al. Histological conversion of follicular lymphoma with structural alterations of t(14;18) and immunoglobin genes. Leukemia 1995; 9:1748-55. 76. Tilly H, Rossi A, Stamatoullas A, et al. Prognostic value of chromosomal abnormalities in follicular lymphoma. Blood 1994; 84:1043-9. 77. Sander CA, Yano T, Clark HM, et al. p53 mutation is associated with progression in follicular lymphomas. Blood 1993; 82:1994-2004. 78. Dalla-Favera R, Ye BH, Lo Coco F, et al. Identification of genetic lesions associated with diffuse large-cell lymphoma. Ann Oncol 1994; 5 (suppl 1): 55-60. 79. Symmans WF, Katz RL, Ordonez NG, Dalton H, Romaguera JE, Cabanillas F. Transformation of follicular lymphoma. Expression of p53 and bcl-2 oncoprotein, apoptosis and cell proliferation. Acta Cytol 1995; 39: 673-82. 80. Thangavelu M, Olopade 0, Beckman E, et al. Clinical, morphologic, and cytogenetic characteristics of patients with lymphoid malignancies characterized by both t(14; 18)(q32;q21) and t(8;14)(q24;q32) or t(8;22)(q24;q11). Genes Chromosomes Cancer 1990; 2:147-58.

26 Follicular lymphoma 81. Gauwerky CE, Huebner K, Isobe M, Nowell PC, Croce CM. Activation of MYC in a masked t(8;17) translocation results in an aggressive B-cell leukemia. Proc Natl Acad SciLISA 1989; 86: 8867-71. 82. Gauwerky CE, Hoxie J, Nowell PC, Croce CM. Pre-B-cell leukemia with a t(8; 14) and a t(14; 18) translocation is preceded by follicular lymphoma. Oncogene 1988; 2: 431-5. 83. Sham RL, Phatak P, Carignan J, Janas J, Olson JP. Progression of follicular large cell lymphoma to Burkitt's lymphoma. Cancer 1989; 63: 700-2. 84. Yano T, Jaffe ES, Longo DL, Raffeld M. MYC rearrangements in histologically progressed follicular lymphomas. Blood 1992; 80: 758-67. 85. Bisiau H, Daudignon A, Le Baron F, et al. Transformation of follicular lymphoma with both t(14;18) and t(8; 22). Nouv Rev Fr Hematol 1995; 37: 241--4. 86. Brito-Babapulle V, Crawford A, Khokhar T, et al. Translations t(14;18) and t(8;14) with rearranged bcl-2 and c-myc in a case presenting as B-ALL (L3). Leukemia 1991; 5: 83-7. 87. Alsabeh R, Medeiros LJ, Glackin C, Weiss LM. Transformation of follicular lymphoma into CD30-large cell lymphoma with anaplastic cytologic features. AmJ Surg Pathol 1997; 21: 528-36. 88. Criel A, Pittaluga S, Verhoef G, et al. Small B cell NHL and their leukemic counterpart: differences in subtyping and assessment of leukemic spread. Leukemia 1996; 10: 848-53. 89. Salisbury JR, Deverell MH, Seaton JM, Cookson MJ. Three-dimensional reconstruction of non-Hodgkin's lymphoma in bone marrow trephines J Pathol 1997; 181:451-4. 90. Juneja SK, Wolf MM, Cooper IA. Value of bilateral bone marrow biopsy specimens in non-Hodgkin's lymphoma. J Clin Pathol 1990; 43: 630-2. 91. Baroni CD, Manente L, Occhionero M, Marzullo A, Mandelli F, Biagini, C. Involvement of the bone marrow by non-Hodgkin's lymphomas: incidence, histology and pathologic correlations. Tumori 1981; 67:191-6. 92. Meuge-Moraw C, Delacretaz F, Baur AS. Follicular dendritic cells in bone marrow lymphoproliferative diseases: an immunohistochemical study including a new paraffin-resistant monoclonal antibody, DR53. Histopathology 1996; 28: 341-7.

93. Chetty R, Echezarreta G, Comley M, Gatter K. Immunohistochemistry in apparently normal bone marrow trephine specimens from patients with nodal follicular lymphoma. J Clin Pathol 1995; 48:1035-8. 94. Chilosi M, Pizzolo G, Fiore-Donati L, Bofill M, Janossy G. Routine immunofluorescentand histochemical analysis of bone marrow involvement of lymphoma/leukaemia: the use of cryostat sections. BrJ Cancer 1983; 48: 763-75. 95. Kim H, Dorfman RF. Morphological studies of 84 untreated patients subjected to laparotomy for the staging of non-Hodgkin's lymphomas. Cancer 1974; 33: 657-74. 96. Spiro S, Gallon DAG, Wiltshaw E, Lohmann R. Follicular lymphoma: a survey of 75 cases with special reference to the syndrome resembling chronic lymphocytic leukaemia. BrJ Cancer 1975; 31: 60-72. 97. Come SE, Jaffe ES, Andersen JC, et al. Non-Hodgkin's lymphomas in leukemic phase: clinicopathologic correlations. AmJ Med 1980; 69: 667-74. 98. Alkan S, Ross CW, Hanson CA, Schnitzer B. Follicular lymphoma with involvement of the splenic marginal zone: a pitfall in the differential diagnosis of splenic marginal zone cell lymphoma. Hum Pathol 1996; 27: 503-6. 99. Burke JS. Splenic lymphoid hyperplasias versus lymphomas/leukemias. A diagnostic guide. Am J Clin Pathol 1993; 99: 486-93. 100. Piris MA, Mollejo M, Campo E, MenarguezJ, FloresT, Isaacson PG. A marginal zone pattern may be found in different varieties of non-Hodgkin's lymphoma: the morphology and immunohistology of splenic involvement by B-cell lymphomas simulating splenic marginal zone lymphoma. Histopathology 1998; 33: 230-9. 101. Warnke R, Levy R. Immunopathology of follicular lymphomas. A model of B-lymphocyte homing. N EnglJ Med 1978; 298: 481-6. 102. Salamao DR, Nascimento AG, Lloyd RV, Chen MG, Habermann TM, Strickler JG. Lymphoma in soft tissue: a clinicopathologic study of 19 cases. Hum Pathol 1996; 27: 253-7. 103. Garcia CF, Weiss LM, Warnke RA, Wood GS. Cutaneous follicular lymphoma. AmJ Surg Pfltfjo/,1986; 10: 454-63.

4 Mantle cell lymphoma DD WEISENBURGER AND JO ARMITAGE

Introduction Pathologic features

27 27

Immunologic features Cytogenetic and molecular genetic features

31

Normal cellular counterpart Differential diagnosis

33 33

31

INTRODUCTION In the mid-1970s, Berard and colleagues1"4 coined the term lymphocytic lymphoma of intermediate differentiation to describe a group of non-Hodgkin's lymphomas that were not readily classifiable as either well-differentiated (small lymphocytic) or poorly differentiated (small cleaved cell) lymphoma. In lymph node sections, the tumors usually had a diffuse pattern of growth and were composed of a mixture of small lymphoid cells, some with round nuclei like those of small lymphocytic lymphoma, and others with indented and cleaved nuclei like those of small cleaved cell lymphoma. Thus, the term intermediate was used to describe the intermediate morphologic appearance of the tumors. About the same time, Lennert and co-workers5~7 described a similarappearing lymphoma, termed centrocytic, which was characterized by a predominance of irregular and cleaved lymphoid cells. Early immunologic studies of these tumors revealed a B-cell phenotype with the neoplastic cells showing moderate to intense staining for monoclonal surface immunoglobulin (Ig).3'4'7 Cytochemical stains for surface alkaline phosphatase suggested to Berard and colleagues3'4 that intermediate lymphocytic lymphoma corresponded to the cells of primary lymphoid follicles and the mantle zones of secondary follicles, whereas Lennert and co-workers" believed that centrocytic lymphoma was a germinal center cell lymphoma. In the early 1980s, Weisenburger and associates8 and Palutke and colleagues9 described a distinctive type of

Clinical features Treatment and survival Tumor grade Conclusion References

34 35 36 37 37

follicular lymphoma that was characterized by the proliferation of atypical small lymphoid cells in wide mantles around benign germinal centers. Weisenburger and associates8'10 coined the term mantle zone lymphoma for this entity and suggested that it represented the follicular counterpart of diffuse intermediate lymphocytic lymphoma. More recent studies, which are detailed herein, have characterized all of these various lymphomas clinically and at the molecular level, and have led to the conclusion that they represent a closely related spectrum of tumors that correspond to lymphocytes in the primary lymphoid follicles and mantle zones of secondary follicles. Thus, the term mantle cell lymphoma (MCL) is now the accepted name for this group of lymphomas.11,12

PATHOLOGIC FEATURES The pathologic features of MCL have been refined and the histologic spectrum of the disease has been expanded in recent years through the use of immunologic, cytogenetic and molecular techniques. A number of large, wellstudied series with detailed descriptions of the pathology of the MCL have been published.13-19 Lymph nodes The non-Hodgkin's lymphomas of mantle cell type usually consist of atypical small lymphoid cells, and have

28 Mantle cell lymphoma

Image Not Available

Figure 4.1 Mantle cell lymphoma composed of nodules with reactive germinal centers surrounded by wide mantles of neoplastic small lymphoid cells. Reproduced with permission from Weisenburger DD. Mantle cell lymphoma. In: Knowles D, ed. Neoplastic hematopathology. Baltimore: Williams & Wilkins, 1992: 617-28.

either a nodular or diffuse pattern of growth, or a combination of the two patterns. Modularity is present, at least focally, in approximately 30 per cent of cases of MCL at the time of initial diagnosis. Early in the course of disease, nodular MCL may have a distinctly nodular or a vaguely nodular growth pattern at low magnification. In nodular MCL, some or many of the nodules may consist of follicles with reactive germinal centers surrounded by broad and expansive mantles of small lymphoid cells (Fig. 4.1), the so-called mantle zone pattern.8,20 In such cases, however, some neoplastic nodules without germinal centers, which mimic primary follicles, are also present. In other cases, these latter nodules may predominate or be present exclusively (Fig. 4.2), and the process may be confused with a follicular center cell lymphoma of the small cleaved cell type. Later in the course of disease, invasion

Image Not Available

Figure 4.2 Mantle cell lymphoma composed of nodules of neoplastic small lymphoid cells without reactive germinal centers. Reproduced with permission from Weisenburger DD. Mantle cell lymphoma. In: Knowles D, ed. Neoplastic hematopathology. Baltimore: Williams & Wilkins, 1992: 617-28.

and obliteration of the reactive germinal centers and interfollicular areas by neoplastic cells results in a diffuse pattern of growth. Residual vague nodularity may be seen in such cases, and naked germinal centers lacking a normal lymphocyte cuff are found within the diffuse areas in approximately one-quarter of the cases (Fig. 4.3). Cytologically, a MCL usually consists of a monotonous population of atypical small to medium-sized lymphoid cells with irregular and indented nuclei, moderately coarse chromatin, inconspicuous nucleoli, and scant cytoplasm (typical 'intermediate' cytology). Small round lymphocytes, some of which are T cells, are admixed in variable numbers, and neoplastic cells with cleaved nuclei are often present as well. However, cases of MCL with predominantly round nuclei or only slight nuclear irregularity, and cases with markedly angulated and cleaved nuclei ('centrocytic' cytology) or even cerebriform nuclei do occur. Although the neoplastic lymphoid cells show a spectrum of nuclear irregularity from case to case, ranging from slight to marked, the cells usually show little variation in an individual neoplasm. In about 20 per cent of cases of MCL, the neoplastic cells are larger than usual and have more finely dispersed nuclear chromatin and small nucleoli. Such cases have been referred to as large cell ('anaplastic centrocytic') or blastic variants of MCL.6,15-17 Sometimes, a mixture of atypical small cells and larger blastic cells is present, imparting a more pleomorphic cytologic picture. In other cases, the blastic cells are quite monotonous, ranging from medium to large in size, with very fine chromatin and multiple small nucleoli ('centrocytoid centroblastic' cytology). Thus, the diversity of morphologies seen in different cases of MCL is broad, ranging from small cells with round or slightly irregular nuclei at one end of the spectrum to large transformed cells with distinct nucleoli at the other end. The cytologic spectrum of MCL is shown in Fig. 4.4.

Image Not Available

Figure 4.3 Diffuse mantle cell lymphoma with a naked germinal center lacking a normal lymphocyte cuff. Reproduced with permission from Weisenburger DD. Mantle cell lymphoma. In: Knowles D, ed. Neoplastic hematopathology. Baltimore: Williams & Wilkins, 1992: 617-28.

Pathologic features 29

Figure 4.4 Cytologic spectrum of mantle cell lymphoma including cases with round to slightly irregular nuclei (a), markedly irregular nuclei (b), blastic nuclei (c), and large vesicular nuclei with prominent nucleoli (d).

In general, large transformed lymphoid cells with vesicular nuclei and prominent nucleoli (large noncleaved cells or centroblasts) are not seen in the lymphocytic forms of MCL, and plasma cells are usually absent or only present in small numbers and polyclonal in nature. The mitotic rate is generally low in the lymphocytic forms of MCL, but an increased mitotic rate is usually seen in the pleomorphic and blastic variants, and is often accompanied by admixed benign histiocytes. These rather distinctive histiocytes have abundant pink cytoplasm and may contain phagocytized cellular debris (Fig. 4.5). Histologic progression from a nodular pattern to a diffuse pattern may be evident in a subsequent biopsy, and progression from lymphocytic to blastic cytology with a high mitotic rate is not uncommon. Norton and colleagues17 noted histological transformation to blastic

cytology upon rebiopsy in 17 per cent of their cases of MCL, and found blastic cytology in 70 per cent of their cases at autopsy. However, transformation of MCL to the more common forms of diffuse large cell lymphoma is a rare event. Cytology, peripheral blood and bone marrow In lymph node touch preparations and other cytologic specimens, the neoplastic cells are small to medium sized, with irregular, indented and cleaved nuclear contours, moderately clumped (smudged) to more finely dispersed chromatin, one or more conspicuous nucleoli, and small to moderate amounts of cytoplasm (Fig. 4.6).

Figure 4.6 Touch preparation of mantle cell lymphoma Figure 4.5 Blastic mantle cell lymphoma with admixed benign

showing medium-sized lymphoid cells with irregular nuclear contours, moderately clumped (smudged) chromatin, small

histiocytes, one of which contains phagocytized cellular debris.

nucleoli and scant cytoplasm.

30 Mantle cell lymphoma

Larger cells with round nuclei, fine chromatin, prominent nucleoli and moderate amounts of basophilic cytoplasm are seen in the blastic variants of MCL. Smears of involved bone marrow and peripheral blood generally reflect the lymphoid population present in the lymph nodes.10'21'22 The neoplastic cells in the blood and bone marrow of a given patient maybe quite heterogeneous in appearance (Fig. 4.7). In bone marrow sections, the neoplastic cells may infiltrate in either a focal, often paratrabecular, pattern or a diffuse pattern. However, one should not make a diagnosis of MCL based upon the examination of peripheral blood or bone marrow alone because of the lack of precise criteria for such a diagnosis. However, immunological studies by flow cytometry (see 'Immunologic features') may be very useful in the diagnosis of such specimens.21'22

Spleen The spleen is often enlarged in patients with MCL and particularly in those with the nodular (mantle zone) type.8'20 Spleen weights have ranged from 600 to 3700 g.8'13 Macroscopically, the cut surface often reveals numerous lymphoid nodules measuring 1-3 mm in diameter. Microscopically, the white pulp areas are markedly expanded by a proliferation of atypical lymphoid cells similar to those found in the lymph nodes. Benign and reactive-appearing germinal centers may be present in the white pulp areas, and the marginal zone is sometimes preserved (Fig. 4.8). Nodular infiltration of the red pulp is usually also present, albeit in varying degrees.

Image Not Available

Figure 4.7 Peripheral blood smear of mantle cell lymphoma showing a spectrum of lymphoma cells. Reproduced with permission from Weisenburger DD. Mantle cell lymphoma. In: Knowles D, ed. Neoplastic hematopathology. Baltimore: Williams & Wilkins, 1992: 617-28.

Image Not Available

Figure 4.8 Spleen in mantle cell lymphoma showing an expanded white pulp area with a small germinal center surrounded by a wide mantle of small lymphoid cells. Note that the marginal zone is preserved. Reproduced with permission from Weisenburger DD. Mantle cell lymphoma. In: Knowles D, ed. Neoplastic hematopathology. Baltimore: Williams & Wilkins, 1992: 617-28.

Other organs Involvement of other organs by MCL is not uncommon because the patients usually have advanced stage disease at the time of diagnosis. Liver involvement is common and is characterized by atypical portal lymphoid infiltrates. Involvement of other extranodal sites is also common. Extranodal sites that are most likely to be involved primarily or as part of a disseminated process include the gastrointestinal tract and Waldeyer's ring (20-30 per cent of cases). Gastrointestinal involvement as multiple lymphomatous polyposis (Fig. 4.9), often

Image Not Available

Figure 4.9 Multiple lymphomatous polyposis of the intestine with myriads of confluent polyps within the ileum (top) and scattered, more sessile polyps within the colon (bottom). Reproduced with permission from Moynihan MJ, Bast MA, Chan WC, et al. Lymphomatous polyposis: a neoplasm of either follicular mantle or germinal center cell origin. Am J Surg Pathol 7996; 20: 442-52.

Cytogenetic and molecular genetic features 31

accompanied by a large localized mass, has been reported23'24 but is not entirely specific for MCL.25

rates in the lymphocytic forms and high rates in the biastic variants, but with considerable overlap.15'19'28'29

IMMUNOLOGIC FEATURES

CYTOGENETIC AND MOLECULAR GENETIC FEATURES

The immunohistologic features of MCL reveal a characteristic phenotype.13-15,19,26,27 In frozen sections, the cells have a monoclonal B cell phenotype, almost always bearing surface IgM and often slgD. Surface IgG is expressed along with slgM in about 20 per cent of cases. The kappa to lambda light-chain ratio is reversed in MCL with about 60 per cent of cases expressing monoclonal lambda light chains, and the residual germinal centers are polyclonal. The neoplastic cells also stain for a variety of pan-B cell antigens (CD 19, 20, 22 and 24) and HLA-DR antigen. Interestingly, the cells usually have the pan-T cell antigen CD 5 on the surface (Fig. 4.10) and are negative for CD 10 (CALLA) antigen. The neoplastic cell$ may also bear the T cell-associated antigens CD 43 and Leu 8, but fail to stain for other pan-T cell antigens. The cells are usually also negative for CD 23 antigen. Antibodies to dendritic reticulum cells reveal large aggregates of these cells in cases with a nodular or mantle-zone pattern, whereas a more sparse and irregular meshwork of dendritic cells is usually found in diffuse areas. Cases of blastic MCL are less likely to express slgD, CD 5 and CD 43, and may express CD 10 antigen. The phenotype of MCL is remarkably similar to that of small lymphocytic lymphoma and chronic lymphocytic leukemia, except for more intense slg and CD 20 staining and lack of CD 23 expression in MCL. Studies of cellular proliferation rates in MCL have generally found low

The characteristic cytogenetic abnormality in MCL is the t(ll;14)(ql3;q32), which is seen in the majority of cases.3M3 Variant translocations involving the Ilql3 breakpoint have also been reported,33,34 whereas the presence of trisomy 12 appears to be a secondary abnormality.35 The presence of a complex karyotype with hyperdiploidy has been associated with large atypical cells36 and may suggest a more aggressive clinical course in MCL. However, the t(ll;14)(ql3;q32) also occurs, albeit infrequently, in other types of non-Hodgkin's lymphoma, lymphocytic leukemia and multiple myeloma. Therefore, cytogenetic findings need to be carefully correlated with the pathologic and immunologic features to confirm a diagnosis of MCL. The molecular counterpart of the t(ll;14) involves an error in V-D-J joining during Ig heavy-chain gene rearrangement, resulting in the movement of a putative cellular oncogene adjacent to the bd-1 (Ilql3) breakpoint into proximity of the enhancer region of the Ig heavy chain gene (14q32). Breaks in the latter region are thought to occur during early B cell development and are mediated by the recombinase system, whereas 1 Iql3 appears to be a common fragile site.37 The breakpoints in the bd-1 locus are not tightly clustered, although 30-40 per cent of cases of MCL have breaks in the major translocation cluster (MTC) region (Fig. 4.II).38"42 However, using multiple probes including those for a number of minor breakpoint regions, a variety of investigators have detected clonal rearrangements in 50-70

Figure 4.11 Diagram of the t(11; 14) in mantle cell lymphoma. An 1lql3 breakpoint at the bcl-1 major translocation cluster is shown; other described breakpoints (arrows in upper panel) exist as close as 1 kbfrom the first exon of the PRAD1 gene. Figure 4.10 Mantle cell lymphoma stained with CD 5 antibody.

Reproduced with permission from Arnold A. The cyclin

Note that the tumor cells do not stain as intensely as the few admixed T cells.

43: 543-9.

D1/PRAD1 oncogene in human neoplasia. ] Invest Med 7995;

32 Mantle cell lymphoma

per cent of patients with MCL.38"42 A polymerase chain reaction (PCR) assay has been developed and used to detect most of the breaks in the MTC region.9'43"45 This assay may also be used on DNA extracted from paraffinembedded tissues. The use of chromosome 11 paints and fluorescence in situ hybridization (FISH) to detect the t(ll;14) in interphase cells of MCL has also been reported.46'47 Both the PCR and FISH techniques will be useful to detect minimal residual disease in MCL. The putative oncogene deregulated by the t(ll;14) was identified by two groups and is located approximately 120 kb telomeric from the MTC breakpoint (Fig. 4.II). 48,49 The gene was named PRAD1 because of its original recognition in parathyroid adenoma50 but has been officially named CCND1. The gene encodes for cyclin Dl and is overexpressed in nearly all cases of MCL, whereas it is expressed only rarely in other forms of hematopoietic cancer.39,41,42,48,51,52 Since overexpression of this gene at the RNA level has also been noted in most cases of MCL without detectable bd-1 rearrangements, additional minor breakpoint sites outside of those detected by the available probes are likely to be involved in the translocation of chromosome Ilql3. Alternatively, deregulation could occur by mutation or deletion of negative regulator elements adjacent to the gene, or extra copies of the gene may result in its overexpression. All of the known breakpoints leave the CCND1 coding region structurally intact and result in increased protein expression. In some cases, loss of 3' end regulatory sequences may also increase the half-life of cyclin Dl.53 Antibodies to cyclin Dl, which work on paraffin-embedded material (Fig. 4.12), have been shown to be highly sensitive and specific for MCL54-59 and are very useful diagnostically. Alternatively, in situ hybridization detection of cyclin Dl mRNA in cytopreps or paraffin tissues can be used to elucidate the nature of diagnostically difficult cases.60,61 The mechanism by which cyclin Dl overexpression facilitates lymphomagenesis is not yet well understood,

but its key role in cell cycle regulation and the progression of cells through the main commitment checkpoint in Gl to S phase is certainly important.62"64 Overexpression of cyclin Dl results in a shortened Gl phase, probably through its physical interaction with the tumor-suppressor retinoblastoma protein (RB).65 Cyclin Dl binds to and activates important enzymes called cyclin-dependent kinases (CDK; mainly CDK4 and CDK6), whose activity is needed to propel cells through the Gl checkpoint. Cyclin D1-CDK4 complexes then bind to and hyperphosphorylate RB, which in turn prevents RB from binding important transcription factors such as E2F. Thus, the growth-restraint effect of RB via its binding of transcription factors is removed and the cells are propelled into S phase (Fig. 4.13). Mutations of the tumor-suppressor p53 gene have been reported in aggressive variants of MCL.66'67 This gene regulates the expression of p21 protein, which is an important universal inhibitor of cyclin-CDK complexes, including cyclin D-CDK4.68 Thus, mutations of the p53 gene with loss of this inhibition could further enhance the effects of overexpressed cyclin Dl. The normal p53 gene acts as a molecular monitor of the genome.69 If DNA is damaged, p21 protein accumulates and switches off replication to allow extra time for DNA repair. If the repair fails, p53 may trigger cell suicide by apoptosis. However, tumor cells in which p53 is inactivated by mutation cannot carry out this arrest and are genetically unstable. Such cells will accumulate mutations and chromosomal rearrangements at an increased rate, thus leading to the rapid selection of highly malignant clones. Thus, p53 also plays a critical role at the Gl checkpoint62'68'69 and mutations of p53 are important in the progression of MCL.66'67 Evidence has accumulated that CCND1 can function like an oncogene by causing abnormalities of cellular growth control, cell cycle progression and gene expression, as well as malignant transformation.70"72 Studies

Image Not Available

Figure 4.12 Mantle cell lymphoma stained with a polyclonal antibody to cyclin Dl. Note the nuclear positivity of variable intensity in a majority of the cells.

Figure 4.13 Schematic diagram showing the functional interrelationships of cyclin Dl. Reproduced with permission from Arnold A. The cyclin D1/PRAD1 oncogene in human neoplasia. J Invest Med 7995; 43: 543-9.

Differential diagnosis 33

using transgenic mice have shown that CCND1 cooperates with myc genes in the generation of B cell lymphomas, although CCND1 was not oncogenic by itself.73,74 However, these studies demonstrated subtle alterations in cell cycle progression and the number of bone marrow B cells due to CCND1 overexpression.73'74 Activation of cyclin D genes by proviral insertions in murine lymphomas has also been reported.75,76 Also, cyclin Dl was shown to induce mammary hyperplasia and carcinoma in a different transgenic model.77 Thus, it appears that CCND1 is a bona fide oncogene whose activity appears to depend on the specific cell type as well as specific co-operating partner genes72-74,78 in order to induce tumors. Further elucidation and study of such gene interactions is needed in MCL.

NORMAL CELLULAR COUNTERPART Currently, the various types of B cell neoplasia are thought to represent cells arrested at various stages in the normal differentiation scheme.79 The histologic and immunologic features of MCL suggest that the neoplastic cells correspond to normal, naive B lymphocytes that home to and reside in primary lymphoid follicles and the mantle zones of secondary follicles. These cells seem to correspond phenotypically to a major population of fetal B cells that leave the bone marrow and form the primary lymphoid follicles in the lymph nodes and spleen.80"82 At birth, 68 per cent of cord blood B cells and approximately half of peripheral blood B cells are CD 5positive83'84 and these cells are morphologically similar to the cells of MCL.85 In the adult, CD 5-positive B cells circulate in small numbers8"18 and are found in the inner area of mantle zones of lymphoid follicles.86'89 Normal mantle cells have been shown to express a diverse repertoire of unmutated Ig heavy-chain variable region genes, as one would expect of naive pregerminal center B cells.90 Identical findings have also been reported in MCL.91 Furthermore, CD 5-positive B cells can be induced to differentiate to CD 5-negative cells with the immunologic features of germinal center cells.92 Thus, the cells of MCL appear to correspond to precursor cells of the

normal germinal center reaction.79,93 The possibility that some cases of MCL arise from a subset of mantle zone lymphocytes with the immunologic features of marginal zone cells94,95 has been suggested by some authors.96,97

DIFFERENTIAL DIAGNOSIS A diagnosis of MCL with a mantle zone pattern may be difficult to make when incomplete obliteration of the normal lymph node architecture and numerous benignappearing germinal centers are present. However, the presence of wide follicular mantles in mantle zone lymphoma is distinctly different from the thin mantles found in most cases of reactive follicular hyperplasia. In the spleen, involvement of the red pulp by lymphoma is also a helpful diagnostic feature. However, in lymph nodes, mantle zone hyperplasia and angiofollicular lymphoid hyperplasia of the hyaline-vascular type (Castleman's disease) are two uncommon reactive processes that may be difficult to distinguish from mantle zone lymphoma. Mantle zone hyperplasia usually occurs as an isolated small node in the neck of a young individual. In mantle zone hyperplasia, the follicles are usually localized to the cortex of the node, and the architectural effacement and diffuse areas of involvement characteristic of lymphoma are lacking. Angiofollicular lymphoid hyperplasia also usually presents in young individuals, but as a large and localized mass, and is characterized by typical hyaline-vascular germinal centers without diffuse areas of involvement. Immunohistochemical stains may be very helpful in distinguishing mantle zone lymphoma from these reactive processes. The monoclonality, and CD 5 and CD 43 positivity, of the neoplastic cells clearly separate mantle zone lymphoma from the follicular, mantle zone and angiofollicular hyperplasias. This rule is also valid for separating diffuse MCL from diffuse reactive lymphoid proliferations of B cell type. A variety of non-Hodgkin's lymphomas may also be confused with the lymphomas of mantle cell origin. However, immunohistochemical and cytogenetic or molecular studies may be very useful in differentiating the various entities (Table 4.1). The nodular (primary

Table 4.1 Phenotypes of various B lymphocytic lymphomas

+

Mantle cell lymphoma Follicular center cell lymphoma Small lymphocytic lymphoma/CLL Monocytoid B cell lymphoma Mucosa-associated lymphoma

M±D G±M M±D M M

-/+ -/+ -/+

Lymphoplasmacytic lymphoma

M

+

+

+ -

+/+ -/+

+ + -/+

+ +

t(11;14)(q13;q32) t(14;18)(q32;q21) Trisomy 12, del 13q14 Trisomy 3 and 18 t(11;18)(q21;q21) Trisomy 3 and 18 t(9;14)(p13;q32), de!6q23

slg = surface immunoglobulin, clg = cytoplasmic immunoglobulin, DRC = dendritic reticulum cell network, CLL = chronic lymphocytic leukemia, + = >80 per cent positive, +/- = >50 per cent positive, -/+ = <50 per cent positive, - = <20 per cent positive.

34 Mantle cell lymphoma

follicular) form of MCL may be difficult to differentiate from follicular small cleaved cell lymphoma. However, the cells of MCL are usually not as markedly angulated and cleaved as those of follicular center cell lymphoma. Also, large transformed cells are usually absent in MCL, although residual large cells from invaded benign germinal centers may occasionally confuse the issue. Harris and Bhan98 have described a rare form of follicular center cell lymphoma in which small cleaved cells exit the neoplastic germinal centers and accumulate in the adjacent mantle zones. However, such cases should not be considered as mantle zone lymphoma since they arise from germinal center cells. In difficult cases, immunohistochemical stains can be used to separate follicular center cell lymphoma from MCL by the fact that the former has monoclonal, CD 10-positive germinal centers and CD 5-negative mantle zones, whereas polyclonal germinal centers and monoclonal, CD 5-positive mantle zones are seen in nodular MCL. Immunologic studies may also be helpful in separating diffuse MCL from diffuse small cleaved follicular center cell lymphoma, which is CD 5-negative and CD 10-positive, and often exhibits immunoglobulin heavy-chain switching to a more mature phenotype." Also, transformed large cells, and small cells with the markedly elongated and twisted nuclei of follicular center cell lymphoma, are generally absent in diffuse MCL. Interfollicular small lymphocytic lymphomas may encroach upon and invade reactive follicles and produce a pseudo-mantle zone pattern.100 This pattern is characterized by reactive germinal centers with thin, residual mantle zones that are surrounded by the neoplastic infiltrate. However, the predominance of small lymphocytes with uniformly round nuclei and the presence of pseudofollicular proliferation centers and paraimmunoblasts in small lymphocytic lymphoma are useful differential features, since they do not occur in MCL. Perry and associates101 have also shown that lymphocytic lymphomas composed of cells with irregular nuclei, but having pseudofollicular proliferation centers, should be classified as small lymphocytic lymphoma for clinical purposes. The immunophenotypes of MCL and small lymphocytic lymphoma are similar, but the presence of numerous dendritic reticulum cells and the absence of CD 23 antigen in MCL are useful diagnostic features. A pseudo-mantle zone pattern may also be seen in monocytoid B cell lymphoma, centrocyte-like B cell lymphoma occurring in mucosa-associated lymphoid tissues, and peripheral T cell lymphoma composed of atypical small lymphoid cells. These lymphomas arise in the parafollicular or interfollicular regions, and may secondarily invade reactive lymphoid follicles. Each of these lymphomas has distinctive histologic and immunologic features that are useful in the differential diagnosis (Table 4.1). However, the presence of lymphoepithelial lesions is not useful in differentiating MCL from centrocyte-like lymphoma of mucosa-associated lymphoid

tissue, since they have also been described in MCL.24,25,102 Pileri and associates103 have described cases of apparent 'mantle zone' lymphoma of the lymphocytic type with plasma cell differentiation. However, it is not clear whether these authors are describing interfollicular lymphoplasmacytoid/cytic lymphomas with a pseudo-mantle zone pattern or a rare form of MCL with plasma cell differentiation. In the spleen, MCL must also be distinguished from splenic marginal zone lymphoma. The presence of predominantly white pulp involvement with a prominent follicular dendritic network, cellular monotony with the absence of large transformed cells (centroblasts) or clonal plasma cells, and CD 5 positivity favor a diagnosis of MCL.104 The blastic variants of MCL may sometimes be confused with B lymphoblastic lymphoma105 or granulocytic sarcoma, although the chromatin pattern is usually somewhat more coarse in blastic MCL. Immunologic studies are usually helpful in this regard, since blastic MCL is surface Ig- and CD 5-positive, and terminal deoxynucleotidyl transferase (tdt)-negative, whereas B lymphoblastic lymphoma is CD 5-negative, usually surface Ig-negative, and tdt-positive. The presence of CD 10 is not helpful since it may be expressed in either entity. In addition to the above features, a number of myeloid markers including myeloperoxidase, lysozyme and specific esterase, will clearly delineate granulocytic sarcoma from MCL. Although MCL may be diagnosed in extranodal sites, such as the gastrointestinal tract, one should hesitate to make a primary diagnosis of MCL in extranodal sites, such as the bone marrow, liver or soft tissue, because of the nuclear irregularities that may occur as a result of the surrounding fibrous tissue reaction. Such cases are better diagnosed as lymphocytic lymphoma, not further classified, if corroborating evidence for MCL cannot be obtained. Similarly, one should not make a diagnosis of MCL based on bone marrow or peripheral blood smears alone, since criteria for such a diagnosis have not been well defined. A lymph node biopsy with immunologic studies is often necessary to categorize such cases precisely, although flow cytometric and molecular studies of blood and bone marrow may also be useful.21,22,27

CLINICAL FEATURES Mantle cell lymphoma comprises 2.5-4.0 per cent of all non-Hodgkin's lymphomas in the USA, whereas higher rates of 7-9 per cent are found in Europe. A number of detailed studies have defined the clinical features of MCL (Table 4.2).13-15,17-19,106-12 Patients with MCL have a median age of approximately 60 years and males predominate. Patients generally present with advanced (stage III/IV) disease, usually with generalized lymphadenopathy and bone marrow and liver involvement, but fewer than a

Treatment and survival 35

Table 4.2 Clinical features of mantle cell lymphoma at initial presentation Median age Male to female ratio

60 years 4:1

Generalized lymphadenopathy Splenomegaly Hepatomegaly Peripheral blood lymphocytosis Bone marrow infiltration Gastrointestinal involvement Waldeyer's ring involvement

90% 60% 30% 30% 80% 20% 10%

Ann Arbor Stage IM/IV B symptoms Bulky disease Poor performance status Elevated lactate dehydrogenase Elevated (32 microglobulin

90% 40% 30% 20% 40% 55%

Image Not Available

Figure 4.14 Overall survival of patients with mantle cell lymphoma (MCL) compared with those having Working Formulation (WF) types A through E. Reproduced with permission from Fisher Rl, DahlbergS, Nathwani BN, Banks PM, Miller TP, Grogan TM. A clinical analysis of two indolent lymphoma entities: mantle cell lymphoma and marginal zone lymphomas, including mucosa-associated lymphoid tissue and monocytoid B-

half of the patients have systemic (B) symptoms. Splenomegaly is present at initial diagnosis in approximately 60 per cent of the patients. In the nodular (mantle zone) type, 80 per cent of the patients have splenomegaly, which may be massive. Other extranodal sites are also frequently involved, particularly the gastrointestinal tract and Waldeyer's ring (20-30 per cent of cases). A particularly striking extranodal presentation is multiple lymphomatous polyposis of the intestine, which should suggest a diagnosis of MCL. Mild anemia is not uncommon at presentation, whereas thrombocytopenia occurs in fewer than 15 per cent of the patients. A peripheral blood lymphocytosis of greater than 4000/mm3 occurs in 20-40 per cent of the cases, but absolute counts above 20000/mm3 are uncommon. Hypogammaglobulinemia, a monoclonal gammopathy and a positive Coombs' test are also decidedly uncommon.

cell subcategories: a Southwest Oncology Group study. Blood 7995; 85:1075-82.

combination chemotherapy, which usually did not contain doxorubicin, various investigators obtained complete remission (CR) rates of 20-40 percent. 106-108,114In a prospective comparative analysis of MCL and folliclecenter lymphoma, the German Low Grade Lymphoma Study Group found that patients with MCL had more disease at presentation, a lower and slower response to such chemotherapy and a worse prognosis.115 Meusers and colleagues107 reported a CR rate of 58 per cent when using a combination of cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP), but few long-term remissions or cures have been reported in any series

TREATMENT AND SURVIVAL Mantle cell lymphoma is a vexing and increasingly frequent problem for oncologists. The disease brings together the worst characteristics of high-grade and lowgrade lymphomas, i.e. the course is not indolent and the disease is rarely curable. The median survival of patients with MCL has ranged between 3 and 4 years in large series.13,15,17-19,106,107,109-111 This is significantly shorter than the survival of the patients with similar forms of lymphoma (Fig. 4.14). In two detailed studies,14,15 patients with a nodular (mantle zone) pattern had a significantly longer median survival (77-88 months) when compared to those with diffuse MCL (30-33 months) (Fig. 4.15). The prognostic significance of a predominantly nodular pattern has recently been confirmed by others.19,110,112,113 With the use of non-curative, pre-first-generation

Image Not Available

Figure 4.15 Overall survival of patients with mantle cell lymphoma having a mantle zone pattern compared with those with a diffuse pattern. Reproduced with permission from Weisenburger DD, Duggan MJ, Perry DA, Sanger WG, ArmitageJO. Non-Hodgkin's lymphomas of mantle zone origin. In: Rosen PP, Fechner RE, eds Pathology annual. East Norwalk, CT: Appleton & Lange, 7990:739-58.

36 Mantle cell lymphoma

because of disease recurrence and progression. Zucca and associates111 have reported a benefit from aggressive chemotherapy in a subset of patients with good prognostic indicators. Teodorovic and colleagues114 recently reported a CR rate of 52 per cent for patients treated with aggressive chemotherapy and suggested that improved survival may be achieved if a CR after CHOPlike aggressive chemotherapy, also containing bleomycin, is obtained. In elderly patients, less aggressive therapy, such as cyclophosphamide, vincristine and prednisone (CVP), may be justified. Therapeutic experience with the purine analogs, fludarabine and 2-CDA, and interferon has been disappointing.12'114 Although a small proportion of patients may benefit from observation only, Bookman and colleagues108 found that CRs could not be obtained when such patients were later treated for progressive symptomatic disease. Most studies14,15,20,106-108,111,114 have shown, however, that patients who achieve a CR have a longer survival than those who do not achieve a CR, but few patients are cured. Since the long-term prognosis of patients receiving conventional therapy for MCL is rather poor, the use of aggressive combination chemotherapy with stem-cell transplantation for younger patients has been suggested.17'107'108'116 Stewart and colleagues117 treated nine such patients with high-dose therapy and stem-cell transplantation, and three were progression-free at 7, 12 and 25 months post-transplantation. However, longer follow-up of greater patient numbers will be required to determine whether high-dose therapy can overcome the chemoresistance and increase the cure rate of MCL. The optimal timing for high-dose therapy may be early as part of front-line treatment.117 Against the background of these early promising results, the European Bone Marrow Transplantation guidelines118 suggest that appropriate patients should be offered high-dose chemotherapy with autotransplant; however, Coiffier in a review of reported series found that, whilst response rates were improved, no patient was cured.119 Purging of harvested stem cells with anti-B cell antibody does not improve the situation.120 Coiffier concludes that, outside of randomized prospective studies, high-dose therapy is not appropriate for MCL patients and suggests that this (and the promising role of new agents, such as rituximab, the anti-CD 20 antibody)121 should be prospectively compared with standard CHOP therapy. A number of clinical and pathologic features are predictive of survival in MCL. The clinical features predicting a poor prognosis are generally the same as those found in other lymphoma subtypes, and include advanced age and stage, B symptoms, poor performance status, peripheral blood lymphocytosis, elevated lactate dehydrogenase or fte-microglobulin levels, high risk with the International Prognostic Index (Fig. 4.16), and failure to achieve a good clinical response to therapy.13,14,17,106,107,109,111 The pathologic features that predict a

Image Not Available

Figure 4.16 Overall survival of patients with mantle cell lymphoma grouped according to the International Prognostic Index. Reproduced with permission from Kluwer Academic Publishers; Zucca E, Roggero E, Pinotti G, et al. Patterns of survival in mantle cell lymphoma. Ann Oncol 7995; 6:259-62.

poor prognosis are a diffuse pattern, a high mitotic rate or proliferative fraction, blastic cytology and p53 overexpression 13-15,17,19,42,64,65,106,110,112,113

TUMOR GRADE The Working Formulation divides the different subtypes of non-Hodgkin's lymphoma into low-grade, intermediate-grade and high-grade categories according to their median survivals, whereas the Kiel classification utilizes only low-grade and high-grade categories based on cytologic features rather than survival. Since MCL was not well understood when the Working Formulation was prepared, it was not included as a category in the Working Formulation. However, most cases of MCL were probably included in the intermediate-grade category of diffuse small cleaved cell lymphoma in that study. In contrast, MCL is considered to be a low-grade lymphoma in the Kiel classification. Based on the studies cited herein, we believe that the predominantly nodular (mantle zone) form of MCL composed of small lymphoid cells should be considered a low-grade lymphoma (median survival, >5 years), whereas diffuse MCL composed of small cells should be considered an intermediate-grade lymphoma (median survival, 3 years). However, the lymphocytic types of MCL are similar to other lymphomas of lowgrade malignancy in that they are generally incurable, except for the uncommon case with low-stage disease. The blastic variants of MCL have cytologic features and proliferative rates similar to those of the high-grade lymphomas (small non-cleaved and lymphoblastic) in the Working Formulation and, regardless of pattern, should probably be considered as such (median survival, <2 years), and this is recognized in the proposed WHO classification (see Chapter 1). De novo cases of blastic MCL may be the most responsive to high-dose therapy and should probably be treated with curative intent.

References 37

Future classifications of non-Hodgkin's lymphoma should include MCL, with all of its various patterns and cytologies, so that future clinical studies can clearly delineate and further characterize this important entity.

CONCLUSION

4. Namba K, Jaffe ES, Braylan RC, Soban EJ, Berard CW. Alkaline phosphatase-positive malignant lymphoma. A subtype of B-cell lymphomas. AmJ Clin Pathol 1977; 68: 535-42. 5. Lennert K, Stein H, Kaiserling E. Cytological and functional criteria for the classification of malignant lymphomata. BrJ Cancer 1975; 31 (suppl II): 29-43. 6. Lennert K. Malignant lymphomas other than Hodgkin's

Numerous recent studies have confirmed that MCL is a distinct clinicopathologic entity. The neoplastic cells of MCL appear to correspond to naive B cells that normally home to and reside in primary lymphoid follicles and the mantle zones of secondary follicles. As such, they correspond to a subset of normal follicular B cells, which are thought to transform into germinal center cells in response to antigen. The relationship between the nodular (mantle zone) and diffuse lymphocytic forms of MCL is biologically analogous to the germinal center cell lymphomas of follicular and diffuse types, respectively, whereas the blastic forms of MCL are analogous to the transformed lymphomas arising in other low-grade lymphomas. New and better therapies are badly needed for this group of lymphomas,122 including further exploration of high-dose therapy with stem-cell rescue,117 immunotherapy with anti-shared idiotype monoclonal antibodies,123 radioimmunotherapy with 13T-labelled B cell-specific antibodies,124 and innovative approaches, which take advantage of cell-cycle checkpoints and proliferation controls.125'126 Until such progress is made, MCL will continue to be one of the worst forms of nonHodgkin's lymphoma, a clinically aggressive disease with little hope of a cure.

ACKNOWLEDGEMENT

disease. Berlin: Springer-Verlag, 1978: 284-302. 7. Tolksdorf G, Stein H, Lennert K. Morphological and immunological definition of a malignant lymphoma derived from germinal-center cells with cleaved nuclei (centrocytes). BrJ Cancer 1980; 41:168-82. 8. Weisenburger DD, Kim H, Rappaport H. Mantle-zone lymphoma. A follicular variant of intermediate lymphocytic lymphoma. Cancer 1982; 49:1429-38. 9. Palutke M, Eisenberg L, Mirchandani I, Tabaczka P, Husain M. Malignant lymphoma of small cleaved lymphocytes of the follicular mantle zone. Blood 1982; 59: 317-22. 10. Weisenburger DD, Nathwani BN, Diamond LW, Winberg CD, Rappaport H. Malignant lymphoma, intermediate lymphocytic type. A clinicopathologic study of 42 cases. Cancer 1981; 48:1415-25. 11. Banks PM, Chan J, Cleary ML, etal. Mantle cell lymphoma: a proposal for unification of morphologic, immunologic, and molecular data. Am J Surg Pathol 1992; 16: 637-40. 12. Zucca E, Stein H, Coffier B. European Lymphoma Task Force (ELTF). Report of the Workshop on mantle cell lymphoma (MCI). Ann Oncol 1994; 5: 507-11. 13. SwerdlowSH, HabeshawJA, Murray LJ, Dhaliwal HS, Lister TA, Stansfeld AG. Centrocytic lymphoma. A distinct clinicopathologic and immunologic entity. A multiparameter study of 18 cases at diagnosis and relapse. AmJ Pathol 1983; 113:181-97. 14. Weisenburger DD, Duggan MJ, Perry DA, Sanger WG, ArmitageJO. Non-Hodgkin's lymphomas of mantle-zone

This work was supported in part by USPHS CA36727 awarded by the National Cancer Institute, Department of Health and Human Services, and is reproduced in part from a review by the authors (Blood; 87: 4483-94).

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38 Mantle cell lymphoma

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32.

associated with an overall poor prognosis. Blood 1995; 85: 1570-9. Duggan MJ, Weisenburger DD, Ye YL, et al. Mantle zone lymphoma. A dinicopathologic study of 22 cases. Cancer 1990; 66: 522-9. Pombo de Oliveira MS, Jaffe ES, Catovsky D. Leukemic phase of mantle zone (intermediate) lymphoma: its characterization in 11 cases. J Clin Pathol 1989; 42: 962-72. Criel A, Billiet J, Vandenberghe E, et al. Leukemia intermediate lymphocytic lymphomas: analysis of twelve cases diagnosed by morphology. Leuk Lymph 1992; 8: 381-7. O'Brian DS, Kennedy MJ, Daley PA, etal. Multiple lymphomatous polyposis of the gastrointestinal tract. A clinicopathologically distinctive form of non-Hodgkin's lymphoma of B-cell centrocytic type. AmJ Surg Pathol 1989; 13: 691-9. Lavergne A, Brouland J, Launay E, Nemeth J, RuskoneFourmestraux A, Galian A. Multiple lymphomatous polyposis of the gastrointestinal tract. An extensive histopathologic and immunohistochemical study of 12 cases. Cancer 1994; 74: 3042-50. Moynihan MJ, Bast MA, Chan WC, et al. Lymphomatous polyposis: a neoplasm of either follicular mantle or germinal center cell origin. Am J Surg Pathol 1996; 20: 442-52. Zuckerberg LR, MedeirosJL, Ferry JA, Harris NL. Diffuse low-grade B-cell lymphomas. Four clinically distinct subtypes defined by a combination of morphologic and immunophenotypic features. AmJ Clin Pathol 1993; 100: 373-85. Molot RJ, Meeker TC, Wittwar CT, et al. Antigen expression and polymerase chain reaction amplification in mantle cell lymphomas. Blood 1994; 83:1626-31. Ott MM, Ott G, Kuse P, et al. The anaplastic variant of centrocytic lymphoma is marked by frequent rearrangements of the bcl-1 gene and high proliferation indices. Histopathology 1994; 24: 329-34. Czader M, Porwit A, Tahi E, Ost A, Mazur J, Auer G. DMA image cytometry and the expression of proliferative markers (proliferating cell nuclear antigen and Ki-67) in non-Hodgkin's lymphomas. Modern Pathol 1995; 8: 51-8. Weisenburger DD, Sanger WG, Armitage JO, Purtilo DT. Intermediate lymphocytic lymphoma: immunophenotypic and cytogenetic findings. Blood 1987;69:1617-21. Rimokh R, Berger F, Cornillet P, etal. Break in the bcl-1 locus is closely associated with intermediate lymphocytic lymphoma subtype. Genes Chromosomes Cancer 1990; 2: 223-6. Leroux D, Le Marc'hadour F, Gressin R, etal. NonHodgkin's lymphomas with t(11;14)(q13;q32): a subset of mantle zone/intermediate lymphocytic lymphomas. BrJ Haematol 1991; 77: 346-53.

33. Vandeberghe E, de Wolfe-Peeters C, Wlodarska I, et al. Chromosome 11q rearrangements in B non-Hodgkin's lymphoma. BrJ Haematol 1992; 81: 212-17. 34. Komatsu H, lida S, Yamamoto K, et al. A variant chromosome translocation at11q13 identifying PRADI/Cyclin D1 as the bcl-1 gene. Blood 1994; 84: 1226-31. 35. Neilson JR, Cai M, Bienz N, Leyland MJ. Leukemic mantle cell lymphoma with t(11;14) and trisomy 12 showing clinical features of stage AO B cell chronic lymphocytic leukemia. J Clin Pathol Molec Pathol 1995; 48: M165-6. 36. Daniel MT, Tagaud I, Flexor MA, Nogueira ME, Berger R, Jonveaux P. Leukemic non-Hodgkin's lymphomas with hyperdiploid cells and t(11;14)(q13;q32): a subtype of mantle cell lymphoma? BrJ Haematol 1995; 90: 77-84. 37. Chary-Reddy S, Prasad VS, Ahuja YR. Expression of common fragile sites in untreated non-Hodgkin's lymphoma with aphidicolin and folate deficiency. Cancer Lett 1994; 86:111-17. 38. Williams ME, Swerdlow SH, Rosenberg CL, Arnold A. Chromosome 11 translocation breakpoint at the PRADI/Cyclin D1 gene locus in centrocytic lymphoma. Leukemia 1993; 7: 241-5. 39. Rimokh R, Berger F, Delsol G, et al. Rearrangement and overexpression of the bcl-1/PRAD-1 gene in intermediate lymphocytic lymphomas and in t(11 q13)bearing leukemias. Blood 1993; 81: 3063-7. 40. de Boer CJ, Loyson S, Kluin PM, Kluin-Nelemans HC, Schuuring E, van Krieken JHJM. Multiple breakpoints within the Bcl-1 locus in B-cell lymphoma: rearrangements of the cyclin D1 gene. Cancer Res 1993; 53: 4148-52. 41. Hayashi T, Ohno H, Yamabe H, etal. Clinical aspects of B-cell malignancy involving the BCL-1/PRAD1 locus. IntJ Hematol 1995; 59: 281-96. 42. Bosch F, Jares P, Campo E, etal. PRADI/Cyclin D1 gene overexpression in chronic lymphoproliferative disorders: a highly specific marker of mantle cell lymphoma. Blood 1994; 84: 2726-32. 43. Williams ME, Swerdlow SH, Meeker TC. Chromosome t(11;14)(q13;q32) breakpoints in centrocytic lymphoma are highly localized at the bcl-1 major translocation cluster. Leukemia 1993; 7:1437-40. 44. Rimokh R, Berger F, Delsol G, etal. Detection of the chromosomal translocation in t(11;14) by polymerase chain reaction in mantle cell lymphomas. Blood 1994; 83: 1871-5. 45. Luthra R, Hai S, Pugh WC. Polymerase chain reaction detection of the t(11;14) translocation involving the bcl1 major translocation cluster in mantle cell lymphoma. Diagnos Molec Pathol 1995; 4: 4-7. 46. Zucca E, Soldati G, Schlegelberger B, et al. Detection of chromosome 11 alterations in blood and bone marrow by interphase cytogenetics in mantle cell lymphoma. Br yWomwto/1995; 89: 665-8.

References 39 47. Lionel JA, Schuuring E, Kibbelaar RE, et al. Detection of 11q13 rearrangements in hematologic neoplasias by double-color fluorescence in situ hybridization. Blood 1996;87:1512-19. 48. Rosenberg CL, Wong E, Petty Em, et al. PRAD1, a candidate BCL1 oncogene: mapping and expression in centrocytic lymphoma. Proc NatAcadSci USA 1991; 88: 9636-42. 49. Withers DA, Harvey RC, Faust JB, Melnyk 0, Carey K, Meeker TC. Characterization of a candidate bcl-1 gene. Molec Cell Biol 1991; 11: 4846-53. 50. Motokura T, Bloom T, Kim HG, et al. A novel cyclin encoded by a bcl 1-linked candidate oncogene. Nature 1991;350:512-15. 51. Oka K, Ohno T, Kita K, et al. PRAD1 gene overexpression in mantle-cell lymphoma but not in other low-grade Bcell lymphomas, including extranodal lymphoma. BrJ Haematol 1994; 86: 786-91. 52. de Boer CJ, van Krieken JHJM, Kluin-Nelemans HC, Kluin PM, Schuuring E. (1995). Cyclin D1 messenger RNA overexpression as a marker for mantle cell lymphoma. Oncogene 1995; 10:1833-40. 53. Rimokh R, Berger F, Bastard C, et al. Rearrangement of CCND1 (BCL1/PRAD1) 3' untranslated region in mantlecell lymphomas and thet(11q13)-associated leukemias. Blood 1994; 10: 3689-96. 54. Yang Wl, Zukerberg LR, Motokura T, Arnold A, Harris NL. Cyclin D1 (bcl-1, PRAD1) protein expression in low-grade B-cell lymphomas and reactive hyperplasia. AmJ Pathol 1994:145:86-96. 55. Zuckerberg LR, Yang Wl, Arnold A, Harris NL Cyclin D1 expression in non-Hodgkin's lymphomas. Detection by immunohistochemistry. AmJ Clin Pathol 1995; 103: 756-60. 56. Swerdlow SH, Yang Wl, Zuckerberg LR, Harris NL, Arnold A, Williams ME. Expression of cyclin D1 protein in centrocytic/mantle cell lymphomas with and without rearrangement of the BCL1/cyclin D1 gene. Human Pathol 1995; 26: 999-1004. 57. Nakamura S, Seto M, Banno S, et al. Immunohistochemical analysis of cyclin D1 protein in hematopoietic neoplasms with special reference to mantle cell lymphomas. Japj Cancer Res 1994; 85: 1270-9. 58. Kuroda H, Komatsu H, Nakamura S, etal. The positive nuclear staining observed with monoclonal antibody against PRADI/cyclin D1 correlates with mRNA expression in mantle cell lymphoma. Jap J Cancer Res 1995:86:890-8. 59. de Boer CJ, Schuuring E, Dreef E, etal. Cyclin D1 protein analysis in the diagnosis of mantle cell lymphoma. Blood 1995; 86: 2715-23. 60. Delmer A, Ajchenbaum-Cymbalista F, Tang R, et al. Over-expression of cyclin D1 in chronic B-cell malignancies with abnormality of chromosome 11q13. BrJ Haematol 1995; 89: 798-804. 61. Williams ME, Nichols GE, Swerdlow SH, Stoler MH. In

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situ hybridization detection of cyclin D1 mRNA in centrocytic/mantle cell lymphoma. Ann Oncol 1995; 6: 297-9. Hunter T, Pines J. Cyclins and cancer II: cyclin D and CDK inhibitors come of age. Cell 1994; 79: 573-82. Lukas J, Jadayel D, Bartikova J, et al. BCL-1/cyclin D1 oncoprotein oscillates and subverts the G1 phase control in B-cell neoplasms carrying the t(11;14) translocation. Oncogene 1994; 9: 2159-67. Arnold A. The cyclin D1/PRAD1 oncogene in human neoplasia.y Invest Med 1995; 43: 543-9. Daudy SF, Hinds PW, Louie K, Reed SI, Arnold A, Weinberg RA. Physical interactions of the retinoblastoma protein with human D cyclins. Cell 1993;73:499-511. Louie DC, Offit K, Jaslow R, et al. p53 overexpression as a marker of poor prognosis in mantle cell lymphomas with the t(11;14)(q13;q32). Blood 1995; 86: 2892-9. GreinerTC, Moynihan MJ, Chan WC, etal. p53 mutations in mantle cell lymphoma are associated with variant cytology and predict a poor prognosis. Blood 1966; 87: 4302-10. Hirama T, Koeffler HP. Role of cyclin-dependent kinase inhibitors in the development of cancer. Blood 1995; 86: 841-54. Lane DP. p53, guardian of the genome. Nature 1992; 358:15-16. Jiang W, Kahn SM, Zhou P, et al. Overexpression of cyclin-D1 in rat fibroblasts cause abnormalities in growth control, cell cycle progression and gene expression. Oncogene 1993; 8: 3447-57. Hinds PW, Daudy SF, Eaton EN, Arnold A, Weinberg RA. Function of a human cyclin gene as an oncogene. Proc NatAcadSci USA 1994; 91: 709-13. Lovec H, Sewing A, Lucibello FC, Miiller R, Mbrby T. Oncogenic activity of cyclin D1 revealed through cooperation with Ha-ras: link between cell cycle control and malignant transformation. Oncogene 1994; 9: 323-6. Bodrug SE, Warner BJ, Bath ML, Lindeman GJ, Harris AW, Adams JM. Cyclin D1 transgene impedes lymphocyte maturation and collaborates in lymphomagenesis with the myc gene. EMBOJ 1994; 13: 2124-30. Lovec H, Grzeschiezek A, Kowalski MB, Mbrb'y T. Cyclin D1/bcl-1 cooperates with myc genes in the generation of B-cell lymphoma in transgenic mice. EMBOJ 1994; 13: 3487-95. Lammie GA, Smith R, Silver J, Brookes S, Dickson C, Peters G. Proviral insertions near cyclin D1 in mouse lymphomas: a parallel for BCL1 translocations in human B-cell neoplasms. Oncogene 1992; 7: 2381-7. Hanna Z, Jankowski M, Tremblay P, et al. The vin-1 gene, identified by proviral insertional mutagenesis, is the cyclin D2. Oncogene 1993; 8:1661-6. Wang TC, Cardiff RD, Zukerberg L, Lees E, Arnold A, Schmidt EV. Mammary hyperplasia and carcinoma in MMTV-cyclin D1 transgenic mice. Nature 1994; 369: 669-71.

40 Mantle cell lymphoma 78. Afar DEH, Mclaughlin J, Sherr CJ, Witte ON, Roussel MF. Signaling by ABL oncogenes through cyclin D1. Proc Nat Acad Sci USA 1995; 92: 9540-4. 79. Weisenburger DD, Harrington DS, Armitage JO. B-cell neoplasia. A conceptual understanding based on the normal humoral immune response. In: Rosen PP, Fechner RE, eds Pathology annual. East Norwalk, CT: Appleton and Lange, 1990: 99-115. 80. Bofill M, Janossy G, Janossa M, et al. Human B cell development: II. Subpopulations in the human fetus. J Immunol 1985; 134:1531-8. 81. Antin JH, Emerson SG, Martin P, Gadol N, Ault KA. Leu-1+ (CD5+) B cells. A major lymphoid subpopulation in human fetal spleen: phenotypic and functional studies.) Immunol 1986; 136: 505-10. 82. Asano S, Akaike Y, Muramatsu T, Mochizuki M, Tsuda T, Wakesa H. Immunohistologic detection of the primary follicle (PF) in human fetal and newborn lymph node anlages. Pathol Res Practice 1993; 189: 921-7. 83. Rabian-Herzog C, Lesage S, Gluckman E. Characterization of lymphocyte subpopulations in cord blood. Bone Marrow Transplant 1992; 9 (suppl 1): 64-7. 84. Durandy A, Thuillier L, Forvielle M, Fischer A. Phenotypic and functional characteristics of human newborns' B lymphocytes. J Immunol 1990; 144: 60-5. 85. Hamburg A, Brynes RK, Reese C, Golomb HM. Human cord blood lymphocytes. Ultrastructural and immunologic surface marker characteristics; a comparison with B- and T-cell lymphomas. Lab Invest 1976; 34: 207-15. 86. Gobbi M, Caligaris-Cappio F, Janossy G. Normal equivalent cells of B cell malignancies: analysis with monoclonal antibodies. BrJHaematolWSl; 54: 393-403. 87. Gadol N, Ault KA. Phenotypic and functional characterization of Leu-1 (CDS) B cells. Immunol Rev 1986; 93: 23-34. 88. Freedman AS, Boyd AW, Bieber FR, et al. Normal cellular counterparts of B cell chronic lymphocytic leukemia. fi/oorf1987;70:418-27. 89. Abe M, Tominga K, Wakesa H. Phenotypic characterization of human B-lymphocyte subpopulations, particularly human CD5+ Blymphocyte subpopulation within the mantle zones of secondary follicles. Leukemia 1994; 8:1039-44. 90. Kiippers R, Zhoa M, Hansmann ML, Rajewsky K. Tracing B cell development in human germinal centers by molecular analysis of single cells picked from histological sections. EMBOJ 1993; 12: 4955-67. 91. Hummel M, Tamaru J, Kalvelage B, Stein H. Mantle cell (previously centrocytic) lymphomas express VH gendes with no or very little somatic mutations like the physiologic cells of the follicle mantle. Blood 1994; 84: 403-7. 92. Caligaris-Cappio F, Riva M, Tesio L, Schena M, Gaidano GL, Bergui L. Human normal CD5+ B lymphocytes can be induced to differentiate to CDS- B lymphocytes with germinal center features. Blood 1989; 73:1259-63.

93. Holder MJ, Abbot SD, Milner AE, et al. II-2 expands and maintains IgM plasmablasts from a CD5+ subset contained within the germinal centre cell-enriched (surface lgD-/CD39- buoyant) fraction of human tonsil. //7t/mmwA70/1993; 5:1059-66. 94. van den Oord JJ, de Wolf-Peeters C, Desmet VJ. The marginal zone in the human reactive lymph node. AmJ Clin Pathol 1986; 86: 475-9. 95. van Krieken JHJM, von Schilling C, Kluin PM, Lennert K. Splenic marginal zone lymphocytes and related cells in the lymph node. A morphologic and immunohistochemical study. Human Pathol 1989; 20: 320-5. 96. van den Oord JJ, de Wolf-Peeters C, Pulford KAP, Mason DY, Desmet VJ. Mantle-zone lymphoma. Immuno-and enzyme-histochemical studies on the cell of origin. AmJ Surg Pathol 1986; 10: 780-8. 97. Takeshita M, Masuda Y, Sumiyoshi Y, et al. Clinicopathologic, enzyme and histochemical studies of centrocytic (mantle cell) lymphoma: comparison with other types of low grade lymphoma based on the updated Kiel Classification. Acta Pathol Jap 1993; 43: 244-52. 98. Harris NL, Bahn AK. Mantle-zone lymphoma. A pattern produced by lymphomas of more than one cell type. AmJ Surg Pathol 1985; 9: 872-82. 99. Weisenburger DD, Linder J, Daley DT, Armitage JO. Intermediate lymphocytic lymphoma. An immunohistologic study with comparison to other lymphocytic lymphomas. Human Pathol 1987; 18: 781-90. 100. Ellison DJ, Nathwani BN, Cho SY, Martin SE. Interfollicular small lymphocytic lymphomas. The diagnostic significance of pseudofollicles. Human P0tf?o/1989;20:1108-18. 101. Perry DA, Bast MA, Armitage JO, Weisenburger DD. Diffuse intermediate lymphocytic lymphoma. A Clinicopathologic study with comparison to small lymphocytic lymphoma and diffuse small cleaved cell lymphoma. Cancer 1990; 66:1995-2000. 102. Fraga M, Leoret E, Sanchez-Verde L, et al. Mucosal mantle cell (centrocytic) lymphomas. Histopathology 1995;26:413-22. 103. Pileri S, Rivano MT, Gobbi M, Taruseio D, Lennert K. Neoplasticand reactive follicles within B-cell malignant lymphomas. A morphological and immunological study of 30 cases. Hematol Oncol 1985; 3: 243-60. 104. Pittaluga S, Verhoef G, Criel A, et al. 'Small' B-cell nonHodgkin's lymphomas with splenomegaly at presentation are either mantle cell lymphoma or marginal zone cell lymphoma. AmJ Surg Pathol 1996; 20: 211-23. 105. Cheng AL, Su IJ, Tien HF, Wang CC, Chen YC, Wang CH. Characteristic Clinicopathologic features of adult B-cell lymphoblastic lymphoma with special emphasis on differential diagnosis with an atypical form probably of blastic lymphocytic lymphoma of intermediate differentiation origin. Cancer 1994; 73: 706-10.

References 41 106. BrittingerG, Bartels H, Common H, etal. (Kiel Lymphoma Study Group). Clinical and prognostic relevance of the Kiel classification of non-Hodgkin's lymphomas. Results of a prospective multicenter study by the Kiel Lymphoma Study Group. Hematol Oncol 1984; 2: 269-306. 107. Meusers P, Engelhard M, Bartels H, etal. Multicentre randomized therapeutic trial for advanced centrocytic lymphoma. Anthracycline does not improve prognosis. Hematol Oncol 1989; 7: 365-80. 108. Bookman MA, Lardelli P, Jaffe ES, Duffey PL, Longo DL. Lymphocytic lymphoma of intermediate differentiation: morphologic, immunophenotypic, and prognostic factors. J Nat Cancer Inst 1990; 82: 742-8. 109. BergerF, Felman P, Sonet A, et al. Nonfollicular small B-cell lymphomas: a heterogeneous group of patients with distinct clinical features and outcome. Blood 1994; 83: 2829-35. 110. Fisher Rl, DahlbergS, Nathwani BN, Banks PM, Miller TP, Grogan TM. A clinical analysis of two indolent lymphoma entities: mantle cell lymphoma and marginal zone lymphoma (including mucosa-associated lymphoid tissue and monocytoid B cell categories): a Southwest Oncology Group study. Blood 1995; 85:1075-82. 111. Zucca E, Roggero E, Pinotti G, etal. Patterns of survival in mantle cell lymphoma. Ann Oncol 1995; 6: 259-62. 112. Plank L, Lennert K. Centrocytic lymphoma. Am J Surg Pathol 1993; 17: 638-9. 113. Garcia-CondeJ, Cabanillas F. Mantle cell lymphoma: a new lymphoproliferative entity with definite histopathological patterns, clinical characteristics and prognostic factors, and an investigational therapeutic approach. Ann Oncol 1995; 6: 305-6. 114. Teodorovic I, Pittaluga S, Kluin-NelemansJC, etal. Efficacy of four different regimens in 64 mantle-cell lymphoma cases: clinicopathologic comparison with 498 other non-Hodgkin's lymphoma subtypes.) C/m Oncol 1995; 13: 2819-26. 115. Hiddemann W, Unterhalt M, Herrmann R, et al. Mantlecell lymphomas have more widespread disease and a slower response to chemotherapy compared with follicle-center lymphomas: results of a prospective comparative analysis of the German Low-Grade Lymphoma Study Group. 7 Clin Oncol 1998; 16: 1922-30.

116. Haas R, Brittinger G, Meusers P, etal. Myeloablative therapy with blood stem cell transplantation is effective in mantle cell lymphoma. Leukemia 1996; 10: 1975-9. 117. Stewart DA, Vose JM, Weisenburger DD, etal. The role of high-dose therapy and autologous hematopoietic stem cell transplantation for mantle cell lymphoma. Ann Oncol 1995; 6: 263-6. 118. Goldman JM, Schmitz N, Niethammer D, Gratwohl A for the Accreditation Sub-Committee of the European Group for Blood and Marrow Transplantation. Allogeneic and autologous transplantation for haematological diseases, solid tumours and immune disorders: current practice in Europe in 1998. Bone Marrow Transplant 1998; 21:1-7. 119. Coiffier B. Which treatment for mantle-cell lymphoma patients in 1998?y Clin Oncol 1998; 16: 3-5. 120. Freedman AS, Neuberg D, Gribben JG, et al. High-dose chemoradiotherapy and anti-B-cell monoclonal antibody-purged autologous bone marrow transplantation in mantle-cell lymphoma: no evidence for long-term remission.7 Clin Oncol 1998; 16:13-18. 121. Coiffier B, Haioun C, Ketterer N, etal. Rituximab (antiCD20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: a multicenter phase II study. Blood 1998; 92:1927-32. 122. Coffier B, Hiddemann W, Stein H. Mantle cell lymphoma: a therapeutic dilemma. Ann Oncol 1995; 6: 208-10. 123. Ohno T, Oka K, Yamaguchi M, Kita K, Shirakawa S. Frequent expression of shared idiotypes in mantle cell lymphoma and extranodal small lymphocytic/nonmantle cell diffuse small cleaved lymphoma. Leukemia 1995:9:1935-9. 124. Kaminski MS, Zasadny KR, Francis IR, et al. Radioimmunotherapy of B-cell lymphoma with [131I] anti-B1 (anti-CD20) antibody. N EnglJ Med 1993; 329: 459-65. 125. Hartwell LH, Kastan MB. Cell cycle control and cancer. Science 1994; 266:1821-8. 126. Peng B, Mehta NH, Fernandez H, Chan CC, Ravechi E. Growth inhibition of malignant CD5+ B(B1) cells by antisense IL-10 oligonucleotide. Leukemia Res 1995; 19: 159-67.

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5 Diffuse indolent B cell neoplasms KAMACLENNAN

Introduction Small lymphocytic lymphoma/B cell chronic lymphocytic leukemia

43 43

INTRODUCTION Diffuse low-grade B cell neoplasms form a heterogeneous group having in common relatively small cell size and a B cell phenotype. These lymphomas may have a variety of morphological appearances and in many cases may prove difficult to separate on the basis of morphology alone requiring detailed phenotyping for accurate characterization.1 Included within the diffuse indolent B cell lymphomas are a number of well-defined clinicopathological entities as well as a group of tumors that are less clearly defined.

SMALL LYMPHOCYTIC LYMPHOMA/B CELL CHRONIC LYMPHOCYTIC LEUKEMIA The vast majority of patients with lymphadenopathy showing the typical features of small lymphocytic lymphoma will have evidence of peripheral blood involvement by a clonal B cell population. Likewise, many patients who have a lymphocytosis due to B cell chronic lymphocytic leukemia (B-CLL) will show evidence of lymph node involvement demonstrating a morphological pattern identical to small lymphocytic lymphoma. The morphology and phenotype of small lymphocytic lymphoma and B-CLL are identical, and it is now clear that they are one and the same disease process.2 The question whether very rare cases of typical small lymphocytic lymphoma that never develop a leukemic phase exist remains controversial.3 Lymphadenopathy in B-CLL is typically of modest size and does not usually exceed 2 cm. Macroscopically,

Lymphoplasmacytic lymphoma Marginal zone lymphoma References

44 45 46

the lymph nodes have a delicate capsule and their cut surface has a pale white grey coloration and is soft in texture. Histologically, the lymph node architecture is diffusely replaced by small round lymphocytes, which typically have a clumped chromatin pattern and scanty cytoplasm4 (Plate 30). Scattered among these are slightly larger cells with more abundant pale cytoplasm, an open nuclear chromatin and a visible nucleolus; these are prolymphocytes. Occasional large cells with immunoblastic features termed paraimmunoblasts are also present.5 Prolymphocytes and paraimmunoblasts may be aggregated together to form rather ill-defined nodules termed pseudofollicles (Plate 31) and these are important diagnostic features, as they are not seen in other low-grade B cell lymphomas.6 Pseudofollicles occur in approximately 85 per cent of cases of B-CLL.5 Uncommonly, large aggregates of prolymphocytes may extensively infiltrate and replace the nodal architecture, which has been termed the tumor-forming subtype of B-CLL by Lennert;5 a very similar morphologic pattern has been termed the paraimmunoblastic variant of small lymphocytic lymphoma/leukemia by Pugh.7 The prognostic significance of this histologic pattern remains unclear but there is some evidence that these patients may have a worse prognosis.8 In addition, the relationship of this histologic pattern to CLL/prolymphocytic leukemia (PL) has yet to be clarified. A small percentage of cases of B-CLL may show evidence of plasmacytoid differentiation, and contain a number of plasmacytoid lymphocytes and mature plasma cells, which are clonally related to the B-CLL clone. These have previously been separated from B-CLL and termed lymphoplasmacytoid immunocytoma.2'5 However, many now believe when pseudofollicles are present these cases represent examples of B-CLL, which

44 Diffuse indolent B cell neoplasms

have acquired immunoglobulin secretory capacity and behave in an identical fashion to more typical B-CLL.9'10 Bone marrow infiltration is extremely common in BCLL and a variety of histological patterns may be observed in the bone marrow trephine, some of which have prognostic significance. The bone marrow trephine may show interstitial infiltration where B-CLL cells permeate between normal hemopoietic elements and fat cells. There may be nodular infiltration where rounded aggregates of small B cells are seen in the intertrabecular regions. On occasions these may be associated with proliferation centers. There is generally preservation of normal hemopoietic marrow around these nodules. There may be also a mixture of interstitial and nodular infiltration. In cases of heavy bone marrow involvement by BCLL, there may be diffuse effacement of the normal marrow architecture by sheets of small lymphocytes, often with admixed pseudofollicles and replacement of fat cells.11 The pattern of bone marrow infiltration correlates with prognosis with a median survival of 90 months for the nodular pattern, 46 months for the interstitial and 28 months for diffuse marrow replacement.12 B-CLL has a rather unique immunophenotype, which distinguishes it from normal B cells and other indolent B cell lymphomas. There is weak expression of surface immunoglobulin usually of IgM, or IgM and IgG type. There is expression of pan-B cell antigen CD 19 and CD 20. CD 5 and CD 23 are expressed in the majority of cases. FMC 7 is usually not seen.13'14 This phenotype has formed the basis of a scoring system for the diagnosis of B-CLL.13 Some cases of B-CLL will demonstrate atypical morphological features or possess a divergent phenotype with loss of CD 23 or 'bright' expression of Sig and CD 20; expression of atypical markers, such as FMC 7, CD 38 and CD lla may be seen. These cases have been termed 'atypical CLL' and are associated with a more advanced stage and have a more aggressive clinical course. They are also associated with complex cytogenetic abnormalities, such as trisomy 12.15-18 A minority of cases of B-CLL undergo transformation. This may take the form of increased numbers of prolymphocytes in the peripheral blood, termed prolymphocytoid transformation, or CLL/PL, when there are between 10 and 55 per cent of prolymphocytes in the peripheral blood.19 This is associated with a tendency to be refractory to chemotherapy and a poor prognosis. In some patients there is a striking increase in the size of lymphadenopathy, which may achieve diameters of 5 cm or more. This is often associated with development of a diffuse large B cell lymphoma, often showing pleomorphic immunoblastic cytology20 (Plate 32). This has been termed Richter's syndrome. In many cases the large B cell lymphoma is clonally related to the original CLL but in some it appears to be a clonally independent second tumor.21'22 Rare cases of high-grade transformation with lymphoblastic cytology and nuclear terminal

deoxynucleotidyl transferase (tdt) expression have been described. The occurrence of cells with the morphology and phenotype of classical Hodgkin's disease have been described and termed the Hodgkin's variant of Richter's transformation (Plate 33).23-25 These show evidence of the presence of Epstein-Barr virus in some cases.26'27 Microdissection studies of the H-RS cells have shown them to be clonally related to the original B-CLL clone.28 The clinical course of the Hodgkin's disease variant of Richter's syndrome is still not entirely clear as few cases have been reported; some at least seem to follow the clinical pattern of Hodgkin's disease with persistent B-CLL. Rare cases of nodular lymphocyte-predominant Hodgkin's disease have been described in association with B-CLL.29

LYMPHOPLASMACYTIC LYMPHOMA A variety of terms have been used to describe immunosecretory small B cell neoplasms without features of other lymphoma subtypes including small lymphocytic lymphoma plasmacytoid, lymphoplasmacytoid and lymphoplasmacytic immunocytoma, and Waldenstrom's macroglobulinemia. Included under these terms are a heterogeneous group of B cell lymphomas showing variable degrees of plasma cell differentiation. In the Kiel classification three subtypes of immunocytoma have been recognized: lymphoplasmacytoid, lymphoplasmacytic and polymorphic.5 The polymorphic subtype was abandoned to avoid confusion.30 The Kiel definition of immunocytoma assumes that there is no evidence of follicle center cell, mantle cell or marginal zone differentiation, and that the tumor is composed predominantly of small lymphocytes showing variable degrees of plasmacytoid differentiation and, in the lymphoplasmacytic subtype, mature or Marshalko plasma cells. More recently, the International Lymphoma Study Group has redefined immunocytoma and excluded cases that show features of B-CLL, and have restricted the diagnosis of immunocytoma to one of a small B lymphocytic lymphoma showing lymphoplasmacytoid or plasma cell differentiation without features of any other lymphoma subtype.9,10 Lymph nodes affected by lymphoplasmacytic immunocytoma are usually only modestly enlarged. The normal architecture is partially or completely effaced by diffuse proliferation of small lymphoid cells with scattered lymphoplasmacytoid forms and in some cases mature plasma cells (Plate 34). Periodic acid-Schiff (PAS) staining may reveal the presence of positive intranuclear inclusions called Dutcher bodies in up to half the cases. There may be scattered large lymphoid cells with immunoblastic morphology, some showing plasmacytoid features. In some cases these may be

Marginal zone lymphoma 45

numerous and the borderline between diffuse large B cell lymphoma of immunoblastic type and immunocytoma can be difficult to define. In lymph nodes where there is not complete effacement of the architecture, the growth pattern tends to be interfollicular and the peripheral sinuses are often preserved. The mere presence of lymphoplasmacytoid and plasma cells in a B cell neoplasm does not define the tumor as immunocytoma. The plasmacytoid component should show the same light-chain restriction as the small B cell component and there should be no evidence of BCLL, such as proliferation centers and prolymphocytes. The spleen is commonly infiltrated in cases of advanced-stage immunocytoma, where there may be infiltration of both the red and the white pulp, which may cause diagnostic difficulties in the separation of immunocytoma from splenic marginal zone lymphoma. Precise criteria for this distinction are not currently available and the precise inter-relationship of these two entities is still unclear. Bone marrow infiltration is common and may be nodular or interstitial. Immunophenotypically, lymphoplasmacytic immunocytoma differs from B-CLL in lacking CD 5 and CD 23. There is usually strong surface immunoglobulin, usually of the IgM type, which shows the same light-chain restriction as lymphoplasmacytoid cells containing cytoplasmic immunoglobulin (Plate 35). There is expression of the pan-B cell markers CD 19, CD 20, CD 22 and CD 79a, and in cases showing pronounced plasma cell differentiation, CD 79a is the most reliable marker for paraffin-section immunohistochemistry. It is clear from the above descriptions of the morphology and phenotype of lymphoplasmacytic immunocytoma that the diagnosis is to a certain extent one of exclusion of other lymphoma subtypes. In a recent study it has been shown that the interobserver and intraobserver concordance rates for the diagnosis of lymphoplasmacytic immunocytoma are relatively poor compared to other better-defined lymphoma entities. A chromosomal translocation that has been associated with lymphoplasmacytic immunocytoma is the t(9;14)(p!3;q32).This has been shown to deregulate the pax 5 gene, which encodes the B cell specific activator protein.31 There is considerable controversy in the literature as to whether the prognosis of lymphoplasmacytic immunocytoma differs significantly from small lymphocytic lymphoma/B-CLL. Preliminary data from St Bartholomew's Hospital in London would suggest that any degree of plasmacytoid differentiation is associated with an inferior overall and disease-free survival.32

MARGINAL ZONE LYMPHOMA Proliferations of marginal zone B cells have been recognized for many years in reactive lymphadenopathies, in

particular, toxoplasmosis.33'34 Although initially considered to be of monocyte/macrophage origin, their B cell lineage was later clarified.35'36 Malignant lymphomas showing cytological features of monocytoid B cells were later recognized and termed monocytoid B cell lymphoma37-46 or parafollicular B cell lymphoma by some.47 Lymph nodes involved by monocytoid B cell lymphoma show infiltration around and within the nodal sinuses, which extends in to the parenchyma and often surrounds reactive germinal centers (Plate 36). Cytologically there is variability in cell size and a significant degree of nuclear irregularity; there is often relatively abundant clear or grey cytoplasm45 (Plate 37). It became apparent there was a morphologic overlap with extranodal MALT lymphomas (see Chapter 8) and this commonality became more obvious when cases presenting as nodal disease later developed typical extranodal MALT-type disease.45,46 There developed a considerable controversy as to whether nodal monocytoid B cell lymphoma actually existed as an entity or whether it was a manifestation of metastatic MALT lymphoma involving lymph nodes.48 In 1994, the International Lymphoma Study Group published the revised European-American lymphoma classification (REAL),9 which included the term marginal zone B cell lymphoma (MZL). Under this heading were three entities, extranodal MZL of MALT type (see Chapter 8) and two provisional entities of nodal and splenic MZL. Nodal MZLs were regarded as having identical morphology to their extranodal equivalent and it was believed that the majority were disseminated MALT lymphomas with only a small minority being true primary, nodal MZLs.9 Recent work suggests primary nodal MZL does exist and shows significant differences in the distribution of disease, clinical parameters and survival.49 Nodal MZLs present with peripheral and para-aortic lymphadenopathy more commonly than extranodal MZL; they also have a significantly worse overall and failure-free survival.49 Primary splenic lymphomas with involvement of the red and white pulp have been described.50,51 These may show the presence of villous lymphocytes in the peripheral blood.50,52 In the REAL classification these are termed splenic marginal zone lymphoma. Splenic infiltration is characterized by white pulp involvement, which may surround or replace germinal centers. In the red pulp there may be small nodules or diffuse sinusoidal infiltration.52 Cytologically the lymphoma cells may contain small lymphocytes, typically located in the mantle zone or larger 'monocytoid' cells present in the marginal zone. Bone marrow involvement is common and usually nodular. Circulating lymphoma cells are frequently detected in the peripheral blood and may possess thin cytoplasmic projections, termed villous lymphocytes50 (Plate 38). Splenic MZL corresponds closely to the entity termed splenic lymphoma with circulating villous lymphocytes.53,54

46 Diffuse indolent B cell neoplasms

REFERENCES 1. Harris NL Low grade B-cell neoplasms. In: Weiss LM, ed. Pathology of lymph nodes. New York: Churchill Livingstone,1996: 236-74.

18. Matutes E, Oscier D, Garcia-Marco J, et al. Trisomy 12 defines a group of CLL with atypical morphology: correlation between cytogenetic, clinical and laboratory features in 544 patients. BrJ Haematol 1996; 92: 382-8.

2. Jaffe ES, Raffeld M, Medeiros LJ. Histopathologic subtypes of indolent lymphomas: caricatures of the mature B-cell system. Semin Oncol 1993; 20: 3-30.

19. Bennett JM, Catovsky D, Daniel MT, et al. Proposals for the classification of chronic (mature) B and T lymphoid leukaemias. French-American-British (FAB) Cooperative

3. Ben-Ezra JM. Small lymphocytic lymphoma. In: Knowles

Group.7 Clin Pathol 1989; 42: 567-84. 20. Armitage JO, Dick FR, Corder MP. Diffuse histiocytic

DM, ed. Neoplastic hematopathology. Baltimore: Williams &Wilkins, 1992:603-16. 4. Pangalis GA, Nathwani BN, Rappaport H. Malignant lymphoma, well differentiated lymphocytic: its relationship with chronic lymphocytic leukemia and

lymphoma complicating chronic lymphocytic leukemia. Cancer 1978; 41: 422-7. 21. Matolcsy A, Casali P, Knowles DM. Different clonal origin of B-cell populations of chronic lymphocytic leukemia

macroglobulinemia of Waldenstrom. Cancer 1977; 39:

and large-cell lymphoma in Richter's syndrome. Ann NY

999-1010. 5. Lennert K. Malignant lymphomas other than Hodgkin's disease. New York: Springer-Verlag, 1978. 6. Dick FR, Maca RD. The lymph node in chronic

AcadSci 1995; 764: 496-503. 22. Matolcsy A, Inghirami G, Knowles DM. Molecular genetic demonstration of the diverse evolution of Richter's

lymphocytic leukemia. Cancer 1978; 41: 283-92. 7. Pugh WC, Manning JT, Butler JJ. Paraimmunoblastic variant of small lymphocytic lymphoma/leukemia. Am J Surg Pathol 1988; 12: 907-17. 8. Bonato M, Pittaluga S, Tierens A, et al. Lymph node histology in typical and atypical chronic lymphocytic leukemia. Am J Surg Pathol 1998; 22: 49-56. 9. Harris NL, Jaffe ES, Stein H, et al. A revised EuropeanAmerican classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 10. Harris NL. Low grade B-cell neoplasms.ln: Weiss LM, ed. Pathology of lymph nodes. New York: Churchill Livingstone, 1996: 247. 11. Rozman C, Hernandez-Nieto L, Montserrat E, Brugues R. Prognostic significance of bone-marrow patterns in chronic lymphocytic leukaemia. BrJ Haematol 1981; 47: 529-37. 12. Frisch B, Bartl R. Biopsy pathology of bone and bone marrow, 2nd edn. London: Arnold, 1999. 13. Moreau EJ, Matutes E, A'Hern RP, et al. Improvement of the chronic lymphocytic leukemia scoring system with the monoclonal antibody SN8 (CD79b). AmJ Clin Pathol 1997; 108: 378-82. 14. Molica S, Levato D, Dattilo A, Mannella A. Clinicoprognostic relevance of quantitative immunophenotyping in B-cell chronic lymphocytic leukemia with emphasis on the expression of CD20 antigen and surface immunoglobulins. EuroJ Haematol 1998;60:47-52. 15. Mould S, Gardiner A, Corcoran M, Oscier DG. Trisomy 12 and structural abnormalities of 13q14 occurring in the same clone in chronic lymphocytic leukaemia. BrJ Haematol 1996; 92: 389-92. 16. Juliusson G, Merup M. Cytogenetics in chronic lymphocytic leukemia. Semin Oncol 1998; 25:19-26. 17. Oscier DG. Cytogenetic and molecular abnormalities in chronic lymphocytic leukaemia. Blood Rev 1994; 8: 88-97.

syndrome (chronic lymphocytic leukemia and subsequent large cell lymphoma). Blood 1994; 83: 1363-72. 23. Brecher M, Banks PM. Hodgkin's disease variant of Richter's syndrome. Report of eight cases. AmJ Clin Pathol 1990; 93: 333-9. 24. Fayad L, Robertson LE, O'Brien S, et al. Hodgkin's disease variant of Richter's syndrome: experience at a single institution. Leuk Lymphoma 1996; 23: 333-7. 25. Williams J, Schned A, Cotelingam JD, Jaffe ES. Chronic lymphocytic leukemia with coexistent Hodgkin's disease. Implications for the origin of the Reed-Stern berg cell. Am J Surg Pathol 1991; 15: 33-42. 26. Momose H, Jaffe ES, Shin SS, Chen YY, Weiss LM. Chronic lymphocytic leukemia/small lymphocytic lymphoma with Reed-Sternberg-like cells and possible transformation to Hodgkin's disease. Mediation by Epstein-Barr virus. AmJ Surg Pathol 1992; 16: 859-67. 27. Rubin D, Hudnall SD, Aisenberg A, Jacobson JO, Harris NL. Richter's transformation of chronic lymphocytic leukemia with Hodgkin's-like cells is associated with Epstein-Barr virus infection. Mod Pathol 1994; 7: 91-8. 28. Ohno T, Smir BN, Weisenburger DD, Gascoyne RD, Hinrichs SD, Chan WC. Origin of the Hodgkin/Reed-Sternberg cells in chronic lymphocytic leukemia with 'Hodgkin's transformation'. Blood 1998; 91:1757-61. 29. Weisenberg E, Anastasi J, Adeyanju M, Variakojis D, Vardiman JW. Hodgkin's disease associated with chronic lymphocytic leukemia. Eight additional cases, including two of the nodular lymphocyte predominant type. AmJ Clin Pathol 1995; 103: 479-84. 30. Lennert K, Feller AC. Histopathology of non-Hodgkin's lymphomas (based on the updated Kiel classification). Berlin: Springer-Verlag, 1990. 31. Amakawa R, Ohno H, Fukuhara, S. t(9;14)(p13;q32) involving the PAX-5 gene: a unique subtype of 14q32 translocation in B cell non-Hodgkin's lymphoma. IntJ Hematol 1999; 69: 65-9.

References 47 32. Rohatiner A, personal communication, 1998. 33. Stansfeld AG. The histologic diagnosis of toxoplasmic lymphadenitis.) Clin Pathol 1961; 14: 565-73. 34. Dorfman RF, Remmington JS. Value of lymph node biopsy in the diagnosis of acute acquired toxoplasmosis. N EnglJ Med 1973; 289: 878-81. 35. Cardoso DA, Harris NL, Bhan AK. Characterization of immature sinus histiocytes (monocytoid cells) in reactive lymph nodes by use of monoclonal antibodies. Human Pathol 1984; 15: 330-5. 36. Kojima M, Nakamura S, Itoh H, et al. Occurrence of monocytoid B-cells in reactive lymph node lesions. Pathol Res Pract 1998; 194: 559-65. 37. Nathwani BN, Mohrmann RL, Brynes RK, Taylor CR, Hansmann ML, Sheibani K. Monocytoid B-cell lymphomas: an assessment of diagnostic criteria and a perspective on histogenesis. Human Pathol 1992; 23: 1061-71. 38. Sheibani K, Burke JS, Swartz WG, Nademanee A, Winberg CD. Monocytoid B-cell lymphoma. Clinicopathologic study of 21 cases of a unique type of low-grade lymphoma. Cancer 1988; 62:1531-8. 39. Sheibani K, Sohn CC, Burke JS, Winberg CD, Wu AM, Rappaport H. Monocytoid B-cell lymphoma. A novel Bcell neoplasm. Amj Pathol 1986; 124: 310-18. 40. Arber DA, Sheibani K, Weiss LM. UCL3D3 and UCL4D12 reactivity in small B-cell neoplasms with special emphasis on monocytoid B-cell lymphoma. Human Pathol 1994; 25:1084-90. 41. Shin SS, Sheibani K. Monocytoid B-cell lymphoma. Am J C//>7P0tfjo/1993;99:421-5. 42. TraweekST, Sheibani K. Monocytoid B-cell lymphoma. The biologic and clinical implications of peripheral blood involvement. Am J Clin Pathol 1992; 97: 591-8. 43. Traweek ST, Sheibani K, Winberg CD, Mena RR, Wu AM, Rappaport H. Monocytoid B-cell lymphoma: its evolution and relationship to other low-grade B-cell neoplasms. Blood 1989; 73: 573-8.

44. Plank L, Hansmann ML, Fischer R. The cytological spectrum of the monocytoid B-cell reaction: recognition of its large cell type. Histopathology 1993; 23: 425-31. 45. Cogliatti SB, Lennert K, Hansmann ML, Zwingers TL. Monocytoid B cell lymphoma: clinical and prognostic features of 21 patients. J Clin Pathol 1990; 43: 619-25. 46. Nizze H, Cogliatti SB, von Schilling C, Feller AC, Lennert K. Monocytoid B-cell lymphoma: morphological variants and relationship to low-grade B-cell lymphoma of the mucosa-associated lymphoid tissue. Histopathology 1991; 18: 403-14. 47. Davis GG, York JC, Glick AD, McCurley TL, Collins RD, CousarJB. Plasmacytic differentiation in parafollicular (monocytoid) B-cell lymphoma. A study of 12 cases. Amj Surg Pathol 1992; 16:1066-74. 48. Campo E, Miquel R, Krenacs L, Sorbara L, Raffeld M, Jaffe ES. Primary nodal marginal zone lymphomas of splenic and MALT type. Amj Surg Pathol 1999; 23: 59-68. 49. Nathwani BN, Anderson JR, Armitage JO, et al. Marginal zone B-cell lymphoma: a clinical comparison of nodal and mucosa-associated lymphoid tissue types. 7 Clin Oncol 1999; 17: 2486-92. 50. Neiman RS, Sullivan AL, Jaffe R. Malignant lymphoma simulating leukemic reticuloendotheliosis: a clinicopathologic study of ten cases. Cancer 1979; 43: 329-42. 51. Schmid C, Kirkham N, DissT, Isaacson PG. Splenic marginal zone cell lymphoma./4/r?7 Surg Pathol 1992; 16: 455-66. 52. Isaacson PG, Matutes E, Burke M, Catovsky D. The histopathology of splenic lymphoma with villous lymphocytes. Blood 1994; 84: 3828-34. 53. Mulligan SP, Matutes E, Dearden C, Catovsky D. Splenic lymphoma with villous lymphocytes: natural history and response to therapy in 50 cases. BrJ Haematol 1991; 78: 206-9. 54. Mulligan SP, Catovsky D. The chronic B-cell leukaemias. Austral N ZealJ Med 1993; 23: 42-50.

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6 Diffuse aggressive B cell lymphoma KAMACLENNAN

Burkitt's lymphoma High-grade B cell lymphoma Burkitt-like

49 49

BURKITTS LYMPHOMA Burkitt's l y m p h o a was first recognized as an endemic malignancy of childhood in equatorial Africa where it comprised 50 per cent of childhood cancer.1'5 The association between Epstein-Barr virus (EBV) and Burkitt's lymphoma was established, and it has been shown that all the cells of the malignant clone in endemic Burkitt's lymphoma show evidence of EBV infection.6-10 Later the characteristic chromosomal translocation t(8;14)(q24;q32) and the variant translocations involving chromosome 2pl 1 and 22ql 1, at the loci of the K and l immunoglobulin light-chain genes were described. These translocations deregulate the c-myc gene and are present in all cases of Burkitt's lymphoma whether endemic or non-endemic.11-23 There are marked differences in the clinical presentation between endemic and non-endemic Burkitt's lymphoma. Endemic Burkitt's lymphoma shows a high frequency of involvement of the jaw, which is more common in younger patients (70 per cent in children under 5 reducing to 25 per cent in patients over 14) and is centred around the developing dental lamina. Abdominal disease is frequently encountered in endemic Burkitt's lymphoma, being present in over half the patients at presentation. The pattern of disease within the abdomen differs from non-endemic Burkitt's (see below) with a relatively high frequency of mesenteric involvement and ascites. While localized ileocecal disease is uncommon,24 sporadic Burkitt's frequently presents with disease centred around the terminal ileum and cecum. It may present with bulky disease at this site or relatively small volume disease, which comes to clinical attention because it forms the apex of an intussusception. There is also a high frequency of involvement of peripheral lymph nodes, tonsils and oropharynx and pleura.

Diffuse large B cell lymphoma References

50 51

Burkitt's lymphoma, whether endemic or sporadic shows an identical histological picture. The tumor adopts a diffuse growth pattern with a starry sky appearance caused by actively phagocytic macrophages engulfing apoptotic debris. The tumor cells are monomorphous medium-sized lymphoid cells arranged in cohesive sheets (Plate 39). They have an open nuclear chromatin with multiple small nucleoli and a thin rim of basophilic cytoplasm that is best appreciated in Giemsa-stained preparations.25-28 The proliferation rate is high29 and numerous cells are seen to undergo apoptosis. The histological appearances of Burkitt's lymphoma are critically dependent on good fixation and the diagnosis maybe problematic in poorly fixed material. Imprint cytology is often extremely helpful in establishing the diagnosis where the typical L3 cytology with basophilic, vacuolated cytoplasm is apparent. Burkitt's lymphoma displays a mature B cell phenotype expressing CD 19, CD 20 and CD 79a. CD 5 and CD 23 are absent and CD 10 is almost invariably present (Plate 40). There is expression of strong monoclonal surface immunoglobulin, usually of IgM type. Almost 100 per cent of the cells are labeled with the proliferationassociated antigen Ki 67 (Plate 41).

HIGH-GRADE B CELL LYMPHOMA BURKITT-LIKE High-grade B cell lymphoma Burkitt-like is included as a provisional entity in the Revised European-American Lymphoma (REAL) classification to denote cases that are borderline in their morphology between true Burkitt's and large B cell lymphoma.30 Some of these cases correspond to the entity of Burkitt's lymphoma

50 Diffuse aggressive B cell lymphoma

with cytoplasmic immunoglobulin or the plasmablastic subtype of Burkitt's lymphoma described by the Kiel group.28 Morphologically, there is considerably more pleomorphism in high-grade B cell lymphoma Burkittlike than in true Burkitt's, with the presence of some large pleomorphic cells, medium-sized cells with more abundant cytoplasm than true Burkitt's and scattered small B cells. Phenotypically, there is expression of panB cell antigen CD 19 and CD 20, but CD 10, which is almost invariably present in true Burkitt's lymphoma, is absent from a significant percentage of cases of highgrade B cell lymphoma Burkitt-like. Recent data from the lymphoma classification project show that the diagnostic reproducibility of a diagnosis of high-grade B cell lymphoma Burkitt-like is poor. The clinical presentation and prognosis are identical to diffuse large B cell lymphoma. It would thus appear that there is little value in the separate recognition of this intermediate group between true Burkitt's lymphoma and diffuse large B cell lymphoma, and these cases should be classified as diffuse large B cell lymphoma.31

DIFFUSE LARGE B CELL LYMPHOMA

Introduction Large cell lymphomas were initially regarded as arising from a variety of cell lineages, including reticulum cells and histiocytes, before immunologic techniques clearly defined them as being of lymphoid origin.32"41 The majority of diffuse large cell lymphomas (90 per cent) are of B cell lineage and make up between 30 and 40 per cent of all non-Hodgkin's lymphomas (NHLs).31 Up to 40 per cent of cases present with extranodal disease, and there is an approximately equal division between localized and advanced stage disease. Diffuse large B cell lymphoma may be primary or secondary to a pre-existing or synchronous low-grade B cell NHL, usually follicular lymphoma. A small percentage of diffuse large B cell lymphomas arise in the setting of lymphocyte-predominant nodular Hodgkin's disease, which usually has undergone multiple relapses over a long period of time.

Morphology Diffuse large B cell lymphomas are composed of large lymphoid cells whose nuclei are approximately twice the size of a small lymphocyte. There is an open nuclear chromatin with often multiple punctate nucleoli (Plate 42). The cytoplasm is basophilic and may be scanty or abundant with evidence of plasmacytoid differentiation. This diversity of morphology has been used as the basis for subdivision of large cell NHL of B cell lineage into numerous subtypes.28,42-48 Centroblastic lymphoma,

immunoblastic lymphoma, large cell, sclerosing B cell lymphoma of the mediastinum and large cell anaplastic lymphoma of B cell lineage are all separately designated in the updated Kiel classification and subsequent publications.49'50 Centroblastic lymphoma has been subdivided into four cytologic groups in the Kiel classification. These are: monomorphic, where the cellular composition consists of over 60 per cent of typical centroblasts, which are medium sized to large cells with round or oval pale nuclei, multiple peripheral nucleoli and a thin rim of basophilic cytoplasm. The polymorphic subtype is characterized by an admixture of centroblasts and immunoblasts, the latter comprising more than 10 per cent of the cellular population. The multilobated variant is diagnosed when more than 10 per cent of the tumor cells show three or four nuclear lobulations. Centrocytoid Centroblastic lymphoma is characterized by intermediate cytology between large centrocytes and centroblasts.28 The latter subtype is felt by many to include many cases of blastically transformed mantle cell lymphoma. Using the Kiel criteria, B immunoblastic lymphoma is defined as a monomorphic tumor composed of sheets of immunoblasts that comprise more than 90 per cent of the cellular population. Immunoblasts are characterized by large oval nuclei with clear nucleoplasm and a single large central nucleolus or multiple central nucleoli (Plate 43). They may show pronounced plasmacytic differentiation.28 A small study by the International Lymphoma Study Group, included in the publication of the REAL classification showed that subdivision of large B cell lymphoma was poorly reproducible, even by experienced hematopathologists. The REAL classification amalgamated these entities and termed them diffuse large B cell lymphoma, and included primary mediastinal (thymic) large B cell lymphoma as a subtype.

Phenotype Diffuse large B cell lymphomas express pan-B cell antigens CD 19, CD 20, CD 22 and CD 79a. In conventionally fixed and processed sections, over 80 per cent of diffuse large B cell lymphomas express CD 20 (Plate 44). Cases that are CD 20 negative often show immunoblastic cytology; the majority of these are CD 79a positive. The germinal centre-associated marker, CD 10, is seen in a significant percentage of diffuse large B cell lymphomas. CD 5 is present in around 10 per cent of cases and may be associated with immunoblastic morphology. Expression of BCL 2 protein has been shown to be an independent prognostic marker in diffuse large B cell lymphoma and is seen in approximately 50 per cent (Plate 45). Overexpression is associated with a significantly reduced relapse-free and cause-specific survival.28,51-54

References 51

Rare subtypes of diffuse large B cell lymphoma A distinctive type of large B cell lymphoma has been described, which arises in the mediastinum, probably from a population of thymic B cells.55'56 This tumor affects a younger age group than typical large B cell lymphomas, with a median age ranging from 25 to 32 years. There is a female predominance with a male to female ratio of 1:2. Most patients present with localized disease (Ann Arbor stage I and II). However, there is often extension into adjacent structures such as lung, pericardium and anterior chest wall.57 Histologically, mediastinal large B cell lymphoma shows distinctive features: it is characterized by compartmentalizing fine fibrosis, which separates lobules of large lymphoid cells with clear cytoplasm (Plate 46). There are a wide variety of different nuclear cytological features that range from irregular nuclei resembling large centrocytes to a typical centroblastic morphology and some cases show immunoblastic nuclear features. Immunophenotypically, mediastinal large B cell lymphomas express pan-B cell antigen CD 19 and CD 20 and, in common with normal thymic B cells, are usually CD 21 negative. It is rarely possible to demonstrate the presence of monoclonal immunoglobulin in these tumors. Genotypically, mediastinal large B cell lymphomas show rearrangement of both heavy- and light-chain immunoglobulin genes. There are point mutations or translocations involving the c-myc oncogene.58 The bd 2 gene is in germline configuration.59 Large cell anaplastic lymphoma (LCAL) of B cell lineage shows similar morphologic features to anaplastic large cell lymphoma (ALCL) of T/null type. Phenotypically LCAL shows weaker expression of CD 30, which, rather than having a characteristic distinct membrane and Golgi distribution, shows a diffuse cytoplasmic staining. Recently, an unusual subtype of large B cell lymphoma has been described which shows immunoblastic cytology, lacks B lineage markers and contains monoclonal cytoplasmic IgA. Epithelial membrane antigen is expressed in all described cases but there is no reactivity with CD 30. This lymphoma is unusual as it expresses the full-length form of the anaplastic lymphoma kinase, which is only detected as a truncated fusion protein in malignant lymphomas in association with t(2;5) in ALCL of T/null type; this translocation has not been identified in this type of large B cell lymphoma. Rare cases of diffuse large B cell lymphoma demonstrate a small number of neoplastic large B cells, comprising 5-10 per cent of the total cellular population, in a numerically predominant background of non-neoplastic small T cells or histiocytes. These cases have been termed pseudo-T cell lymphoma and T cell-rich B cell lymphoma (Plate 47). Morphologically T cell-rich B cell lymphoma shows a diffuse growth pattern composed of

sheets of small lymphocytes sometimes admixed with epithelioid histiocytes. The large neoplastic B cells may be inconspicuous and only become apparent on immunostaining with B cell markers. Small B cells are notable by their absence. The morphology of the large B cell component is variable and they may show immunoblastic, centroblastic or pleomorphic cytology. A common cytologic subtype shows marked similarities with the popcorn or lymphocytic and/or histiocytic cell of lymphocyte-predominant Hodgkin's disease, which causes difficulties in the differential diagnosis of diffuse lymphocytic predominance. The clinical behavior of T cell-rich B cell lymphoma does not appear to differ from other diffuse large B cell lymphomas in terms of the complete response rate, overall and relapse-free survival. Some workers have demonstrated an unusually high rate of bone marrow disease, which is in excess of 50 per cent.60 Intravascular large cell lymphoma is a rare but distinctive form of high-grade lymphoma characterized by the accumulation of large lymphoid cells within vascular lumina. These may lie free within the vascular space or may be enmeshed within fibrin (Plate 48). Rarely, lymphoma cells may spread into adjacent lymph node or extranodal structures. Most cases exhibit a B cell phenotype,61"67 but rare T lineage cases have been described.68,69 The clinical manifestations of intravascular large cell lymphoma are variable, but central nervous system and cutaneous disease are extremely common.63,70 Other extranodal sites, such as lung, kidney and gastrointestinal tract, maybe involved.61,71-73 Primary effusion lymphoma (PEL), originally termed body cavity-based lymphoma, is a rare form of large cell lymphoma that is characterized by the development of lymphomatous effusions in the pleural and abdominal cavity in the absence of solid tumor masses. Initially reported cases were all associated with human immunodeficiency virus (HIV) infection, EBV and a newly described human herpes virus type 8 (HHV-8).74"80 Recently two distinctive forms of PEL have been described in those that are HIV and EBV positive; the majority of these are associated with HHV-8 and show a germline configuration of c-myc. These cases show immunoblastic or anaplastic cytology. The remaining cases are not associated with HHV-8 and show rearrangements of c-myc. These show Burkitt's or Burkitt-like morphology.81 Most cases lack B cell marker expression and show evidence of clonal immunoglobulin gene rearrangement indicating their B cell lineage. Structural analysis of the IgH genes suggest that PELs may arise from different stages of B cell development.82

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52 Diffuse aggressive B cell lymphoma 2. Burkitt D, Wright D. Geographical and tribal distribution of the African lymphoma in Uganda. Br MedJ 1966; 1: 569-73. 3. Wright DH. The epidemiology of Burkitt's tumor. Cancer Res 1967; 27: 2424-38. 4. Burkitt D. Burkitt's lymphoma. JAMA 1972; 222:1164. 5. Burkitt DP. Classics in oncology. A sarcoma involving the jaws in African children. CA Cancer] Clin 1972; 22: 345-55. 6. Niedobitek G, Agathanggelou A, Rowe M, et al. Heterogeneous expression of Epstein-Barr virus latent proteins in endemic Burkitt's lymphoma. Blood 1995; 86: 659-65. 7. Geser A, Lenoir GM, Anvret M, et al. Epstein-Barr virus markers in a series of Burkitt's lymphomas from the West Nile District, Uganda. EurJ Cancer Clin Oncol 1983; 19: 1393^04. 8. Purtilo DT, Manolov G, Manolova Y, Harada S, Lipscomb H, Tatsumi E. Role of Epstein-Barr virus in the etiology of Burkitt's lymphoma. lARCSci Publ 1985; 231-47. 9. Rowe M, Rowe DT, Gregory CD, et al. Differences in B cell growth phenotype reflect novel patterns of Epstein-Barr virus latent gene expression in Burkitt's lymphoma cells. EM BO J 1987; 6: 2743-51. 10. Tao Q, Robertson KD, Manns A, Hildesheim A, Ambinder RF. Epstein-Barr virus (EBV) in endemic Burkitt's lymphoma: molecular analysis of primary tumor tissue. Blood 1998; 91:1373-81. 11. Siebert R, Matthiesen P, Harder S, et al. Application of interphase fluorescence in situ hybridization for the detection of the Burkitt translocation t(8;14)(q24;q32) in B-cell lymphomas. Blood 1998; 91: 984-90. 12. Niwano H, Aoki S, Tsukada N, et al. An aggressive case of Burkitt's lymphoma with t(8;14) and c-myc rearrangement transformed from CD5+ B-cell lymphoma. Ann Hematol 1997; 75: 221-5. 13. Berger R, Bernheim A. Cytogenetics of Burkitt's lymphoma-leukaemia: a review. lARCSci Publ 1985; 65-80. 14. Berger R, Bernheim A. Cytogenetic studies on Burkitt's lymphoma-leukemia. Cancer Genet Cytogenet 1982; 7: 231^4. 15. Whang-Peng J, Lee EC, Sieverts H, Magrath IT. Burkitt's lymphoma in AIDS: cytogenetic study. Blood 1984; 63: 818-22. 16. Lenoir GM, Land H, Parada LF, Cunningham JM, Weinberg RA. Activated oncogenes in Burkitt's lymphoma. Curr Top Microbiol Immunol 1984; 113: 6-14. 17. Douglass EC, Magrath IT, Lee EC, Whang-Peng J. Cytogenetic studies in non-African Burkitt lymphoma. Blood 1980; 55:148-55. 18. Taub R, Kirsch I, Morton C, et al. Translocation of the cmyc gene into the immunoglobulin heavy chain locus in human Burkitt lymphoma and murine plasmacytoma cells. Proc Natl Acad Sci USA 1982; 79: 7837-41. 19. Lai JL, Fenaux P, Zandecki M, Nelken B, Huart JJ, Deminatti M. Cytogenetic studies in 30 patients with

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Burkitt's lymphoma or L3 acute lymphoblastic leukemia with special reference to additional chromosome abnormalities. Ann Genet 1989; 32: 26-32. Emanuel BS, Selden JR, Chaganti RS, Jhanwar S, Nowell PC, Croce CM. The 2p breakpoint of a 2;8 translocation in Burkitt lymphoma interrupts the V kappa locus. Proc Natl Acad Sci USA 1984; 81: 2444-6. Gelmann EP, Psallidopoulos MC, Papas TS, Dalla-Favera R. Identification of reciprocal translocation sites within the c-myc oncogene and immunoglobulin mu locus in a Burkitt lymphoma. Nature 1983; 306: 799-803. Dalla-Favera R, Bregni M, Erikson J, Patterson D, Gallo RC, Croce CM. Human c-myc one gene is located on the region of chromosome 8 that is translocated in Burkitt lymphoma cells. Proc Natl Acad Sci USA 1982; 79: 7824-7. Aventin A, Mecucci C, Guanyabens C, et al. Variant t(2;18) translocation in a Burkitt conversion of follicular lymphoma. BrJ Haematol 1990; 74: 367-9. Magrath I and Bhatia K. Pathogenesis of small noncleaved cell lymphomas (Burkitt's lymphoma). In: Magrath I, ed. The non-Hodgkin's lymphomas. London: Arnold, 1997: 385-410. Wright DH. Burkitt's lymphoma: a review of the pathology, immunology, and possible etiologic factors. PatholAnnu 1971; 6: 337-63. Wright DH. Definition of Burkitt's tumor. Int J Cancer 1968; 3: 410. Rappaport H, Wright DH, Dorfman RF. Suggested criteria for the diagnosis of Burkitt's tumor. Cancer Res 1967; 27: 2632. Hui PK, Feller AC, Lennert K. High-grade non-Hodgkin's lymphoma of B-cell type. I. Histopathology. Histopathology 1988; 12:127-43. Cooper EH, Frank GL, Wright DH. Cell proliferation in Burkitt tumours. EurJ Cancer 1966; 2: 377-84. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. Anonymous. A clinical evaluation of the International Lymphoma Study Group classification of non-Hodgkin's lymphoma. The Non-Hodgkin's Lymphoma Classification Project. Blood 1997; 89: 3909-18. Berard CW, Jaffe ES, Braylan RC, Mann RB, Nanba K. Immunologic aspects and pathology of the malignant lymphomas. Cancer 1978; 42: 911-21. Stein H, Papadimitriou CS, Bouman H, Lennert K, FuchsJ. Demonstration of immunoglobulin production by tumor cells in non-Hodgkin's and Hodgkin's malignant lymphomas and its significance for their classification. Recent Results Cancer Res 1978; 64:158-75. Taylor CR. Immunocytochemical methods in the study of lymphoma and related conditions.) Histochem Cytochem 1978; 26: 496-512. Habeshaw JA, Catley PF, Stansfeld AG, Brearley RL Surface phenotyping, histology and the nature of non-

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50. Lennert K and Feller AC. In: Anonymous, Histopathology of non-Hodgkin's lymphomas (based on the updated Kiel classification). Berlin: Springer-Verlag, 1990. 51. Gascoyne RD. Pathologic prognostic factors in diffuse aggressive non-Hodgkin's lymphoma. Hematol Oncol Clin North Am 1997; 11: 847-62.

52. Gascoyne RD, Adomat SA, Krajewski S, et al. Prognostic significance of Bcl-2 protein expression and Bcl-2 gene rearrangement in diffuse aggressive non-Hodgkin's lymphoma. Blood 1997; 90: 244-51. 53. Hermine 0, Haioun C, Lepage E, et al. Prognostic significance of bcl-2 protein expression in aggressive non-Hodgkin's lymphoma. Groupe d'Etude des Lymphomes de I'Adulte (GELA). Blood 1996; 87: 265-72. 54. Hill ME, MacLennan KA, Cunningham DC, et al. Prognostic significance of BCL-2 expression and bcl-2 major breakpoint region rearrangement in diffuse large cell non-Hodgkin's lymphoma: a British National Lymphoma Investigation Study. Blood 1996; 88: 1046-51. 55. Davis RE, Dorfman RF, Warnke RA. Primary large-cell lymphoma of the thymus: a diffuse B-cell neoplasm presenting as primary mediastinal lymphoma. Hum Pathol 1990; 21:1262-8. 56. Perrone T, Frizzera G, Rosai J. Mediastinal diffuse largecell lymphoma with sclerosis. A clinicopathologic study of 60 cases. Am J Surg Pathol 1986; 10:176-91. 57. Haioun C, Gaulard P, Roudot-Thoraval F, et al. Mediastinal diffuse large-cell lymphoma with sclerosis: a condition with a poor prognosis. Am J Clin Oncol 1989; 12: 425-9. 58. Scarpa A, Borgato L, Chilosi M, et al. Evidence of c-myc gene abnormalities in mediastinal large B-cell lymphoma of young adult age [see comments]. Blood 1991,78:780-8. 59. Tsang P, Cesarman E, Chadburn A, Liu YF, Knowles DM. Molecular characterization of primary mediastinal B cell lymphoma. Am J Pathol 1996; 148: 2017-25. 60. Skinnider BF, Connors JM, Gascoyne RD. Bone marrow involvement in T-cell-rich B-cell lymphoma. Am J Clin Pathol 1997; 108: 570-8. 61. KoYH, Han JH, GoJH,et al. Intravascular lymphomatosis: a clinicopathological study of two cases presenting as an interstitial lung disease. Histopathology 1997; 31: 555-62. 62. Murase T, Nakamura S, Tashiro K, et al. Malignant histiocytosis-like B-cell lymphoma, a distinct pathologic variant of intravascular lymphomatosis: a report of five cases and review of the literature. BrJ Haematol 1997; 99: 656-64. 63. DiGiuseppe JA, Nelson WG, Seifter EJ, Boitnott JK, Mann RB. Intravascular lymphomatosis: a clinicopathologic study of 10 cases and assessment of response to chemotherapy. J Clin Oncol 1994; 12: 2573-9. 64. Wick MR, Mills SE. Intravascular lymphomatosis: clinicopathologic features and differential diagnosis. Semin Diagn Pathol 1991; 8: 91-101. 65. Ferry JA, Harris NL, Picker LJ, et al. Intravascular lymphomatosis (malignant angioendotheliomatosis). A B-cell neoplasm expressing surface homing receptors. Mod Pathol 1988; 1: 444-52. 66. Bhawan J. Angioendotheliomatosis proliferans systemisata: an angiotropic neoplasm of lymphoid origin. Semin Diagn Pathol 1987; 4:18-27.

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67. Sheibani K, Battifora H, Winberg CD, etal. Further

demonstration of human herpesvirus-8: a case report.

evidence that 'malignant angioendotheliomatosis' is an angiotropic large-cell lymphoma. N EnglJ Med 1986; 314: 943-8. 68. Au WY, Shek WH, Nicholls J, Tse KM, Todd D, Kwong YL

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T-cell intravascular lymphomatosis (angiotropic large cell lymphoma): association with Epstein-Barr viral infection. Histopathology 1997; 31: 563-7. 69. Sepp N, Schuler G, Romani N, et al. 'Intravascular lymphomatosis' (angioendotheliomatosis): evidence for a T-cell origin in two cases. Hum Pathol 1990; 21:1051-8. 70. Glass J, Hochberg FH, Miller DC. Intravascular lymphomatosis. A systemic disease with neurologic manifestations. Cancer 1993; 71: 3156-64. 71. Bogomolski-Yahalom V, Lossos IS, Okun E, Sherman Y,

76. Horenstein MG, Nador RG, Chadburn A, et al. Epstein-Barr virus latent gene expression in primary effusion lymphomas containing Kaposi's sarcomaassociated herpesvirus/human herpesvirus-8. Blood 1997; 90:1186-91. 77. Karcher DS, Alkan S. Human herpesvirus-8-associated body cavity-based lymphoma in human immunodeficiency virus-infected patients: a unique Bcell neoplasm. Hum Pathol 1997; 28: 801-8. 78. Carbone A, Gaidano G. HHV-8-positive body-cavity-based lymphoma: a novel lymphoma entity. BrJ Haematol 1997; 97: 515-22. 79. Said W, Chien K, Takeuchi S, et al. Kaposi's sarcoma-

Lossos A, Polliack A. Intravascular lymphomatosis - an

associated herpesvirus (KSHV or HHV8) in primary

indolent or aggressive entity? Leuk Lymphoma 1998; 29: 585-93.

effusion lymphoma: ultrastructural demonstration of

72. Levin KH, Lutz G. Angiotropic large-cell lymphoma with

herpesvirus in lymphoma cells. Blood 1996; 87: 4937-43. 80. Cesarman E, Chang Y, Moore PS, Said JW, Knowles DM.

peripheral nerve and skeletal muscle involvement: early

Kaposi's sarcoma-associated herpesvirus-like DMA

diagnosis and treatment. Neurology 1996; 47:1009-11.

sequences in AIDS-related body-cavity-based lymphomas.

73. Demirer T, Dail DH, Aboulafia DM. Four varied cases of intravascular lymphomatosis and a literature review. Cancer 1994; 73:1738^5. 74. Uphoff CC, Carbone A, Gaidano G, Drexler HG. HHV-8 infection is specific for cell lines derived from primary effusion (body cavity-based) lymphomas. Leukemia 1998; 12:1806-9. 75. Hsi ED, Foreman KE, Duggan J, et al. Molecular and

N EnglJ Med 1995; 332:1186-91. 81. Nador RG, Cesarman E, Chadburn A, et al. Primary effusion lymphoma: a distinct clinicopathologic entity associated with the Kaposi's sarcoma-associated herpes virus. Blood 1996; 88: 645-56. 82. Matolcsy A, Nador RG, Cesarman E, Knowles DM. Immunoglobulin VH gene mutational analysis suggests that primary effusion lymphomas derive from different

pathologic characterization of an AIDS-related body

stages of B cell maturation. AmJ Pathol 1998; 153:

cavity-based lymphoma, including ultrastructural

1609-14.

7 T cell lymphoproliferative disorders AS JACK, SJ RICHARDS, KA MACLENNAN

Introduction

55

Nodal-based peripheral T cell lymphomas

60

Precursor T cell lymphoblastic leukemia/lymphoma

56

References

64

Predominately leukemic peripheral T cell lymphoproliferative disorders

57

INTRODUCTION T cells greatly outnumber B cells in the peripheral blood and also form a majority of cells in peripheral lymphoid tissue and in bone marrow. Despite this, T cell lymphoproliferative disorders are much less common than their B cell counterparts. The incidence of all types of T cell lymphoma and leukemia in the UK is around 2.0/ 100 000 per annum and, as such, constitute around oneseventh of the total number of lymphoproliferative disorders. The reason for the much higher rate of malignant transformation in B cells has not been satisfactorily explained but several factors may be important. B cells are produced throughout life by differentiation of lineage-committed precursors in the bone marrow. In contrast, de novo production of T cells in the thymus from bone mar row-derived precursors declines rapidly after the age of 40 years and T cell numbers in later life are maintained by division of existing peripheral lymphocytes. Peripheral T cells respond to antigenic stimulation by division and differentiation, but do not undergo further episodes of genetic recombination or somatic hypermutation as B cells do within germinal centers. This may result in a lower risk of a T cell sustaining an aberrant recombination event during antigen receptor gene rearrangement. T cell lymphoproliferative disorders were first recognized in the late 1970s using sheep red blood cell resetting technique.1 A few years later the introduction of the first monoclonal antibodies to CD 3 and other T cell surface molecules greatly increased the ease with which these tumors could be recognized.2 It is only in the past few years with the introduction of new antibodies, tyramide-mediated amplification and heat-mediated antigen retrieval that relatively detailed immunophenotypic

studies can be performed on fixed paraffin- or resinembedded tissues.3'5 The use of Southern blotting and later polymerase chain reaction (PCR)-based techniques made it possible to study T cell clonality in clinical samples.6"8 The widespread use of these techniques has raised interesting questions that have not been fully resolved about the boundaries between T cell malignancy and reactive inflammatory conditions. It is only recently that some consensus has begun to emerge as to the classification of T cell lymphoproliferative disorders. The National Cancer Institute Working Formulation did not subdivide lymphomas by immunophenotype. As a consequence, variable numbers of T cell lymphomas were included in several different categories. Until recently, the Working Formulation was used in most clinical trials throughout the world, and this has led to a paucity of good-quality data on the clinical behavior and response to treatment. T cell lymphomas were separately recognized in the Kiel classification.9 Subdivision of tumor types was based partly on cells size and morphology, and partly on the nature of reactive non-neoplastic elements in the tumor.10,11 This was much less robust and clinically relevant than the Kiel classification of B cell lymphomas and was criticized for lack of reproducibility.12 Like their B cell counterparts, T cell lymphomas were subdivided into high and low grade according to cell size, but these gradings did not correlate well with clinical behavior.13 Very few T cell lymphomas can be regarded as indolent, and the distinction between high and low grade, even if this could be done reproducibly, was of limited value in the selection of treatment.14 The Revised European-American Lymhoma (REAL) classification15 differs from other lymphoma classifications in that it is based on the recognition of clinical-

56 T cell lymphoproliferative disorders

pathological entities that are defined in terms of cell lineage morphology, genetic and clinical features. Using this approach, there is now an emerging consensus as to the classification of T cell and natural killer (NK) cell neoplasms, although the definition of entities is less clear than for B cell lymphomas. The starting point of the classification is the identification of tumors of precursor T cells from those peripheral immunocompetent T cells. Precursor T cell leukemia/lymphoma is a relatively homogenous entity that mainly occurs in children and young adults. Peripheral T cell malignancies derived from immunocompetent cells are very heterogeneous and occur mainly in the older adults. Peripheral T cell lymphoproliferative disorders can be subdivided according to their clinical presentation into those that are predominately leukemic, nodal-based disease and primary extranodal lymphomas (see Chapter 8). Although this is a convenient framework for discussing this group of tumors, it must be recognized that there is considerable overlap between these groups and these distinctions have limited clinical significance. Peripheral T cell leukemias, such as T cell prolymphocytic leukemia (T-PLL) often have significant levels of nodal or splenic disease. It is almost certainly the case that systemic nodal-based T cell lymphomas more frequently present with extranodal disease than their B cell counterparts and some tumors, such as the rare panniculitic T cell lymphoma, may be widely disseminated while remaining mainly extranodal. It is now recognized that a very small proportion of tumors previously considered to be T cell lymphomas are in fact true NK cell lymphomas. Most of these tumors appear to occur in the nose and surrounding tissues, although they may be found at other extranodal sites and occasional cases of NK cell leukemia are found.15'16 Improved understanding of the nature of NK cells is likely to facilitate the recognition of these tumors.

PRECURSOR T CELL LYMPHOELASTIC LEUKEMIA/LYMPHOMA All lymphoid cells arise from a committed lymphoid progenitor cell. This is absent in mice deficient in the IKAROS transcription factor. There is evidence that such cells may initially differentiate into B cell or T/NK progenitors. Some of the latter cells remain in the bone marrow to become NK cells, while others enter the thymus and become committed to the T cell lineage.17-24 The first identifiable lineage-committed T cells express CD 1, CD 2, CD 5 and cCD 3. As gene rearrangement occurs, the cells acquire CD 4 and CD Salpha. Non-reactive and selfreactive cells are deleted by positive and negative selection. As the remaining cells enter the thymic medulla, they lose CD 1 expression, switch from CD 45RO to RA and express either CD 4 or CD 8alpha/beta to become immunocompetent peripheral T cells. A small proportion

of T cells are produced by thymic-independent pathways mostly in the gastrointestinal tract. These cells characteristically have express CD 8alpha/alpha.25-30 Precursor T cell lymphoblastic leukemia/lymphoma consists of cells with phenotypic and genotypic features resembling normal thymocytes. There is variation between patients in the extent of marrow involvement and solid tumor formation, but there appears to be little merit in attempting to make an arbitrary distinction between T cell acute lymphoblastic leukemia (T-ALL) and T cell lymphoblastic lymphoma. For simplicity T-ALL will be used as the preferred term. As with B lineage ALL, T-ALL is a disease of children and becomes very rare in later life. T-ALL accounts for around 10 per cent of all childhood acute lymphoblastic leukemias and 25 per cent of cases in adults. It has been suggested, although far from proven, that the incidence may be relatively constant throughout the world in contrast to B-lineage ALL, where the peak in early childhood may be a feature of developed countries. This would suggest a lesser role for environmental factors in the pathogenesis of T-ALL. The only strong risk factor for the development of T-ALL that has been identified is ataxiatelangiectasia. The ATM gene that is mutated in this condition is involved in cell-cycle arrest of cells with sublethal DNA damage.31-33 The reason why precursor T cells are particularly susceptible to loss of this function is not clear. T cell neoplasms also develop in mice deficient in ATM. The blast cells in T-ALL are relatively large cells, often with highly convoluted irregular nuclei, distinct nucleoli and a moderate amount of cytoplasm (Plate 49). The cytoplasm stains positively with PAS and displays dotlike reactivity for acid phosphatase, although these are now obsolete diagnostic tests. The cellular morphology corresponds in most cases to the FAB L2 morphological type but it is not possible to predict the immunophenotype of ALL from the morphology with any degree of certainty. There is considerable variation in the immunophenotype of individual cases of ALL reflecting the complexity of normal thymic differentiation. A small number of cases have features of prothymocytes with expression of CD 7, CD 2 and terminal deoxynucleotidyl transferase (tdt). These cases are the most likely to show CD 34 expression, which is much less common in T lineage than B lineage ALL. It has been suggested that these patients have a poorer prognosis.34-36 The most common immunophenotype corresponds to the common thymocyte stage of normal differentiation. These cells coexpress CD 4 and CD 8 together with cCD 3, CD 2, CD 5 and CD 7. The cells lack surface expression of the T cell receptor and the presence of tdt is evidence of continuing gene rearrangement. In most of these cases CD la will be present. A third group demonstrate a late thymocyte phenotype with loss of tdt expression and some of the cells showing evidence of surface antigen receptor expression. The level of CD 2 expression may also be an

Predominately leukemic peripheral T cell lymphoproliferative disorders 57

independent prognostic factor within this group.37'38 Around 15 per cent of patients with T-ALL will show expression of the myeloid-associated antigens CD 13 and CD 3339 and occasional cases have weak expression of CD 20.40 This is not taken as evidence of biphenotypic leukemia. The influence of CD 13 and CD 33 expression on prognosis appears to be small. Cases of T-ALL expressing CD 10 appear to have a poor prognosis. In ALL as a whole the key clinical presenting features used to assign risk are age (1-9 years; favorable), blast cell count (<50 x 109/1; favorable) and the presence of solid tumors (unfavorable). In most clinical trials, patients with T-ALL are found to have a higher incidence of unfavorable risk factors. These patients tend to be older, with higher blast cell counts. Mediastinal/thymic involvement is a characteristic feature of T-ALL, and lymphadenopathy and hepatosplenomegaly are often present.41 Children with T-ALL are about twice as likely to be placed in a poor risk category than those with Blineage ALL and disease-free survival at 5 years is around 50 per cent. In adults, T-ALL has a better outcome than B-lineage disease. This is most likely due to the higher frequency of bcr-abl translocations in the B cell group. ALL can be classified according to the degree of aneuploidy present. Most cases of T ALL are pseudodiploid, implying a normal chromosomal number with structural abnormalities. A subset of cases with a poor outcome has a near tetraploid chromosome content. The most common non-random chromosomal abnormality in T-ALL involves deregulation of expression of TAL-1, which is present in 20-30 per cent of cases.42-44 This gene is a critical regulator of hematopoiesis in mice but is not normally expressed in lymphoid cells. The gene is capable of forming alternative transcripts that form heterodimers with other DNA binding proteins. The most common rearrangement leading to deregulation of TAL-1 in cases of childhood, but not adult, T-ALL, is a small interstitial deletion on chromosome 1 that leads to the juxtaposition of TAL-1 to the regulatory elements of the SIL gene that is normally expressed in T cells.43,46 The sequences flanking the deletion are homologous to recombination sequences of the TCR genes, suggesting that generation of the abnormality is closely related to TCR rearrangement and is mediated by recombinase activity. In around 3 per cent of cases, TAL-1 is activated by a t( 1:14) involving the TCR alpha/delta locus or by a t(l;7) involving the TCR beta gene.44,47-49 Antibodies to the TAL-1 protein have been produced and abnormal expression of the gene can be shown by immunocytochemistry to be present in cases without evidence of a TAL-1 rearrangement.50 Dysregulation of TAL-1 by whatever mechanism, has not been found to have strong prognostic significance." In addition to TAL-1, a large number of transcription factor genes have been found to be activated by translocations involving the TCR gene loci on chromosome 14 and 7. It is reported that a translocation of this type is present

in 40-50 per cent of cases of T-ALL. The best characterized is the t( 11; 14), which appears exclusive to T-ALL and leads to activation of the tcl-2 gene.52-55 This translocation also appears to be due to recombinase activity.56 The wide range of transcription factors involved in T-ALL-associated translocations belong to three broad groups classified on the basis of structural motifs that mediate binding to DNA or other proteins. The helix HLH group includes TAL-1, TAL-2 and c-wyc.57^0 RBTN1 and RBTN2 are LIM-domain-containing proteins, which interact with TAL-161-63 and HOX11 is a homeoboxcontaining gene.64 Deregulation of HOX11 may be the commonest abnormality in adult T-ALL and is associated with a more favorable outcome. In some cell lines, combinations of abnormalities, such as TALI and RBTN1, may act synergistically in the dysregulation of cell growth.65 In addition to structural chromosomal abnormalities, a variety of specific tumor suppressor gene abnormalities have been described. Inactivation of the cell cycle regulator Rb appear to be the most common, but loss of activity of a range of cyclin-dependent kinase inhibitors have also been described in some cases and may have prognostic significance.66-68 P53 mutations are rare at presentation but are more common in relapse cases.69,70 Individual cases and studies in transgenic mice have also suggested that abnormalities of Ets-1 and IKAROS, both critical genes in lymphoid cell development, may also have a role in the pathogenesis of T-ALL.

PREDOMINATELY LEUKEMIC PERIPHERAL T CELL LYMPHOPROLIFERATIVE DISORDERS Large granular lymphocytosis Large granular lymphocytes (LGLs) are identified by their size and the presence of cytotoxic granules in their cytoplasm (Plate 50). In normal individuals following viral or other infections the LGL fraction will be a mixture of cytotoxic T cell and NK cells. Although morphologically similar, these cells belong to separate lineages. Most cytotoxic T cells recognize the presentation of viral or other endogenous proteins presented on class I major histocompatibility complex (MHC) molecules. In contrast, NK cells recognize cells that have lost expression of MHC class I as a result of infection by some types of virus or neoplastic transformation. Both types of cell contain cytotoxic granules capable of perforating the cell membrane or inducing apoptosis in the target cell. Persistent large granular lymphocytosis is a relatively common finding in older patients. In the majority of patients, this will be detected on a routine blood sample; the lymphocyte count is rarely above 10 x 109/1 and is usually considerably less.71-73 Associations with many diseases of the elderly, such as ischemic heart disease, are likely to be coincidental. However, large granular

58 T cell lymphoproliferative disorders

lymphocytosis is much more common in patients with rheumatoid arthritis and Felty's syndrome. Asymptomatic patients with large granular lymphocytosis may be more likely to have rheumatoid factor and a few patients develop rheumatoid disease after diagnosis of large granular lymphocytosis.74'75 The second important association is with chronic neutropenia.76 In these cases the neutropenia appears to be due to reduced marrow production, possibly as a result of cytokine production by the T cells, although the exact mechanism is poorly understood. Thirdly, LGL proliferations may be associated with underlying B cell malignancy77 and occasionally other non-hematological malignancies.78 In contrast to acute reactive states where a mixture of T cells and NK cells are found, persistent large granular lymphocytosis is almost always due to an expansion of cytotoxic T cells. There is considerable variation between patients in the immunophenotype of the LGL population. Almost all cases express CD 3/TCR alpha/beta and, of these, 60 per cent will be CD 8 positive. The remainder will express CD 4 sometimes in association with weak CD 8.79,80 LGL expansions consisting of CD 3/TCR gamma/delta are rare. A characteristic of LGLs is the expression of the NKa markers CD 16, CD lib, CD 56 and CD 57 in various combinations. CD 16 in particular is strongly associated with rheumatoid arthritis.81 Large granular lymphocytosis due to pure NK cell proliferation is very uncommon. The question of monoclonality has been extensively investigated in large granular lymphocytosis. The immunophenotype CD 8+, CD 16+, CD 56- is strongly predictive of the presence of monoclonality using Vgamma PCR.82 Cases with CD 4 and 8 co-expression are also likely to show monoclonality. It must be emphasized that the presence of monoclonality does not form the basis of a distinction between benign and malignant LGL proliferations. Monoclonality can occur frequently in reactive T cell proliferations, such as infectious mononucleosis, and there is no difference in the prognosis between cases of large granular lymphocytosis with monoclonality and those without. Genetic abnormalities appear to be uncommon, although recently a case showing a t(3;5) has been described.83 It is doubtful whether it is justified to use the term leukemia to describe LGL proliferations. Except in a very few cases, patients do not have progressive disease and tissue or bone marrow infiltration is also very rare. A high level of CD 56 expression maybe a feature of the more aggressive variant.84 In most cases no treatment is required with the exception of those with severe neutropenia who may require granulocyte colony stimulating factor (G-CSF).

T cell prolymphocytic leukemia T cell prolymphocytic leukemia is a very rare entity with an incidence of 1 in 1000 000 per year. The term

prolymphocyte is used to describe the morphological features seen in most cases, and has no implication for the lineage or state of differentiation of the tumor cells. The cells are of medium size with a round nucleus and a large prominent nucleolus (Plate 51). The cell cytoplasm is agranular. Almost every case has the immunophenotype of a CD 4+ peripheral T cell with expression of CD 45RO or CD 45RA and RO. Some cases may have CD 4 and CD 8 co-expression, and there is variable expression of T cell activation markers, such as CD 38 and HLA-DR. CD 4-, CD 8+ cases are rare.85 Expression of NKa markers are not seen in T-PLL. The presence of inv 14(qllq32) is a characteristic feature of this type of leukemia.86'87 A possible role for inactivation of the ATM tumor supressor gene in the pathogenesis of T-PLL has been suggested.88-90 Occasional cases are seen in which a small proportion of the cells express tdt. This raises the possibility that T-PLL may consist of cells at the immediate post-thymic stage of differentiation. The clinical features of T-PLL are distinctive with a very high lymphocyte count that may rise rapidly even within a few days. The peripheral lymphocyte count often exceeds 100 x 109/1 and may rise to 1000 x 109/1. Bone marrow replacement, bulky nodal disease and splenomegaly are usually present, and extranodal involvement may be seen. The overall tumor bulk at presentation is very high. As may be expected from these clinical features, the prognosis is very poor with a median survival around 6-7 months. Until recently, there was little evidence that any treatment was effective but a recent study has suggested that anti-CD 52 can rapidly reduce the lymphocyte count.91 It has been suggested that there is a subgroup of patients with a more stable clinical course. One feature of these patients appears to be expression of CD 45RA. There are a small number of patients who have similar clinical features and outcome, but in whom the tumor consists of small lymphocytes with condensed nuclear chromatin and small indistinct nucleoli. These cases invariably have a CD 4+ peripheral T cell immunophenotype and typically are associated with lymphadenopathy and hepatosplenomegaly. There seems little merit at present in classifying these cases separately. In particular, use of the term T cell chronic lymphocytic leukemia (T-CLL) would seem to be misleading since the clinical features are certainly not those of a chronic leukemia analogous to B cell chronic lymphocytic leukemia (B-CLL).

Adult T cell leukemia/lymphoma In spite of its rather uninformative name, adult T cell leukemia/lymphoma (ATLL) is a specific clinical and pathological entity. The key defining feature of this condition is the association with human T cell leukemia/lymphoma virus type 1 (HTVL-1). This virus

Predominately leukemic peripheral T cell lymphoproliferative disorders 59

is endemic in the islands of the Caribbean and in Southwest Japan. Areas of high incidence have also been described in South America and sporadic cases are found world-wide.92'95 As well as the association with T cell leukemia and lymphoma, this virus appears to play a role in the pathogenesis of tropical spastic paraparesis and possibly a variety of systemic inflammatory disorders.96 HTLV-1 is transmitted through infected cells in transfused blood, breast milk and by sexual contact.97'98 HTLV-1 is a retrovirus that does not carry a conventional viral oncogene and the incidence of ATLL in those infected is low. Viral infection of CD 4+ T cells appears to be an essential first step but other genetic events are required before the onset of overt malignant disease. Carriers of the virus have a polyclonal T cell expansion99 and the emergence of a monoclonal population as judged by the viral integration pattern increases the risk of subsequent malignant progression. The mechanism by which the virus facilitates neoplastic transformation of T cells is not fully understood. It appears likely that one of the main effects of the virus is through the viral tax gene, which is capable of transactivation of a wide variety of cellular genes coding for cytokine and adhesion molecules. Transfection experiments show that this gene is capable of immortalizing T cells in vitro. One of the most important genes activated by tax is IL-2R (interleuk-2 receptor), which may prolong the life of the cell increasing the probability that critical genetic abnormalities will develop. Among the abnormalities described in ATLL are constitutive activation of the JAK-STAT signaling pathway100 and alterations in the tumor suppresor gene pi6.101 Overexpression of IL-4Rhas been associated with aggressive disease.102 A wide range of other cellular genes are activated by HTLV-1. These include the cytokines IL-4, IL-10, IL-1, G-CSF and MIP-1.103,104 Virally infected cells may express high levels of the adhesion molecules L-selectin (CD 62 L) and HML-1 (CD 103), and it has been suggested that this is the basis of the widespread dissemination of tumor cells seen in many patients.105,107 The cellular features of ATLL are relatively distinctive. The characteristic cells are medium-sized lymphocytes that show a high degree of nuclear pleomorphism including a proportion of cells with polylobated nuclei. Large lymphoid cells with more abundant cytoplasm and prominent nucleoli may also be seen in tissue biopsies. The tumor cells are CD 4+, CD 45RO+ peripheral T cells. The presence of IL-2R identified by the anti-CD 25 is always present. Other more variable features include weak or absent surface TCR alpha/beta/CD 3 expression, weak expression of CD 8 and CD 38 expression. The rate of cell proliferation defined by the cell-cycle marker Ki67 has been suggested as an important prognostic factor. ATLL causes diffuse infiltration of lymph nodes with effacement of the normal architecture. The cells present in the node may be more variable in morphology than those seen in the peripheral blood.

There are no reliable morphological features that distinguish ATLL from other peripheral T cell malignancies. In endemic areas the diagnosis will not be a problem. In non-endemic areas, cases may be classified as T-PLL, Sezary syndrome or peripheral T cell lymphoma unless HTLV-1 serology is carried out. Attempting to subclassify or grade ATLL on the basis of cellular morphology is of little value. ATLL occurs in older patients with a peak in the fifth decade. A number of distinctive clinical syndromes are recognized.108 The majority of patients have an acute rapidly progressive clinical course. The lymphocyte count is usually raised and can be very high. In some patients this may be associated with anemia or thrombocytopenia. Involvement of lymph nodes is clinically detectable in most of these patients, and infiltration of skin, liver and spleen is also present in around one-third of cases. A subset of patients with acute presentation may have a predominately lymphomatous pattern of disease with only low levels of peripheral blood and marrow involvement. A subset of these patients may show an angiocentric and angiodestructive pattern.109 One of the most typical features of ATLL is the presence of hypercalcemia, which is seen in 75 per cent of patients.110 Only a few of these patients have lytic bone lesions and the mechanism is thought to involve aberrant production of IL-1 and parathyroid hormone (PTH)-related peptide by the tumor cells.111 The conventional treatment of ATLL has been CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) or similar types of combination chemotherapy, but with an almost uniformly poor outcome. The median survival from diagnosis is around 12 months. Two other more indolent clinical syndromes are recognized. Patients with chronic ATLL have peripheral blood and marrow involvement, but no clinically detectable solid tumor. The overall tumor bulk estimated by serological tests is low with lactate dehydrogenase (LDH) within twice the normal upper limit. These patients progress to the acute form of the disease, although this can take a few years. The Ki67 fraction is reported as being predictive of the time to progression. The presence of p53 abnormalities may also be associated with progressive disease. In smouldering ATLL, the peripheral T cell count is low or normal with less than 3 per cent of the T cells showing abnormal morphology. The main clinical feature is the presence of cutaneous infiltration. When biopsied, these lesions show a dense dermal infiltrate of cells similar to those described above. In some patients the histological features resemble mycosis fungoides. In endemic areas, serological studies for HTLV-1 should always be carried out before a definitive diagnosis of mycosis fungoides is made.112 Skin lesions in the smouldering phase are responsive to steroids. Small numbers of circulating morphologically atypical cells may be found in carriers with no other clinical features.

60 T cell lymphoproliferative disorders

Sezary syndrome The term Sezary syndrome is used to described a CD 4+ peripheral T cell leukemia in association with erythroderma and lymphadenopathy. This probably includes two distinct entities. In patients with typical cutaneous T cell lymphoma of mycosis fungoides type, small numbers of circulating tumor cells can be detected in the peripheral blood, particularly where sensitive flow cytometric or PCR tests are used. In the terminal stages of disease, some patients may progress to overt leukemia, sometimes defined as tumor cells greater than 1 x 109/1 or more than 10 per cent atypical lymphocytes. The more common form of Sezary syndrome is where patients present with a T cell leukemia and generalized skin infiltration, but with no preceding history of mycosis fungoides. These patients often have a very high lymphocyte count and evidence of generalized lymphadenopathy. These cases of de novo Sezary syndrome have many features in common with T-PLL, which may also involve the skin.113,114 In both forms of Sezary syndrome, the leukemic cells are of small to intermediate size with highly convoluted nuclei. All cases have the immunophenotype of an activated CD 4+,TCR alpha/beta, CD 45RO+ peripheral T cell, sometimes with loss of CD 7 expression. Phenotypic differences may be reflected in the functional properties of the neoplastic T cells.115"117 The prognosis of Sezary syndrome, whether de novo or secondary to mycosis fungoides, is generally poor.118

NODAL-BASED PERIPHERAL T CELL LYMPHOMAS Peripheral T cell lymphomas found in lymph nodes are morphologically and immunophenotypically complex leading to the problems in classification described above. At present there are three main entities with distinctive cellular and clinical features. Anaplastic large cell lymphoma of T cell type has in the past been defined in terms of morphology and immunophenotype. More recently, the presence of the t(2;5) with abnormal expression of ALK protein has become a key feature. As the definition has become clearer it has become apparent that this group has a significantly better prognosis than other nodal peripheral T cell lymphomas. The second distinctive entity is angioimmunoblastic T cell lymphoma, which is characterized by proliferation of stromal elements and B cells, and is associated with various autoimmune phenomena. The remaining T cell lymphomas, although they are morphologically heterogeneous, are currently considered as a single group known variously as common or unspecified type. It is likely that, in the future, other distinctive entities may be separated from this group on the basis of cytogenetic or other

features. Most cases of nodal peripheral T cell lymphoma are of common type, up to one-third are anaplastic lymphomas and angioimmunoblastic lymphoma accounts for a further 15-20 per cent.

Anaplastic lymphoma of T cell lineage The history of the term anaplastic large cell lymphoma illustrates one of the key problems encountered by those new to hematopathology. A diagnostic term may be in use for many years during which time the underlying concept may change almost beyond recognition. This can make valid retrospective comparisons very difficult. Subsequent developments have also shown the problem inherent in defining a diagnostic entity on the basis of reactivity with a single antibody. Anaplastic large cell lymphoma was first defined in terms of reactivity with the anti-CD 30 antibody Ki-1 that had been raised against the Hodgkin's cell line L428. Ki-1 lymphoma was a synonymous term for many years. CD 30 is a member of the tumor necrosis factor (TNF) receptor superfamily and is expressed on normal activated T and B cell and, of course, Reed-Sternberg cells in classical Hodgkin's disease. In vitro studies suggest that CD 30, like other members of the TNF superfamily may have a role in the induction of apoptosis and the release of cytokines.93 Circulating soluble CD 30 may block induction of tumor cell death by CD 30 ligandbearing lymphocytes.119 The types of tumor included in the Ki-1 lymphoma category had been previously diagnosed as histiocytic lymphoma, malignant histiocytosis, Hodgkin's disease, various types of large cell lymphoma and even metastatic carcinoma. CD 30 expression appeared to correlate strongly with highly pleomorphic cellular morphology and a sinusoidal pattern of nodal infiltration. Since these original descriptions were given, the definition of this condition has undergone almost continuous evolution in terms of morphological features, immunophenotype, cytogenetics and the separate recognition of the primary cutaneous CD 30-positive lymphoma. The common type of ALCL consists of large lymphoid cells with an eccentric bean-shaped nucleus and a welldemarcated Golgi apparatus. This cell is sometimes referred to as the 'hallmark' cell.120 Multinucleated and other bizarre forms may also be present (Plate 52). This cellular morphology is often associated with invasion of the marginal sinus of the lymph node (Plate 53). However, it is now recognized that the morphological spectrum of this tumor is much wider and only about 60-70 per cent of cases have a common type of morphology. Although hallmark cells are a key defining feature of the condition and correlate closely with the t(2;5), in some cases they may be present in relatively small numbers. In the small-cell variant, the predominant population consists of small to intermediate-sized

Nodal-based peripheral T cell lymphomas 61

lymphoid cells with cerebriform nuclei (Plate 54). These cells are considered to be part of the neoplastic clone. In other variants, large numbers of reactive epithelioid histiocytes or neutrophils maybe present.121'124 There is also a rare sarcomatoid variant where the cells may be spindle shaped or have other bizarre morphological features not normally seen in lymphoid cells. The term Hodgkin's-like ALCL has also been proposed, although it is now clear that most of these cases are part of the spectrum of classical Hodgkin's disease. With the increasing development of cell markers, it became apparent that many cases included in the original description of Ki-l+ ALCL were of B cell origin, with strong expression of CD 20, CD 19 and other B cell markers. These cases of CD 30+ B cell lymphoma are part of the spectrum of diffuse large B cell lymphoma (DLBCL) and do not appear to be clinically different from C30-negative DLBCL. They should no longer be classified as ALCL. The remaining cases have a T cell or null phenotype. Around 50 per cent of cases have expression of CD 3 or CD 2, although the proportion with definitive evidence of T cell differentiation is increasing with improvements in immunocytochemistry techniques. Most null cases can be shown to have a clonal T cell gene rearrangement. The term ALCL is, therefore, now used exclusively to describe a subset of T cell lymphoma. The presence of a T cell phenotype is a key feature in the distinction between ALCL and Hodgkin's disease. Some cases of Hodgkin's disease have in the past been reported as showing evidence of T cell differentiation; however, recent studies in the pathogenesis of Hodgkin's disease suggest that the term should be probably reserved for tumors of B lineage. A total of 60 per cent of cases of ALCL express CD 45 and, when present, this is also a useful feature distinguishing this tumor from classical Hodgkin's disease in which this marker is typically absent. The expression of epithelial membrane antigen is a relatively constant feature of ALCL and this is not seen in classical Hodgkin's disease. Conversely, CD 15 expression is rare in ALCL. A wide range of T cell activation markers including CD 71, class II MHC and CD 25 are commonly seen in ALCL and cells frequently contain cytotoxic granules as demonstrated by the presence of perforin, granzyme B or perform.125 A very important observation in clarifying the nature of ALCL has been the description of the t(2;5)(p23;q35). This produces a fusion protein containing elements of anaplastic lymphoma kinase (ALK) and nuclephosmin. The resulting product has tyrosine receptor kinase activity. ALK may also be deregulated by variant translocations including t(l;2)(q25;p23) and inv(2)(p23;q35). These translocations can be identified by cytogenetics, fluorescence in situ hybridization (FISH) or reverse transcription PCR (RT-PCR). The ALK protein is not expressed in normal hematolymphoid cells and its presence, demonstrated by immunocytochemistry, is in most cases indicative of the translocation.126 The exception is a

recently described rare B cell lymphoma variant in which the p80 fusion protein is present without the translocation.127 In most cases, the protein will be found in the cytoplasm and nucleus (Plate 55). A recent study has suggested that the absence of nuclear staining correlates with variant translocation not involving the nucleophosmin gene.120 The proportion of cases classified as ALCL reported to contain the t(2;5) varies widely from 15 to 60 per cent.128'130 The reason for these differences lies in the individual composition of the series. These and other studies show that the translocation is much more frequent in younger patients with disseminated predominately nodal disease.131'132 Several studies have failed to show a prognostic difference between CD 30-positive and other types of large cell lymphoma.117'118 However, tumors showing expression of ALK appear to have a more favorable outcome.132"136 These differences in clinical features and outcome have led to the proposal that the presence of the translocation should be the defining feature of the disease entity.120 While there is clearly a strong case for adopting this proposal there remains the problem of small numbers of cases that have identical morphology and immunophenotype but lack evidence of ALK dysregulation. A further problem in the definition of ALCL has been the relationship between nodal systemic disease and primary cutaneous CD 30-positive lymphoma. Lymphomatoid papulosis is characterized by relapsing selfhealing cutaneous nodules. Two forms of this condition are described. The rare type A form has morphological features similar to mycosis fungoides but with distinctive clinical features. In the type B form the nodules consist of an inflammatory background population admixed with highly pleomorphic large CD 30-positive cells, some of which may resemble Reed-Sternberg cells.137 Typically these cells have a more normal T cell phenotype than is seen in ALCL and do not show expression of ALK protein.130,131,138 These cells are monoclonal and in a few cases it has been possible to show that recurrences are derived from the same clone.139 In a small and as yet undefined proportion of patients, there is progression of lymphomatoid papulosis to a non-regressing CD 30positive lymphoma.140 Similar tumors may also arise in patients with no previous history of lymphomatoid papulosis. Most studies have shown that the prognosis of this group of patients is excellent with few recorded cases of death from disease.141 One of the problems in accurately defining this group of patients is that systemic ALCL, like other types of T cell lymphoma, frequently involves the skin either at presentation or subsequently, and cases of apparently localized cutaneous disease may be encountered that subsequently have a very aggressive clinical course. The presence of ALK or a t(2;5) may be helpful in the differential diagnosis of a lesion, although the absence of ALK in a CD 30-positive T cell lymphoma presenting in the skin should not lead to the assumption that this is a primary cutaneous lymphoma.

62 T cell lymphoproliferative disorders

Angioimmunoblastic T cell lymphoma Angioimmunoblastic lymphadenopathy was first described in the early 1970s and at that time was considered to be a reactive condition. Many series from that time contained cases that would now be considered to be angioimmunoblastic T cell lymphoma mixed with patients with lymphadenopathy caused by hypersensitivity to drugs such as phenytoin or viral infections. This led to considerable confusion about the prognosis and appropriate management of such patients. There are a number of key features that must be present in a lymph node biopsy to make a firm diagnosis of angioimmunoblastic T cell lymphoma (AIL). As with all types of lymphoproliferative disorders, the nodal architecture should be replaced by lymphoma. A point of particular importance in the case of AIL is the disruption of normal B cell development in the node. A greatly expanded population of plasma cells, preplasma cells and sometimes B-immunoblasts is present but with the absence of organized B cell follicles and reactive germinal centers. In a few cases a significant monoclonal population of B cells may be detected by PCR. Only in very rare cases are intact B cells follicles with reactive germinal centers present.142 A further key feature is loss of definition of the peripheral sinus of the node with spread into the adjacent connective tissues. Again this would not be expected in benign conditions. The T cell population in AIL is usually highly pleomorphic and includes small lymphocytes, intermediate sized cells with irregular nuclei, which are usually the predominant cell type, and large blast cells. In some cases the blast cells have abundant clear cytoplasm (Plate 56). Occasionally cells resembling Reed-Sternberg cells may be present but Hodgkin's disease is not usually a feasible differential diagnosis. The immunophenotype of the neoplastic cells is usually that of a normal CD 4+, CD 45RO+ peripheral T cell; data on aberrant phenotypes are sparse. Variable numbers of CD 8+ T cells are present and these are assumed to be non-neoplastic. The rate of cell proliferation, as defined by Ki-67, is usually relatively low. In most cases that satisfy the strict morphological criteria of this condition, it would be expected that a clonal T cell gene rearrangement would be detected by PCR. In many cases Epstein-Barr virus can be detected in the T cell population. The virus is usually present in a small minority of the cells and its significance to the pathogenesis of the condition remains uncertain.143-145 It has been suggested that, in AIL and other T cell lymphomas, abnormalities of the viral LMP-1 gene may be associated with a poorer prognosis. Chromosomal abnormalites are frequently found in the neoplastic T cells. The most common are trisomies of chromosome 3,5 and x.146'147 A feature of AIL appears to the presence of multiple subclones showing variable cytogenetic features within the same tumor.148

One of the defining features of AIL is the proliferation of stromal elements within the node. The most striking feature on routinely stained sections is the extensive branching vascular networks that consist mainly of large endothelial cells, similar to those seen in high endothelial venules, surrounded by a greatly thickened basement membrane (Plate 57). This can be demonstrated using a periodic acid-Schiff (PAS) stain. Proliferation of normal high endothelial venules may occur in the paracortex of reactive lymph nodes and abnormal vessel morphology is an important feature in distinguishing AIL from benign conditions. The second main stromal abnormality in AIL is the proliferation of follicular dendritic cells. These cells, which are of non-hemopoietic origin, normally display antigens to B cells in the centrocyte-rich zone of the germinal center. In AIL these cells are present as extensive diffuse networks (Plate 58). These may be associated with ill-defined B cell aggregates but organized germinal centers are not seen. The presence of this feature is not apparent on hematoxylin and eosin section but can be readily demonstrated using a variety of antibodies, including CD 21, CD 35 or CD 23. The final stromal element is the presence of a general increase in collagen and other extracellular matrix elements. As a result of this, parts of the tumor may appear hypocellular in comparison with normal lymphoid tissue. The final key morphological feature is the presence of increased numbers of other non-neoplastic cell types. There is almost always significant eosinophilia and epithelioid macrophages may be present, sometimes forming microgranulomas. The clinical features of AIL are distinctive and form an integral part of the diagnosis. Almost all patients have generalized nodal disease sometimes with hepatosplenomegaly. A wide range of systemic effects, including arthropathy, skin rashes and neurological effects are described.149'150 However, in many cases, the systemic effects may appear disproportionate to the bulk of the tumor determined by imaging studies. Fever and raised plasma viscosity are very common in these patients. In most cases the skin lesions do not appear to be due to direct tumor infiltration, although a pre-AIL state presenting as a skin rash has been described.151 Gastrointestinal ulceration may also be found and, in a few patients, gastrointestinal symptoms maybe severe. Again, endoscopic biopsies do not usually show infiltration by tumor. One of the most common systemic manifestations of disease is the presence of hypergammaglobulinemia reflecting the plasmacytosis seen in lymph node biopsies. This is likely to reflect excess IL-6 production by the tumor cells.152 In a few cases circulating plasma cells may be found and occasional patients may present with extramedullary plasmacytomas in the skin or other sites, or associated B cell lymphomas may be found.153 A paraprotein may be present at presentation or develop during the course of the illness. Around 25 per cent of patients have a Coomb's positive hemolytic anemia and a wide

Nodal-based peripheral T cell lymphomas 63

variety of other autoantibodies may be seen. Lymphopenia is often present but in some patients there may be a large granular lymphocytosis. Examination of the bone marrow may show a variety of abnormalities in patients with AIL. Focal infiltration by tumor may be present, although marrow replacement is not common. Erythroid hyperplasia may be present in patients with haemolytic anemia. In other patients there may be suppression of normal hematopoiesis. Many of the cellular and clinical features described above may be found in other types of peripheral T cell lymphoma. The accurate definition of AIL relies on demonstrating the pattern as a whole. If this is done, it is unlikely that confusion with reactive states will be a problem in most cases. When this approach to diagnosis is used, it is clear that AIL has a relatively poor prognosis. There appears to be little merit in attempting to treat these patients with steroids or alkylating agents. Using combination chemotherapy, only a minority of patients will have a sustained complete remission and the median survival appears to be less than 2 years. In addition to the usual prognostic factors it has been suggested that the number of systemic symptoms may correlate with prognosis.154

Peripheral T cell lymphoma - common type The common type of peripheral T cell lymphoma is a morphologically heterogeneous group of tumors that include a number of well-described histological subtypes. The rationale for regarding this as a single group is that many cases are difficult to classify by the Kiel criteria and distinct clinical entities have not been described. The value in continuing to describe these subtypes is that it illustrates the range of morphological features that may be encountered in diagnosing this group of tumors. The most morphologically distinct subtype in this group, and the one with the greatest claim to be a distinct entity, is Lennert's lymphoma (lymphoepithelioid lymphoma). The defining feature of this tumor is the presence of very large numbers of epithelioid macrophages (Plate 59). These are activated macrophages that have undergone further differentiation leading to increased secretory activity and mutual cohesion. The reactive macrophage population is often the major cellular component in the affected lymph node. The neoplastic T cells are found in small clusters lying between the macrophages. Usually these are mainly medium-sized cells with irregular nuclei together with variable numbers of blast cells. In most cases the tumor cells have a normal CD 4+, CD 45RO+, peripheral T cell phenotype. In most cases the rate of cell proliferation in the tumor cells is low. Lennert's lymphoma in most cases is a disseminated disease, although some patients have more

localized disease. Fever and other systemic symptoms are common. Like AIL this is a tumor that has a low proliferative potential and was regarded in the Kiel classification as low grade. However, the prognosis with any type of therapy appears to be poor with a median survival of around 16 months.155 The diagnosis of Lennert's lymphoma has in the past given rise to considerable problems. It is important to realize that other types of lymphoma may be rich in epithelioid macrophages. These include follicle center and diffuse large B cell lymphoma as well as both classical and lymphocyte-predominant nodular Hodgkin's disease. The use of appropriate marker studies will readily resolve most of these cases. Some cases of AIL may also be rich in epithelioid macrophages. In these cases the clinical features may be helpful in making the distinction. The majority of cases within this group consist of a variable mixture of medium- and large-sized neoplastic cells. The most typical morphological feature is the presence of highly irregular nuclei that may show a wide variety of bizarre shapes and contain multiple nucleoli. In some cases, T immunoblasts predominate. Like their B cell counterparts, these cells have a coarse chromatin pattern and one or more large nucleoli. A feature of some T immunoblasts is the presence of abundant clear cytoplasm. Eosinophils and reactive macrophages may be present in variable numbers. Although these features may be suggestive of T cell lineage, a reliable distinction from diffuse large B cell lymphoma is only possible with marker studies. In most cases, these tumors are CD 4+, CD 45RO+ but abnormal T cell immunophenotypes are common in this group. Peripheral T cell lymphomas of small cell type are rare. They consist of a relatively monomorphic population of small lymphocytes with irregularly shaped nuclei and sometimes a rim of clear cytoplasm. In these cases reactive non-neoplastic cells are generally sparse or absent. Like most other types of peripheral T cell lymphoma, the tumor cells are CD 4+, CD 45RO+. The main morphological differential diagnosis in these cases is mantle cell lymphoma but this distinction is not a problem when adequate marker studies are performed. Most peripheral T cell lymphomas present with disseminated nodal disease and extranodal deposits may also be present. A proportion of patients may have extensive bone marrow disease. Fever and other systemic symptoms are often present. It is suspected that the prognosis of peripheral T cell lymphomas is worse than that for diffuse large B cell lymphoma, although definitive data are difficult to obtain. The results obtained will depend on the exact population of cases included. Large numbers of anaplastic lymphomas will tend to improve the overall survival, while the opposite is the case with T lymphoblastic leukemia/lymphoma and possibly AIL.

64 T cell lymphoproliferative disorders

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36. Cascavilla N, Musto P, D'Arena G, et al. Are 'early' and 'late' T-acute lymphoblastic leukemias different diseases? A single center study of 34 patients. Leuk Lymphoma 1996; 21: 437-42. 37. Uckun FM, Steinherz PG, Sather H, et al. CD2 antigen expression on leukemic cells as a predictor of event-free survival after chemotherapy for T-lineage acute

Cancer 1990; 1:194-208. 50. Delabesse E, Bernard M, Meyer V, et al. TAL1 expression does not occur in the majority of T-ALL blasts. BrJ Haematol 1998; 102: 449-57. 51. Bash RO, Crist WM, Shuster JJ, et al. Clinical features and outcome of T-cell acute lymphoblastic leukemia in childhood with respect to alterations at the TAL1 locus:

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38. Uckun FM, Gaynon P, Sather H, et al. Clinical features and treatment outcome of children with biphenotypic CD2+ CD19+ acute lymphoblastic leukemia: a Children's Cancer Group study. Blood 1997; 89: 2488-93. 39. Uckun FM, Sather HN, Gaynon PS, et al. Clinical features and treatment outcome of children with myeloid antigen positive acute lymphoblastic leukemia: a report from the Children's Cancer Group. Blood 1997; 90: 28-35.

52. Cheng JT, Yang CY, Hernandez J, Embrey J, Baer R. The chromosome translocation (11;14)(p13;q11) associated with T cell acute leukemia. Asymmetric diversification of the translocational junctions. J Exp Med 1990; 171: 489-501. 53. Finver SN, Martiniere C, Kagan J, Cavenee W, Croce CM. The chromosome 11 region flanking the t(11;14) breakpoint in human T-ALL is deleted in Wilms' tumor hybrids. Oncogene Res 1989; 5:143-8. 54. Royer-Pokora B, Fleischer B, Ragg S, Loos U, Williams D.

40. Warzynski MJ, Graham DM, Axtell RA, Zakem MH, Rotman RK. Low level CD20 expression on T cell

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66 T cell lymphoproliferative disorders

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73. Sivakumaran M, Richards S. Immunological abnormalities of chronic large granular lymphocytosis. Clin Lab Haematol 1997; 19: 57-60. 74. Bowman SJ, Sivakumaran M, Snowden N, et al. The large granular lymphocyte syndrome with rheumatoid arthritis. Immunogenetic evidence for a broader definition of Felty's syndrome. Arthritis Rheum 1994; 37: 1326-30. 75. Yoe J, Gause BL, Curti BD, Longo DL, Bagg A, Kopp WC, Janik JE. Development of rheumatoid arthritis after treatment of large granular lymphocyte leukemia with deoxycoformycin. Am J Hematol 1998; 57: 253-7. 76. Scott CS, Richards SJ, Sivakumaran M, etal. Persistent clonal expansions of CD3+TCR gamma delta+ and CD3+TCR alpha beta+CD4-CD8- lymphocytes associated with neutropenia. LeukLymphoma 1994; 14: 429-40. 77. Frolova EA, Richards SJ, Jones RA, et al. Immunophenotypic and DMA genotypic analysis of T-cell and NK-cell subpopulations in patients with B-cell chronic lymphocytic leukaemia (B-CLL). Leuk Lymphoma 1995; 16: 307-18. 78. Claudepierre P, Bergamasco P, Delfau MH, et al. Unusual CD3+, CD4+ large granular lymphocyte expansion associated with a solid tumor.7 Rheumatol 1998; 25:1434-6. 79. Richards SJ, Sivakumaran M, Parapia LA, et al. A distinct

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66. Cayuela JM, Gardie B, Sigaux F. Disruption of the multiple tumor suppressor gene MTS1/p16(INK4a)/CDKN2 by illegitimate V(D)J recombinase activity in T-cell acute lymphoblastic leukemias. Blood 1997; 90: 3720-6. 67. Diccianni MB, Batova A, Yu J, et al. Shortened survival after relapse in T-cell acute lymphoblastic leukemia patients with p16/p15 deletions. Leukemia Research 1997; 21: 549-58. 68. Yamada Y, Hatta Y, Murata K, et al. Deletions of p15 and/or p16 genes as a poor-prognosis factor in adult T-cell leukemia. J Clin Oncol 1997; 15:1778-85. 69. Hsiao MH, Yu AL, Yeargin J, Ku D, Haas M. Nonhereditary p53 mutations in T-cell acute lymphoblastic leukemia are associated with the relapse phase. Blood 1994; 83: 2922-30. 70. Jonveaux P, Berger R. Infrequent mutations in the P53 gene in primary human T-cell acute lymphoblastic leukemia. Leukemia 1991; 5: 839-40. 71. Scott CS, Richards SJ, Sivakumaran M, et al. Transient and persistent expansions of large granular lymphocytes (LGL) and NK-associated (NKa) cells: the Yorkshire Leukaemia Group Study. BrJ Haematol 1993; 83: 505-15. 72. Chen CL, Sadler RH, Walling DM, Su IJ, Hsieh HC, Raab-

80. Sala P, Tonutti E, Feruglio C, Florian F, Colombatti A. Persistent expansions of CD4+ CD8+ peripheral blood T cells. Blood 1993; 82:1546-52. 81. Scott CS, Richards SJ. Classification of large granular lymphocyte (LGL) and NK-associated (NKa) disorders. Blood Rev 1992; 6: 220-33. 82. Sivakumaran M, Richards SJ, Hunt KM, et al. Patterns of CD16 and CD56 expression in persistent expansions of CD3+NKa+ lymphocytes are predictive for clonal T-cell receptor gene rearrangements. The Yorkshire Leukaemia Group. BrJ Haematol 1991; 78: 368-77. 83. Schmidt HH, Pirc-Danoewinata H, Panzer-Grumayer ER, et al. Translocation (3;5)(p26;q13) in a patient with chronic T cell lymphoproliferative disorder. Cancer Genet Cytogenet 1998; 104: 82-5. 84. Prieto J, Rios E, Parrado A, Martin A, de Bias JM, Rodriguez JM. Leukaemia of natural killer cell large granular lymphocyte type with HLA-DR-CD16-CD56bright+ phenotypej Clin Pathol 1996; 49:1011-13. 85. Matutes E, Brito-Babapull V, Swansbury J, et al. Clinical and laboratory features of 78 cases of T-prolymphocytic leukemia. Blood 1991; 78: 3269-74. 86. Maljaei SH, Brito-Babapulle V, Hiorns LR, Catovsky D.

Traub N. Epstein-Barr virus (EBV) gene expression in

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T-prolymphocytic leukemia studied by fluorescence in situ hybridization. Cancer Genet Cytogenet 1998; 103:110-16.

References 67 87. Brito-Babapulle V, Catovsky D. Inversions and tandem translocations involving chromosome 14q11 and 14q32 in T-prolymphocytic leukemia and T-cell leukemias in patients with ataxia telangiectasia. Cancer Genet Cytogenet 1991; 55:1-9. 88. Yuille MA, Coignet LJ, Abraham SM, et al. ATM is usually rearranged in T-cell prolymphocytic leukaemia. Oncogene 1998; 16: 789-96. 89. Uhrhammer N, Bay JO, Bignon YJ. Seventh International Workshop on Ataxia-Telangiectasia. Cancer Res 1998; 58: 3480-5. 90. Stilgenbauer S, Schaffner C, Litterst A, et al. Biallelic mutations in the ATM gene in T-prolymphocytic leukemia. Nature Medicine 1997; 3:1155-9. 91. Pawson R, Dyer MJ, Barge R, et al. Treatment of T-cell prolymphocytic leukemia with human CD52 antibody. J Clin Oncol 1997; 15: 2667-72. 92. Pombo de Oliveira MS, Matutes E, Schulz T, et al. T-cell malignancies in Brazil. Clinico-pathological and molecular studies of HTLV-l-positive and -negative cases. Int J Cancer 1995; 60: 823-7. 93. Masuda M, Ishida C, Arai Y, et al. Dual action of CD30 antigen: anti-CD30 antibody induced apoptosis and interleukin-8 secretion in Ki-1 lymphoma cells. Int J Hematol 1998; 67: 257-65. 94. Harrington WJ Jr, Ucar A, Gill P, et al. Clinical spectrum of HTLV-I in south Florida. J Acquired Immune Defic Syndr Human Retrovirol 1995; 8: 466-73. 95. de Oliveira M, do S, Hamerschlak N, Chiattone C, Loureiro P. HTLV-I infection and adult T-cell leukemia in Brazil: an overview. Rev Paulista de Medicina 1996; 114: 1177-85. 96. Sharata HH, Colvin JH, Fujiwara K, Goldman B, Hashimoto K. Cutaneous and neurologic disease associated with HTLV-I infection. J Am Acad Dermatol 1997; 36 (Pt 2): 869-71. 97. Hu CY, Lin MT, Yang YC, et al. Familial transmission of human T-lymphotropk virus type 1 (HTLV-1) in patients with adult T-cell leukemia/lymphoma or HTLV-1associated myelopathy.y Formosan MedAssoc 1998; 97: 101-5. 98. Kanzaki T, Setoyama M, Katahira Y. Human T lymphotropic virus-1 infection. Austral] Dermatol 1996; 37(suppl1):S20-2. 99. Cavrois M, Wain-Hobson S, Gessain A, Plumelle Y, Wattel E. Adult T-cell leukemia/lymphoma on a background of clonally expanding human T-cell leukemia virus type-1positive cells. Blood 1996; 88:, 4646-50. 100. Takemoto S, Mulloy JC, Cereseto A, etal. Proliferation of adult T cell leukemia/lymphoma cells is associated with the constitutive activation of JAK/STAT proteins. Proc Natl Acad Sci USA 1997; 94:13897-902. 101. Uchid T, Kinoshita T, Murate T, Saito H, Hotta T. CDKN2 (MTS1/p16INK4A) gene alterations in adult T-cell leukemia/lymphoma. Leuk Lymphoma 1998; 29: 27-35. 102. Mori N, Shirakawa F, Murakami S, Oda S, Eto S. Characterization and regulation of interleukin-4

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68 T cell lymphoproliferative disorders 117. Saed G, Fivenson DP, Naidu Y, Nickoloff BJ. Mycosis fungoides exhibits a Thl-type cell-mediated cytokine profile whereas Sezary syndrome expresses a Th2-type profile.7 Invest Dermatol 1994; 103: 29-33. 118. Hoppe RT, Wood GS, Abel EA. Mycosis fungoides and the Sezary syndrome: pathology, staging, and treatment. Curr Prob Cancer 1990; 14: 293-371. 119. Younes A, Consoli U, Snell V, etal. CD30 ligand in lymphoma patients with CD30+ tumors. J Clin Oncol 1997; 15: 3355-62. 120. Benharroch D, Meguerian-Bedoyan Z, Lamant L, et al. ALK-positive lymphoma: a single disease with a broad spectrum of morphology. Blood 1998; 91: 2076-84. 121. Kadin ME. Anaplastic large cell lymphoma and its morphological variants. Cancer Surveys 1997; 30: 77-86. 122. McCluggage WG, Walsh MY, Bharucha H. Anaplastic large cell malignant lymphoma with extensive eosinophilic or neutrophilic infiltration. Histopathology 1998;32:110-15. 123. Ott G, Bastian BC, Katzenberger T, et al. A lymphohistiocytic variant of anaplastic large cell lymphoma with demonstration of the t(2;5)(p23;q35) chromosome translocation. BrJ Haematol 1998; 100: 187-90. 124. Pileri SA, Pulford K, Mori S, et al. Frequent expression of the NPM-ALKchimeric fusion protein in anaplastic large-cell lymphoma, lymphohistiocytic type. AmJ Pathol 1997; 150:1207-11. 125. Foss HD, Demel G, Anagnostopoulos I, Araujo I, Hummel M, Stein H. Uniform expression of cytotoxic molecules in anaplastic large cell lymphoma of null/T cell phenotype and in cell lines derived from anaplastic large cell lymphoma. Pathobiology 1997; 65: 83-90. 126. Pulford K, Lamant L, Morris SW, et al. Detection of anaplastic lymphoma kinase (ALK) and nucleolar protein nudeophosmin (NPM)-ALK proteins in normal and neoplastic cells with the monoclonal antibody ALK1. Blood 1997; 89:1394-1404. 127. Delsol G, Lamant L, Mariame B, et al. A new subtype of large B-cell lymphoma expressing the ALK kinase and lacking the 2;5 translocation. Blood 1997; 89:1483-90. 128. Sarris AH, Luthra R, Papadimitracopoulou V, et al. Longrange amplification of genomic DNA detects the t(2;5)(p23;q35) in anaplastic large-cell lymphoma, but not in other non-Hodgkin's lymphomas, Hodgkin's disease, or lymphomatoid papulosis. Ann Oncol 1997; 8 (suppl 2): 59-63. 129. Nakamura S, Shiota M, Nakagawa A, et al. Anaplastic large cell lymphoma: a distinct molecular pathologic entity: a reappraisal with special reference to p80(NPM/ALK) expression. Am J Surg PatholW97; 21: 1420-32. 130. Sarris AH, Luthra R, Cabanillas F, Morris SW, Pugh WC. Genomic DNA amplification and the detection of t(2;5)(p23;q35) in lymphoid neoplasms. Leuk Lymphoma 1998; 29: 507-14.

131. Pittaluga S, Wiodarska I, Pulford K, etal. The monoclonal antibody ALK1 identifies a distinct morphological subtype of anaplastic large cell lymphoma associated with 2p23/ALK rearrangements. Am J Pathol 1997; 151: 343-51. 132. Shiota M, Mori S. The dinicopathological features of anaplastic large cell lymphomas expressing pSONPM/ALK. Leuk Lymphoma 1996; 23: 25-32. 133. Zinzani PL, Bendandi M, Martelli M, etal. Anaplastic large-cell lymphoma: clinical and prognostic evaluation of 90 adult patients. J Clin Oncol 1996; 14: 955-62. 134. Longo G, Federico M, Pieresca C, et al. Anaplastic large cell lymphoma (CD30+/Ki-1+). Analysis of 35 cases followed at GISL centres. EurJ Cancer 1995; 31 A: 1763-7. 135. Weisenburger D., Gordon BG, VoseJM, etal. Occurrence of the t(2;5)(p23;q35) in non-Hodgkin's lymphoma. Blood 1996; 87: 3860-8. 136. Kadin ME, Morris SW. The t(2;5) in human lymphomas. Leuk Lymphoma 1998; 29: 249-56. 137. LeBoit PE. Lymphomatoid papulosis and cutaneous CD30+ lymphoma. AmJ Dermatopathol 1996; 18: 221-35. 138. Herbst H, Sander C, Tronnier M, Kutzner H, Hugel H, Kaudewitz P. Absence of anaplastic lymphoma kinase (ALK) and Epstein-Barr virus gene products in primary cutaneous anaplastic large cell lymphoma and lymphomatoid papulosis. BrJ Dermatol 1997; 137: 680-6. 139. Chott A, Vonderheid EC, Olbricht S, Miao NN, Balk SP, Kadin ME. The dominant T cell clone is present in multiple regressing skin lesions and associated T cell lymphomas of patients with lymphomatoid papulosis. J Invest Dermatol 1996; 106: 696-700. 140. Amagai M, Kawakubo Y, Tsuyuki A, Harada R. Lymphomatoid papulosis followed by Ki-1 positive anaplastic large cell lymphoma: proliferation of a common T-cell clone. J Dermatol 1995; 22: 743-6. 141. Paulli M, Berti E, Rosso R, etal. CD30/KM-positive lymphoproliferative disorders of the skin clinicopathologic correlation and statistical analysis of 86 cases: a multicentric study from the European Organization for Research and Treatment of Cancer Cutaneous Lymphoma Project Group.7 Clin Oncol 1995; 13:1343-54. 142. Ree HJ, Kadin ME, Kikuchi M, Ko YH, Go JH, Suzumiya J, Kim DS. Angioimmunoblastic lymphoma (AILD-type T-cell lymphoma) with hyperplastic germinal centers. AmJSurg Pathol 1998; 22: 643-55. 143. Anagnostopoulos I, Hummel M, Stein H. Frequent presence of latent Epstein-Barr virus infection in peripheral T cell lymphomas. Leuk Lymphoma 1995; 19: 1-12. 144. Khan G, Norton AJ, Slavin G. Epstein-Barr virus in angioimmunoblastic T-cell lymphomas. Histopathology 1993;22:145-9.

References 69 145. Ohshima K, Takeo H, Kikuchi M, et al. Heterogeneity of Epstein-Barr virus infection in angioimmunoblastic lymphadenopathy type T-cell lymphoma. Histopathology 1994; 25: 569-79. 146. Kumaravel TS, Tanaka K, Arif M, et al. Clonal identification of trisomies 3, 5 and X in angioimmunoblastic lymphadenopathy with dysproteinemia by fluorescence in situ hybridization. Leuk Lymphoma 1997; 24: 523-32. 147. Schlegelberger B, Zwingers T, Hohenadel K, et al. Significance of cytogenetic findings for the clinical outcome in patients with T-cell lymphoma of angioimmunoblastic lymphadenopathy type. J Clin Onaj/1996;14: 593-9. 148. Schlegelberger B, Zhang Y, Weber-Matthiesen K, Grote W. Detection of aberrant clones in nearly all cases of angioimmunoblastic lymphadenopathy with dysproteinemia-type T-cell lymphoma by combined interphase and metaphase cytogenetics. Blood 1994; 84: 2640-8. 149. Sonobe M, Yasuda H, Okabe H, et al. Neuropathy associated with angioimmunoblastic lymphadenopathylike T-cell lymphoma. Int Med 1998; 37: 631-4. 150. Layton MA, Musgrove C, Dawes PT. Polyarthritis, rash

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8 Extranodal lymphomas PG ISAACSON

Introduction Mucosa-associated lymphoid tissue: the MALT lymphoma concept Malignant lymphoma of the gastrointestinal tract Malignant lymphoma of the salivary glands Malignant lymphoma of the lung Malignant lymphoma of the thyroid Lymphomas of the ocular adnexa and eye Malignant lymphoma of the skin Malignant lymphoma of the upper aerodigestive tract

71 72 74 77 77 79 79 80 81

INTRODUCTION Reliable data on the proportion of lymphomas that arise in tissues or organs other than lymph nodes are not readily available, but the figure probably lies somewhere between 20 and 40 per cent.1'2 One reason for this imprecision derives from the problem of definition. Nodal lymphomas frequently spread to extranodal sites, which can lead to a mistaken diagnosis of primary extranodal disease, and, equally, extranodal tumors often disseminate to lymph nodes and may erroneously be thought to arise there. No watertight definition of extranodal lymphomas exists but a reasonable operational definition is that a lymphoma may be considered to be extranodal if it presents with the main bulk of disease in an extranodal site, provided that primary lymphomas of that site, without nodal involvement, have previously been described.3 Almost all extranodal lymphomas are of non-Hodgkin's type, with the single exception of the thymus; extranodal Hodgkin's disease is vanishingly rare. Sites of origin Extranodal lymphomas may arise from primary lymphoid organs such as the spleen, thymus or Waldeyer's ring, from organs with a significant lymphoid tissue

Malignant lymphoma of the central nervous system Malignant lymphoma of the thymus Malignant lymphomas of the spleen Malignant lymphoma of the urogenital tract Extranodal lymphomas of miscellaneous sites Multifocal extranodal lymphoma Extranodal lymphoma associated with immunodeficiency References

83 83 84 85 85 86 86 87

component, such as the gastrointestinal tract, or from organs or tissues normally devoid of lymphoid tissue, such as the brain or skeletal muscle. In effect, lymphomas may arise anywhere in the body but certain sites are more prone than others. The gastrointestinal tract is by far the commonest site of extranodal lymphoma followed by the skin, Waldeyer's ring and the salivary glands.

Classification The first rational classifications of non-Hodgkin's lymphomas, which emerged in the late 1970s and early 1980s, emphasized the architectural and cytological resemblances between lymphomas and normal lymph nodes.4,5 With the single exception of cutaneous T cell lymphomas, which were categorized separately in the Kiel classification, site of origin was not considered a significant factor. Its importance, however, became apparent following the description of lymphomas of mucosa-associated lymphoid tissue (MALT) in 1983,6 which was soon followed by a description of other clinicopathologically distinct extranodal lymphomas. It was partly this omission of extranodal entities from the currently used lymphoma classifications that provoked the proposal of a new lymphoma classification in 1994. The Revised European-American Lymphoma (REAL) classification7 (see Table 1.6, page 6) essentially lists those

72 Extranodal lymphomas

lymphomas that are recognized as disease entities and is the first classification specifically to include extranodal lymphomas. In this chapter extranodal lymphomas will be grouped together according to their site of origin and described following the principles of the REAL classification.

MUCOSA-ASSOCIATED LYMPHOID TISSUE: THE MALT LYMPHOMA CONCEPT In the 1970s, Lukes and Collins4 and Lennert5 observed that lymphomas tended to recapitulate the histological features of normal lymph nodes and emphasized the importance of this in lymphoma classification. In attempting to apply these principles to the classification of certain extranodal B cell lymphomas, Isaacson and Wright6'8 noted that their histology was more closely related to that of mucosa-associated lymphoid tissue than of lymph nodes and coined the term 'MALT lymphoma'. Histology of MALT The features of MALT can best be observed in the gastrointestinal tract where it comprises the Peyer's patches, lymphocytes in the lamina propria, intraepithelial lymphocytes and mesenteric lymph nodes. Peyer's patches are distinguished by a central B cell follicle, which is surrounded by a prominent marginal zone; small T cell areas are present between these prominent B cell foci (Fig. 8.1). These lymphoid aggregates form dome-like protuberances covered by intestinal epithelium, which characteristically contains clusters of intraepithelial marginal zone B cells; this so-called lymphoepithelium is a defining structure of MALT. The intraepithelial B cells must be distinguished from the more prominent intraepithelial T cells, which are present throughout the intestinal epithelium with the exception of the dome areas above Peyer's patches. Functional properties There are no afferent lymphatics in MALT and antigen passes directly across the covering mucosa into the lymphoid tissue. The antigen-stimulated B cells leave MALT via efferent lymphatics and the B cells then 'home' back to the mucosal lamina propria where they comprise the antibody forming plasma cells.9 The behavior of Peyer's patch T cells is less well understood but is probably similar. Most lamina propria plasma cells synthesize immunoglobulin A (IgA) antibodies, which, together with secretory component, are transported to the surface of the intestinal epithelium where they provide local immunity.

Figure 8.1 Peyer's patch showing a central B cell follicle (F) with surrounding marginal zone (M) and intraepithelial B cells (arrows). Tcell areas are also present (T).

Acquired MALT Paradoxically, MALT lymphomas arise most commonly in organs such as the stomach, salivary gland and thyroid, which normally contain no lymphoid tissue. A common feature, however, is that the lymphomas arise in a setting of a variety of chronic inflammatory, often autoimmune disorders (chronic gastritis, Sjogren's syndrome, Hashimoto's thyroiditis, etc.), which result in the accumulation of lymphoid tissue characterized by the presence of abundant B cell follicles with an adjacent lymphoepithelium (i.e. MALT).10-12 More details of acquired MALT as it relates to the different sites where MALT lymphomas occur are given later in the following sections. MALT lymphoma concept The term MALT lymphoma refers to a group of B cell extranodal lymphomas that recapitulate the features of the B cell component of MALT. They are thought to be derived from the marginal zone B cells that are found

Mucosa-associated lymphoid tissue 73

surrounding B cell follicles and within the adjacent lymphoepithelium. First characterized in the gastrointestinal tract,6 it is now evident that a significant proportion of extranodal B cell lymphomas arising in a wide variety of organs are of MALT type and share common clinical, histological and molecular genetic properties.3 The features described below are those common to all MALT lymphomas and will be repeatedly referred to in the discussions of lymphomas arising in various extranodal sites that are described later in this chapter. Clinical presentation MALT lymphomas occur predominantly, but not exclusively, in individuals over 50. The presentation is subtle since the symptoms and signs tend to merge with those of the chronic inflammatory disorder that almost invariably precedes the emergence of lymphoma. In keeping with their indolent course (see later) MALT lymphomas are usually at stage IE or IIE (Musshoff)13 when diagnosed.

Low-grade MALT lymphoma HISTOPATHOLOGY

The cells of low-grade B cell MALT lymphomas (Fig. 8.2) characteristically resemble centrocytes and are often referred to as centrocyte-like (CCL) cells even when, as is often the case, their appearance is not entirely characteristic and they more closely resemble small round lymphocytes or monocytoid B cells. The CCL cells invade adjacent epithelial structures to form the characteristic lymphoepithelial lesions. A variable number of nucleolated transformed blasts is always present. Plasma cell differentiation is common and is usually maximal adjacent to epithelium. The presence of benign reactive B cell follicles, comprising a follicle center and mantle zone, within the neoplastic infiltrate is an invariable feature and, especially in small foci of disease, it is clear that the neoplastic CCL cells are distributed around the follicles in the marginal zone. The CCL cells may specifically colonize reactive follicle centers where they may undergo blast transformation or differentiate into plasma cells. This 'follicular colonization' can lead to a remarkable resemblance to follicular lymphoma (Fig. 8.3). MALT lymphomas are frequently multifocal and in paired organs, such as the salivary glands and conjunctivae, bilateral presentation often occurs, which poses problems in staging the disease. Both clinically and histologically, the emergence of low-grade MALT lymphoma in conditions such as chronic gastritis and Sjogren's syndrome in which MALT is acquired can be extremely difficult to diagnose. Under these circumstances demonstration of B cell monoclonality, which is indicative of neoplastic rather than

Figure 8.2

Low-grade B cell gastric MALT lymphoma showing

reactive follicle (F) surrounded by an infiltrate of centrocyte-like eel Is forming lymphoepithelial lesions (arrows). Note the similarity of the structure to a Peyer's patch.

Figure 8.3 Follicular colonization in a low-grade gastric B cell MALT lymphoma.

reactive B cell proliferation is very useful. This can be done either using immunohistochemistry to demonstrate Ig light-chain restriction or molecular genetic methods to show monoclonal Ig gene rearrangement.

74 Extranodal lymphomas

sharp contrast to comparable nodal lymphomas. Fiveand 10-year survivals of 91 and 75 per cent, respectively, have been reported for low-grade gastric MALT lymphoma at stage IE with slightly lower figures (82 per cent at 5 years) for stage IIE.16

High-grade B cell MALT lymphoma

Figure 8.4 Gastric lymph node infiltrated by a low-grade MALT lymphoma causing marked expansion of the marginal zones.

LYMPH NODE INVOLVEMENT AND DISTANT SPREAD Low-grade MALT lymphoma cells first colonize the marginal zones of regional lymph nodes (Fig. 8.4) and this infiltrate extends into the whole interfollicular area with eventual replacement of the entire node. Follicular colonization may occur in lymph nodes. Distant spread occurs late in the course of the disease; the bone marrow is characteristically, but not always, spared. Some cases manifest a tendency to spread to other mucosal sites. IMMUNOPHENOTYPE The cells of low-grade MALT lymphoma express all mature B cell antigens, and may be CD 43+, but are CD 5- and CD 10-. Like marginal zone cells they also express CD 21 and CD 35. In most cases MALT lymphomas synthesize surface and cytoplasmic IgM, and more rarely IgA or IgG.

High-grade transformation of low-grade MALT lymphoma is well documented.17 Coexistence of both lowand high-grade disease is not uncommon and can lead to difficulty in grading the disease as a whole. In many cases of apparently primary (i.e. de novo] extranodal B cell lymphoma arising in sites where low-grade MALT lymphomas are known to occur, careful searching will reveal microscopic foci of low-grade disease suggesting that the high-grade lymphoma is secondary. However, there remain those cases in which no low-grade component can be found and these must be categorized as primary high-grade lymphomas. Whether this group of lymphomas should be categorized as high-grade MALT lymphoma or more properly be designated large B cell lymphoma is problematical. There are several points in favor of classifying such cases as high-grade MALT lymphomas. Histologically, they are indistinguishable from secondary high-grade MALT lymphoma and they manifest similar molecular genetic properties, which distinguish them from nodal large B cell (high-grade) lymphomas. Some reports suggest that the clinical behavior of high-grade MALT lymphoma is similar to that of the low-grade tumors,18 while others have shown that high-grade MALT lymphomas have a less favorable outlook but nevertheless better than that of comparable nodal disease.17

MALIGNANT LYMPHOMA OF THE GASTROINTESTINAL TRACT

MOLECULAR GENETICS

The translocations that characterize other low-grade B cell lymphomas are not found in MALT lymphomas. By contrast, trisomy 3 is a common abnormality.14 Abnormalities of chromosome Ip22, in particular translocation t(l;14)(p22;q32), have been identified as uncommon but recurrent events. A novel gene bd-10 has been shown to be involved in this translocation.15 More recently t(ll;18)(q21;q21) has been identified as a characteristic property of MALT lymphoma and the breakpoint has been cloned.153 Clinical behavior The extremely indolent behavior of low-grade MALT lymphoma and its tendency to remain localized are in

The gastrointestinal tract is the commonest site of extranodal lymphoma and there is considerable geographic variation in its incidence. The intestine is a major secondary lymphoid organ so it is not surprising that it can be the primary site of a wide spectrum of lymphoma types (Table 8.1).

Low-grade B cell MALT lymphoma Low-grade MALT lymphomas may arise anywhere in the gastrointestinal tract but, in Western countries occur most frequently in the stomach. In the Middle East, where gastrointestinal lymphomas are much commoner, the distribution between stomach and intestine is more even.

Malignant lymphoma of the gastrointestinal tract 75

Table 8.1 Primary gastrointestinal non-Hodgkin's lymphoma

Bcell Mucosa-associated lymphoid tissue (MALT) type Low-grade High-grade with or without a low-grade component Immunoproliferative small intestinal disease Low-grade High-grade with or without a low-grade component Mantle cell (lymphomatous polyposis) Burkitt'sand Burkitt-like Other types of low- or high-grade lymphoma corresponding to lymph node equivalents

Tcell Enteropathy-associated T cell lymphoma (EATL) Other types unassociated with enteropathy Rare types (including conditions that may simulate lymphoma)

Low-grade gastric MALT lymphoma Because the stomach is by far the commonest site, gastric MALT lymphoma has served as the paradigm for the group as a whole. Under normal circumstances there is no lymphoid tissue in gastric mucosa. However, accumulation of lymphoid tissue with MALT characteristics follows infection with H. pylori1* (Fig. 8.5). Indeed, the presence of MALT in the stomach is virtually pathognomonic of H. pylori infection and there is strong evidence that the infection is a necessary first step in the pathogenesis of gastric MALT lymphoma. H. pylori is present in over 90 per cent of cases of gastric MALT lymphoma10'19 and epidemiological studies have confirmed the association between the infection and the development of lymphoma.20 Clinically, gastric MALT lymphoma presents as nonspecific dyspepsia; the endoscopic findings are usually similar to those of chronic gastritis with erosions and/or ulceration and not suggestive of malignancy. The histological features of low-grade gastric MALT lymphoma conform to the classical description of MALT lymphoma as outlined above3 (Fig. 8.2). Low-grade gastric MALT lymphomas remain localized to the stomach and gastric lymph nodes for long periods; unlike low-grade B cell lymphomas of lymph nodes, early bone marrow involvement is not characteristic. It was this favorable clinical behavior that resulted in the use of the term 'pseudolymphoma' for these tumors. However, in time, and without treatment, systemic spread occurs. The presence of the B cell clone which will become predominant in the transformation to MALT lymphoma has been demonstrated in H. pylori gastritis specimens taken several years before the development of gastric lymphoma.21'23 A possible explanation for the remarkably favorable clinical behavior of low-grade gastric MALT lymphoma

Figure 8.5

Gastric mucosa showing the effects of H. pylori

infection. There is a prominent B cell follicle with an associated lymphoepithelium (arrows) and surrounding chronic inflammation of the lamina propria.

is that it is immunoresponsive and, if so, H. pylori would be the most likely antigen. In vitro studies have confirmed that this is the case by showing specific responses of lymphoma cells to individual strains of H. pylori.24 Several clinical studies have now shown that eradication of H. pylori with appropriate antibiotics can lead to regression of the lymphoma.25-27a High-grade gastric MALT lymphoma There are few objective studies on the incidence of highversus low-grade gastric lymphoma but the present consensus is that high-grade disease is commoner. Many, if not most, cases evolve from the low-grade MALT lymphoma, therefore, not surprisingly, the same relationship to H. pylori infection can be shown.20 However, highgrade gastric lymphoma is not an immunoresponsive tumor, therefore, although eradication of H. pylori is probably a prudent step in terms of avoiding recurrences, it will not per se have any therapeutic effect on the lymphoma.

76 Extranodal lymphomas

MALT lymphoma of the intestine Distinction must be made between the usual type of intestinal lymphoma that has no apparent epidemiological specificity, sometimes called the 'western type', and immunoproliferative small intestinal disease (IPSID), which is a special type of MALT lymphoma that occurs in the Middle East and other defined geographic areas. 'WESTERN-TYPE* INTESTINAL MALT LYMPHOMA

These lymphomas can arise anywhere in the intestinal tract but, despite the concentration of MALT (Peyer's patches) in the terminal ileum, they are more common in the jejunum,28 where they may well arise from some form of 'acquired MALT'. High-grade lymphoma is considerably commoner and the relationship between low-grade intestinal MALT lymphoma is similar to that already described.28 The clinical behavior is not as favorable as that of gastric MALT lymphoma with reported 5-year survivals of 44-75 per cent for lowgrade and 25-37 per cent for high-grade disease.28 IMMUNOPROLIFERATIVE SMALL INTESTINAL DISEASE

This special variant of small intestinal MALT lymphoma occurs in the Middle East29 and has also been reported in the Indian subcontinent and the Cape region of South Africa.30 Most cases occur in patients under 30 and present with profound malabsorption. An alpha heavychain paraprotein is present in the serum in 70 per cent of cases, which has led to the term alpha chain disease. IPSID usually involves long segments of the jejunum. Histologically, the features are similar to other MALT lymphomas20 except that all cases show marked plasma cell differentiation. These plasma cells synthesize alpha heavy chain and, with the exception of a few cases, no light chain. IPSID runs a prolonged course and spreads out of the abdomen only in the terminal stages, usually following high-grade transformation. IPSID is similar to lowgrade gastric MALT lymphoma in that some cases respond to broad-spectrum antibiotics presumably following the eradication of an as yet unknown antigen in the small intestine.31 Mantle cell lymphoma Although mantle cell lymphoma typically presents as a nodal lymphoma, a minority of cases appears to arise primarily in the gastrointestinal tract.32 The clinical presentation is usually that of lymphomatous polyposis with multiple lymphomatous polyps peppering the intestinal and sometimes the gastric mucosa. The histological features are those of the nodal disease, and comprise a diffuse or nodular infiltrate of cells, which often

Figure 8.6

Small intestinal infiltration by mantle cell

lymphoma. Note the 'naked'follicle centers.

resemble centrocytes and typically surround 'naked' follicle centers (Fig 8.6). In small biopsy specimens the differential diagnosis between mantle cell lymphoma and MALT lymphoma can be extremely difficult. Unlike MALT lymphoma, lymphoepithelial lesions and transformed blasts are rare or absent in mantle cell lymphoma, and CD 5 expression is common. In contrast with low-grade MALT lymphoma, mantle cell lymphoma is an aggressive disease that soon disseminates beyond the gastrointestinal tract to involve peripheral lymph nodes and bone marrow. The median survival after diagnosis is 3-5 years.33 Burkitt's and Burkitt-like lymphoma In the Middle East, classical Burkitt's lymphoma commonly presents as an intestinal, usually ileocecal, tumor.34 The disease has a propensity to occur in boys under 10 years of age. In Western countries, childhood gastrointestinal lymphoma is rare but the commonest form, although not fulfilling all the criteria, bears a close resemblance to Burkitt's lymphoma as described above. Other types of B cell nodal lymphoma Although, theoretically, any type of nodal lymphoma could arise from gastrointestinal MALT, if strict criteria for primary disease are applied, primary gastrointestinal lymphomas other than those described earlier are extremely rare. Thus, for example, although follicular lymphoma is the commonest nodal non-Hodgkin's lymphoma, only a handful of cases of truly primary gastrointestinal follicular lymphoma have been described. Enteropathy-associated T cell lymphoma

(|^[|L_________ It has been known for many years that primary intestinal lymphoma occurs with greater frequency in patients

Malignant lymphoma of the lung 77

with celiac disease. The lymphoma has since been characterized as a distinct type of T cell lymphoma, which probably arises from intraepithelial T cells.35'36 Clinically, EATL usually presents with acute intestinal hemorrhage, perforation or obstruction in a patient with a history of gluten-sensitive enteropathy. In some cases there is no clinical history of malabsorption but villous atrophy is found in the resection specimen, while, more rarely, the intestinal mucosa appears normal. Currently, it is thought that patients representative of this last group are suffering from a latent from of enteropathy in which histological changes in the mucosa are minimal or absent. Multiple 'benign' chronic inflammatory small intestinal mucosa ulcers are often present in EATL and may be the dominant, or only, pathological lesion. Careful histological and, more recently, molecular genetic analysis has shown that these ulcers in fact are lymphomatous.37 The proximal small intestine is more commonly involved in EATL, which produces either large tumor masses, ulcers or an extensive diffuse cryptic lesion. In most cases the histological appearances of EATL are those of a highly pleomorphic large cell lymphoma, often with considerable accompanying inflammation, which can be of such a degree as to mask the neoplastic T cells. Intraepithelial tumor cells, sometimes smaller and less pleomorphic, may be prominent. The clinical course of EATL is very unfavorable since in most cases the lymphoma involves multiple foci of the small intestine and has already disseminated peripherally.

MALIGNANT LYMPHOMA OF THE SALIVARY GLANDS For a number of reasons, which include recent changes in diagnostic criteria, the presence of entrapped lymph nodes in the parotid glands and ectopic salivary tissue within these nodes, the true incidence of salivary gland lymphoma is difficult to estimate. It probably accounts for 10-15 per cent of all malignant salivary gland tumors.38 The normal salivary gland contains no organized lymphoid tissue but, as a consequence of Sjogren's syndrome and other, as yet undefined, chronic inflammatory conditions, MALT accumulates in salivary tissue as Peyer's patch-like structures around salivary ducts associated with a prominent lymphoepithelium11 (Fig. 8.7). The term myoepithelial sialadenitis (MESA) is often used to describe this lesion. It is from this acquired MALT that most salivary lymphomas arise. Patients with primary salivary gland lymphoma are usually over 50 and there is a marked female preponderance; this is a reflection of the much higher incidence of Sjogren's syndrome and accompanying MESA in females. There is often a long history of salivary gland (usually parotid) enlargement prior to the development

Figure 8.7 Parotid gland from a patient with Sjogren 's syndrome showing the accumulation of MALT around the dilated ducts.

of lymphoma. In some cases lymph node dissemination with cervical lymphadenopathy is the first evidence that the salivary gland is harboring a lymphoma. Although lymphoma can arise in any of the major or minor salivary glands, the parotid is by far the commonest site. In most cases the lymphoma is of the low-grade MALT type with prominent lymphoepithelial lesions (Fig. 8.8); high-grade transformation can occur as previously described. Dissemination is a late phenomenon and results in the typical marginal zone or interfollicular infiltrate in regional lymph nodes. This appearance has frequently led to the mistaken diagnosis of primary nodal 'monocytoid' B cell lymphoma in cervical lymph node biopsies from patients with Sjogren's syndrome.39 The clinical course of salivary gland MALT lymphoma is often prolonged but unpredictable with systemic dissemination to lymph nodes and bone marrow occurring at any time from a few months to many years following the diagnosis.40 Other types of lymphoma, including T cell lymphoma, occur with extreme rarity as primary salivary gland tumors. Most reports of such cases are, in fact, describing lymphomas of intraparotid lymph nodes rather than the salivary gland itself.

MALIGNANT LYMPHOMA OF THE LUNG Because almost all cases of pulmonary MALT lymphoma were, until fairly recently, called pseudolymphoma, the incidence of primary pulmonary lymphoma, most of which are of the MALT type, is unknown. The normal lung contains no organized lymphoid tissue but a number of conditions, including so-called follicular bronchiolitis, lead to the accumulation of MALT in relation to small bronchi or bronchioles.3'41 Although pulmonary MALT lymphoma must be assumed to arise from this acquired MALT, unlike the stomach and to a lesser extent the salivary glands, no defined prelymphomatous

78 Extranodal lymphomas

Figure 8.8

Low-grade salivary gland MALT lymphoma showing

a reactive B cell follicle surrounded by the neoplastic infiltrate within which is a prominent lymphoepithelial lesion (arrows).

chronic inflammatory condition has been defined in the lung. Low-grade pulmonary MALT lymphomas usually occur in elderly patients and most are discovered accidentally as a well-defined opacity following a routine chest X-ray. Histologically, the typical features of MALT lymphoma are present (Fig. 8.9) with lymphoepithelial lesions produced by lymphomatous invasion of bronchiolar epithelium. Dissemination to local lymph nodes or systemic spread is rare and high-grade transformation, although well documented, is rare. The clinical behavior of low-grade pulmonary MALT lymphoma is remarkably indolent,42 and cure is easily achieved following either surgical resection or radiotherapy. There are insufficient data for evaluation of the behavior of high-grade B cell lymphomas of the lung.

Lymphomatoid granulomatosis The term lymphomatoid granulomatosis was originally coined to describe a curious progressive chronic inflammatory condition.43 The lymphomatous nature of this disease only gradually became apparent and, until

Figure 8.9

MALT lymphoma of the lung showing the

neoplastic infiltrate surrounding a follicle center and forming lymphoepithelial lesions with bronchiolar epithelium (arrows).

recently, it was thought that the lymphoma was of T or NK cell origin and fell into the loosely characterized group of angiocentric lymphomas. The B cell nature of lymphomatoid granulomatosis and its association with the Epstein-Barr virus (EBV) has recently been clarified.44 Lymphomatoid granulomatosis presents with hemoptysis due to multifocal necrotizing lesions of the lungs. In a minority of cases there is a history of therapeutic immunosuppression. Dissemination outside the lung may be present at the time of diagnosis. Histologically, there is a mixed lymphoid infiltrate often with an angiocentric pattern and large areas of necrosis. Most of the cells are small T lymphocytes but also present are scattered large transformed B blasts, which can be shown to be monoclonal. These large blasts contain EBV. Lymphomatoid granulomatosis is an aggressive disease. Most patients die within 2 years of diagnosis despite intensive chemotherapy.

Other pulmonary lymphomas Primary T cell lymphomas of the lung with features similar to lymphomatoid granulomatosis are rare but well

Lymphomas of the ocular adnexa and eye 79

documented.45 High-grade B cell lymphomas associated with immunodeficiency, other than lymphomatoid granulomatosis also occur and will be described later in this chapter. Hodgkin's disease rarely arises primarily in the lung. Lymphoma of the pleura A distinctive type of high-grade B cell lymphoma arising in the pleura has been reported in Japan46 and, more recently, similar cases have been described in France.47 This type of lymphoma arises in the setting of longstanding pyothorax and is associated with the presence of EBV genome in all the neoplastic cells.

MALIGNANT LYMPHOMA OF THE THYROID The close association between Hashimoto's thyroiditis and thyroid lymphoma has been appreciated for many years but, until the advent of the MALT concept, it was thought that thyroid lymphoma was heterogeneous, comprising the full spectrum of nodal tumors. It is now clear that virtually all lymphomas arising in the thyroid are low- or high-grade MALT lymphomas.12 The lymphoid tissue that accumulates in the thyroid gland in Hashimoto's disease is characterized by B cell follicles, a minor perifollicular component and pronounced plasma cell differentiation. Focally, a lymphoepithelium, comprising B cells within the thyroid acinar epithelium, can be identified but this is not as florid as in other examples of acquired MALT. Like Hashimoto's disease, most cases of thyroid MALT lymphoma occur in females. A sudden increase in the size of the thyroid in a patient with Hashimoto's disease should raise the suspicion of lymphoma. The histological features of low-grade MALT lymphoma of the thyroid are notable for the prominence of lymphoepithelial lesions, which often comprise thyroid acini stuffed with lymphoma cells; reactive B cell follicles are often prominent and follicular colonization is common (Fig. 8.10). High-grade transformation maybe seen. There are few adequate follow-up studies of patients with either high- or low-grade thyroid MALT lymphoma. The presence of capsular invasion is thought to worsen the prognosis significantly.

LYMPHOMAS OF THE OCULAR ADNEXA AND EYE The ocular adnexa comprise the eyelids, conjunctiva, lacrimal gland and orbit. No significant clinicopathological differences exist between lymphomas arising in

Figure 8.10

Low-grade MALT lymphoma of the thyroid with a

lymphoid follicle surmounted by the neoplastic infiltrate, which forms a lymphoepithelial lesion with a thyroid acinus.

individual adnexa and, in any event, lymphoma arising in any one of these structures may soon extend into another. Ocular adnexal lymphomas are therefore best considered as a single entity. This homogeneity extends to histological type; virtually all lymphomas arising in the ocular adnexa are of the MALT type and most are low grade. Like other sites where MALT lymphomas occur, there is normally no organized lymphoid tissue in the ocular adnexa but a post-mortem study has shown that MALT is acquired in the ocular adnexa with increasing frequency according to age.48 Lymphomas of the ocular adnexa occur characteristically in patients over 50. The orbit is the commonest site, often together with lacrimal gland involvement, followed by the conjunctiva. Bilateral involvement is present in 15 per cent of cases. The histology of ocular adnexal lymphomas is typical of MALT lymphoma with a low frequency of high-grade transformation. Use of the term 'MALT' in describing localized orbital lymphomas is open to question, since there is no mucosa or epithelium in the orbit. However, with the exception that lymphoepithelial lesions are not present, the architecture and cytology of orbital

80 Extranodal lymphomas

lymphomas is identical to that of the other adnexa. Purists should, perhaps, use the term 'marginal zone' to designate orbital lymphomas. Progression, with systemic involvement, occurs in 15-20 per cent of patients diagnosed with stage IE lymphoma of the ocular adnexa. The interval between diagnosis and dissemination is very variable and unpredictable.

Table 8.2 Lymphomas of the skin

Tcell Epidermotropic small cerebriform cell Mycosis fungoides Sezary syndrome Non-epidermotropic small cell Non-epidermotropic pleomorphic large cell Anaplastic large cell

Bcell

Intraocular lymphoma This very rare tumor is usually a manifestation of highgrade B cell lymphoma of the brain. It carries a very poor prognosis.

MALIGNANT LYMPHOMA OF THE SKIN The skin is the third commonest site of primary extranodal lymphoma after the gastrointestinal tract and Waldeyer's ring.1 Unlike other extranodal lymphomas, those arising in the skin, or at least some of them, have been recognized as a special entity in various lymphoma classifications for many years, and also discussed at length in many dermatological and hematopathological publications. A full discussion of this complicated group of lymphomas is, clearly, beyond the scope of this chapter and only a concise summary will be presented here. The high concentration of immunological accessory cells present in the skin as the intraepidermal Langerhans cell population suggests that the skin is an important immunological organ. However, the normal resident lymphoid population is confined to a thin scattering of intraepidermal T cells, which are often in contact with the Langerhans cells, and an even more scanty intradermal T cell population. These resident cutaneous T cells express a distinctive 200 kDa surface antigen (HECA-452),49 which suggests that, despite their small numbers, they are especially committed to the skin. Many inflammatory dermatoses lead to the accumulation of organized lymphoid tissue in the skin and some cutaneous lymphomas may arise from this in a manner similar to MALT lymphoma. A wide variety of both T and B cell lymphomas can arise in the skin as summarized in Table 8.2.

Epidermotropic small cerebriform cell lymphomas This form of lymphoma, which accounts for more than half of all cutaneous T cell lymphomas, is commonly known as mycosis fungoides or, when circulating cells are present, Sezary syndrome. Dermatologists recognize multiple clinical variants.

Low-grade marginal zone type High-grade

Mycosis fungoides characteristically occurs in patients over 50 and presents as widespread erythematous patches, which, as the disease progresses, evolve into plaques and, finally, nodular tumors. The presence of circulating lymphoma cells (Sezary syndrome) is associated with pronounced erythroderma. In the early (patch) phase the histological changes resemble those of inflammatory dermatoses and the diagnosis can be very difficult. The classical features of a dense subepithelial infiltrate and intraepithelial collections of atypical cells with cerebriform nuclei are hallmarks of the later plaque phase, while large sheets of tumor cells, often showing high-grade transformation, are present in the final tumor phase. The clinical course is variable and related to the clinical stage at presentation. Over 50 per cent of patients die within 10 years of diagnosis following visceral or nodal involvement.

Non-epidermotropic small T cell lymphoma This is a poorly characterized and rare group of lymphomas whose main importance is to draw attention to the fact that epidermotropism is not a sine qua non for the diagnosis of cutaneous T cell lymphoma.

Non-epidermotropic pleomorphic large T cell lymphoma This type of lymphoma accounts for 5-10 per cent of cutaneous T cell lymphomas. It presents as distinct, sometimes multiple tumor nodules in the skin and, histologically, shows sheets of intradermal large and often pleomorphic lymphoma cell without epidermotropism. The lack of expression of the CD 30 antigen serves to define the poor prognosis of this group.

Anaplastic large cell lymphoma (ALCL) Until its lymphoid nature was clarified in 1985,50 this tumor was thought to be derived from histiocytes. In the skin it was known as 'regressing atypical histiocytosis'.

Malignant lymphoma of the upper aerodigestive tract 81

Primary cutaneous ALCL can occur at any age but is commoner in patients over 60. It presents as single or multiple ulcerating nodules. Histologically, ALCL is characterized by sheets of large cells with abundant eosinophilic cytoplasm and pleomorphic nuclei with prominent nucleoli (Fig. 8.11). An important defining feature is strong expression of the CD 30 antigen.51 Unlike its nodal equivalent, the t(2;5) translocation is not a feature. Some cases of cutaneous ALCL regress spontaneously. Overall, the disease has a remarkably good prognosis with tumor-related death occurring in only 10 per cent.52 This is in striking contrast to nodal ALCL, which is a much more aggressive tumor. Lymphomatoid papulosis This disease, which may be related to ALCL, is characterized by continuously developing, self-healing papular eruptions, usually on the trunk and limbs, in otherwise healthy individuals. It occurs in all age groups. Histologically, the appearances are those of a malignant lymphoid neoplasm with many features in common with ALCL except that the CD 30+ atypical cells tend to occur in small groups or singly, separated by a chronic inflammatory infiltrate.53,54 The T cell proliferation has been shown to be monoclonal.55 In the majority of patients, lymphomatoid papulosis 'burns itself out' after a few years but a minority progress to develop T cell lymphoma.

Low-grade B cell lymphoma of marginal zone type These uncommon tumors present as single or multiple violaceous plaques, or nodules on any part of the body. Histologically,3 their structure is similar to that of MALT lymphoma with reactive follicles surrounded by a monotypic population of small, often centrocyte-like or monocytoid B cells in the marginal zone. However, lymphoepithelial lesions are only rarely seen. Scattered blasts are characteristic and plasma cell differentiation is present in some cases. Primary low-grade marginal zone lymphoma of the skin runs an extremely indolent clinical course. Multiple recurrences and/or high-grade transformation may occur but the lymphoma remains localized in the skin for many years. High-grade B cell lymphoma These tumors characteristically occur in patients over 50 and present as red or violaceous nodules, which usually do not ulcerate. They tend to occur on the head, neck or back.56 In some cases there is histological evidence that the lesion has evolved from a low-grade B cell lymphoma of marginal zone type. The tumor is composed of sheets of large B cells, which may be separated from the epidermis by a so-called Grenz zone. Despite their histology, high-grade B cell lymphomas of the skin, like the low-grade B cell lymphomas, are remarkably indolent tumors. Only 2-5 per cent ever spread beyond the skin.

B cell lymphomas of the skin B cell lymphomas may arise primarily in the skin. Because their pathology has only recently been defined,3 their true incidence is unknown but they are uncommon. The majority are high-grade lymphomas but in some of these a residual low-grade component can be recognized.

Figure 8.11 (a) An anaplastic large cell lymphoma of the skin. 30 expression by tumor cells.

MALIGNANT LYMPHOMA OF THE UPPER AERODIGESTIVE TRACT This loosely defined anatomic area includes the nose, paranasal sinuses, mouth, tongue and the lymphoid

The same case stained with antibody to CD 30 showing strong CD

82 Extranodal lymphomas

tissue comprising Waldeyer's ring. By convention, the salivary glands are not included. The upper aerodigestive tract is the second commonest site of extranodal lymphoma1 but is also commonly involved in disseminated nodal disease; careful staging is therefore necessary before making a diagnosis of extranodal lymphoma at this site. The upper aerodigestive tract is an important site of lymphoid tissue, which occurs as well-recognized structures, such as the palatine tonsils and other elements of Waldeyer's ring, and also as less well-defined collections distributed throughout the mucosae. There are many anatomical similarities between the lymphoid tissue of Waldeyer's ring and Peyer's patches. Reactive B cell follicles are the most prominent component and between these there is the T cell zone. Beneath the overlying squamous epithelium is a mixture of plasma cells and marginal zone B cells, both of which appear to pass freely into the epithelium. There is, thus, intimate contact between the lymphoid tissue and covering squamous epithelium, which is enhanced in the palatine tonsil by the formation of deep complex crypts. Like Peyer's patches, the lymphoid tissue of Waldeyer's ring lacks afferent lymphatics and antigen gains access directly across the covering epithelium. The palatine tonsils account for most (over 40 per cent) of upper aerodigestive tract lymphomas with the next most common sites in order of frequency being the nasopharynx, the soft palate and the base of tongue. The lymphomas that arise in the upper aerodigestive tract comprise a mixture of nodal and extranodal types (Table 8.3). Low-grade B cell lymphomas of nodal type Immunocytoma, plasmacytoma, follicle center lymphoma and mantle cell lymphoma may all rise in the upper aerodigestive tract. Of these, only plasmacytoma occurs with any frequency elsewhere in the aerodigestive tract. Most plasmacytomas occur in the nose but they account for over 20 per cent of lymphomas of the oral cavity.57 A feature of plasmacytoma of the aerodigestive tract is the high frequency of amyloid deposition within the tumor.

Table 8.3 Lymphomas of the upper aerodigestive tract Bcell Low-grade nodal types, including plasmacytoma MALT type Large cell types (high-grade) Tcell Angiocentric (natural killer cell)

Low-grade MALT B cell lymphoma MALT lymphomas are infrequent in the organized native lymphoid tissue of Waldeyer's ring, a situation similar to that in Peyer's patches. Rare cases have been reported in the nose, nasopharynx, larynx and trachea.

Large (high-grade) B cell lymphoma These account for approximately 85 per cent of lymphomas of Waldeyer's ring and 30-50 per cent of lymphomas of the oral soft tissues.58'59 There may be an associated residual low-grade component of a nodal or extranodal type of B cell lymphoma. Localized, stage IE high-grade lymphomas of Waldeyer's ring have a good prognosis, with 80 per cent surviving 5 years or more. More advanced lymphomas and those of the oral cavity have a worse prognosis.58"61

Angiocentric T and/or NK cell lymphoma For many years a progressive necrotizing lesion of the upper aerodigestive tract has been recognized as an inflammatory disorder, most often called 'lethal mid-line granuloma'. The lymphomatous nature of this condition gradually became apparent and it's now established that this is a single clinicopathological entity probably derived from NK cells.62 The disease occurs most commonly in the Far East and certain parts of South America including Peru.63 The clinical presentation is that of a slowly enlarging ulcer involving, in order of decreasing frequency, the nose, paranasal sinuses, palate, mouth and tongue. The ulceration is progressive and may erode into the facial skeleton. The histology is extremely variable and the neoplastic nature of the infiltrate is often masked by intense chronic inflammation and extensive necrosis. Characteristically, the malignant cells have pleomorphic nuclei and delicate pale staining cytoplasm are arranged in an angiocentric pattern with invasion of the walls of small muscular arteries. In some cases the immunophenotype is typical of NK cells (CD 2+, CD 3-, CD 56+) but in others the cells express the T cell antigen CD 3. However, in favor of an origin from NK cells, rather than T cells, is the absence of T cell receptor gene rearrangement. Another consistent finding is the presence of monoclonal EBV genome in the malignant cells.64 Left untreated or undertreated these lymphomas are relentlessly locally progressive and can cause grotesque disfigurement. They preferentially spread to the skin, lungs and gastrointestinal tract, and seldom involve lymph nodes; meaningful data on the prognosis are not yet available.

Malignant lymphoma of the thymus 83

MALIGNANT LYMPHOMA OF THE CENTRAL NERVOUS SYSTEM Previously rare, there is now a rising incidence of primary lymphoma of the central nervous system (CNS).65 This increase is independent of those lymphomas occurring in immunocompromised patients, which will be discussed as a group elsewhere in this chapter. The peak incidence is in the sixth decade and most occur in the superficial parts of the brain; however, any site, including the spinal cord, may be involved and CNS lymphoma may be multifocal. The clinical presentation is that of any space occupying lesion. CNS lymphomas are almost always B cell tumors but occasional cases of T cell lymphoma have been described. Low-grade B cell lymphomas account for 10-20 per cent of cases. Most of these are lymphoplasmacytic lymphomas (immunocytomas). The pattern of infiltration is diffuse, without necrosis, and with conspicuous perivascular cuffing (Fig. 8.12). Most primary CNS lymphomas are high grade and result in large necrotizing masses; perivascular cuffing is also a characteristic finding in these high-grade tumors. Primary CNS lymphoma has a very poor prognosis with a median survival of less than 2 years.66 A pattern of recurrences within the CNS is the rule but distant spread is well recognized.

The thymus essentially consists of an epithelial skeleton extending from cortex to medulla where it forms the HassalPs corpuscles. Packed within this epithelial framework are proliferating T cells whose phenotype steadily matures with progression from cortex to medulla. Less well appreciated is the recently identified intramedullary B cell population, which is most concentrated around Hassall's corpuscles.67

Hodgkin's disease The thymus may be the site of presentation of Hodgkin's disease. Almost all cases are of the nodular sclerosis subtype. Hodgkin's disease presenting with mediastinal widening due to thymic involvement is especially common in young women.

T cell lymphoblastic lymphoma Thymic enlargement maybe the presenting sign of T cell acute lymphoblastic leukemia. The use of the term 'lymphoma' in this disease should be restricted to those cases in which the tissue phase is clearly separate from the leukemia; leukemia, however, invariably follows. This disease pattern is commonest in young males.

Low-grade B cell lymphoma of MALT type MALIGNANT LYMPHOMA OF THE THYMUS Most primary tumors of the thymus are epithelial rather than lymphoid in origin. The thymus is also the only extranodal site where Hodgkin's disease occurs with any frequency. Not surprisingly, given its role in T cell ontogenesis, T cell lymphoblastic lymphoma, usually associated with acute lymphoblastic leukemia, is the commonest non-Hodgkin's lymphoma in the thymus, but both low- and high-grade B cell lymphoma can arise in the thymus, the former being of the MALT type.

Three cases of this variant of MALT lymphoma have recently been described68,69 and the author has seen a further case. Interestingly, three of the four patients have been Chinese. One patient had a long history of Sjogren's syndrome. This form of lymphoma presents with mediastinal widening. The histology is typical of low-grade MALT lymphoma with prominent lymphoepithelial lesions formed by lymphomatous infiltration of Hassall's corpuscles. The indolent clinical behavior is typical of MALT lymphomas as a group.

High-grade B cell lymphoma of the thymus

Figure 8.12 A low-grade (lymphoplasmacytic) lymphoma of the brain showing marked perivascular cuffing.

This type of lymphoma was first recognized in 1980 and called 'sclerosing high-grade lymphoma of the mediastinum'.70 As more cases were reported, less emphasis was placed on the sclerosis and the thymic origin of the lymphoma was clarified.71,72 Although mentioned as a possible variant of large B cell lymphoma, high-grade B cell lymphoma of the thymus is not yet recognized as a disease entity in the REAL classification.7 There is speculation that thymic high-grade B cell lymphoma may arise from the distinctive thymic intramedullary B cell population. Seventy per cent of cases occur in patients under 35, 60 per cent of whom are females. The disease presents as a locally invasive mediastinal mass.

84 Extranodal lymphomas

Figure 8.13

High-grade B cell lymphoma of the mediastinum

(thymus). There is striking sclerosis with pocketing of the tumor cells.

Histologically, the large pleomorphic lymphoma cells are usually compartmentalized by sclerotic bands (Fig. 8.13). Thymic remnants, usually in the form of epithelial cysts, or less commonly as Hassall's corpuscles, are trapped within the tumor. High-grade B cell lymphoma of the thymus is locally highly invasive. Dissemination commonly involves extranodal sites, such as the kidney, liver and brain. The prognosis is dependent on the stage and is similar to that for nodal high-grade B cell lymphoma.

MALIGNANT LYMPHOMAS OF THE SPLEEN Although the spleen is a major lymphoid organ and very often involved by disseminated nodal lymphoma, primary lymphomas of the spleen are uncommon, accounting for less than 2 per cent of all lymphomas. The histology of splenic lymphoid tissue is complex and can only be summarized briefly here. The so-called white pulp comprises a sheath of T cells around the branching splenic arteries from which B-cell follicles are 'suspended' at regular intervals. Splenic B cell follicles are distinguished by the presence of a prominent marginal zone (Fig. 8.14) but otherwise are similar to those of the lymph nodes. The splenic red pulp consists of a complex network of anastomosing venous sinuses separated by an intervening sponge-like network of macrophages and 'reticular' cells. Small aggregates of B and T cells are present in the red pulp. The splenic circulation is remarkably complex, being designed in the interests of its functions as an organ concerned with mounting immune responses and acting as a red cell filter. Any type of B or T cell lymphoma can arise in the spleen, where its clinicopathological features are otherwise identical to those of the nodal disease. Although relatively rare, this group accounts for the majority of cases of 'primary' splenic lymphoma. To complicate matters further, splenic infiltration is often a feature of the B cell

Figure 8.14

A section of a normal spleen showing the white

pulp comprising a B cell follicle surrounded by a prominent marginal zone.

and other leukemias that not infrequently present with splenomegaly. Only two types of lymphoma characteristically arise in the spleen as opposed to peripheral lymph nodes; these are splenic marginal zone B cell lymphoma and gamma/delta T cell lymphoma.

Splenic marginal zone lymphoma The incidence of this recently described disorder is not yet known.73'74 It has a median age of onset of 60 years and there appears to be a female preponderance. Patients characteristically present with massive splenomegaly, which may be associated with the various cytopenias and anemias of hypersplenism. In a significant number of cases a peripheral lymphocytosis is present due to 'spillage' of the lymphoma into the peripheral blood. In many of these cases the circulating lymphoma cells are characterized by short, often polarized villi and this has given rise to the term 'splenic lymphoma with villous lymphocytes'.75 In splenic marginal zone lymphoma, the B cell follicles are greatly enlarged by an infiltrate of small and medium-sized lymphocytes that surround and replace the follicle center with obliteration of the mantle zone (Fig. 8.15). The medium-sized cells resemble marginal zone cells and tend to concentrate at the periphery of the nodules, which lends a 'marginal zone' appearance to the lymphoma. The red pulp is also heavily infiltrated with prominent intrasinusoidal invasion. Despite its name, splenic marginal zone lymphoma is probably not derived from splenic marginal zone cells and bears no resemblance to MALT lymphoma, which exhibits true marginal zone cell characteristics. In splenic marginal zone lymphoma neither the architecture nor the immunophenotype resemble those of the normal splenic marginal zone. Clinical experience with this newly described entity is still limited. Currently, it seems that splenectomy rather than chemotherapy is the treatment of choice.76 Although some cases progress and transform to a high-grade

Extranodal lymphomas of miscellaneous sites 85

Primary testicular lymphoma High-grade B cell lymphoma is the commonest testicular tumor in elderly males.78 These usually present as a painless unilateral testicular swelling, although both synchronous and metachronous bilateral examples are well recognized. Histologically, the large high-grade neoplastic B cells surround and replace the seminiferous tubules, often imparting a nodular appearance to the tumor. The prognosis of stage IE and IIE high-grade B cell testicular lymphoma is relatively favorable with a 60 per cent probability of surviving 5 years. Lymphoma of the bladder Bladder lymphoma is commoner in females, probably reflecting the higher incidence of chronic follicular cystitis in women, a condition which is characterized by the acquisition of MALT by the bladder mucosa. Most bladder lymphomas are of the low-grade MALT type79 and manifest the indolent clinical behavior that is characteristic of this group. High-grade B cell lymphomas of the bladder are rare and probably result from transformation of a low-grade MALT lymphoma. Lymphomas of the female genital tract

Figure 8.15

Splenic marginal zone lymphoma showing two

white pulp nodules, one of which contains a residual reactive follicle center (arrow). The red pulp is diffusely infiltrated.

Primary lymphomas of the ovary, fallopian tube, uterus, cervix and vagina have all been documented but are rare. Most reported cases have been high-grade B cell lymphomas but low-grade MALT lymphomas have also been described.

lymphoma, the majority run an indolent course following splenectomy. Splenic gamma/delta T cell lymphoma

EXTRANODAL LYMPHOMAS OF MISCELLANEOUS SITES

This rare lymphoma77 usually presents with splenomegaly and hepatomegaly. Bone marrow infiltration is also usually present or soon follows, and variable numbers of tumor cells are present in the peripheral blood. The splenic white pulp may be preserved, but there is heavy infiltration of the red pulp by small cells with pale cytoplasm and oval nuclei. The tumor cells express CD 3 and the gamma/delta T cell receptor hetrodimer, but are CD 4- and CD 8- and usually also CD 5- and CD 7-. This is an aggressive disease.

Primary lymphomas have been described arising in almost every organ or tissue in the human body. Some, including lymphomas of bone, breast, liver and soft tissues have been reported as substantial series, while others, such as lymphomas of kidney, heart, adrenal, gall bladder and pancreas, feature essentially as single case reports.

MALIGNANT LYMPHOMA OF THE UROGENITAL TRACT Apart from lymphomas of the testis and, to a lesser extent, the urinary bladder, urogenital lymphomas are very rare indeed.

Lymphomas of bone Excluding myeloma, primary lymphomas of bone are rare and most reports of large series have included substantial numbers of cases associated with nodal disease. Fifty per cent of bone lymphomas80 present as single osteolytic lesions in the long bones but any bone may be involved. Polyostotic cases have been described. Virtually all reported cases have been high-grade B cell

86 Extranodal lymphomas

lymphomas. The clinical behavior depends on the stage with a 55 per cent overall survival for stage IE and IIE cases. With soft tissue or nodal involvement this falls to 10-20 per cent. Lymphomas of the breast Lymphoma accounts for approximately 0.5 per cent of all malignant breast tumors.81 Twenty per cent of reported cases have been examples of Burkitt's lymphoma and these will be discussed separately together with other aspects of this disease. Lymphoma of the breast usually presents in older women as a unilateral lump indistinguishable from carcinoma. Most breast lymphomas are high-grade B cell tumors; there are occasional reports of low-grade MALT lymphoma arising in the breast. The clinical behavior of breast lymphoma is not well documented. Lymphoma of the liver More than 50 cases of primary hepatic lymphoma have been reported. Most have occurred in males over 50 and a history of chronic liver disease has been documented in a substantial minority of cases. Almost all reported cases of liver lymphoma have been highgrade B cell tumors,82 although recently a series of lowgrade MALT lymphomas of the liver has been described.83

Endemic Burkitt's lymphoma Burkitt's original descriptions were of an endemic tumor, later characterized as a lymphoma, that classically presented in the jaw, more often in the maxilla.84 Multiple quadrants of the jaw are frequently involved. The next most frequent site of presentation is the abdomen. Here the retroperitoneum, kidneys, adrenal glands and ovaries may be involved. Less frequent sites of presentation include the eyelids (lacrimal glands), salivary glands, testes and female breasts. In the breasts, the tumor is bilateral and typically associated with pregnancy; interruption of the pregnancy is rapidly followed by involution of the lymphoma. Even in advanced cases there is relative sparing of the lymph nodes and bone marrow.85 Sporadic Burkitt's lymphoma Although the histology of sporadic Burkitt's lymphoma is identical to that of the endemic disease, its biology, including sites of origin, is quite different.86 Jaw masses are only rarely encountered and most cases present with lymphoma in the abdomen due to involvement of the intestine, particularly the ileocecal region, ovaries and retroperitoneal lymph nodes. Other sites of presentation include Waldeyer's ring, peripheral lymph nodes and the bone marrow, where there is often an associated leukemic component. Angiotropic large cell lymphoma (Fig. 8.16)

Lymphomas of soft tissues Lymphomas have been reported arising in most soft tissues. The thigh, abdominal wall and limbs are the commonest sites. The histological type is highly variable and includes both low- and high-grade, mostly B cell, lymphomas.

MULTIFOCAL EXTRANODAL LYMPHOMA Two types of extranodal lymphoma, namely Burkitt's lymphoma and angiotropic (intravascular) large-cell lymphoma, typically present at multiple sites simultaneously.

This curious type of lymphoma87,88 was originally thought to be a tumor of endothelial origin and cases were labeled as variants of angioendotheliomatosis. Most cases present de novo with ill-denned skin lesions, CNS signs, including blindness, and occasionally adrenal insufficiency. Less commonly, there is a preceding solid lymphomatous deposit. The characteristic histological changes are seen most often in the skin, brain and adrenal gland but may be surprisingly widespread. There is distension of capillaries venules and small arteries by dyscohesive masses of large pleomorphic lymphoma cells. Only rarely do the lymphoma cells invade surrounding tissues. Most cases have exhibited a B cell phenotype but a few T cell cases have been reported. Angiotropic large cell lymphoma is an aggressive disease with a median survival of only 5 months.

Burkitt's lymphoma Burkitt's lymphoma84 provides a graphic illustration of the biological relevance of the site of origin of lymphoma. The mechanisms underlying the predilection of Burkitt's lymphoma for discrete anatomical sites remain unknown but potentially could provide useful insights into treatment.

EXTRANODAL LYMPHOMA ASSOCIATED WITH IMMUNODEFICIENCY The increased risk of developing lymphoma in patients with congenital immunodeficiency has long been

References 87

phoma' for this group of EBV-associated lesions evolved for two reasons. Despite the classical histological features of a high-grade B cell lymphoma, molecular studies of some cases failed to show monoclonal immunoglobulin gene rearrangement and in other cases, occurring in immunosuppressed organ transplant recipients, the 'lymphoma' regressed completely following decrease in the dose of immunosuppressive drugs and restoration of immunocompetence. Currently, there are no objective criteria by which such cases can be recognized and, in any event, in patients whose immunodeficiency is due to AIDS, the immunodeficiency cannot, as yet, be reversed. With the exception of those few cases that respond to immunological manipulation, polymorphic immunoblastic lymphoproliferation is rapidly progressive.

Burkitt-like lymphoma This type of lymphoma is named for its resemblance to Burkitt's lymphoma from which it shows subtle cytological and molecular genetic differences. Only 20-30 per cent of cases are characterized by the presence of EBV in the neoplastic cells. All cases are monoclonal and reversal of the immunosuppression has no effect in this disease. As to be expected, the prognosis is poor.92

REFERENCES Figure 8.16

Angiotropic large cell lymphoma of the brain.

recognized. The association of immunodeficiency and lymphoma has recently been highlighted by the increasing use of therapeutic immunosuppression in organ transplant recipients, and the advent of the acquired immunodeficiency syndrome (AIDS) epidemic. Although there are subtle differences between the lymphomas associated with particular causes of immunodeficiency, there are many more similarities, which are sufficient to suggest that immunodeficiency associated lymphomas as a group share a common pathogenesis and manifest common biological features. These include a strong tendency to arise extranodally, similar histology and the frequent presence of EBV in the tumor cells. Lymphomas associated with immunodeficiency can arise at any extranodal or nodal site amongst which the gastrointestinal tract and brain are the commonest. The histological types include Hodgkin's disease,89 which arises in lymph nodes, and is therefore strictly beyond the brief of this chapter, polymorphic immunoblastic B cell lymphoproliferations90 and Burkitt-like lymphoma.91 Occasional cases have been characterized as T cell lymphoma.

Polymorphic immunoblastic B cell lymphoproliferations Use of the term 'lymphoproliferation' rather than 'lym-

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53. Willemze R, Meijer CJLM, van Vloten WA, Scheffer E. The clinical and histological spectrum of lymphomatoid papulosis. BrJ Dermatol 1982; 107:131-44. 54. Parks JD, Synovec MS, Masih AS, et al. Immunophenotypic and genotypic characterization of lymphomatoid papulosis. J Am Acad Dermatol 1992; 26: 968-75. 55. Whittaker S, Smith N, Russell Jones R, Luzzatto L. Analysis of p, y, 8 T-cell receptor genes in lymphomatoid papulosis: cellular basis of two distinct histologic subsets. J Invest Dermatol 1991; 96: 786-91. 56. Santucci M, Pimpinelli N, Arganini L. Primary cutaneous B-cell lymphoma: a unique type of low-grade lymphoma. Clinicopathologic and immunologic study of 83 cases. Cancer 1991; 67: 2311 -26. 57. Handlers JP, Howell RE, Abrams AM, Melrose RJ. Extranodal oral lymphoma. Part 1. A morphologic and immunoperoxidase study of 34 cases. Oral Surg Oral Med Oral Pathol 1986; 61: 362-7. 58. Barton JH, Osborne BM, Butler JJ, et al. Non-Hodgkin's lymphoma of the tonsil. A clinico-pathological study of 55 cases. Cancer 1984; 53: 86-95. 59. Falbaum Chr, Hansmann ML, Lannert K. Malignant lymphomas of the nasal cavity and paranasal sinuses. Virchows Arch A Pathol Anat 1989; 414: 399-405. 60. Eisenbud L, Sciubba J, Mir R, Sachs SA. Oral presentations in non-Hodgkin's lymphoma: a review of thirty-one cases. Part 1. Data analysis. Oral Surg Oral Med Oral Pof/70/1983;56:151-6. 61. Fukuda Y, Ishida T, Fujimoto M, et al. Malignant lymphoma of the oral cavity: Clinicopathologic analysis of 20 cases. 7 Oral Pathol 1987; 16: 8-12. 62. Ng CS, Chan JKC, Lo STH. Expression of natural killer cell markers in non-Hodgkin's lymphomas. Human Pathol 1987; 18:1257-62. 63. Arber DA, Weiss LM, Albujar PF, Chen Y-Y, Jaffe ES. Nasal lymphomas in Peru. High incidence of T-cell immunophenotype and Epstein-Barr virus infection. Am J Surg Pathol 1993; 17: 392-9. 64. Van Gorp J, De Bruin PC, Sie-Go DMDS. Nasal T-cell lymphoma: a clinicopathological and immunophenotypic analysis of 13 cases. Histopathology 1995; 27: 139-48. 65. David DL, Hoel D, FoxJ, Lopez A. International trends in cancer mortality in France, West Germany, Italy, Japan, England and Wales, and in the USA. Lancet 1990; 336: 474-81. 66. Hochberg FH, Miller DC. Primary central nervous system lymphoma. J Neurosurg 1988; 68: 835-53. 67. Isaacson PG, Norton AJ, Addis BJ. The human thymus contains a novel population of B lymphocytes. Lancet 1987; ii: 1488-91. 68. Isaacson PG, Chan JKC, Tang C, Addis BJ. Low-grade B-cell lymphoma of mucosa-associated lymphoid tissue arising in the thymus. A thymic lymphoma mimicking myoepithelial sialadenitis. Am J Surg Pathol 1990; 14: 342-51.

90 Extranodal lymphomas 69. Takagi N, Nakamura S, Yamamoto K, et al. Malignant lymphoma of mucosa-associated lymphoid tissue arising in the thymus of a patient with Sjogren's syndrome. A morphologic, phenotypic and genotypic study. Cancer 1992; 69:1347-55. 70. Lichtenstein AK, Levine A, Taylor CR, et al. Primary mediastinal lymphoma in adults. Am J Med 1980; 68: 509-14. 71. Addis BJ, Isaacson PG. Large cell lymphoma of the mediastinum: a B-cell tumour of probable thymic origin. Histopathology 1986; 10: 379-90. 72. Moller P, Moldenhauer G, Momburg F, et al. Mediastinal lymphoma of clear cell type is a tumor corresponding to terminal steps of B cell differentiation. Blood 1987; 69: 1087-95. 73. Schmid C, Kirkham N, DissT, Isaacson PG. Splenic marginal zone cell lymphoma. AmJ Surg Pathol 1992; 16: 455-66. 74. Isaacson PG, Matutes E, Burke M, Catovsky D. The histopathology of splenic lymphoma with villous lymphocytes. Blood 1994; 11: 3828-34. 75. Melo JV, Hedge U, Parreira A, et al. Splenic B cell lymphoma with circulating villous lymphocytes: differential diagnosis of B cell leukaemias with large spleens. J Clin Pathol 1987; 40: 642. 76. Mulligan SP, Matutes E, Dearden C, Catovsky D. Splenic lymphoma with villous lymphocytes: natural history and response to therapy in 50 cases. BrJ Haematol 1991; 78: 206-9. 77. Gaulard P, Bourquelot P, Kanavaros P, et al. Expression of the alpha-beta and gamma-delta T-cell receptors in 57 cases of peripheral T-cell lymphomas. Identification of a subset of y/8 T-cell lymphomas. AmJ Pathol 1990; 137: 617-28. 78. Paladugu RR, Bearman RM, Rappaport H. Malignant lymphoma with primary manifestation in the gonad. A clinicopathologic study of 38 patients. Cancer 1980; 45: 561-71. 79. Pawade J, Banerjee SS, Harris M, Isaacson PG, Wright D. Lymphomas of mucosa-associated lymphoid tissue arising in the urinary bladder. Histopathology 1993; 23:147-51. 80. Ostrowski ML, Unni KK, Banks PM, etal. Malignant lymphoma of bone. Cancer 1986; 58: 2646-55.

81. Bobrow LG, Richards MA, Happerfield LC, et al. Breast lymphomas: a clinicopathologic review. Human Pathol 1993; 24: 274-8. 82. Osborne BM, Butler JJ, Guarda LA. Primary lymphoma of the liver. Ten cases and a review of the literature. Cancer 1985;56:2902-10. 83. Isaacson PG, Banks PM, Best PV. Primary low-grade hepatic B-cell lymphoma of mucosa-associated lymphoid tissue (MALT)-type. AmJ Surg Pathol 1995; 19: 571-5. 84. Burkitt D. A sarcoma involving the jaws in African children. BrJ Surg, 1958; 46: 218-33. 85. Burkitt DP, Wright DH, eds. Burkitt's lymphoma. Edinburgh: E & S Livingstone, 1970. 86. Dorfman RF. Childhood lymphosarcoma in St Louis, Missouri, clinically and histologically resembling Burkitt's tumor. Cancer 1965; 18: 418-30. 87. Domizio P, Hall PA, Cotter F, etal. (1989) Angiotropic large cell lymphoma (ALCL): morphological, immunohistochemical and genotypic studies with analysis of previous reports. Hematol Oncol 1989; 7: 195-206. 88. Sheibani K, Battifora H, Winberg CD, etal. Further evidence that 'malignant angioendotheliomatosis' is an angiotropic large-cell lymphoma. N EnglJ Med 1986; 314: 943-8. 89. Monfardini S, Tirelli U, Vaccher E, et al. Hodgkin's disease in 63 intravenous drug users infected with human immunodeficiency virus. Gruppo Italiano Cooperative AIDS&Tumori (GICATMw) Onco/1991; 2(suppl 2): 201-5. 90. Frizzera G, Hanto DW, Gajl-Peczalska KJ, etal. Polymorphic diffuse B-cell hyperplasias and lymphomas in renal transplant recipients. Cancer Res 1981; 41: 4262-79. 91. ZieglerJL, DrewWL, Miner RC, etal. Outbreak of Burkitt's-1 ike lymphoma in homosexual men. Lancet 1982; H: 631-4. 92. Roithmann S, Toledano M, Tourami JM, et al. HIVassociated non-Hodgkin's lymphomas: clinical characteristics and outcome. The experience of the French Registry of HIV-associated tumours. Ann Oncol 1991; 2: 289-95.

9 Cytogenetics WG SANGER, BJ DAVE AND MR BISHOP

Introduction Methods Hodgkin's disease Non-Hodgkin's lymphoma

91 91 92 93

INTRODUCTION Investigation into the role of cytogenetic abnormalities in tumorigenesis is one of the most rapidly progressing areas in cancer research. As early as 1914, Boveri, hypothesized that chromosome abnormalities were responsible for the initiation of malignancies.1 The first direct evidence of this hypothesis was forwarded by Nowell and Hungerford in I9602 when they described the Philadelphia chromosome, which appeared to be a deletion of a portion of the long arm of one G-group chromosome in certain patients with chronic myelogenous leukemia (CML). The Philadelphia chromosome was later shown to involve chromosome 22 by chromosome banding.3 With further banding techniques development, the Philadelphia chromosome was shown to be a reciprocal translocation between chromosomes 9 and 22, and found in 90-95 per cent of CML cases.4 It is now known that all true CML cases involve a classical t(9;22), a variant or cytogenetically cryptic chromosome rearrangement. Overall, developments in cancer cytogenetics between 1960 and 1980 were comparatively slow to the present pace, primarily because of the use of cytogenetic procedures, which were traditionally used for the study of constitutional abnormalities, thereby leading to the inadvertent study of non-malignant cells in some patients with malignancies. Additionally, the procedures utilized before 1980 resulted in chromosomes that were very contracted and poorly banded, resulting in subtle rearrangements being undetectable. Cytogenetic procedures and banding quality have continually improved from that period until the present, and have led to the discovery of specific chromosome abnormalities associated

Clinical and prognostic correlations Future studies References

99 99 100

with various subtypes of leukemia and lymphoma, as well as numerous soft tissue and solid tumors. The association of specific chromosome rearrangements in the leukemias have been the most exhaustively studied and specific rearrangements have been associated with the various subtypes of acute myelogenous leukemia (AML), CML, acute lymphocytic leukemia (ALL) and chronic lymphocytic leukemia (CLL). Compared to the leukemias, which are frequently characterized by only one or a few chromosome changes, the lymphomas are more difficult to study because they are commonly associated with numerous chromosome rearrangements and numerical abnormalities, thus making it more of a challenge to ascertain which events are critical in tumorigenesis and which ones are secondary. Nevertheless, there have been numerous series of lymphoma studies carried out.5-12 A summary of the known primary chromosome abnormalities is represented in Table 9.1 and a listing of the secondary acquired abnormalities with their clinical correlations are summarized in Table 9.2. A review of lymphoma cytogenetic studies and the implications of these findings to diagnosis and prognosis are the objectives of this chapter.

METHODS It is imperative that tumor cells (and not non-malignant cells) are analysed cytogenetically when attempting to characterize chromosome changes in malignant disease. To accomplish this, it is necessary that the cytogenetics laboratory receive tumor tissue, and that appropriate culture methods are utilized to culture tumor cells and not normal stromal cells in mitosis for cytogenetic analysis.

92 Cytogenetics Table 9.1 'Primary' acquired chromosome abnormalities in lymphoma

Multiple numerical abnormalities (often pseudotetraploid state)

?

t(8;14)(q24;q32) IgH with c-myc or variants t(2;8)(p21;q24) and t(8;22)(q24;q11) (Ig with c-myc) t(14;18)(q32;q21) IgH with bcl-2 t(3;14)(q27;q32) bcl-6 with IgH t(11;14)(q13;q32) bc\A with IgH t(9;14)(p13;q32) PAX-5 with IgH

Reed-Stern berg

Hodgkin's disease

Bcell

Small non-cleaved (Burkitt's)

Bcell Bcell Bcell Bcell

Follicular (70-90%)/high-grade (20-40%) Diffuse with large cell component Centrocytic (intermediate) lymphoma Small lymphocytotic with plasmacytoid differentiation Low-grade mucosa associated lymphoid tissue (MALT) type lymphoma Anaplastic large cell lymphoma Tcell lymphoma

t(11;18)(q21;q21)

7

Bcell

t(2;5)(p23;q35) inv(14)(q11?)ort(14;?)(q11;?)

ALK gene with NPM T cell receptor deregulation

Tcell Tcell

NPM = nucleophosmin.

Additionally, cell synchronization methodologies are sometimes used to accomplish a higher resolution study. In the case of the lymphomas, lymph node tissue is typically processed by our laboratories within 1 hour after the biopsy procedure, followed by direct harvest or following 24-hour and/or 48-hour culture without mitogens, and with or without synchronization. Following Colcemid exposure, hypotonic and fixation steps are accomplished prior to slide preparation. The slides are generally aged for a minimum of 24-hours and G-banded with Wright's stain, with or without trypsin pretreatment or with Giemsa following enzyme pretreatment. Cytogenetic analysis is accomplished by microscopic analysis of at least 20 cells, when available, followed by karyotyping at least two cells from each abnormal clone according to the International System for Human Cytogenetic Nomenclature.13 An abnormal clone is defined as either two or more cells with the same structural abnormality or the same extra

chromosome, or three or more cells with the same missing chromosome. If a metaphase cannot be analysed confidently, the cell is not included in the analysis. If certain chromosome rearrangements cannot be confirmed utilizing G-banding methods, other banding methods are utilized to clarify the abnormality. Fluorescence in situ hybridization (FISH) procedures, utilizing some of the commercially available ex-satellite, cosmid and paint probes are useful in clarifying and confirming certain complex chromosome rearrangements. These latter methodologies are being used with increasing frequency by most cytogenetics laboratories performing lymphoma studies.

HODGKIN'S DISEASE Compared to the non-Hodgkin's lymphomas (NHLs), relatively few Cytogenetic studies have been performed

Table 9.2 Probable 'secondary' acquired chromosome abnormalities in lymphoma and possible clinical significance

1p22 1q21-22

2p +3 +5, +6, +18 rea(5), or rea(14q11) rea(6q13-16) +7witht(14;18) 10q22-24

+12 13q21-24 +17ori(17q) +der(18)t(14;18) Many abnormalities and no normal cells Normal cells present with abnormal clone

Large cell diffuse lymphoma Poor survival in intermediate/high-grade lymphoma Skin infiltration High-grade lymphoma Shorter survival Shorter survival B cell disease and short survival Diffuse histology Shorter survival Large cell diffuse lymphoma Bulky disease Diffuse histology and shorter survival Disease progression Rapid progression and short survival Better prognosis than those cases without normal cells

Non-Hodgkin's lymphoma 93

on Hodgkin's disease. A primary restraint in the successful study of Hodgkin's disease is that there is typically a low number of mitotic cells, many of which are nonmalignant, cytogenetically normal cells. For example, aneuploid clones were found in only 6 of 20 cases,1413 of 29 cases15 and 13 of 70 cases.16 A probable explanation of this is that cytogenetically normal reactive cells are undergoing mitosis in this disease rather than neoplastic cells. To date, there has been no single structural chromosomal abnormality correlated with any of the histopathological Hodgkin's disease subtypes.14"22 Simultaneous application of FISH and immunophenotyping are being used to define chromosome abnormalities in Hodgkin-Reed Sternberg cells.23-25 Generally speaking, clonal abnormalities in Hodgkin's disease consistently involved numerical abnormalities, quite often reaching the near tetraploid range. The most common numerical abnormalities include trisomies for chromosomes 1, 3, 7, 8 and 21.14-16 A broad spectrum of structural abnormalities which are also common in NHL, were reported among these studies and frequently involved Ip36, 6ql5, 6q21, 7q22, 7q32, 8q24, Ilq23, 12q24, 13pll, 14pll, 14q32, and 15pll rearrangements.14-22 Even though there are some cytogenetic similarities between Hodgkin's disease and NHL, the number of chromosomes observed in Hodgkin's disease cases is frequently in the triploid to tetraploid range, which is in contrast to most other NHLs. The frequency of polyploidy in Hodgkin's disease would be consistent with the theory that these are derived from the Reed-Sternberg cell, which is quite often a polyploid cell.26

NON-HODGKIN'S LYMPHOMA In contrast to Hodgkin's disease, the non-Hodgkin's lymphomas demonstrate abnormal clones in 75-100 per

cent of cases studied.5'12 Compared to the leukemias, the frequency of cytogenetic abnormalities is higher in NHL and the chromosome rearrangements are much more numerous and complex. NHLs have shown one of the widest varieties of recurrent (reported in 3 cases or more) chromosomal changes and these are not frequently seen as sole chromosomal abnormality.27 In attempting to correlate cytogenetic abnormalities with histological classification, most groups utilize the International Working Formulation (IWF)28 and, using this formulation, the correlations between cytogenetic abnormalities and histology have been somewhat successful. In NHL, it has been shown that many oncogenes are activated via translocation of chromosomal material causing a juxtaposition to an enhancer of a lymphoid immunoglobulin gene.29 Among all subtypes of lymphoma, the single most common chromosome abnormality, which is found in at least two-thirds of all NHL cases, is that of a rearrangement involving band 32 on the long arm of chromosome 14 (14q32). The 14q32 region is the immunoglobulin heavy chain (IgH) gene locus and, when this is juxtaposed with other oncogenes, there is an etiological correlation with B cell NHL. A summary of some of the primary chromosome rearrangements in NHL follow.

Translocation 8/14 - t(8;14)(q24;q32) (Fig. 9.1) The t(8;14)(q24;q32) was first described by Manolov and Manolova in 197230 as being associated with Burkitt's lymphoma. This translocation juxtaposes the IgH locus at 14q32 with the c-myc oncogene located on 8q24. At least 60 per cent of patients with Burkitt's lymphoma have the t(8;14) and another 20 per cent have a variant translocation demonstrating either a t(8;22)(q24;qll) or a t(2;8)(p21;q24). All three of these

Figure 9.1

Translocation 8/14 -

t(8;14)(q24;q32). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in Burkitt's lymphoma and certain other highgrade B cell lymphomas and leukemias. c-myc - oncogene, IgH = immunoglobulin heavy-chain gene.

94 Cytogenetics

chromosome rearrangements are believed to result in deregulation of the cellular oncogene, c-myc, thereby resulting in Burkitt's lymphoma. Generally, patients with one of the variant translocations have poorer survival rates than those with the t(8;14).31 In addition to Burkitt's lymphoma, the t(8;14) has also been observed in patients with acute lymphocytic leukemia (L3). Additionally, the t(8;14) or other variant translocations have been observed in other lymphomas, particularly in high-grade lymphomas.5,32 With only rare exception, all cases with a t(8;14), a t(8;22), or a t(2;8) have a B cell phenotype.

Translocation 14/18 - t(14;18)(q32;q21) (

^:^^

The t(14;18) reciprocal translocation juxtaposes the IgH locus with the bd-2 oncogene during early B cell development. The 18q21 region includes major (mbr) and minor (mcr) breakpoint regions, which recombine with the IgH locus at 14q32.33 The mbr and mcr are involved in approximately 66 and 16 per cent, respectively, of those cases with a t(14;18)(q32;q21) by cytogenetics,34 with the remaining cases apparently involving other nearby breakpoints. The t(14;18) occurs in 70-90 per cent of follicular lymphomas and in approximately 30 per cent of diffuse large-cell NHL cases.12 The resulting bd-2 gene product of this translocation apparently inhibits programmed cell death or apoptosis, and extends cell survival rather than causing increased proliferation. The t(14;18) is believed to represent a premalignant change, which, after a second genetic change, results in the development of follicular lymphoma. The course of the disease is generally slow, lasting for several years; however, it is incurable with conventional therapy and is ultimately fatal. Although the observation of the t(14;18) in high-grade lymphomas represents transformation in some cases, the presence of additional or secondary chromosome abnormalities are more likely to be

responsible for the aggressive nature of these tumors.8'11 With only extremely rare exceptions, the presence of a t( 14; 18) is associated with a B cell phenotype.

Translocation 3/14 - t(3;14)(q27;q32)

!!!iL:!^L___ ______ The t(3;14) results in the juxtaposition of the site which codes for a zinc-finger protein (bd-6 or LAZ-3) located at 3q27 with the IgH region of 14q32.35 A variant of this translocation involves the bd-6 region of 3q27 with the immunoglobulin light-chain region of chromosome 22qll.36,37 Offit et a/.38 described the rearrangement of bd-6 in 23/102 cases of diffuse lymphomas with large cell components. Horsman et a/.39 also reported that in 5 of their 22 t(3;14) cases, there was a second lymphoma specific translocation - three cases of t( 14; 18) and two cases of t(8;14). The presence of the t(3;14) is commonly associated with extranodal involvement and is associated with B cell markers. Patients with the t(3;14) have a higher rate of complete remissions with conventional therapy and have a longer disease-free survival compared to other cases of diffuse lymphomas with a large cell component.38,40

Translocation 11/14-t(11;14)(q13;q32)

fig. 9.4

!— ___

_______

The t(ll;14) results in the juxtaposition of the bd-l proto-oncogene with the IgH region of 14q32 and is commonly found in mantle cell (intermediate lymphocytic) lymphomas.41'42 This rearrangement in this intermediate grade of lymphoma is thought to deregulate the nearby CCND1(BCL1/PRAD1) proto-oncogene, which is a member of the cyclin family.43'44 Median survival ranges from 2 to 5 years following diagnosis. Responses to chemotherapy are seen in half of the patients and long-term survival is uncommon. Patients with the t(ll;14) rearrangement frequently develop a

Figure 9.2 Translocation 14/18 t(!4;18)(q32;q21). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in follicular lymphoma and in some highgrade NHLs. IgH = immunoglobulin heavy-chain gene, bd-2 - bd-2 proto-oncogene.

Non-Hodgkin's lymphoma 95 Figure 9.3 Translation 3/14 t(3;14)(q27;q32). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in diffuse large cell lymphoma. IgH = immunoglobulin heavy-chain gene, bcl-6 = bcl-6 oncogene.

Figure 9.4 Translocation 11/14-t(l1;l4)(q13;q32). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in centrocytic or mantle cell lymphoma. IgH = immunoglobulin heavy-chain gene, bcl-3 - bcl-3 oncogene.

96 Cytogenetics

leukemic phase. Nearly all lymphomas with a t(ll;14) are B cell diseases.

Translocation 9/14 - t(9;14)(p13;q32)

(FigJ).^ The t(9;14) is associated with small lymphocytic lymphoma with plasmacytoid differentiation, according to the Working Formulation (lympho plasmacytoid lymphoma (LPL) according to Revised European-American Classification of Lymphoid Neoplasms [REAL]), a subtype of B cell NHL.45,46 The PAX-5 gene which encodes a B cell specific transcription factor involved in the control of B cell proliferation and differentiation is the target of the t(9;14) in LPL whereby its expression may be deregulated by juxtaposition to IgH regulatory elements, thus contributing to lymphomagenesis.47 The disease follows an indolent clinical course.48

Translocation 2/5 - t(2;5)(p23;q35) (Fig. 9.7) The t(2;5) results in the fusion of the amino terminus of the nucleophosmin gene (NPM) on chromosome 5q35 with the anaplastic lymphoma kinase (ALK) gene on chromosome 2p2356 and leads to the constitutive expression of a truncated form of ALK protein p80. This is frequently associated with Ki-1 (CD30)-positive anaplastic large cell lymphoma.56'57 Of all CD30+ anaplastic large cell lymphomas, approximately 36 per cent have a detectable t(2;5)(p23;q35) with a higher incidence in childhood cases and cases with a non-B cell phenotype.58 This is a group of morphologically and immunotypically heterogeneous high-grade large cell lymphomas.58-63 Ki-1-positive lymphomas associated with the t(2;5) rearrangement are almost exclusively T cell diseases. Patients with Ki-l+ anaplastic large cell lymphoma with the t(2;5), have a favorable prognosis and a higher 5-year survival rate, compared to anaplastic large cell cases without the t(2;5).64-65

Translocation 11/18 - t(11;18)(q21;q21) 14q11 clpnal rearrangements-t(14)(q11)

fig 9.6—__________lesions (Fig. 9.8) The t(ll;18) is a frequent and specific chromosomal translocation in low-grade but not high-grade malignant NHLs of the mucosa associated lymphoid tissue (MALT) type.49"52 The molecular equivalent of the t( 11; 18) (q21 ;q21) is yet to be determined. No rearrangements of bd-2 gene, localized in 18q21, have been demonstrated in MALT lymphomas thus far53'55 or in cases cytogenetically positive for the t( 11;18). The primary extra-nodal malignant NHL arising from MALT represents a subtype of B cell lymphoid malignancies and is often associated with a favorable prognosis.

The t(ll;14)(pl3;qll), the t(8;14)(q24;qll), the inv(14)(qllql2) and other 14qll rearrangements result in a rearrangement of the T cell alpha- and delta-chain receptor genes (TCRA and TCRD) at the 14qll region, which deregulates the T cell receptor gene, resulting in a T cell neoplasm. The T cell receptor genes are highly and specifically expressed only in T cells. There are also other chromosomal regions on chromosomes 1, 7, 8, 10, 11 and 14, which, when translocated to the T cell receptor region at 14ql 1, result in a T cell lymphoma process.5,9,10,12

Figure 9.5 Translocation 9/14 t(9;14)(p!3;q32). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in small lymphocytic lymphoma with plasmacytoid differentiation [lympho plasmacytoid lymphoma (LPL)]. PAX5 = paired homeobox-5 gene, IgH = Immunoglobulin heavy chain gene.

Non-Hodgkin's lymphoma 97 Figure 9.6 Translocation 77/78t(11;18)(q21;q21). Ideogram showing critical chromosome breakpoints which, when rearranged, have been implicated in low-grade B-cell lymphomas of the (MALT mucosa associated lymphoid tissue) type.

Additional chromosome abnormalities in NHLs Compared to the leukemias, where there are one or a very few chromosome lesions in the neoplastic clone, lymphomas commonly involve numerous chromosome

rearrangements and other abnormalities. This increases the challenge for cytogeneticists to determine which chromosome rearrangements are primary, and which are secondary or progressive changes. The chromosome rearrangements summarized in Table 9.1 are thought to be primary events in lymphomagenesis; however, there

Figure 9.7 Translocation 2/5 t(2;5)(p23;q35). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in high-grade large cell lymphoma. ALK = anaplastic lymphoma kinase gene, NPM = amino-terminus of nucleophosmin gene.

98 Cytogenetics

Figure 9.8

14q1l clonal

rearrangements - rea(T4)(qll). Ideogram showing critical chromosome breakpoints and associated genes, which, when rearranged, have been implicated in Tcell lymphoma. TCRA - T cell alpha-chain receptor gene, TCRD - Tcell delta-chain receptor gene.

are undoubtedly others involved as primary events in this disease process. It is thought that the reciprocal (balanced) translocations or inversions represent primary chromosome abnormalities of pathogenic importance. In contrast, the unbalanced translocations resulting into trisomies or monosomies of chromosomal regions may constitute secondary or progression-related

abnormalities in NHL. There have been numerous relatively large series of cytogenetic studies on lymphomas.5'12 Some of the common lymphoma breakpoints and oncogene locations are summarized in Fig. 9.9. Among these series, some of the more common structural chromosome abnormalities, in addition to those previously mentioned, include rearrangements at lq21-23, lp32-36, 6pll, 6q21-25, 9p21-23, 10q22-24, llq!3-23, 19pl3, an additional chromosome 17 or isochromosome for the long-arm of chromosome 17, as well as trisomy 3, 7,12,20 per cent and 21. Some investigators have emphasized the correlation of trisomies of certain chromosomes or deletions of chromosomal regions with specific histologic subsets of NHLs,66"70 however, these have been frequently observed as secondary changes in addition to other lymphoma associated chromosomal translocation. Deletion 7q32 is associated with a subset of small lymphocytic lymphoma with plasmocytoid features.71 Deletion of 6q21-23 is associated with a subset of small lymphocytic NHL,72 and deletion llq is associated with small lymphocytic lymphoma.73 Isochromosome 7q and trisomy 8 have been reported in hepatosplenic T gamma/delta peripheral T cell

Figure 9.9 Summary of common lymphoma breakpoints and oncogene locations. The numbers on the left represent approximate number of cases with rearrangements/500 total cases studied at University of Nebraska Medical Center [this does not include cases with t(2;5), t(3;14), t(8;14), t(11;14) or t(14;!8) rearrangements]; - = loci of described proto-oncogenes, oncogenes and critical regions associated with lymphomagenesis.

Future studies 99

lymphoma and isochromosome 7q is thought to be primary nonrandom abnormality.74'75 There is also a relatively large group of patients (approximately 10 per cent) with additional chromosome material translocated to the IgH region of 14q32, which does not involve chromosomes 2, 3, 8, 11 or 18, and most likely represents other groups of primary chromosome rearrangements, which have not yet been adequately studied.12,76,77 Additionally, some of the Ip and 6q rearrangements represent additional primary/secondary chromosome lesions that have been studied cytogenetically or molecularly.78"83 Chromosome regions lp35-36,5qll, 6q21,9p24,12ql3, 13qll, 15pll, 15q21-24 have been reported (in at least two different cases) in reciprocal or balanced translocations with 14q32 or 22ql 1, the regions containing the IgH and IgK loci, respectively.84 These regions may be sites of putative oncogenes, which are activated through juxtaposition to Ig loci and may be potentially important in lymphomagenesis. Thirty per cent of cases in a UK series of lymphomas have also been shown to contain additional X chromosomes.85 Although structural changes affecting the X chromosome are infrequent, the regions most commonly involved are X p22 and X q28.86 Investigation of secondary cytogenetic abnormalities has been addressed by performing serial biopsies on NHL patients.11'87'88 Another approach has been that of analysing chromosome rearrangements that have occurred in conjunction with those chromosomal lesions known to be a primary event.7 These studies have revealed that some of the more common secondary numerical abnormalities include trisomy for chromosomes 3, 7, 8,9,12,17,18, 20 and 21. Some of the more common probable secondary structural abnormalities include isochromosomes Iq, 6p and 17q89 and rearrangements involving lp21-22, lq21-22, Ip36, 2q21, 6ql3, 6q21, 10q22-24.

CLINICAL AND PROGNOSTIC CORRELATIONS A number of studies have attempted to correlate specific chromosome abnormalities with clinical and prognostic factors7,11,68,90-93 (Table 9.2). Although the t(14;18) is the most common abnormality in NHL, it is more frequently seen in follicular histology than in diffuse histology, but most studies have been unable to agree upon whether a correlation with clinical outcome exists. However, other secondary abnormalities, occurring with the t(14;18), have revealed that either an additional chromosome 21 or isochromosome of the large arm of chromosome 17 is associated with a shorter survival.94 Trisomy 7, in conjunction with a t( 14;18), is associated with a diffuse histological pattern, rather than a follicular pattern. Also, an additional der(18)t(14;18) and trisomy 12 are associated with disease progression. On the other hand, absence of the t(14;18) but presence of 6q rearrangements is associ-

ated with shorter survivals.11,95 Involvement of lq21-22 was also significantly associated with poor survival in patients with an intermediate or high-grade disease. Patients with Ki-l+ anaplastic large cell lymphoma with the t(2;5) have a favorable prognosis compared to anaplastic large cell cases without the t(2;5).64 Shorter survivals were also correlated with trisomy 5, 6, 18, and any rearrangement of chromosome 5 or a breakpoint at 14qll-12.8 The 13ql4 deletions have been correlated with low complete remission rate and poor survival.96,97,98 Also, in general, the more complex the karyotype, the poorer the prognosis.99 Additionally, patients with normal metaphases tend to survive longer than those with only abnormal cells, with the possible exception of Hodgkin's disease.15 If the cytogenetically normal cells represent non-neoplastic cells, the frequency of abnormal cells compared to normal cells may imply an immune response to the tumor or may reflect a smaller tumor burden than was presumed and thereby reflect a longer survival.

FUTURE STUDIES The role of cytogenetic changes in lymphomagenesis has been addressed by numerous studies and investigators. Specific primary chromosome abnormalities have been described in the lymphomagenesis process and numerous secondary abnormalities are known to be associated with prognosis and clinical outcome. Cytogenetic elucidation of the lymphomas has been somewhat hampered by the complexity of chromosome abnormalities in lymphomas compared to other hematological neoplastic processes, by frequent less than ideal chromosome morphology and, to some extent, by inconsistency of histological and cytogenetic classification by different research groups. It is imperative that there is a marriage between cytogenetics and molecular biology to elucidate the chromosome rearrangements that have proved to be important in lymphomagenesis and lymphoma progression. It is important that cytogeneticists and molecular biologists communicate closely and collaborate in studying the genetic role of lymphomagenesis and lymphoma progression as well as the association of specific chromosome rearrangements with potential treatment modalities. Chromosome rearrangements that previously could not be defined by classic cytogenetics can now be classified in view of the relatively recent fluorescent FISH methodologies that are utilized increasingly by cytogenetics laboratories.76,78-80,100-104 Plate 60 depicts the presence of a t(14;18) in a metaphase preparation utilizing FISH procedures incorporating a two-color whole chromosome painting and telomere probe assay. Also, in the large number of patients with translocations of unidentifiable material to 14q32 and to other critical chromosome regions, the previously unknown chromosome material can now be ascertained by utilizing some

100 Cytogenetics

of the new FISH technologies,76,78,100,102 including comparative genomic hybridization (CGH) and multicolor FISH.105-107 Plate 61 depicits multicolor FISH analysis of an NHL case which could not be clearly resolved by cytogenetics alone. Likewise, with the development of additional probes, some of the chromosome rearrangements can be more meticulously elucidated by the polymerase chain reaction and other molecular techniques. This must, of course, be correlated and compared with cytogenetic observations. It is quite likely, as we begin to better understand the nature of chromosome rearrangements that cause the loss of cell control in the lymphoma process, that specific and effective treatment modalities be considered for each different type of primary chromosomal rearrangement associated with the lymphoma process. It is becoming more apparent, with the development of non-conventional therapeutics, that specific treatment modalities might be developed for each subtype of lymphoma, based on the specific cytogenetic and/or molecular lesion present.108 In order for us to better understand this spectrum of lymphoma diseases, and to improve disease management, it is mandatory that clinicians, pathologists, molecular biologists, cytogeneticists and researchers in other disciplines collaborate closely, communicate and pursue appropriate clinical trials based on solid biological logic.

5. Bloomfield CD, Arthur DC, Frizzera G, Levine EG, Peterson BA, Gajl-Peczalska KJ. Nonrandom chromosome abnormalities in lymphoma. Cancer Res 1983;43:2975-84. 6. Yunis JJ, Oken MM, Theologides A, Howe RB, Kaplan ME. Recurrent chromosomal defects are found in most patients with non-Hodgkin's lymphoma. Cancer Genet Cytogenet 1984; 13:17-28. 7. Armitage JO, Sanger WG, Weisenburger DD, et al. Correlation of secondary cytogenetic abnormalities with histologic appearances in non-Hodgkin's lymphomas bearing t(14;18)(q32;q21).y Natl Cancer Inst 1988; 80: 576-80. 8. Schouten HC, Sanger WG, Weisenburger DD, Armitage JO. Chromosomal abnormalities in untreated patients with non-Hodgkin's lymphoma: associations with histology, clinical characteristics and treatment outcome. B/ood1990; 75:1841-7. 9. Juneja S, Lukeis R, Tan L, et al. Cytogenetic analysis of 147 cases of non-Hodgkin's lymphoma: non-random chromosomal abnormalities and histological correlations. BrJ Haematol 1990; 76: 231-7. 10. Offit K, Wong G, Filippa DA, Tao Y, Chaganti RS. Cytogenetic analysis of 434 consecutively ascertained specimens of non-Hodgkin's lymphoma: clinical correlations. Blood 1991; 77:1508-15. 11. Whang-Peng J, Knutsen T, Jeffe ES, et al. Sequential

ACKNOWLEDGEMENTS

analysis of 43 patients with non-Hodgkin's lymphoma: clinical correlations with cytogenetic, histologic, immunophenotyping, and molecular studies. Blood

The authors gratefully acknowledge the grant support from the National Cancer Institute (USPHS CA36727), the Department of Health and Human Services, Bethesda, MD, USA, and the Leukemia and Lymphoma Society of America, USA (LSA 6032-99). Thanks to Kathy Olin for her skills in the typing and editing of this chapter, as well as special thanks for the assistance of Michelle Hess, Diane Pickering and Christine Higgins for their help with some of the illustrations.

1995;85:203-16. 12. Sanger WG, and the Nebraska Lymphoma Group. Current Nebraska Lymphoma Study Group database including 1200 lymphoma cases. 1995. 13. Mitelman F (ed). ISCN: An International System for Human Cytogenetic Nomenclature. Basel: Karger, 1995. 14. Slavutsky I, de Vinuesa ML, Esteuev ME, Sen L, de Salum SB. Cytogenetic and immunologic phenotype findings in Hodgkin's disease. Cancer Genet Cytogenet 1985; 114: 123-8. 15. Schouten HC, Sanger WG, Duggan M, Weisenburger DD,

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lymphoplasmacytoid lymphoma involves the PAX-5 48. Offit K, Parsa NZ, Jhanwar SC, et al. Clusters of chromosome 9 aberrations are associated with clinicopathologic subsets of non Hodgkin's lymphoma. Genes Chromosomes Cancer 1993; 7:1-7. 49. Griffin CA, Zehnbauer BA, Beschorner WE, et al. t(11;18)(q21;q21) is a recurrent chromosome abnormality in small lymphocytic lymphoma. Genes Chromosomes Cancer 1992; 4:153-7.

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65. Shiota M, Nakamura S, Ichinohasama R, etal. Anaplastic large cell lymphomas expressing the novel chimeric protein p80 NPM/ALK: a distinct clinicopathologic entity. Blood 1995; 86:1954-60. 66. Wotherspoon AC, Finn TM, Isaacson PG. Trisomy 3 in low-grade B-cell lymphomas of mucosa-associated lymphoid tissue. Blood 1995; 85: 2000-4. 67. Brynes RK, Almaguer PD, Leathery KE, et al. Numerical cytogenetic abnormalities of chromosomes 3, 7 and 12 in marginal zone B-cell lymphomas. Modem Pathol 1996; 9: 995-1000. 68. Offit K, Jhanwar SC, Ladanyi M, et al. Cytogenetic analysis of 434 consecutively ascertained specimens of non-Hodgkin's lymphoma: correlations between recurrent aberrations, histology, and exposure to cytotoxic treatment. Genes Chromosomes Cancer 1991; 3:189-201. 69. Cabanillas F, Pathak S, Trujillo J, et al. Frequent nonrandom chromosome abnormalities in 27 patients with untreated large cell lymphoma and immunoblastic lymphoma. Cancer Res 1988; 48: 5557-64. 70. Fifth International Workshop on Chromosomes in Leukemia-Lymphoma. Correlation of chromosome abnormalities with histologicand immunologic characteristics in non-Hodgkin's lymphoma and adult T-cell leukemia-lymphoma. Blood ^37, 70:1554-64. 71. Offit K, Louie DC, Parsa NZ, etal. Del(7)(q32) is associated with a subset of small lymphocytic lymphoma with plasmacytoid features. Blood 1995; 86: 2365-70. 72. Offit K, Louie DC, Parsa NZ, etal. Clinical and morphologic features of B-cell small lymphocytic lymphoma with del(6)(q21q23). Blood 1994; 83: 2611-8. 73. Mrozek K, Bloomfield CD. Cytogenetics of indolent lymphomas. Seminars in Oncol 1993; 20: 47-57. 74. Wang CC, Tien HF, Lin MT, et al. Consistent presence of isochromosome7q in hepatosplenicT gamma/delta lymphoma: a new cytogenetic-clinicopathologic entity. Genes Chromosomes Cancer 1995; 12:161^. 75. Yao M, Tien HF, Lin MT, et al. Clinical and hematological characteristics of hepatosplenic T gamma/delta lymphoma with isochromosome for long arm of chromosome 7. Leuk Lymphoma 1996; 22: 495-500. 76. Arcaroli JA, Dave BJ, Pickering DL, et al. Is duplication 14q32 a new recurrent alteration in non-Hodgkin's lymphoma? Cancer Genet Cytogenet 1999; 113:19-24. 77. Nakamine H, Masih AS, Chan WC, Sanger WG, Armitage JO, Weisenburger DD. Oncogene rearrangement in nonHodgkin's lymphoma with a 14q+ chromosome of unknown origin. Lymphoma Leuk 1993; 10: 79-88. 78. Dave BJ, Hess MM, Pickering DL, etal. Rearrangements of chromosome band 1p36 in non-Hodgkin's lymphoma. Clinical Cancer Res 1999; 5:1401-9. 79. Dave BJ Pickering DL, Hess MM, etal. Deletion of Cell Division Cycle 2 Like 1 gene locus on chromosome 1p36 in non-Hodgkin's lymphoma. Cancer Genet Cytogenet 1999; 108:120-6.

References 103 80. Zhang Q, Siebert R, Van M, et al. Inactivating mutations and overexpression of BCL10, a caspase recruitment domain-containing gene, in MALT lymphoma with t(1;14)(p22;q32). Nature Genet 1999; 22: 63-8. 81. Guan XY, Horsman D, Zhang HE, etal. Localization by chromosome microdissection of a recurrent breakpoint region on chromosome 6 in human B-cell lymphoma. Blood 1996; 88:1418-22. 82. Vitolo U, Gaidano G, Botto B, et al. Rearrangements of bcl-6, bcl-2, c-myc and 6q deletion in B-diffuse largecell lymphoma: clinical relevance in 71 patients. Ann Oncol 1998; 9: 55-61. 83. Zhang Y, Matthiesen P, Harder S, et al. A 3-cM commonly deleted region in 6q21 in leukemias and lymphomas delineated by fluorescence in situ hybridization. Genes Chromosomes Cancer 2000; 27: 52-8. 84. Mrozek K, Bloomfield CD. New recurrent structural chromosome aberrations in non-Hodgkin's lymphoma: a review of the published literature. Int J Oncol 1996; 8: 851-8. 85. Hammond DW, Goepel JR, Aitken M, Hancock BW, Potter AM, Goyns MH. Cytogenetic analysis of a United Kingdom series of non-Hodgkin's lymphomas. Cancer Genet Cytogenet 1992; 61: 31-8. 86. Goyns MH, Hammond DW, Harrison CJ, Menasce LP, Ross F, Hancock BW. Structural abnormalities of the X chromosome in non-Hodgkin's lymphoma. Leukemia 1993; 7: 848-52. 87. Sanger WG, Armitage JO, Bridge JA. Weisenburger DD, Fordyce R, and Purtilo DT. Initial and subsequent cytogenetic studies in malignant lymphoma. Cancer 1987; 60: 3014-19. 88. Levine EG, Juneja S, Arthur D, et al. Sequentional karyotypes in non-Hodgkin's lymphoma: their nature and significance. Genes Chromosomes Cancer 1990; 1: 270-80. 89. Mertens F, Johansson B, Mitelman F. Isochromosomes in neoplasia. Genes Chromosomes Cancer 1994; 10: 221-30. 90. Offit K, Chaganti RS. Chromosomal aberrations in nonHodgkin's lymphoma. Biological and clinical correlations. Hematol Oncol Clinic North America 1991; 5: 853-69. 91. Levine EG, Arthur DC, Frizzera G, et al. Cytogenetic abnormalities predict clinical outcome in non-Hodgkin's lymphoma. Ann Intern Med 1988; 108:14-20. 92. Cabanillas F, Pathak S, Grant G, et al. Refractoriness to chemotherapy and poor survival related to abnormalities of chromosomes 17 and 7 in lymphoma. Am J Med 1989; 87:167-72. 93. Johansson B, Mertens f, Mitelman F. Cytogenetic evolution patterns in non-Hodgkin's lymphoma. Blood 1995; 86: 3905-14. 94. Weisenburger DD, Gascoyne RD, Bierman PJ, et al. Clinical significance of the t(14;18) and BCL2 overexpression in follicular large cell lymphoma. Leuk Lymphoma 2000; 36: 513-23.

95. Schouten H, Sanger WG, Weisenburger DD, Armitage JO. Abnormalities involving chromosome 6 in newly diagnosed patients with non-Hodgkin's lymphoma. Cancer Genet Cytogenet 1990; 47: 73-89. 96. Cuneo A, Bigoni, R, Rigolin GM,et al. 13q14 deletion in non-Hodgkin's lymphoma: correlation with clinicopathologic features. Haematologica 1999; 84: 589-93. 97. Wada M, Okamura T, Okada M, etal. Frequent chromosome arm 13q deletion in aggressive nonHodgkin's lymphoma. Leukemia 1999; 13: 792-8. 98. Rosenwald A, Ott G, Krumdiek AK, et al. A biological role for deletions in chromosomal band 13q14 in mantle cell and peripheral t-cell lymphomas? Genes Chromosomes Cflncer 1999; 26: 210-4. 99. Tilly H, Rossi A, Stamatoullas A, et al. Prognostic value of chromosomal abnormalities in follicular lymphoma. Blood 1994; 84:1043-9. 100. Bajalica S, Sorenson AG, Pederson NT, Heim S, Brodrum-Nielson K. Chromosome painting as a supplement to cytogenetic banding analysis in nonHodgkin's lymphoma. Genes Chromosomes Cancer 1993; 7:231-9. 101. Hammond DW, Hancock BW, Goyns MH. Chromosome analysis of non-Hodgkin's lymphomas by fluorescence in-situ hybridization. Ann Oncol 1994; 5 (suppl 1): 51-4. 102. Hammond DW, Hancock BW, Goyns MH. Analysis of 14q+ derivative chromosomes in non-Hodgkin's lymphomas by fluorescent in-situ hybridization. Leuk Lymphoma 1995; 20:111-7. 103. Zhang Y, Weber-Matthiesen K, Siebert R, et al. Frequent deletions of 6q23-24 in B-cell non-Hodgkin's lymphomas detected by fluorescence in situ hybridization. Genes Chromosomes Cancer 1997; 18: 310-3. 104. Mathew P, Sanger WG, Weisenburger DD, et al. Detection of the t(2;5)(p23;q35) and NPM-ALK fusion in nonHodgkin's lymphoma by two color fluorescence in situ hybridization. Blood 1997; 89:1678-85. 105. Peters K, Zettl A, Starostik P, et al. Genetic imbalances in primary gastric diffuse large B-cell lymphomas: comparison of comparative genomic hybridization, microsatellite, and cytogenetic analysis. Diagn Mol Pathol 2000; 9: 58-65. 106. Alqahtani MH, Hammond DW, Goepel JR, Goyns MH. Cytogenetic analysis of non-Hodgkin's lymphomas by ratio-painting and comparative genomic hybridization reveals unsuspected chromosomal abnormalities. Leuk Lymphoma 1999; 35: 325-37. 107. Hilgenfeld E, Padilla-Nash H, Schrock E, Reid T. Analysis of B-cell neoplasias by special karotyping (SKY). Curr Top Microbiol Immunol 1999; 246:169-74. 108. Hammond DW, Hancock BW, Goyns MH. Clinical implications of molecular and cytogenetic studies of non-Hodgkin's lymphomas. Cancer Treat Rev 1998; 24: 157-63.

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Pathogenesis

Hodgkin's disease Viruses and malignant lymphoma Molecular biology

107 115 133

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10 Hodgkin's disease VDIEHL AND J WOLF

Introduction Hodgkin's disease: a malignant proliferation of Hodgkin/Reed-Sternberg cells

107 107

INTRODUCTION There is still a discrepancy between the impressive success of radiation therapy and/or chemotherapy in the treatment of Hodgkin's lymphoma and the lack of understanding of the pathogenetic essential events of this disease, which unusually combines the features of a neoplasm with those of an inflammatory/infectious process. The main reason for this is that methodological problems occur, owing to the scarcity of the Hodgkin/Reed-Sternberg (H-RS) cells in affected lymphatic tissue and their poor outgrowth in vitro and in vivo. Isolation of single H-RS cells from frozen lymph node sections or cytospin preparations followed by enzymatic amplification of their nucleic acids (H-RS single-cell polymerase chain reaction; PCR) provides an opportunity to perform specific genetic analyses of the H-RS cells as well as of their bystander cells. Using this new method, the monoclonal B cell origin of H-RS cells could be demonstrated, at least in the majority of cases analysed. Although Hodgkin's disease can be understood now as a monoclonal B cell disorder, the mechanism of transformation is still unclear. New cytogenetic techniques, such as combined immunophenotyping and fluorescence in situ hybridization (FISH), show that all H-RS cells have structural and/or numerical, but not consistent, chromosomal aberrations. Cytogenetic instability might thus represent one pathogenetic factor in Hodgkin's disease. Epstein-Barr virus (EBV) infection of H-RS cells has now been confirmed in about 50 per cent of cases in industrialized countries and in up to 95 per cent in developing countries. EBV-positive H-RS cells express the viral latent protein LMP with transforming as well as (T cell) immunogenic functions. Activated T helper cells represent the majority of lymphocytes

Hodgkin's disease: an atypical immune reaction

110

Conclusions

111

References

112

surrounding H-RS cells. The H-RS cells themselves express all accessory molecules necessary for efficient T cell recruitment. Thus, in the initial stages of Hodgkin's disease a pronounced but inefficient T cell reaction against a target antigen (LMP in EBV-positive cases?) expressed on H-RS cells seems to take place.

HODGKIN'S DISEASE: A MALIGNANT PROLIFERATION OF HODGKIN/REED-STERNBERG CELLS Lineage origin and cionality Lymph nodes affected by Hodgkin's disease (HD) consist of a heterogeneous mixture of lymphocytes, histiocytes, eosinophils, plasma cells, fibroblasts and other cells. The mononuclear Hodgkin cells and their polynucleated counterparts, the Reed-Sternberg cells, are considered to represent the malignant substrate of classical HD, which summarizes the nodular sclerosing subtype (NSHD), the mixed cellularity subtype (MCHD) and the lymphocyte-depleted subtype (LDHD). Hodgkin/ Reed-Sternberg cells represent only 0.1-1 per cent of the entire cell population in classical HD.1 In the lymphocyte-predominant subtype of HD (LPHD), the lymphocytic and histiocytic (L & H) cells represent the malignant population and consistently express B cell specific surface antigens (CD 19, CD 20). In classical HD, H-RS cells in the majority of cases express the activation markers Ki-1 (CD 30), the Leu-Mi antigen (CD 15), the interleukin-2 receptor (CD 25), the transferrin receptor (CD 71) and HLA class II molecules (HLA-DR), but not surface antigens, which might help unequivocally to determine their cell of origin (Table

108 Hodgkin's disease

Table 10.1 Immunophenotyping of H-RS cells in biopsies:" frequency of cases (per cent) with expression of a given marker dependent on histological subtype

Activation markers CD 30 (KM) CD15(LeuM1) CD25(IL2-R) CD 71 (transferrin-R) HLA-DR

84-91 76-85 82-86 64-94 95-97

32 28 100 89 83

13-30 0(LD)-19

77 88

17-34 13-21 24-33 1-6

5 12 5 6

B cell markers CD 20 CD 75

T cell markers CD 2 CD 3 CD 4

CDS

Monocytes/macrophages CD11b 0 2-14 CD 14

0 0

a

See also Drexler et al. (1992). NS = nodular sclerosis, LP = lymphocyte depleted, MC = mixed cellularity, LP = lymphocyte predominant.

10.1).2'3 Expression of B cell specific and of T cell specific antigens as well as the absence of both have been described. Similiarly, analysis for immunoglobulin (Ig) gene or T cell receptor (TCR) gene rearrangements using Southern blotting has revealed heterogeneous results concerning the cell of origin and clonality.4'6 A methodological breakthrough in the genetic analysis of H-RS cells represents micromanipulation of single H-RS cells from frozen biopsy sections or cytospin preparations, and subsequent enzymatic amplification of their DMA (H-RS single-cell PCR).7'8 Kiippers et al. isolated single H-RS cells from frozen lymph-node sections (Plate 62).7 In all of three cases analysed (nodular sclerosis, lymphocyte predominant and mixed cellularity) clonal rearrangements of genes encoding for Ig heavy chains (VH) could be detected; in addition, in one of these cases a light-chain gene rearrangement was found. Recently, these studies were extended on 11 further cases of HD. In 10 of these cases, clonal Ig gene rearrangements also could be detected.9'10 Using the same method, Hummel et al. studied 12 cases of HD with the B cell immunophenotype for Ig gene heavychain rearrangements.11 In three cases identical (monoclonal) rearrangements were found, in six cases heterogenous (polyclonal) rearrangements and in three cases monoclonal as well as polyclonal rearrangements. However, a reanalysis of four of the polyclonal cases revealed a clonal H-RS cell population in two cases.12

Delabie et al. analysed single cells resuspended from formalin-fixed, paraffin-embedded lymph-node specimens from patients with LPHD. In four cases polyclonal Ig gene rearrangements were described.13 Similarly, only polyclonal Ig gene rearrangements were found by this group in three cases of NSHD with a B cell immunophenotype, while in three cases without expression of lineage-specific antigens (null-phenotype), no Ig gene rearrangement could be amplified.14 Since it could not be ruled out, however, that the specific method used for isolating the tumor cells (see earlier) led to nondetection of clonal Ig gene rearrangements, this group performed another study with micromanipulation of single cells from frozen tissue sections. In five cases of LPHD clonally related Ig gene rearrangements were detected in L & H cells.15 The finding of clonal L & H cell populations was confirmed in further cases of LPHD by others.4'16 In summary, the results of single-cell analysis obtained so far suggest that both H-RS cells in classical HD and L & H cells in LPHD are clonal B cells. The view of HD as a clonal B cell disorder is further supported by the detection of clonally identical H-RS cells in the first diagnosis and disseminated relapse of a patient with MCHD17'18 as well as by the detection of clonal EBV genomes19 and of clonal cytogenetic aberrations20 in H-RS cells obtained from different lymph nodes of the same patient, and in different nodules in one node of NSHD.21 DNA sequence analysis of the rearranged Ig genes in LPHD revealed ongoing mutations in 14 out of 21 cases.4,15,16 These observations suggest that L & H cells are germinal-center-derived B cells and that their growth is dependent on antigen binding and selection, comparable to follicular lymphoma cells. In contrast, H-RS cells in classical HD accumulate 'crippling' somatic mutations within their rearranged Ig genes, which prevent antibody expression.10 Thus, most probably, H-RS cells also derive from germinal center B cells. However, they seem to proliferate independently from antigen selection and antibody expression. Physiologically, germinal center B cells with 'crippling' mutations are eliminated by apoptosis. A still unknown mechanism seems to prevent apoptotic death of H-RS cells. Initially studies suggested that H-RS cells showed no telomerase activity implying that they might require novel mechanisms to remain immortal.22 Further work shows that they maintain telomerase but that ribonucleases released by eosinophils degrade the telomerase message leading to misleading negative results.23

Genetic aberrations The questions regarding lineage origin and clonality of H-RS cells are not the only ones to remain unanswered for a long time. Similarly, no consistent cytogenetic aberration with specific alteration of gene expression could

Malignant proliferation of H-RS cells 109

be identified, for instance in Burkitt's lymphoma, follicular lymphoma or chronic myeloid leukemia. Even analysis of gene expression in H-RS cells using the single cell technique revealed no specific pattern.8 In 1995, the presence of npm-alk fusion transcripts was described in H-RS cells.24 These transcripts, which are translated into a protein with tyrosine kinase activity, result from a chromosomal translocation (2;5) and are consistently found in anaplastic large cell lymphoma (ALCL). Other groups, however, could not confirm these results in HD, either by detection of npm-alk transcripts using reverse transcription PCR (RT-PCR) or by immunostaining of the resulting fusion protein.25-27 Conventional karyotype analysis of H-RS cells is hampered by their paucity in affected tissue and their low proliferation rate. Thus, only in a proportion of the cases analysed have clonal chromosomal aberrations been described in H-RS cells.28-30 Tilly et al. karyotyped 60 lymph nodes from untreated HD patients.31 In 82 per cent of the analysable cases, metaphases were obtained, and in 55 per cent numerical and/or structural aberrations were detected. Although some aberrations occurred more frequently than others (e.g. loss of chromosome 13), no consistent change was found. It also remains an open question whether all of these aberrations have been derived from H-RS cells or whether they might also be present in the surrounding bystander cells. The latter possibility may be underlined by transplantation of lymph node and liver specimens affected by HD under the subrenal capsule of T and B cell-deficient severe combined immunodeficient (SCID) mice. In these experiments EBV-positive B cell tumors grew out. These B lymphoblasts had a high frequency of numerical and structural chromosomal aberrations, which are not found in 'normal' EBV-immortalized B cells.32 In situ hybridization studies have suggested chromosomal abnormalities in morphologically normal cells in HD next to H-RS cells.33 Furthermore, cells with the morphology of small lymphocytes in chronic lymphocytic leukemia (CLL) can evolve to H-RS-like cells in Richter's syndrome ('Hodgkin transformation of CLL') and display identical genotypes.34 These observations point to the presence of karyotypically abnormal (semimalignant?) B cells in the surroundings of the H-RS cells, which gain a growth advantage after transplantation into SCID mice. HD-specific problems of conventional cytogenetics may be partly solved by simultaneous FISH and immunophenotyping. This method allows the specific analysis of chromosomal aberrations in CD 30-positive cells. Using this method, Weber-Matthiesen et al35 analysed 30 HD cases. While in 21 of these cases no aberrations could be demonstrated with conventional karyotyping, in all cases numerical chromosomal aberrations could be detected by combined immunophenotyping and FISH. The variability of the described

aberrations, furthermore, confirms the model of genetic instability as one pathogenetic factor in HD (see also later text).

Cell lines and animal models In numerous human neoplasias, the establishment of an animal model allowed the biological and genetic characterization of the tumor cell population. In contrast, outgrowth of a permanent cell line represents an extremely rare event in HD. So far, only 15 cell lines have been established, which may be regarded as HD-derived. Analysis of immunophenotype, karyotype, Ig or TCR gene rearrangements of these cell lines revealed heterogeneous results analogous to analysis of primary tissue. Expression of CD 30, CD 15 and CD 71 is also found on the cell lines, but there is no consistent feature to define the cell of origin of HD. Moreover, results obtained with these cell lines were considered controversial since their derivation from H-RS cells could not be determined unequivocally.36,37 A novel cell line (L1236) was established from the peripheral blood of a patient with advanced HD of the mixedcellularity subtype (Plate 63). These cells are EBV-negative and express the HD-associated antigens CD 30, CD 15 and CD 71. They have a near triploid karyotype with numerous structural and numerical chromosomal aberrations. By Southern blot analysis a biallelic rearrangement of the Ig gene heavy chains and a monoallelic kappa light-chain rearrangement were detected.38 Using H-RS single-cell PCR, Kanzler et al. have shown that the genomic sequences of the Ig gene rearrangements of the H-RS cells in the patient's bone marrow were identical to those detected in L1236 cells.9 This cell line thus represents the first HD-derived cell line where the H-RS cell origin of the cells has been proved at the molecular level. It is a further example for the monoclonal B cell origin of H-RS cells and thus represents a valid model for biological studies on B cell Hodgkin's disease. Neither HD-derived cell lines or biopsy material could be grown reproducibly in thymus-aplastic T celldeficient nude mice. In contrast, most of the HDderived cell lines form progressively growing tumors after subcutaneous inoculation into SCID mice.39 Owing to a genetic recombinase defect, these animals lack functional T and B cells. The HD-derived cell lines L540,40 HD-MyZ41 and L123642 have been shown to disseminate intralymphatically after inoculation into SCID mice. This experimental model for the in vivo growth of H-RS cells has been used successfully for the preclinical testing of immunotoxins43 and bispecific antibodies.44 In contrast to numerous non-Hodgkin's lymphomas, no reproducible growth of primary H-RS cells has been observed after transplantation of biopsy material in SCID mice.32

110 Hodgkin's disease

nuclear antigen 1 (EBNA 1) and latent membrane protein (IMP) 1 and 2.57'58 This pattern is identical to that found in nasopharyngeal carcinoma endemic in the South West of China, but differs from other EBVassociated neoplasias, such as endemic Burkitt's lymphoma and immunoblastic B cell non-Hodgkin's lymphoma of immunocompromised patients (Table 10.2). Except for EBNA 1, all latent viral proteins represent targets for cytotoxic T lymphocytes.59 Thus, EBVinfected cells either express the complete set of latent viral genes in an immunocompromised host (immunoblastic NHL) or they downregulate these proteins, except EBNA 1 (Burkitt's lymphoma), possibly to escape the host's immune response. So far, it remains unclear how the specific latent viral gene expression pattern in HD (EBNA 2-, LMP+) and the pronounced T cell proliferation in affected lymph nodes relate to each other. The functional relevance of LMP expression in H-RS cells is not understood. LMP has a transforming potential: transformation of epithelial cells after transfection of LMP has been described and mice transgenic for LMP 1 develop lymphomas.60 In lymphocytes, apoptoses can be prevented by LMP via upregulation of the bcl-2 gene.61 LMP is also a target for cytotoxic T cells. In addition, it upregulates (partly in cooperation with EBNA 2) numerous cellular genes, e.g. activation-associated antigens (CD 23, CD 30, CD 39) and adhesion molecules (ICAM-1, LFA-3). Thus it may render a cell indirectly more immunogenic.62 Knecht et al. described mutations in the carboxy-terminal part of the LMP 1 gene identical to those previously reported in LMP-isolates from Chinese nasopharyngeal carcinoma in some HD cases.63 These authors discussed an association of these mutations with a clinically more aggressive HD phenotype. Jarrett et al. detected EBV in H-RS cells significantly more often in patients under 15 years and over 50 years of age compared to young adults, which in the majority were EBV-negative.40 Possibly infection with another still undefined tumor virus occurs in young adults; alternatively, EBV is lost after initial infection. Recently, in a Burkitt's lymphoma hybrid cell model, it has been shown that integration of EBV into the host cell genome can lead to a region of enhanced chromosomal instability (fragile site) leading to loss of the virus together with adjacent chromosomal fragments.64 It remains to be

HODGKIN'S DISEASE: AN ATYPICAL IMMUNE REACTION

Epidemiology Hodgkin's lymphoma presents with a bimodal age/ incidence distribution dependent on demographic features. Three epidemiological patterns can be distinguished: Type I in developing countries shows a first peak in early childhood, a low incidence in young adults and a second peak in the older age groups; and Type III in industrialized countries is characterized by a low incidence in children, a first peak in young adults and a second peak in the elderly. In rural areas of industrialized countries, an intermediate third type has been described.45'46 As in infection with paralytic poliovirus, children with a low socioeconomic status and young adults with a high socioeconomic status have an increased risk of developing Hodgkin's disease.47 These observations have led to the hypothesis of an infectious agent underlying HD.48

EBV infection Individuals suffering from infectious mononucleosis have a 2-3-fold increased risk of developing HD.46 Elevated IgG and IgA titers against the viral capsid antigen (VGA) have also been shown to be correlated with an increased risk for HD.49 Weiss et al. were the first to detect EBV DNA in lymph nodes affected by HD using Southern blotting.50 Subsequently, different groups using different detection methods (immunohistology, Southern blotting, PCR) have reported different, partly controversial results for the association of HD and EBV. In situ hybridization with Epstein-Barr early RNA (EBER)-specific RNA probes (EBER-ISH) combines high sensitivity with high specificity. EBER 1 and 2 RNAs are small EBV-encoded, non-polyadenylated transcripts of high abundancy (about 106 copies/viral genome).51 With EBER-ISH, about 50 per cent of the HD cases in industrialized countries and up to 95 per cent in developing countries were found to harbor the virus in the H-RS cells.52-56 H-RS cells show a specific expression pattern of the latent viral genes with expression of Epstein-Barr

Table 10.2 Pattern of Epstein-Barr virus latent sene expression in EBV-associated neoplasias

Endemic Burkitt's lymphoma Immunoblastic NHL in immunocompromised patients Hodgkin's lymphoma Endemic nasopharyngeal carcinoma a

+ + + +

+ -

About 50% of cases analysed. EBNA = Epstein-Barr nuclear antigen, LMP = latent membrane protein, NHL = non-Hodgkin's lymphoma.

+ -

+ +a +

Conclusions 111

established whether such a hit-and-run mechanism also occurs in 'EBV-negative' HD of young adults.

H-RS cells as antigen-presenting cells Clinically HD often presents with pronounced signs of an inflammatory reaction, such as night sweats, fever, monocytosis. Interleukin-2 (IL-2) and tumor necrosis factor (TNF) receptor levels in sera are elevated, and associated with aggressive disease in some cases.65'66 In affected lymph nodes the rare H-RS cells are surrounded by a majority of non-malignant bystander cells. The (deregulated?) expression of cytokines in H-RS - and bystander - cells may explain part of the complex interaction between these cells. Eosinophilia in HD, for instance, is caused by IL-5,67 and fibrosis may be triggered by IL-1 and TGF-p.6869 The interleukins 1,6 and 9, which are produced by H-RS cells, might act as autocrine growth factors and as paracrine growth stimulators for T cells.70-72 The T cells themselves could stimulate H-RS cells via IL-2 and IL-6. The CD 30/CD 30 ligand interaction probably has a central role in this complex network. After cloning and sequencing the gene, the CD 30 molecule was identified as a member of the TNF receptor superfamily.73 The CD 30 ligand has also been cloned.74 While the CD 30 antigen is consistently expressed on cells of classical HD and on activated bystander cells, the CD 30 ligand is only expressed on the bystanders (T cells, monocytes, granulocytes), and not on the H-RS cells. In tissue culture, some biological functions of the CD 30/CD 30 ligand interaction have now been characterized:75 mitogenic stimulation of H-RS cells, enhanced cytokine production of H-RS cells and activation of antigen expression of H-RS cells. What is the underlying mechanism of the complex interaction between H-RS cells and bystander cells? The majority of lymphocytes in affected lymphatic tissue are activated T helper cells (CD 4+, CD 45RO+, CD 45RB).76'77 These lymphocytes, not the malignant H-RS cells, represent the population with the highest mitotic index in affected lymph nodes.78 The lymph nodes often grow slowly and show fluctuations in their size in early disease stages. These observations point to a cellular immune reaction as primary reason for the lymph node enlargement in HD. In contrast to benign lymphoproliferative leasons, e.g. reactive lymph nodes, the immune reaction in HD is not self-limiting. One reason therefore might be the inability of the immune system to eliminate the malignant cells expressing the target antigen.79 The recently established HD-derived cell line L1236 (see above) expresses HLA class I and II molecules, B7.1 and B7.2 (CD 80, CD 86), and the adhesion molecules ICAM-1 (CD 54) and LFA-3 (CD 58).38 All these molecules are essential for efficient T cell recruitment (accessory molecules). Expression of HLA antigens76 and of the B7.1 molecule80 has also been

described on H-RS cells in biopsies and on other HDderived cell lines (L428, L540; unpublished observation). The presence of appropriate transporter protein (TAP) and functional EBV antigen presentation has been shown in vitro for HD cell lines.81 The expression pattern of the surface antigens of H-RS cells and their function thus may well be compatible with an antigenpresenting function.

CONCLUSIONS More than 150 years after the first description of Hodgkin's disease there are still more open questions than answers. Micromanipulation of H-RS cells from primary tissue material and subsequent single-cell PCR now makes it possible to characterize these cells specifically at the molecular level. First results are the demonstration of their monoclonal B cell origin, at least in the majority of cases analysed, as well as the demonstration of the H-RS cell origin of a novel cell line (L1236). Further applications of this new technical approach may be the detection of minimal residual disease after therapy, the analysis of H-RS cell-specific genetic markers and the cloning of H-RS cell-specific immunoglobulin gene idiotypes for idiotype vaccination. The ability to fractionate viable H-RS cells from fresh tissue by CD 30based magnetic sorting may now become the basis of further advances.82 The pronounced T cell reaction in affected tissue is still not understood. Is this observation caused by the deregulated cytokine expression of the H-RS cells or does it represent a specific, but inefficient immune reaction against a still-undefined target antigen expressed on H-S cells? Is the inability of the immune system to eliminate the H-RS cells caused by an alteration of the immune system itself or by the stepwise transformation of the H-RS cells resulting in an immune escape mechanism? Is the putative target antigen represented by a virally encoded protein (e.g. LMP) or by a cellular protein (autoimmune disease)? The association between infection with human papillomaviruses and cervical carcinoma, as well as between infection with hepatitis B virus and hepatocellular carcinoma demonstrates that initial infective genesis of a disease and malignant progression do not exclude each other. Hodgkin's disease might be understood as the unsuccessful attempt of the organism to eliminate a growth-deregulated cell expressing a still-undefined (cellular or viral) target antigen. In the course of the disease the inability of the immune system to eliminate this antigen expressing cell coincides with a stepwise transformation of the cell, most probably due to an inherited genetic instability. This process might then lead to aggressive, therapy-refractary Hodgkin's disease in the late stages of the disease (Fig. 10.1).

112 Hodgkin's disease

Figure 10.1 A possible pathway for viral genesis of Germinal center B cell Early stage: Pronounced T cell response without elimination of H-RS cells

Hodgkin's disease and malignant progression.

HD-specific (viral) antigen? Immune defect?

Advanced stage/relapse: Increasing malignant potential of H-RS cells Genetic instability Inactivation of suppressor genes? Activation of oncogenes? Deregulated cytokine/cytokine receptor interaction?

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33. Jansen MP, Hopman AH, Haesevoets AM, etal. Chromosomal abnormalities in Hodgkin's disease are not restricted to Hodgkin/Reed-Sternberg cells.y Pathol 1998; 185:145-52. 34. Ohno T, Smir BN, Weisenburger DD, Gascoyne RD, Hinrichs SD, Chan WC. Origin of the Hodgkin/Reed-Sternberg cells in chronic lymphocytic leukemia with 'Hodgkin's transformation'. Blood 1998; 91:1757-61. 35. Weber-Matthiesen K, DeerbergJ, Poetsch M, etal. Numerical chromosome aberrations are present within the CD30+ Hodgkin and Reed-Stern berg cells in 100% of analyzed cases of Hodgkin's disease. Blood 1995; 86: 1464. 36. Diehl V, von Kalle C, Fonatsch C, et al. The cell of origin of Hodgkin's disease. Semin Oncol 1990; 17: 660.

Hodgkin's disease. N EnglJ Med 1989; 320: 502. 51. Glickman JN, Howe JG, Steitz JA. Structural analysis of EBER1 and EBER2 ribonucleoprotein particles present in Epstein-Barr virus-infected cells. J V/Vo/1988; 52: 902. 52. Herbst H, Steinbrecher E, Niedobitek G, et al. Distribution and phenotype of Epstein-Barr virus-harboring cells in Hodgkin's disease. Blood 1992; 80: 484. 53. Weiss LM, Chen YY, Liu XF, et al. Epstein-Barr virus and Hodgkin's disease. A correlative in situ hybridization and polymerase chain reaction study. AmJ Pathol 1991; 139: 1259. 54. Wu TC, Mann RB, Charache P, etal. Detection of EBV gene expression in Reed-Stern berg cells of Hodgkin's disease. IntJ Cancer 1990; 46: 801.

114 Hodgkin's disease 55. Dolcetti R, Boiocchi M. Epstein-Barr virus in the pathogenesis of Hodgkin's disease. Biomed Pharmacother 1998; 52:13-25. 56. Liu SM, Chow KC, Chiu CF, Tzeng CH. Expression of Epstein-Barr virus in patients with Hodgkin's disease in Taiwan. Cancer 1998; 83: 367-71. 57. Herbst H, Dallenbach F, Hummel M, etal. Epstein-Barr virus latent membrane protein expression in Hodgkin and Reed-Stern berg cells. Proc Natl Acad Scl USA 1991; 88: 4766. 58. Young LS, Rowe M. Epstein-Barr virus, lymphomas and Hodgkin's disease. Semin Cancer Biol 1992; 3: 273. 59. Klein G. Viral latency and transformation: the strategy of Epstein-Barr virus. Cell 1989; 58: 5. 60. Wang D, Liebowitz D, Kieff E. An EBV membrane protein expressed in immortalized lymphocytes transforms established rodent cells. Cell 1985; 43: 831. 61. Gregory CD, Dive C, Henderson S, et al. Activation of Epstein-Barr virus latent genes protects human B cells from death by apoptosis. Nature 1991; 349: 612. 62. Diehl V, Bohlen H, Wolf J. CD30: Cytokine-receptor, differentiation marker or a target molecule for specific immune response? Ann Oncol 1994; 5: 300. 63. Knecht H, Bachmann E, Brousset P, etal. Deletions within the LMP1 oncogene of Epstein-Barr virus are clustered in Hodgkin's disease and identical to those observed in nasopharyngeal carcinoma. Blood 1993; 82: 2937. 64. Wolf J, Jox A, Skarbek H, et al. Selective loss of integrated Epstein Barr virus genomes after long term cultivation of Burkitt's lymphoma x B-lymphoblastoid cell hybrids due to an increased chromatin instability at the integration site. Virology 1995; 212:179-85. 65. Gause A, Roscshansky V, Tschiersch A, et al. Low serum interleukin-2 receptor levels correlate with a good prognosis in patients with Hodgkin's lymphoma. Ann Onto/1991; 2: 43. 66. Warzocha K, Bienvenu J, Ribeiro P, et al. Plasma levels of tumour necrosis factor and its soluble receptors correlate with clinical features and outcome of Hodgkin's disease patients. BrJ Cancer 1998; 77: 2357-62. 67. Samoszuk M, Nansen L. Detection of interleukin-5 messenger RNA in Reed-Stern berg cells of Hodgkin's disease with eosinophiliea. Blood 1990; 75:13. 68. Kadin M, Agnarrson B, Ellingswoth L, etal. Immunohistochemical evidence of a role for transforming growth factor beta in the pathogenesis of

69.

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78.

79. 80.

81.

82.

nodular sclerosing Hodgkin's disease. AmJPathol 1990; 136:1209. Xerri L, Birg F, Giugou V, et al. In situ expression of the IL-1-alpha and TNF-alpha genes by Reed-Stern berg eel Is in Hodgkin's disease. Int J Cancer 1992; 50: 689. Gruss HJ, Brach M, Drexler HG, et al. Interleukin 9 is expressed by primary and cultured Hodgkin and Reed-Stern berg cells. Cancer Res 1992; 52:1026. Jiicker M, Abts H, Ki W, etal. Expression of interleukin-6 and interleukin-6 receptor in Hodgkin's disease. Blood 1991; 77: 2413. Merz H, Houssiau F, Orscheschek K, etal. lnterleukin-9 expression in human malignant lymphomas: unique association with Hodgkin's disease and large cell anaplastic lymphoma. Blood 1991; 78:1311. Durkop H, Latza U, Hummel M, et al. Molecular cloning and expression of a new member of the nerve growth receptor family that is characteristic for Hodgkin's disease. Cell 1992; 69: 421. Smith CA, Gruss HJ, Davis T, et al. CD30 antigen, a marker for Hodgkin's lymphoma, is a receptor whose ligand defines an emerging family of cytokines with homology toTNF.Ce//1993; 73:1349. Gruss HJ, Dower SK. Tumor necrosis factor ligand superfamily: involvement in the pathology of malignant lymphomas. Blood 1995; 85: 3378. Poppema S, Kaleta J, Hepperle B, et al. Biology of Hodgkin's disease. Ann Oncol 1992; 3(suppl 4): 5. Pinto A, Gattei V, Zagonel V et al. Hodgkin's disease: a disorder of dysregulated cellular cross-talk. Biotherapy 1998; 10: 309-20. Peckham MJ, Cooper EH. The cell proliferation characteristic of the various classes of cells in Hodgkin's disease. Cancer 1969; 24:135. Wolf J, Diehl V. Is Hodgkin's disease an infectious disease? Ann Onco/1994; 5(suppl 1): 105. Delabie J, Ceuppens JC, Vandenberghe P, et al. The B7 antigen is expressed by Reed/Sternberg cells of Hodgkin's disease and contributes to the stimulating capacity of Hodgkin derived cell lines. Blood 1993; 82: 2845. Lee SP, Constandinou CM, Thomas WA, et al. Antigen presenting phenotype of Hodgkin Reed-Stern berg cells: analysis of the HLA class I processing pathway and the effects of interleukin-10 on Epstein-Barr virus-specific cytotoxic T-cell recognition. Blood 1998; 92:1020-30. Irsch J, Nitsch S, Hansmann ML, et al. Isolation of viable Hodgkin and Reed-Stern berg cells from Hodgkin disease tissues. Proc Natl Acad Sci USA 1998; 95:10117-22.

11 Viruses and malignant lymphoma LM WEISS AND KL CHANG

Introduction Human T cell leukemia type 1 Kaposi's sarcoma-associated herpes virus Epstein-Barr virus Burkitt's lymphoma B cell lymphomas in immunodeficient patients

115 115 116 117 118 119

INTRODUCTION Over the past several decades, there have been great efforts to implicate several viruses in the etiology of malignant lymphoma. Although there is abundant evidence to indicate that human T cell leukemia virus type 1 (HTLV-1) has an etiologic role in adult T cell leukemia/lymphoma (ATLL), no other viruses have yet been shown to be causative in any of the other malignant lymphomas. Nevertheless, a great deal of data have accumulated over the last several decades to indicate an association of the Epstein-Barr virus (EBV) with the malignant lymphomas including Hodgkin's disease. It is likely that EBV plays an important role in the pathogenesis of a significant subset of these lymphomas. In addition to HTLV-1 and EBV, this chapter will discuss other viruses that may also play a role in the etiology of malignant lymphomas, including the recently discovered Kaposi's sarcoma-associated herpes virus (KSHV, or HHV-8) human herpes virus type 6 (HHV-6) and hepatitis C. A useful additional review is given by Lyons and Liebowitz.1 HUMAN T CELL LEUKEMIA TYPE 1 HTLV-1 is a retrovirus that was first isolated from two patients who had what were thought to be aggressive forms of mycosis fungoides/Sezary syndrome.2'3 The HTLV-1 has been entirely sequenced and shows much more complexity than many of the animal retroviruses.4 In general, an intact retrovirus consists of a diploid RNA

Other B cell lymphomas T/natural killer cell lymphomas Hodgkin's disease Human herpes virus 6 Hepatitis C References

120 121 122 123 124 124

genome covered by a capsid and outer envelope. When the retrovirus enters the cytoplasm of a cell, the RNA is converted into DNA by reverse transcriptase and the DNA integrates into the host genome as a linear provirus. The point of integration is not fixed and varies in different cases,5 but is monoclonal within a given case. The HTLV-1 provirus consists of long terminal repetitive sequences at each end, with gag (coding for core structural protein), pol (coding for DNA polymerase) and env (coding for envelope glycoproteins) genes followed by a long sequence called the X gene region. The X gene includes at least three other genes, including the tax gene, which codes for a 40 kDa protein. The exact mechanism of how HTLV-1 causes lymphoma is not yet known. However, HTLV-1 has been shown to infect and immortalize CD 4-positive T cells in vitro.6 HTLV-1 differs from acutely transforming retroviruses in that it lacks its own viral oncogene and it also differs from chronic leukemogenic retroviruses in that transformation does not depend on integration adjacent to a cellular oncogene. The tax gene product has been shown to trans-activate the long terminal repeats (LTR), which can act as a viral promoter.7 In addition, the tax protein can trans-activate a variety of cellular genes, including the interleukin-2 receptor alpha gene, c-fos, c-jun and the gene encoding parathyroid hormonerelated protein.8 Regardless of the precise lymphomagenic mechanism of HTLV-1, there is a large body of epidemiologic, serologic and molecular biological evidence supporting an etiologic role for the virus in ATLL, an aggressive T cell neoplasm with characteristic clinical features (Fig. 11.1).

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role for HTLV-1 in a subset of cases of mycosis fungoides/Sezary syndrome has been postulated by some.14 Although these patients are usually seronegative for HTLV-1 and HTLV-2, evidence of the HTLV-1 pol and/or tax. gene has been found by polymerase chain reaction (PCR) in lesional tissues or peripheral blood mononuclear cells from mycosis fungoides patients in 0-68 per cent of cases. Overall, about 15 per cent of cases have been positive.15'20 In addition, Hall and colleagues found the presence of monoclonally integrated HTLV-1 provirus with a 5.5 kb deletion in one case.19 In cases shown to contain the tax or pol gene by PCR, there is no evidence of virus capsid p24 protein or reverse transcriptase activity, leading to the hypothesis that the proviruses may be defective.20 Finally, one study of CD 30-positive cutaneous large cell lymphoma has revealed evidence of HTLV-1 by Southern blotting or PCR in six of ten patients with CD 30-positive anaplastic large cell lymphoma. Again, none of the samples contained a full-length proviral DNA, suggesting that the proviruses may contain deletions.21 The demonstration of the role of HTLV-1 in human lymphoma is now the basis of new approaches to therapy.22"24

Figure 11.1 Adult T cell leukemia/lymphoma from Japan. These cases may be indistinguishable from peripheral Tcell lymphomas not associated with HTLV-1, but the former are generally more pleomorphic.

Most cases of ATLL occur in only a few regions of the world, most notably in southwestern Japan, but also in the Caribbean, southeastern USA, equatorial Africa and southern Italy.9-11 These areas of high incidence of ATLL have also been shown to have a high prevalence of HTLV-1 infection, as determined by serological studies. In addition, all patients with ATL have elevated levels of antibodies against HTLV-1. Finally, direct molecular evidence of HTLV-1 can be identified in all cases of ATLL. Antibodies to HTLV-1 have been detected in over one million people. However, only approximately 1000 new cases occur annually; therefore, the large majority of HTLV-1 carriers do not develop lymphoma.9 Approximately one in every 900 male carriers and one in every 2000 female carriers older than 40 years are estimated to develop ATLL each year.12 HTLV-1 may be transmitted by sexual intercourse from male to female, by blood transfusion, by intravenous drug abuse or by breast feeding.10 Human T lymphotropic virus-like particles have been found by ultrastructural analysis of cultures of peripheral blood lymphocytes from 90 per cent of patients with mycosis fungoides, raising the possibility that a high percentage of cases may be associated with retroviruses.13 A

KAPOSI'S SARCOMA-ASSOCIATED HERPES VIRUS In 1994, evidence was reported for a viral etiology for Kaposi's sarcoma.25 Preliminary sequencing data suggest that this candidate virus, called Kaposi's sarcomaassociated herpes virus (KSHV) or human herpes virus-8 (HHV-8), has partial homology to two gammaherpesviruses, the EBV and the animal virus herpesvirus saimiri. The latter virus usually infects squirrel monkeys but also causes fulminant T cell lymphomas in New World primates other than its natural hosts, and also can transform human T lymphocytes. Cesarman and colleagues initially identified KSHV sequences in eight of 193 lymphomas.26 The eight lymphomas occurred in human immunodeficiency virus (HIV)-infected patients, were predominantly body cavity-based, and were characterized by pleural, pericardial or peritoneal lymphomatous effusions (Fig. 11.2). All eight lymphomas were CD 45 (panleukocyte) positive and showed variable expression of activationassociated markers, but, with the exception of one case, lacked B lineage, T lineage, myeloid and monocyte markers. However, all eight lymphomas had clonal immunoglobulin heavy-chain gene rearrangements, consistent with a B cell lineage. Interestingly, all eight lymphomas were also EBV positive. Since that initial report, KSHV sequences have been identified in rare body cavity-based lymphomas in nonHlV-infected patients.27 These studies have helped define

Epstein-Barr virus 117

EPSTEIN-BARR VIRUS

Figure 11.2

Body cavity-based AIDS-associated malignant

lymphoma. Note the marked pleomorphism. This case contained both KSHVand EBV. Case courtesy of Dr Ethel Cesarman, Cornell University Medical College.

a new clinicopathological entity, termed primary effusion lymphoma, as a distinctive type of lymphoma associated with KSHV.28 This new lymphoma can be distinguished from small non-cleaved cell (Burkitt-like) lymphoma involving body cavities because the latter lymphoma is associated with c-myc gene rearrangements and is not associated with KSHV. Primary effusion lymphomas can also be distinguished from pyothoraxassociated lymphomas that may develop after longstanding inflammation; the latter are usually associated with a tumor mass, and lack KSHV sequences.29'30 KSHV sequences have also been consistently identified in multicentric Castleman's disease, both HIV- and nonHIV-associated.31,32 Early studies of KSHV identified the presence of two potential oncogenes, including a cellular-type cyclin D similar to the PRAD 1 oncogene involved in mantle cell lymphoma, a gene homologous to the cellular G proteincoupled receptor family of proteins,33 as well as a functional bd-2 homologue.34-36 KSHV-infected cell lines are now available and KSHV-infected cells from primary effusion lymphoma have been grown in BNX tripleimmunodeficient mice, with the development of malignant ascites as well as solid tumor masses.37,38

Epstein-Barr virus is a double-stranded DNA virus and is a member of the gammaherpesvirus group. It consists of approximately 172 kilobase pairs, making it the largest human tumor virus. An association between EBV and human neoplasia was suspected since the virus was first identified in electron micrographs of a cell line derived from a case of African Burkitt's lymphoma.39 The virus is endemic world-wide. It is found universally in developing countries and is present in 90-95 per cent of individuals in developed countries, casting doubt on any significant role in the etiology or pathogenesis of neoplasms. However, interest in EBV has been rekindled in the past decade, with the demonstration of a significant association between EBV and several types of malignant lymphomas, including B cell lymphomas, T cell lymphomas and Hodgkin's disease. When EBV infection occurs in early childhood, it is usually asymptomatic. When EBV infection occurs at a later time, it results in a benign, self-limited lymphoproliferation, which is clinically recognized as acute infectious mononucleosis. The virus causes a lytic (active) infection of epithelial cells and lymphocytes that is rapidly converted to a latent infection of lymphocytes once the individual mounts an immune response. In the lytic phase, the virus has a linear form, and expresses most of its genes (approximately 100 genes), including the early antigens and components of the viral capsid and envelope. When the infection converts to the latent phase, the genome circularizes into an episome by fusion of two terminal repeat regions; a small proportion of the genomes may also become randomly integrated into the host DNA. In the latent phase, only a few genes are expressed. These include genes encoding six nuclear antigens, including Epstein-Barr nuclear antigen (EBNA)-l, EBNA-2, EBNA-3A, EBNA-3B and EBNA-3C, and leader protein, and three membrane proteins, including latent membrane protein (LMP)-l, LMP-2A and LMP-2B. In addition, two non-translated small RNAs, Epstein-Barr early RNA (EBER)-l and EBER-2, are transcribed. EBNA-1 binds to specific genomic sequences and is essential for the establishment and maintenance of EBV latency. EBNA-2 is needed for transformation, but is not essential for the maintenance of EBV latent infection. EBNA-2 also can upregulate several host and viral genes, including LMP-1 and the activation antigen CD 23 in B cells. EBNA-3A and 3C are also required for immortalization. LMP-1 acts as an oncogene in transfection studies, and causes upregulation of a variety of cellular genes. In B cells, it induces CD 23, the adhesion molecules LFA-1 and LFA-3, and CD 54, interleukin-10 and bd-2. Induction of bd-2 may prevent EBV-infected cells from undergoing programmed cell death. A characteristic 30 bp deletion near the 3' end of the LMP-1 gene occasionally may be found, and in some studies, the LMP

118 Viruses and malignant lymphoma

deletion variant has been found to be associated with more clinically aggressive behavior: LMP-1 transgenic mice develop lymphomas.40 However, the function of the EBERs is not yet known. However, because they are produced in great abundance (up to 107 copies per cell, in all latently infected cells), they are an attractive target for detection by molecular methods. Not all latently infected cells express all of the latent gene proteins. Three general patterns of EBV latency gene expression are recognized. In latency pattern I, only EBNA-1 is expressed. Since EBNA-1 is the only latency antigen that does not elicit a cytotoxic T cell response, this latency pattern may provide a useful form of 'immune escape' in hosts that have a relatively intact immune system. An example of this latency pattern is found in cases of EBV-associated Burkitt's lymphoma. In latency pattern II, LMP-1, LMP-2A and LMP-2B are expressed in addition to EBNA-1. An example of this latency pattern is found in EBV-associated cases of Hodgkin's disease. Finally, in latency pattern III, all of the EBNAs and LMPs are expressed. In this latency pattern, the promoter used for EBNA-1 is different from that used in latency patterns I and II. This latency pattern may be preferentially used in EBV-infected cells in patients lacking a competent immune system, since immunocompetent individuals might be expected to mount an immune response to and eliminate cells expressing multiple EBNAs and LMPs. An example of this latency pattern is found in many cases of EBV-associated cases of post-transplantation lymphoproliferative disorder. Latency pattern III has also been identified in most EBV-infected lymphoblastoid cell lines, where the phenomenon of EBV latency has been best studied. There are two types of EBV (types A and B, or types 1 and 2), which differ in their EBNA-2 and EBNA-3A-C gene sequences.41 Type A EBV is globally ubiquitous, can readily transform B cells, and is the type usually identified in the oropharynx and peripheral blood of healthy seropositive individuals. Type B EBV has a more restricted geographic distribution (most commonly found in equatorial Africa), does not readily transform B cells and is generally identified in peripheral blood only from immunocompromised patients.42 When evaluating studies putatively identifying a significant association between EBV and a specific neoplasm, one needs to analyse the EBV detection methods critically. Many individuals harbor latent EBV and so, demonstrating EBV exposure by serologic studies or demonstrating EBV within involved tissues by PCR is not sufficient evidence for a true association. One must clearly show that the EBV is actually present in the tumor cells, and that EBV infection is a relatively early event and not merely a superinfection of an already established neoplasm. Currently, the best method for detecting EBV within neoplastic cells is in situ hybridization studies using probes directed against the highly abundant EBERs.43 The EBER in situ hybridization

technique is highly sensitive and highly practical, as it is easy to perform in routinely processed paraffinembedded sections. The demonstration of EBV in all or nearly all tumor cells is indirect evidence that infection occurred early in the neoplastic process, while the presence of EBV in only a subset of the cells implies little causative role or only a role in disease progression. Paraffin section immunohistochemistry for LMP-1 antigen is also practical,44 but only useful in neoplasms with latency patterns II and III, since latency pattern I neoplasms fail to express LMP-1. However, monoclonal antibodies against EBNA-1 that react in paraffin sections have recently become available.45 Southern blotting hybridization studies are not useful for determining which individual cells harbor EBV but may be used to determine the clonality of the EBVpositive cells.46 As mentioned above, the linear EBV genome has highly polymorphic terminal repeat regions at each of its ends that fuse to form the episomal genome. These terminal repeat regions consist of variable numbers of tandemly repeated units approximately 500 bp in length. In the episomal form, the number of repeats is stable over time as well as among progeny virus derived from an EBV-infected cell. Thus, hybridization probes against the terminal repeat regions, and adjacent regions in Southern blotting studies can be used to determine whether a solitary terminal repeat region is present (indicating EBV in a clonal proliferation of cells) or whether multiple terminal repeat regions are present (indicating EBV in a polyclonal population). In addition, by determining the molecular weight of the terminal repeat region, one can distinguish a latent infection (longer fragments due to fusion of the two terminal repeat regions) from a lytic infection (smaller fragments).46'47 PCR is too sensitive to use to determine whether EBV is actually associated with a tumor rather than merely present in host cells, but it can be used to type the EBV strain as well as to analyse the LMP-1 gene for the characteristic 30-bp LMP-1 deletion.48,49

BURKITT'S LYMPHOMA Burkitt's lymphoma was the first malignancy shown to be significantly associated with EBV. Approximately 95 per cent of cases of Burkitt's lymphoma in equatorial Africa, a region of high incidence of Burkitt's lymphoma (endemic Burkitt's lymphoma), are associated with EBV.50 A low percentage of EBV positivity, approximately 5-20 per cent, is seen in Burkitt's lymphoma from Western countries.51'52 An intermediate rate is seen in Burkitt's lymphoma cases from South America and Asia;51,56 however, there may be an endemic region of EBV-associated Burkitt's lymphoma in Bahia, a tropical region of Northeast Brazil that is populated predominantly by Mestizoes, individuals with mixed European,

B cell lymphomas in immunodeficient patients 119

African, and/or Indian ancestry.57 In the EBV-positive cases, the virus is detected in all or virtually all of the tumor cells by in situ hybridization (Fig. 11.3). PCR studies have demonstrated endemic cases to contain either type A or type B EBV, while sporadic cases are almost always type A. Southern blotting studies using probes to the EBV termini have shown that the EBV is present in a monoclonal population. In Brazilian Burkitt's lymphoma, a high incidence of the characteristic 30-bp LMP-1 gene deletion has been reported, similar to the high incidence of the deletion found in EBV-derived non-neoplastic tissues in this population.58 These data are in contrast to another study which failed to identify the same IMP-1 gene deletion in eight EBVassociated cases of Burkitt's lymphoma occurring in Pakistan.59 Despite many years of investigation, the precise role of the virus in the etiology and pathogenesis of Burkitt's lymphoma is not known. Endemic Burkitt's lymphoma was observed early on to occur in areas endemic for malaria, suggesting that chronic immunosuppression induced by chronic malarial infection predisposed an individual to EBV-associated Burkitt's lymphoma. However, a high association with EBV is also found in

Figure 11.3 EBV-positive Burkitt's lymphoma. This EBER RNA in situ hybridization study labels all of the Burkitt cell nuclei positively. The non-staining 'holes' represent the tingible-body macrophages, which fail to demonstrate evidence of EBV.

Burkitt's lymphoma occurring in Egypt, an area outside the malarial belt, suggesting that EBV positivity may correlate more closely with overall socioeconomic status.60 Since EBV can be identified only in a subset of cases of Burkitt's lymphoma, particularly in the sporadic form in Western countries, it is clear that EBV must be of much lesser importance than the nearly constant chromosomal translocations involving the c-myc gene on chromosome 8. There is no correlation between the presence of EBV and the specific breakpoint location at c-myc, providing evidence against a direct role for EBV in the induction of the translocation. Perhaps infection of B lymphocytes by EBV results in stimulation and a polyclonal proliferation, resulting in an increased pool of B cells, each with an increased probability of chromosomal translocation.

B CELL LYMPHOMAS IN IMMUNODEFICIENT PATIENTS Immunocompromised patients have an increased risk for developing a variety of malignant neoplasms, most notably non-Hodgkin's lymphomas. These lymphomas are usually of B lineage. Approximately 90-95 per cent of post-transplantation lymphoproliferations are associated with EBV.61-63 In these cases, DNA in situ hybridization studies have demonstrated EBV in all or virtually all of the tumor cells, generally in large amounts.63 In many cases, a heterogeneous signal is seen from cell to cell, suggesting a lytic infection superimposed on a latent infection. This interpretation is supported by in situ hybridization studies using probes detecting EBV genes expressed in lytic infections and immunohistochemical studies for the BZLF protein, which is involved in the switch from a latent to a lytic infection.64 In situ hybridization studies indicate that increased numbers of EBV-positive cells are often present prior to the development of lymphoma.65 PCR studies have demonstrated that EBV type A, and not type B, is almost always present in post-transplant lymphoproliferations,49 despite the fact that peripheral blood lymphocytes maybe infected with either type.66 Southern blot studies using probes to the EBV termini generally parallel similar studies of the immunoglobulin heavy- and lightchain genes, demonstrating that EBV is present in a polyclonal population in some cases (particularly those cases at the benign end of the histologic spectrum), an oligoclonal population in other cases and a monoclonal population in many cases.47,61,62,67 Different monoclonal populations may be present at different sites of disease within the same patient, again similar to Southern blot studies of the immunoglobulin heavy- and light-chain genes, suggesting that these lymphomas are 'multiclonal'.61'67 In addition, the proliferating cells of monomorphous lymphomas usually contain oncogene alterations in addition to EBV.62

120 Viruses and malignant lymphoma

These studies suggest a important role for EBV in the pathogenesis of immunodeficiency-related lymphoproliferations. In the setting of immunosuppression, greater than normal numbers of EBV-infected lymphocytes are present. In theory, the EBV drives a polyclonal lymphoproliferation, which progresses to an oligoclonal proliferation, followed by a monoclonal proliferation. The presence of lytically infected tumor cells may serve as an additional source of EBV, suggesting a possible clinical role for acyclovir, a drug active only in lytically infected cells. Early in the process, the proliferation may spontaneously reverse itself, if immunosuppression is reduced, giving the immune system a chance to control the EBVinfected cells. Eventually, additional oncogene alterations occur, leading to an autonomous and irreversible malignant lymphoma.68 Lymphomas may also occur in patients with collagen vascular disease who use immunosuppressive agents, such as azathioprine, cyclophosphamide, methotrexate, cyclosporin and steroids. In one study, EBV was found in one-third of lymphomas occurring in patients with connective tissue disease.69 There are anecdotal reports of spontaneous lymphoma regression following cessation of the immunosuppression in these patients.70 EBVassociated lymphomas have also been reported in patients with congenital immunodeficiencies, most commonly in patients with X-linked lymphoproliferative (Duncan's) syndrome, a congenital immunodeficiency in which patients have defective handling of EBV infection.71 Patients with Duncan's disease who survive their first exposure to EBV often subsequently develop an EBV-positive malignant lymphoma. Patients with HIV infection have abnormally high numbers of EBV-positive lymphocytes, both in their peripheral blood and their lymph nodes.72'74 PCR studies have identified EBV types A and B.42 Approximately 40-70 per cent of acquired immunodeficiency syndrome (AIDS)-associated lymphomas are associated with EBV.75-78 In contrast to post-transplantation lymphomas, either type A or type B EBV can be identified in individual cases.79 The presence or absence of EBV in the tumor correlates with the histologic subtype as well as the involved site.76,80 Large cell immunoblastic lymphoma is the most commonly EBV-associated AIDS tumor; approximately 80 per cent of these lymphomas are EBVpositive. A lower percentage of EBV positivity is seen in cases of Burkitt's lymphoma and large cell lymphoma, approximately 30 and 20 per cent, respectively. A high percentage of cases of AIDS-associated anaplastic large cell lymphomas have been reported to be EBV positive.81 Virtually all primary central nervous system lymphomas are EBV positive as are all body cavity-based lymphomas (the latter also contain KSHV), while node-based lymphomas have a much lower association with EBV.26,76,82,83 The EBV latency pattern also varies with the different histological types of lymphoma. Similar to endemic Burkitt's lymphoma, latency type I is most common in

the HIV-associated, small, non-cleaved lymphomas, while latency type III is most commonly seen in the large cell lymphomas.84 Latency type II, a pattern of latency otherwise only seen in Hodgkin's disease among EBVassociated lymphoid neoplasms, can be found in large cell and Burkitt-type lymphomas. Approximately onehalf of EBV-positive lymphomas contain evidence for a lytic infection, as detected by in situ hybridization using probes directed against the EBV NotI gene or immunohistochemical studies using antibodies against ZEBRA protein.85 Almost all AIDS-associated lymphomas have been reported to be monoclonal by immunoglobulin gene rearrangement or EBV termini studies.75'86 One group has reported a subset of cases with a polyclonal proliferation; in these cases, EBV was identified only occasionally.87 Another group reported three cases without detectable clonal immunoglobulin gene rearrangements; EBV was present in two of the cases and was found to be clonal.80 The role of EBV in the etiology of AIDS-associated lymphomas is less clear than its role in the post-transplant setting because a significant subset of AIDS-related lymphomas lack evidence of EBV. Nevertheless, the presence of EBV in about one-half of cases, and particularly its consistent identification in a monoclonal population, even in rare cases that lack detectable clonal immunoglobulin gene rearrangements,88 suggests a strong role in pathogenesis in those. EBV-positive cases. Understanding of the role of EBV in lymphoproliferation and lymphoma following transplant has led to novel approaches to immunomerapy using EBV-specific cytotoxic T lymphocytes (CTL) with some early encouraging results.89

OTHER B CELL LYMPHOMAS Most B cell lymphomas are not associated with EBV. In fact, less than 5 per cent of sporadic B cell lymphomas are EBV positive, particularly those with lymphoplasmacytic features, or those occurring in the stomach or head and neck region.90,91 There have been no reports of EBV positivity in cases of follicular lymphoma and the only cases of small lymphocytic lymphoma/chronic lymphocytic leukemia reported to be EBV-positive have been rare cases associated with Reed-Sternberg-like cells (see below).92 Hairy cell leukemia was once thought to be EBV associated, but the early results probably represented technical artefact, since EBER in situ hybridization studies have been uniformly negative.93 In contrast, the rare pyothorax-associated pleural B cell lymphoma, which occurs at the site of chronic inflammation and fibrosis 20-50 years after active tuberculosis, does have a significant and fairly uniform association with EBV.29,30 These cases show a type III latency pattern.94 Finally, lymphomatoid granulomatosis, a rare entity long

T/natural killer cell lymphomas 121

thought to be a T cell lymphoproliferation, is now thought to represent an EBV-positive monoclonal B cell lymphoma with a prominent T cell reaction.95

T/NATURAL KILLER CELL LYMPHOMAS Infection of B cells by EBV has been recognized for years. B cells represent the primary EBV-infected cell population in a latent infection, with the virus usually entering the cell via the CD 21 (C3d) complement receptor. However, EBV has recently been shown to also infect T cells in vitro96 and EBV-infected T cells have been shown to represent another reservoir of latent infection in seropositive individuals.97 What receptor the virus uses to enter T cells is not definitely known, although fetal T cells express CD 21 and even adult T cells may express CD 21 in low levels.98,99 EBV was first identified in T cell lymphoma in a small series of cases of peripheral T cell lymphoma arising in patients with a chronic mononucleosis-like syndrome.100 Since that report, EBV has been identified in 'sporadic' peripheral T cell lymphomas in apparently healthy individuals. Sporadic peripheral T cell lymphomas may, in fact, be more likely to show an EBV association than sporadic B cell lymphomas,88 especially in Asian or Latin populations.101-104 The detection of EBV in non-lymphoblastic T cell lymphoma has been correlated with a poor prognosis.105 Nasal T/natural killer (NK) cell lymphoma is the T/NK cell lymphoma most strongly associated with EBV (Fig. 11.4).106 The tumor is more frequently seen in the Orient than in Western countries, where it is extremely rare. The neoplasm often has a polymorphous cell population; the tumor cells usually permeate vascular structures. Thus, in the past, many of these cases had been diagnosed as polymorphic reticulosis or lymphomatoid granulomatosis. The cells have an unusual phenotype, expressing the T lineage markers CD 2 and CD 3 (the latter in paraffin sections only), as well the NK marker CD 56. However, other T lineage and NK markers are rarely or not expressed, thus, the true lineage of these neoplasms is still not clear. Molecular studies usually show a germline configuration of the beta T cell receptor gene. Similar neoplasms may occur in other locations, usually elsewhere in the head and neck. Using a variety of detection methods, EBV has been consistently identified in approximately 90 per cent of cases of nasal T/NK cell lymphoma in Western, Asian and South American populations.90,101,103,107-110 In EBVpositive cases, double-labeling immunohistochemical/m situ hybridization studies have localized EBV within all or nearly all of the neoplastic cells. Southern blotting studies using probes to the EBV termini have demonstrated EBV in a clonal population of cells, even in cases that are germline for the beta T cell receptor gene.111 Approximately 50 per cent of cases have EBV type A and

Figu re 11.4

EB V-positive T/NK cell nasalT cell lymphoma.

This EBER RNA in situ hybridization study labels all of the neoplastic nuclei black, indicating the presence of EBV. Note how the neoplastic cells tend to cluster around blood vessels.

the other 50 per cent of cases are positive for EBV type B.112 LMP-1 protein has not been consistently demonstrated in paraffin sections but it has been identified when frozen sections are available, suggesting low levels of the protein.110 EBNA-2 is usually not found; thus, the latency pattern is type II in these neoplasms. EBV has also been found in cases of NK/large granular lymphocyte leukemia and peripheral T cell lymphoma associated with hemophagocytosis, especially in Asian populations.113,114EBV has been found in approximately 20 per cent of cases of the HTLV-1-associated lymphoma ATLL.115 Researchers have hypothesized that EBV and HTD7-1 may coinfect the same T cells early in life, leading to an increased risk of subsequent lymphomagenesis. EBV has also been associated with the rare T cell lymphomas occurring in immunosuppressed populations, including T cell post-transplantation lymphomas and T cell AIDS-associated lymphomas.116,117 In the AIDS population, T cell lymphomas involving skin have been reported to have a high incidence of EBV positivity.117 Many other T cell lymphomas have been shown to be EBV positive in a subset of the neoplastic population. This pattern has been identified in many peripheral T

122 Viruses and malignant lymphoma

cell lymphomas, including angioimmunoblastic lymphadenopathy (AILD)-like T cell lymphoma and Lennert's lymphoma.118'122 Although it is unlikely that the EBV is of etiologic significance in these cases, the virus may contribute to disease progression. In addition to EBV-infected T cells in T cell lymphomas, increased numbers of EBV-infected B cells may also be present, particularly in AILD-like lymphoma. These latter cells may explain the paradoxical occurrence of B cell lymphomas complicating T cell lymphomas; some of these cases have been found to be EBV associated.123,124

HODGKIN'S DISEASE The epidemiology of Hodgkin's disease had long suggested a viral etiology in at least a subset of cases,125,126 particularly the pediatric and young adult cases. Investigators hypothesized that the pediatric cases developed in lower socioeconomic groups as a result of early life exposure to a virus, while the young adult cases resulted from later exposure to the same or different virus.126 EBV had been suspected to be that virus, because patients with Hodgkin's disease had a higher incidence of a history of acute infectious monoucleosis over controls.126-128 In addition, patients with Hodgkin's disease were known to have a higher incidence of abnormally high titers to EBV, both before and after diagnosis.129,130 In the last decade, numerous molecular studies have supplemented the previous epidemiologic and serologic data. EBV genomes were first identified in Hodgkin's disease tissues in 1987,131 and in 1989 EBV genomes were localized to Reed-Sternberg cells in a subset of cases.132 EBER in situ hybridization studies have shown EBV in Reed-Sternberg cells and variants in approximately 40-50 per cent of cases in Western populations (Fig. 11.5).133,134 It has been estimated that the EBV is amplified at least 50-fold in Reed-Sternberg cells.135 More recently, single-cell PCR studies have confirmed these findings and have definitively demonstrated that EBV-negative cases do occur.136 Study of the EBV terminus reveals the EBV to be in a monoclonal population in involved sites, with the same clonal population present when multiple sites from one case are examined.137,138 EBV type A is identified in almost all cases occurring in immunocompetent individuals.139,140 In HIV-infected patients, almost all cases of Hodgkin's disease are EBV associated, with either EBV type A or type B identified.141,142 EBV latency type II is found in the Reed-Sternberg cells of cases of EBV-associated Hodgkin's disease.143-145 In most cases, only a latent infection is present. A minority of cases show evidence of an abortive lytic infection146 and only rare cases show evidence of active viral replication.147 LMP-1 is strongly expressed in the Reed-Sternberg cells and variants (Fig. 11.6).143,144 In a subset of cases, a characteristic 30-bp deletion in the

Figu re 11.5

EB V-positive Hodgkin 's disease. This EBER RNA i n

situ hybridization study labels all or nearly all the Reed-Sternberg nuclei black, indicating the presence of EBV. Note that the vast majority of the small lymphocytes are negative.

LMP-1 gene is detected, particularly those cases with necrosis and numerous or atypical Reed-Sternberg cells.148 This 30-bp deletion is the same deletion reported in some cases of nasopharyngeal carcinoma associated with aggressive behavior when transplanted into nude mice. EBV positivity of Hodgkin's disease is most often seen in the mixed cellularity and lymphocyte depletion subtypes (approximately 80 per cent EBV positive) and infrequently seen in the nodular sclerosing subtype (approximately 20 per cent positive).133,134,143,149 Cases of the nodular, lymphocytic and histiocytic (L & H) lymphocyte predominance subtype, now thought by most investigators to represent a disease distinct from the other subtypes of Hodgkin's disease, are universally EBV negative.133,143,149,150 There is little correlation between EBV status and the cell lineage of the Reed-Sternberg cells, HLA-A2 positivity,151 CD 23 expression,152 cytokine profile153 or p53.154 One study reported a correlation with bd2 expression155 but this has not been confirmed in other reports.152,156,157 Several studies have shown an increased incidence of EBV positivity in pediatric Hodgkin's disease in various

Human herpes virus 6 123

or pathogenesis. The presence of EBV in a significant percentage of cases does suggest some role, but its absence in a large percentage of cases implies that it is not the sole etiologic factor. The presence of LMP-1 deletions in cases with 'aggressive' morphologic features suggest a role for EBV in disease progression. However, the lack of correlation of EBV with stage or patient outcome, at least in preliminary studies, suggests that the impact of EBV is not of major significance to the individual patient. Rare cases of small lymphocytic lymphoma/chronic lymphocytic leukemia contain Reed-Sternberg-like cells.92 In some cases, the Reed-Sternberg cells have the phenotype of the underlying B cell malignancy. In other cases, the Reed-Sternberg cells have the phenotype typical for Hodgkin's disease. Finally, yet other cases have a transitional phenotype. A proportion of these rare cases have progressed to overt Hodgkin's disease. In a study of these rare malignancies, we demonstrated that the Reed-Sternberg-like cells, but not the small lymphocytes, were EBV positive in 12 of 13 cases, as were the Reed-Sternberg cells in one case of Hodgkin's disease complicating this process.92 We hypothesized that EBV superinfected the low-grade B cell lymphoma and transformed the infected cell into a Reed-Sternberg-like cell. We believe that these rare cases, when further analysed, may provide interesting clues to the pathogenesis of Hodgkin's disease. Figure 11.6 EBV-positive Hodgkin's disease. This immunohistochemical study for LMP-1 demonstrates strong cytoplasmic and membrane positivity in the Reed-Stern berg cells. Note that the small lymphocytes are unstained.

populations,158-160 and one study has suggested an increased incidence of EBV positivity in patients older than 50 years, when compared to patients between 15 and 50 years old.158 There is no correlation between EBV status and patient serology,161 stage of disease or patient prognosis.162-164 In stage I patients, EBV positivity has been associated with presentation with neck lymph nodes, which interestingly are the sites of lymphatic draining from most primary EBV infections.165 There has been great interest in correlating EBV positivity with socioeconomic status and geographical, cultural and genetic factors, features that are often difficult to separate from one another. A slightly higher incidence of EBV positivity has been found in Hodgkin's disease occurring in Asian populations,166,167 and a much higher incidence has been found in South America,168 although pediatric patients comprise a relatively high percentage of cases of Hodgkin's disease in the latter population. One study showed an association between the presence of EBV in Hodgkin's disease and Hispanic ethnicity, in a series of cases from the USA, Mexico and Costa Rica.135 Although much progress has been made in elucidating the molecular epidemiology of EBV in Hodgkin's disease, there is not much known about its role in etiology

HUMAN HERPES VIRUS 6 Human herpes virus 6 was originally isolated (as human B lymphotropic virus; HBLV) in patients with a variety of lymphoproliferative disorders,169 leading to speculation that this virus may contribute to the etiology or pathogenesis of the malignant lymphomas. The virus has a wide cellular tropism, infecting primarily T, but also B, lymphocytes, as well as a variety of other cell types.170,171 The HHV-6 genome is a linear, doublestranded DNA of approximately 170 kilobases that has a 66 per cent nucleotide identity to cytomegalovirus (CMV).172 Almost all individuals are seropositive by 2-3 years of age, with liters gradually falling throughout adulthood.173,174 HHV-6 is the etiologic agent of exanthema subitum (roseola infantum),175 and maybe a cause of pneumonitis and other adverse manifestations in bone marrow transplant recipients.171 HHV-6 has been linked to cases of non-EBV/nonCMV-associated acute infectious mononucleosis.176 The virus also has been reported in a variety of other benign and malignant lymphoproliferative disorders,177-180 but many of these studies are difficult to interpret. Some of the findings have been based on assessment of HHV-6 antibody prevalence. Much of the results may be attributed to HHV-6 carrier state reactivations, secondary to

124 Viruses and malignant lymphoma

impaired cellular immune responses associated with the primary disease processes. In one large and carefully performed study, evidence of HHV-6 by Southern blotting studies was found in only three of 104 cases of non-Hodgkin's lymphoma, and none of 61 other benign and malignant lymphoid disorders (including 0/8 cases of Hodgkin's disease).177 Other reports document HHV-6 in occasional cases of non-Hodgkin's lymphoma and 'atypical polyclonal lymphoproliferation'.178 Torelli and colleagues, using PCR methodology, found HHV-6 sequences in 0/41 cases of non-Hodgkin's lymphoma, and in 3/25 cases of Hodgkin's disease. All three positive cases had similar clinical features.179 One study has reported HHV-6 in lesions of sinus histiocytosis with massive lymphadenopathy (RosaiDorfman disease) by in situ hybridization,181 while another group has reported HHV-6 in cases of histiocytic necrotizing lymphadenitis (Kikuchi's disease).182,183 Both reports need confirmation. In this regard, we were unable to demonstrate evidence of HHV-6 in Kikuchi's disease in a study using PCR methodology.

2. Poiesz BJ, Ruscetti FW, Gazdar AF. Detection and isolation of type C retrovirus particles from fresh and cultured lymphocytes of a patient with cutaneous T-cell lymphoma. Proc Natl Acad Sci USA 1980; 77: 7415-19. 3. Poiesz BJ, Ruscetti FW, Reitz MS, Kalyanaraman VS, Gallo RC. Isolation of a new type-C retrovirus (HTLV) in primary uncultured cells of a patient with Sezary T-cell leukaemia. Nature 1981; 294: 268-71. 4. Reitz JMS. Human T-cell leukemia virus, type 1, and human leukemia and lymphoma. In: Cossman J, ed. Molecular genetics in cancer diagnosis. New York: Elsevier, 1990:163-78. 5. Seiki M, Eddy R, Shows TB, Yoshida M. Nonspecific integration of the HTLV provirus into adult T-cell leukemia cells. Nature 1984; 309: 640-2. 6. Myoshi I, Kubonishi I, Yoshimoto S, et al. Type C virus particles in a cord blood T-cell line derived by cocultivating normal human cord leukocytes and human leukaemicT-cells. Nature 1981; 294: 770-2. 7. Seiki M, Inoue J, Takeda T, Yoshida M. Direct evidence that p40X of human T-cell leukemia virus type 1 is a trans-acting transcriptional activator. EMBOJ 1986; 5: 561-5.

HEPATITIS C Hepatitis C (HCV) is a linear, single-stranded RNA virus most similar to the Flaviviridae family. It has long been known to be a significant factor in the development of hepatocellular carcinoma. Recent evidence links this virus to lymphoproliferative diseases. HCV RNA has been detected in peripheral blood, bone marrow as well as in lymph nodes.184 A strong association between HCV infection and mixed cryoglobulinemia has been reported.185 In some populations, particularly in Italy, an increased prevalence of anti-HCV antibodies has been detected in patients with B-lineage non-Hodgkin's lymphomas. These are predominantly marginal zone lymphomas, including lymphomas of mucosa-associated lymphoid tissue, and immunocytoma.186'187 As with other viruses, the identification of a significant association does not necessarily imply a role in the etiology of the lymphoma. The HCV genome does not contain known oncogenes or reverse transcriptase that would lead to viral integration into the host's cellular DNA. Nonetheless, it is possible that HCV infection may induce a chronic B-cell proliferation that may act as a cofactor in lymphomagenesis.

8. Yoshida M, Fujisawa J. Positive and negative regulation of HTLV-1 gene expression and their roles in leukemiogenesis in ATL. In: Takatsuki K, Hinuma Y, Yoshida M, eds. Advances in adult T-cell leukemia and HTLV-I research, Vol. 39. Tokyo: Japanese Scientific Society Press, 1992; 217-35. 9. Yamaguchi K. Human T-lymphotropic virus type I in Japan. Lancet 1994; 343: 213-16. 10. Blattner WA, Blayney DW, Robert-Guroff M, et al. Epidemiology of human T-cell leukemia/lymphoma virus (HTLV).y Infect Dis 1983; 147: 406-16. 11. Catovsky D, Greaves MF, Rose M, et al. Adult T-cell lymphoma-leukaemia in Blacks from the West Indies. Lancet! 982; 1:639-43. 12. Tajima K, Kuroishi T. Estimation of incidence rate of ATL among ATLV(ATLV-I) carriers in Kyushu, Japan. JapJ Clin Oncol 1985; 15: 423-30. 13. Zucker-Franklin D, Coutavas EE, Rush MG, Zouzias DC. Detection of human T-lymphotropic virus-like particles in cultures of peripheral blood lymphocytes from patients with mycosis fungoides. Proc Natl Acad Sci USA 1991;88:7630-4. 14. Hall WW. Human T cell lymphotyropic virus type I and cutaneous T cell leukemia/lymphoma. J Exp Med 1994; 180:1581-5. 15. Whittaker SJ, Luzzatto L. HTLV-1 provirus and mycosis fungoides (letter). Science 1993; 259:1470-1.

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128 Viruses and malignant lymphoma 97. Deamant FD, Albujar PF, Chen Y-Y, Weiss LM. Epstein-Barr virus distribution in non-neoplastic lymph nodes. Mod Pathol 1993; 6: 729-32. 98. Tsoukas CD, Lambris JD. Expression of CR2/EBV receptors on human thymocytes detected by monoclonal antibodies. EurJ Immunol 1988; 18: 1299-302. 99. Fischer E, Delibrias C, Kazatchkine MD. Expression of the CR2 (the C3dg/EBV receptor, CD21) on normal human peripheral blood T lymphocytes.) Immunol 1991; 146: 865-9. 100. Jones J, Shurin S, Abramowsky C, et al. T-cell lymphomas containing Epstein-Barr viral DMA in patients with chronic Epstein-Barr virus infections. N Englj Med 1988; 318: 733-41. 101. Harabuchi Y, Yamanaka N, Kataura A, etal. Epstein-Barr virus in nasal T-cell lymphoma in patients with lethal midline granuloma. Lancet 1990; 335: 128-30. 102. Su I-J, Hsieh H-C, Lin K-H, etal. Aggressive peripheral Tcell lymphomas containing Epstein-Barr viral DMA: a clinicopathologicand molecular analysis. B/oorf1991; 77: 799-808. 103. Chan JKC, Yip TTC, Tsang WYW, et al. Detection of Epstein-Barr viral RNA in malignant lymphomas of the upper aerodigestive tract. AmJ Surg Pathol 1994; 18: 938-46. 104. Quintanilla-Martinez L, Lome-Maldonado C, Ott G, et al. Primary non-Hodgkin's lymphoma of the intestine: high prevalence of Epstein-Barr virus in Mexican lymphomas as compared to European cases. Blood 1997; 89: 644-51. 105. d'Amore F, Johansen P, Houmand A, Weisenburger DD, Mortensen LS. Epstein-Barr virus genome in nonHodgkin's lymphomas occurring in immunocompetent patients: highest prevalence in nonlymphoblastic T-cell lymphoma and correlation with a poor prognosis. Blood 1996;87:1045-55. 106. Weiss LM, Arber DA, Strickler JG. Nasal T cell lymphoma. Ann Oncol 1994; 5: (suppl 1): 39-42. 107. Arber DA, Weiss LM, Albujar PF, Chen Y-Y, Jaffe ES. Nasal lymphomas in Peru: high incidence of T-cell immunophenotype and Epstein-Barr virus infection. AmJ Surg Pathol 1993; 17: 659-65. 108. Strickler JG, Meneses M, Habermann TM, etal. 'Polymorphic reticulosis': a reappraisal. Human Pathol 1994; 25: 659-65. 109. Mishima K, Horiuchi K, Kojya S, Takahashi H, Ohsawa M, Aozasa K. Epstein-Barr virus in patients with polymorphic reticulosis (lethal midline granuloma) from China and Japan. Cancer 1994; 73: 3041-6. 110. Kanavaros P, Lescs M-C, Briere J, et al. Nasal T-cell lymphoma: a clinicopathologic entity associated with peculiar phenotype and with Epstein-Barr virus. Blood 1993;81:2688-95. 111. Medeiros LJ, Peiper SC, Elwood L, Yano T, Raffeld M, Jaffe ES. Angiocentric immunoproliferative lesions: a

112.

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molecular analysis of eight cases. Human Pathol 1991; 22:1150-7. Borisch B, Hennig I, Laeng RH, Waelti ER, Kraft R, Laissue J. Association of the subtype 2 and the Epstein-Barr virus with T-cell non-Hodgkin's lymphoma of the midline granuloma type. Blood 1993; 82: 858-64. Su IJ, HsuYH, Lin MT, Cheng AL, Wang CH, Weiss LM, Epstein-Barr containing T cell lymphoma presents with hemophagocytic syndrome mimicking malignant histiocytosis. Cancer 1993; 72: 2019-27. Kawa-Ha K, Ishihara S, Ninomiya T, etal. CDS-negative lymphoproliferative disease of granular lymphocytes containing Epstein-Barr viral DMA. 7 Clin Invest 1989; 84:51-5. Tokunaga M, Imai S, Uemura Y, TokudomeT, Osato T, Sato E. Epstein-Barr virus in adult T-cell leukemia/lymphoma. AmJ Pathol 1993; 143:1263-9. Kumar S, Kumar D, Kingma DW, Jaffe ES. Epstein-Barr virus-associated T-cell lymphoma in a renal transplant patient. AmJ Surg Pathol 1993; 17:1046-53. Kerschmann RL, Berger TG, Weiss LM, et al. Cutaneous presentations of lymphoma in human immunodeficiency virus disease: predominance of T-cell lineage with two clinicopathologic presentations. Arch Derm 1995; 131:1281 -8. Zhou XG, Hamilton-Dutoit SJ, Yan QH, Pallesen G. High frequency of Epstein-Barr virus in Chinese peripheral T-cell lymphoma. Histopathology 1994; 24:115-22. Weiss LM, Jaffe ES, Liu X, Chen Y, Shibata D, Medeiros LJ. Detection and localization of Epstein-Barr viral genomes in angioimmunoblastic lymphadenopathy and angioimmunoblastic lymphadenopathy-like lymphomas. Blood 1992; 79:1789-95. Anagnostopoulos I, Hummel M, Finn T, et al. Heterogeneous Epstein-Burr virus infection patterns in peripheral T-cell lymphoma of angioimmunoblastic lymphadenopathy type. Blood 1992; 80:1804-12. Korbjuhn P, Anagnostopoulos I, Hummel M, etal. Frequent latent Epstein-Barr virus infection of neoplastic T cells and bystander B cells in HIV-negative European peripheral pleomorphic T-cell lymphomas. Blood 1993; 82: 217-23. Anagnostopoulos I, Hummel M, Tiemann M, Korbjuhn P, Parwaresch MR, Stein H. Frequent presence of latent Epstein-Barr virus infection in lymphoepithelioid cell lymphoma (Lennert's lymphoma). Histopathology 1994; 25:331-7. Abruzzo LV, Schmidt K, Weiss LM, etal. B cell lymphoma evolving from AILD: a case with oligoclonal gene rearrangements associated with Epstein-Barr virus. B/oorf1993;82:241-6. Knecht H, Martius F, Bachmann E, et al. A deletion mutant of the LMP1 oncogene of Epstein-Barr virus is associated with evolution of angioimmunoblastic lymphadenopathy into B immunoblastic lymphoma. Leukemia 1995; 9: 458-65.

References 129 125. MacMahon B. Epidemiology of Hodgkin's disease. Cancer Res 1966; 26:1189-200. 126. Gutensohn N, Cole P. Childhood social environment and Hodgkin's disease. N EnglJ Med 1981; 304:135-40. 127. Kvale G, H0iby E, Pederson E. Hodgkin's disease in patients with previous infectious mononucleosis. Int J Cancer 1979; 23: 593-7. 128. Rosdahl N, Larsen S, Clemmesen J. Hodgkin's disease in patients with previous infectious mononucleosis: 30 years' experience. BrMedJ 1974; 2: 253-6. 129. Mueller N, Evans A, Harris NL, et al. Hodgkin's disease and Epstein-Barr virus: altered antibody pattern before diagnosis. N EnglJ Med 1989; 320: 689-92. 130. Evans AS, Gutensohn NM. A population-based casecontrol study of EBV and other viral antibodies among persons with Hodgkin's disease and their siblings. IntJ Cancer 1984; 34:149-57. 131. Weiss LM, Strickler JG, Warnke RA, Purtilo DT, Sklar J. Epstein-Barr viral DMA in tissues of Hodgkin's disease. AmJ Pathol 1987; 129: 86-91. 132. Weiss LM, Movahed LA, Warnke RA, Sklar J. Detection of Epstein-Barr viral genomes in Reed-Stern berg cells of Hodgkin's disease. N EnglJ Med 1989; 320: 502-6. 133. Weiss LM, Chen Y-Y, Liu X-F, Shibata D. Epstein-Barr virus and Hodgkin's disease: a correlative in situ hybridization and polymerase chain reaction study. Am J Pathol 1991; 139:1259-65. 134. Herbst H, Steinbrecher E, Niedobitek G, et al. Distribution and phenotype of Epstein-Barr virusharboring cells in Hodgkin's disease. Blood 1992; 80: 484-91. 135. Gulley ML, Eagan PA, Quintanilla-Martinez L, et al. Epstein-Barr virus DMA is abundant and monoclonal in the Reed-Stern berg cells of Hodgkin's disease: association with mixed cellularity subtype and Hispanic American ethnicity. Blood 1994; 83:1595-602. 136. Roth J, Daus H, Gause A, Trumper L, Pfreundschuh M. Detection of Epstein-Barr virus DNA in Hodgkin- and Reed-Stern berg-eel Is by single cell PCR. Leuk Lymphoma 1994; 13: 137-42. 137. Boiocchi M, Dolcetti R, Re VD, Gloghini A, Carbone A. Demonstration of a unique Epstein-Barr virus-positive cellular clone in metachronous multiple localizations of Hodgkin's disease. Am J Pathol 1993; 142: 33-8. 138. Brousset P, Schlaifer D, Meggetto F, et al. Persistence of the same viral strain in early and late relapses of Epstein-Barr virus-associated Hodgkin's disease. Blood 1994;84:2447-51. 139. Gledhill S, Gallagher A, Jones DB, et al. Viral involvement in Hodgkin's disease: detection of clonal type A Epstein-Barr virus genomes in tumour samples. BrJ Cancer 1991; 64: 227-32. 140. Lin JC, Lin SC, De BK, Chan WP, Evatt BL Precision of genotyping of Epstein-Barr virus by polymerase chain reaction using three gene loci (EBNA-2, EBNA-3C, and EBER): predominance of type A virus associated with Hodgkin's disease. Blood 1993; 81: 3372-81.

141. Re VD, Boiocchi M, Vita SD, et al. Subtypes of Epstein-Barr virus in HIV-associated and HIV-unrelated Hodgkin's disease cases. IntJ Cancer 1993; 54: 895-8. 142. Boyle MJ, Vasak E, Tschuchnigg M, et al. Subtypes of Epstein-Barr virus (EBV) in Hodgkin's disease: association between B-type EBV and immunocompromise. Blood 1993; 81: 468-74. 143. Pallesen G, Hamilton-Dutoit SJ, Rowe M, Young S. Expression of Epstein-Barr virus latent gene products in tumour cells of Hodgkin's disease. Lancet 1991; 337: 320-2. 144. Herbst H, Dallenbach F, Hummel M, et al. Epstein-Barr virus latent membrane protein expression in Hodgkin and Reed-Stern berg cells. Proc Natl Acad Sci USA 1991; 88: 4766-70. 145. Deacon EM, Pallesen G, Niedobitek G, et al. Epstein-Barr virus and Hodgkin's disease: transcriptional analysis of virus latency in the malignant cells. J Exp Med 1993; 177: 339-49. 146. Pallesen G, Sandvej K, Hamilton-Dutoit SJ, Rowe M, Young LS. Activation of Epstein-Barr virus replication in Hodgkin's and Reed-Stern berg cells. Blood 1991; 78: 1162-5. 147. Bibeau F, Brousset P, Knecht H, et al. Epstein-Barr virus replication in Hodgkin's disease. Bull Cancer 1994; 81: 114-88. 148. Knecht H, Bachmann E, Brousset P, et al. Deletions within the LMP1 oncogene of Epstein-Barr virus are clustered in Hodgkin's disease and identical to those observed in nasopharyngeal carcinoma. Blood 1993; 82: 2937-42. 149. Brousset P, Chittal S, Schlaifer D, et al. Detection of Epstein-Barr virus messenger RNA in Reed-Sternberg cells of Hodgkin's disease by in situ hybridization with biotinylated probes on specially processed modified acetone methyl benzoate xylene (ModAMeX) sections. B/oo
130 Viruses and malignant lymphoma 155. Khan G, Gupta RK, Coates PJ, Slavin G. Epstein-Barr virus infection and bcl-2 proto-oncogene expression. Separate events in the pathogenesis of Hodgkin's disease. Am J Pathol 1993; 143:1270-4. 156. Bhagat SK, Medeiros LJ, Weiss LM, Wang J, Raffeld M, Stetler-Stevenson M. bcl-2 expression in Hodgkin's disease. Correlation with the t(14;18) translocation and Epstein-Barr virus. Am J Clin Pathol 1993; 99: 604-8. 157. LeBrun DP, Ngan BY, Weiss LM, Huie P, Warnke RA, Cleary ML. The bcl-2 oncogene in Hodgkin's disease arising in the setting of follicular non-Hodgkin's lymphoma. Blood 1994; 83: 223-30. 158. Jarrett RF, Gallagher A, Jones DB, et al. Detection of Epstein-Barr virus genomes in Hodgkin's disease: relation to age. 7 Clin Pathol 1991; 44: 844-8. 159. Armstrong AA, Alexander FE, Paes RP, et al. Association of Epstein-Barr virus with pediatric Hodgkin's disease. Am J Pathol 1993; 142:1683-8. 160. Ambinder RF, Browning PJ, Lorenzana I, et al. Epstein-Barr virus and childhood Hodgkin's disease in Honduras and the United States. Blood 1993; 81: 462-7. 161. Levine PH, Pallesen G, Ebbesen P, Harris N, Evans AS, Mueller N. Evaluation of Epstein-Barr virus antibody patterns and detection of viral markers in the biopsies of patients with Hodgkin's disease. Int J Cancer 1994; 59: 48-50. 162. Fellbaum C, Hansmann M-L, Niedermeyer H. Influence of Epstein-Barr virus genomes on patient survival in Hodgkin's disease. Am J Clin Pathol 1992; 98: 319-23. 163. Armstrong AA, Lennard A, Alexander FE, et al. Prognostic significance of Epstein-Barr virus association in Hodgkin's disease (letter). EurJ Cancer 1994; 30A: 1045-6. 164. Vestlev PM, Pallesen G, Sandvej K, Hamilton-Dutoit SJ, Bendtzen SM. Prognosis of Hodgkin's disease is not influenced by Epstein-Barr virus latent membrane antigen. IntJ Cancer 1991; 50: 670-1. 165. O'GradyJ, Stewart S, Elton RA, Krajewski AS. Epstein-Barr virus in Hodgkin's disease and site of origin of tumour. Lancet 1994; 343: 265-6. 166. Zhou X-G, Hamilton-Dutoit SJ, Van Q-H, Pallesen G. The association between Epstein-Barr virus and Chinese Hodgkin's disease. Int J Cancer 1993; 55: 359-63. 167. Chan JKC, Yip TTC, Tsang WYW, Lau W-H, Wong CSC, Ma VWS. Detection of Epstein-Barr virus in Hodgkin's disease occurring in an Oriental population. Human Pathol 1995; 26: 314-18. 168. Chang KL, Albujar PF, Chen Y-Y, Johnson RM, Weiss LM. High prevalence of Epstein-Barr virus in the Reed-Stern berg cells of Hodgkin's disease occurring in Peru. Blood 1993; 81: 496-502. 169. Salahuddin SZ, Ablashi DV, Markham PD, et al. Isolation of a new virus, HBLV, in patients with lymphoproliferative disorders. Science 1986; 234: 596-601.

170. Horwitz C, Beneke J. Human herpesvirus-6 revisited (editorial). Am J Clin Pathol 1993; 99: 533-5. 171. Caserta MT, Hall CB. Human herpesvirus-6. Ann Rev Med 1993; 44: 377-83. 172. Lawrence GL, Chee M, Craxton MA, Honess RW, et al. Human herpesvirus 6 is closely related to human cytomegalovirus.y Virol 1990; 64: 287-99. 173. Yoshikawa T, Suga S, Asano Y, Yazaki T, Ozaki T. Neutralizing antibodies to human herpesvirus-6 in healthy individuals. Pediatr Infect DisJ 1990; 9: 589-90. 174. Brown NA, Sumaya CV, Liu C, Ench Y, Kovacs A, et al. Fall in human herpesvirus 6 seropositivity with age. Lancet 1988; 2: 396. 175. Yamanishi K, Toshiomi 0, Kimiyasu S, Takahashi M, Kondo T, Asano Y. Identification of human herpesvirus 6 as a causal agent for exanthema subitum. Lancet 1988; 1:1065-7. 176. Steeper TA, Horwitz CA, Ablashi AV, Salahuddin SZ, Saxinger C, Saltzman R. The spectrum of clinical and laboratory findings resulting from human herpesvirus-6 (HHV-6) in patients with mononucleosis-like illness not resulting from Epstein-Barr virus or cytoegalovirus. Am J Clin Pathol 1990; 93: 776-83. 177. Josephs SF, Buchbinder A, Streicher HZ, et al. Detection of human B-lymphotropic virus (human herpesvirus 6) sequences in B cell lymphoma tissues of three patients. Leukemia 1988; 2:132-5. 178. Kruger GRF, Manak M, Bourgeois N, et al. Persistent active herpesvirus infection associated with atypical polyclonal lymphoproliferation (APL) and malignant lymphoma. Anticancer Res 1989; 9:1457-76. 179. Torelli G, Marasca R, Luppi M, etal. Human herpesvirus6 in human lymphomas: identification of specific sequences in Hodgkin's lymphomas by polymerase chain reaction. Blood 1991; 77: 2251-8. 180. Borisch B, Ellinger K, Neipel F, et al. Lymphadenitis and lymphoproliferative lesions associated with the human herpes virus-6 (HHV-6). VirchowsArch B Cell Pathol 1991; 61:179-87. 181. Levine PH, Jahan N, Murari P,etal. Detection of HHV-6 in tissues involved by sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease).) Infect Dis 1992; 166: 291-5. 182. Hoffman A, Kirn E, Kuerten A, etal. Active human herpesvirus-6 (HHV-6) infection associated with Kikuchi-Fujimoto disease and systemic lupus erythematosus (SLE). In Vivo 1991; 5: 265-9. 183. Hollingsworth HC, Peiper SC, Weiss LM, Raffeld M, Jaffe ES. An investigation of the viral pathogenesis of Kikuchi-Fujimoto disease (KFD): lack of evidence for Epstein-Barr virus or human herpesvirus-6 as the causative agents. Arch Pathol Lab Med 1994; 118: 134-40. 184. Sansonno D, Vita SD, Cornacchiulo V, Carbone A, Boiocchi M, Dammacco F. Detection and distribution of hepatitis C virus-related proteins in lymph nodes of patients with type II mixed cryoglobulinemia and

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hepatitis C virus infection in patients with lymphoproliferative disorders. Blood 1996; 87: 4296-301. 187. Luppi M, Longo G, Ferrara MG, etal. Additional neoplasms and HCV infection in low-grade lymphoma of MALT type. BrJ Haematol W96; 94: 373-5.

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12 Molecular biology VI PAPPA AND BD YOUNG

Introduction Burkitt's lymphoma and the c-myc oncogene bc/-1/PRAD-1 gene rearrangement t(14;18) and the bcl-2 oncogene bd-6/laz-3 gene rearrangements t(2;5)(p23;q35) translocation 11q23 abnormalities in lymphoma

133 134 135 137 140 141 142

INTRODUCTION Malignant lymphoma cells usually have clonal chromosomal abnormalities and a number of these are associated with clinical and cellular phenotypes. These are now commonly helpful in diagnosis and prognosis. Recent advances in molecular genetics have led to the identification of a series of genes affected by chromosomal translocations in lymphoma. It is now clear that the proteins encoded by these genes play important roles in the control of apoptosis and cell-cycle progression. The timing and frequency of tumors in animals made transgenic for a single event, such as a translocation, has highlighted the requirement for subsequent genetic changes that act in a co-operative manner to create the fully transformed cell. It is now clear that the control mechanisms of both apoptosis and cell-cycle progression involve a complex series of dynamic protein-protein interactions. Disruptions to these interactions, whether by translocation, mutation or gene deletion can be expected to have profound effects on the behavior of cells. The complex nature of these interactions suggests that it may be possible to reach full tumorigenicity by several different routes. Thus, although there are clear associations between certain chromosomal translocations and lymphoma subgroups (Table 12.1), there may well exist underlying co-operative genetic changes that provide full tumorigenicity1 and we are only beginning to understand how specific translocations become associated with specific lineages.2 Molecular analysis of translocations in lymphoma,

fo/-10 and MALT lymphoma

142

Gene mutations in lymphoma

142

Gene amplification, the REL/NFKB transcription factors and bcl-3

144

Conclusion

144

References

144

Table 12.1

Chromosome translocations in lymphoma

t(8;14) t(2;8), t(8;22)

c-myc/IgH c-myc/\gk, IgK

Burkitt's

t(14;18)

bcl-2l\$\

Follicular

t(2;5)

npm/alk

Anaplastic large cell

t(3;14)

bc/-6/lgH + others

Wide range

t(11;14)

(fo/-1) cyclin D1/lgH

Mantle cell

t(l;H)

bd-W

MALT lymphoma

t(14;19)

bd-3/REl, NFKB

Bcell NHLandCLL

t(9;14)

PAX 5/lgH lymphoma

Lymphoplasmacytoid

Ig = immunoglobulin, MALT = mucosa-associated lymphoid tissue, NHL = non-Hodgkin's lymphoma, CLL = chronic lymphocytic leukemia.

leukemia and certain solid tumors3 has shown that they fall into general classes. The first type involves the activation of a proto-oncogene by juxtaposition into the immunoglobulin (Ig) or T cell receptor (TCR) genes, usually resulting in aberrant expression from the coding exons, which are normally intact. The second type involves breakage and rejoining of an intronic sequence in such a way that an in-frame fused mRNA is expressed, resulting in a fused chimaeric protein. In a third type, translocation is associated with mutation and loss of function. All types of event are found in lymphomas.

134 Molecular biology

Cytogenetically, lymphomas frequently reveal few or only one abnormalities and there is little evidence of microsatellite instability or a general defect in DNA repair mechanisms.4 The identification of the molecular basis of these events has provided a wide range of investigative techniques, including the polymerase chain reaction for the junctional sequences and immunohistochemical staining for the proteins encoded by genes involved in translocations. The addition of these approaches to conventional chromosome analysis has helped to clarify the contribution of these events to the various pathological subtypes of lymphomas.

BURKITT'S LYMPHOMA AND THE c-myc ONCOGENE Burkitt's lymphoma has characteristic chromosomal translocations that involve a recombination between the Ig heavy-chain locus and the c-myc oncogene.5"11 The human Ig heavy-chain locus is oriented on chromosome 14 with the variable regions telomeric to the constant regions. The breakpoint on chromosome 14 is often in the switch region located 5' to the C|l constant region gene. The breakpoints on chromosome 8 are usually in or around the first non-coding exon of the c-myc gene. The usual result of this translocation is to create a fusion sequence with c-myc joined with the S(l region in opposite transcriptional directions. The two variant chromosome translocations, t(2;8) and t(8;22), observed in about 10 per cent of Burkitt's lymphoma are due to a recombination between the c-myc locus and the kappa light-chain gene (IgK)12 on chromosome 2 or the lambda light-chain gene (IgX)13 on chromosome 22. In contrast to the heavy-chain locus, both light-chain loci are oriented with their variable regions centromeric to their constant regions and the breakpoints usually lie 5' to the joining region segments, thus leaving the } region enhancer sequences intact. The corresponding breakpoints on chromosome 8 occur 3' to the c-myc gene at a distance that can range from 400 bp to over 100 kb from the c-myc polyadenylation site.14-16 Occasionally the distance can be sufficient to result in a Cytogenetically different breakpoint on chromosome 817 and it remains possible that a different gene may be involved. Indeed, the analogous variant translocation in murine plasmacytomas involves a locus other than c-myc, named pvt-\ (plasmacytoma variant translocation).18 Myc-related translocations are also a feature of acquired immunodeficiency syndrome (AIDS)-related B cell lymphomas,19'20 where it is believed that they represent a stage in the progression toward EBV-independent proliferation. A further consequence of translocation of the c-myc locus can be the introduction of point mutations into its promoter region, the first non-coding exon21,22 or either

of the two coding exons.23 Additional evidence of somatic mutation, particularly in the endemic form of Burkitt's lymphoma has been demonstrated by restriction enzyme mapping. PvuII restriction enzyme digestion of DNA from 13 endemic lymphomas revealed 10 abnormally sized c-myc alleles indicating a high level of point mutation around the site of transcription termination.22 Somatic mutation is a common means of generating antibody diversity during normal VDJ rearrangement and similar mechanisms may be directed at the translocated c-myc allele. Since the other c-myc allele on chromosome 8 is usually in a germline configuration, it can be used as an internal control to evaluate the deregulation of the translocated allele. Most studies indicate that the translocated allele continues to be expressed, whereas the normal allele is switched off.24"26 The extinction of the normal allele and expression of the translocated allele appears to happen independently of whether the breakpoint is within or 5' to the c-myc gene.27'28 A similar analysis of a variant t(2;8) translocation indicated that the rearranged allele continued to be expressed.12 Although this deregulation leads to more c-myc mRNA2930 and more c-Myc protein31'32 in Burkitt's lymphoma cells than other lymphoblastoid cell lines, such quantitative changes may be less important than the inability of the rearranged gene to respond normally to regulatory factors. There is epidemiological and clinical evidence that there are two distinct forms of Burkitt's lymphoma, endemic and sporadic.33 Although both forms have the typical chromosome translocations, there appear to be subtle differences in the mode of activation, with the sporadic form often involving deletion of c-myc regulatory sequences, whereas the endemic form frequently involves point mutations or insertions.22 It has been suggested that cells from the endemic cases may be derived from the germinal center of lymph nodes and that cells from the sporadic cases may be derived from the bone marrow.33 It can be speculated that the endemic form is derived from cells at an earlier stage in the B cell lineage than the sporadic form. Thus the endemic translocations, which have a proportion of light-chain Ig gene involvement and a high rate of mutation, could represent errors in VDJ recombination, an event which takes place early in B cell development.34 The t(8;14) translocation found in AIDS-associated Burkitt's lymphoma appears to resemble more closely that found in the endemic form.35,36 Rearrangements of the c-myc gene have also been reported in other types of high-grade lymphoma, but with a much lower incidence than in Burkitt's.37,38 Direct evidence that deregulated c-myc genes may have a causative role in Burkitt's lymphoma has come from the study of transgenic mice. Animals transgenic for c-myc linked to a steroid inducible promoter often have breast carcinomas,39 whereas mice transgenic for c-myc linked to an Ig enhancer frequently develop

£c/-1/PRAD-1 gene rearrangement 135

lymphomas.40 It is interesting that there is a definite latency period for tumor development, during which further genetic changes take place, implying that c-myc activation alone is insufficient for full tumorigenicity. The c-myc gene encodes a 47-kDa protein, which is concentrated in the nucleus and which is known to have DNA binding properties, albeit at a high concentration.41 It is highly conserved between mouse and man, and is part of a gene family which includes N-rayc and L-myc. The latter have so far been implicated in only one case of lymphoma, where expression of N-myc was detected in an unclassified high-grade T cell lymphoma, which was also observed to have a breakpoint at the N-rayc locus on chromosome 2.42 Many studies have shown that c-Myc promotes cell cycle progression and inhibits differentiation (see review43). Withdrawal of growth factors from normal cells results in the down regulation of c-Myc and the accumulation of cells at the Gl/S boundary.44,45 Enforced c-Myc expression can overcome such cell-cycle arrest and drive cells into S phase.46 Ablation of c-Myc by antisense oligonucleotides or expression constructs blocks entry into S phase.47,48 c-Myc protein may therefore be regarded as a positive regulator of cell-cycle progression with its function being essential for progression through Gl into S phase. The presence of two sequence motifs in c-Myc that mediate protein-protein interactions implies that c-Myc functions as a transcription factor. In particular, the heptad repeat of leucine residues (leucine zipper or LZ) and the helix-loop-helix (HLH) domain are both features known to mediate protein-protein interactions between transcription factors. c-Myc also contains an adjacent basic region (b region), which makes direct sequencespecific interactions with DNA. Thus c-Myc contains an extended bHLH-LZ region of a type also found in a group of closely related transcription factors, including USF,49 TFE3,50 TFEB,51 AP-452 and the c-Myc dimerization partner Max.53,54 c-Myc protein is known to form heterodimers with Max,55 an interaction which greatly enhances the sequence-specific binding of c-Myc to DNA.56 Max can homodimerize56 and heterodimerize with two additional bHLH-LZ proteins, Mxil57 and Mad58 forming complexes that can bind to DNA. Although the c-Myc/Max interaction is central to c-Myc function, other interactions with c-Myc have been demonstrated. For example, c-Myc has been shown to interact with the retinoblastoma-related protein P107 (a suppressor of cell growth).59,60 Interactions between c-Myc and PI07 require the N-terminus of c-Myc and, in some Burkitt's lymphomas, mutations in the N-terminus of c-Myc have been shown to render c-Myc resistant to P107-mediated suppression.59 Thus events that free c-Myc from the negative regulation of PI07 may contribute to tumorigenesis in some lymphomas. A number of experimental systems have been used to demonstrate that the enforced expression of c-Myc not

only results in cell-cycle progression but can also induce apoptosis. For example, enforced c-Myc expression in 32D.3 myeloid progenitor cells induces apoptosis in the absence of interleukin-3-(IL-3).44 Upon withdrawal of IL-3 these cells normally down regulate c-Myc and accumulate at the GO/Gl boundary. These and other experiments have led to the idea that c-Myc expression, in circumstances when the cell would normally be quiescent, leads to apoptosis.43,61 It may seem paradoxical that activation of c-Myc, which can lead to apoptosis, is so strongly linked to tumors such as Burkitt's lymphoma. However, it is clear from c-Myc transgenic mice that additional events are required before tumors develop. Additionally, a series of genes (bd-2,pim-l, bmi-l, raf-l, ras and abl) has been identified as co-operating with c-Myc to accelerate tumorigenesis.43 Some of these genes (bd-2,pim-l, raf-l) can suppress apoptosis and it would seem likely therefore that c-Myc-mediated tumorigenesis is due to c-Myc-induced cell-cycle progression with concomitant suppression of apoptosis provided by other genetic events.

/7C/-1/PRAD-1 GENE REARRANGEMENT The t(l I;14)(ql3;q32) was identified as a recurring cytogenetic abnormality in the lymphoproliferative diseases,62 and subsequently shown to be associated with a subset of diffuse small B cell non-Hodgkin's lymphomas variously described as centrocytic lymphoma, mantle zone lymphoma, intermediate differentiated lymphocytic lymphoma and presently under the term mantle cell lymphoma.63-66 The t(ll;14) translocation has also been found in 2-6 per cent of B cell chronic lymphocytic leukemias (B-CLLs), in about 18 per cent of B cell prolymphocytic leukemias (B-PLLs), multiple myeloma67 and in approximately 15 per cent of splenic lymphomas with villous lymphocytes.68 The breakpoints were cloned in 1984 from cases reported to be CLL and diffuse large cell lymphoma.69'70 The breakpoints on chromosome Ilql3 showed tight clustering in a region called bcl-l (B cell lymphoma leukemia I).71 Most of them involve a 2 kb locus called MTC (major translocation cluster).72,74 The breakpoints on chromosome 14 involve the immunoglobulin heavychain joining regions (J H ) and it was hypothesized that the juxtaposition to enhancer elements associated with the IgH locus would affect the transcription of a gene near the bd-1 locus. However, despite intensive searches surrounding the breakpoint and substantial chromosomal walks, no deregulated transcriptional unit could be readily identified. A number of parathyroid adenomas are characterized by clonal rearrangements of the parathyroid hormone gene at Ilpl5. This proved to be an interchromosomal translocation with Ilql3 that overexpressed a newly

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identified gene located in this region, designated PRAD-1 (parathyroid adenomatosis) gene.75 PRAD-1 encodes a protein of 295 amino acids with sequence similarities to cyclins, and which can complex with p34cdc2 and induce its kinase activity.76 The PRAD-1 gene was considered a good candidate for the bd-1 linked oncogene, especially as the same gene had been identified in two other systems. A p36cyl has been observed in mouse macrophages and is induced by CSF-1 in the Gl phase of the cell cycle.77 p36cyl is the murine equivalent of PRAD-1 and also associates with a cdcl-related polypeptide. Additionally, genes from a human glioblastoma introduced into a budding yeast strain, mutant in all three of the known yeast Gl cyclins, complemented the defect and revealed a new subclass, cyclin Dl.78 Cyclin Dl is abundant in human glioblastoma and is identical to PRAD-1. The PRAD-1/cyclinDl (CCND1) gene on Ilql3 is located 120 kb telomeric from thebcl-1/MTC locus,76,79-81 although there are two minor translocation clusters (mTCs) that are less frequently involved. mTCl is localized 22 kb telomeric of MTC82 and mTC2 maps to the 5' flanking region of cyclin D1 gene.83 Southern blots using probes spanning the 110 kb distance between the bd-l MTC and the PRAD-1 gene, can detect bd-l rearrangements in up to 73 per cent of cases of mantle cell lymphomas.84'85 The relatively tight clustering of bd-1 MTC breakpoints suggests that the polymerase chain reaction (PCR) may be a suitable technique for the detection of the t(ll;14) in clinical samples, providing a diagnostic tool for the differential diagnosis of mantle cell lymphomas.86 Cyclin Dl mRNA is overexpressed in B cell malignancies87,88 with Ilql3 abnormalities and in the vast majority of mantle cell lymphomas analysed so far.79,89,90 Recent evidence suggests that the t(ll;14)(ql3;q32) identifies a cytologically atypical subset of B-CLL, characterized by a frequent cytological and cytogenetic evolution and by a distinct immunophenotype with a bright-staining pattern for surface immunoglobulins (SIg), CD 5 positivity and rare CD 23 expression, sharing some biological features with mantle cell lymphoma.91 Moreover, the cyclin Dl protein has been shown by monoclonal and polyclonal cyclin Dl antibodies to be overexpressed in all cases of mantle cell lymphomas examined with no expression in control tissue.92 The cyclin Dl gene is normally silent in T and B lymphocytes.93 The tight linkage of the cyclin Dl gene with bd-l, without intervening CpG islands, and its overexpression in B cell lymphomas with bd-l rearrangement and cell lines with the t(ll;14)(ql3;q32), provide strong evidence that the cyclin D1 gene is the bd-1 oncogene. The fact that cyclin D1 overexpression has been shown in almost all cases of mantle cell lymphomas79,88,89,94 even in the absence of the t(ll;14)(ql3;q32) raises questions about the mechanisms of cyclin Dl overexpression in these cases. In some examples, the cyclin Dl transcript is

truncated at its 3' untranslated region, resulting in loss of AUUUA sequences involved in mRNA stability. The consequence is the production of more stable transcripts, implying a mechanism of post-transcriptional derangement in the activation of cyclin Dl.88,95,96 This mechanism may account in part for the overexpression of the cyclin Dl mRNA in the absence of chromosomal translocations, which is observed in some B cell tumors and breast cancers. Furthermore, overexpressed cyclin Dl transcripts seem to contain no mutations.97 Overexpression of cyclin Dl has also been reported in numerous solid tumors, including breast cancer,98-100 oesophageal carcinoma,101 colon cancer102 and hepatocarcinoma.103 It is therefore likely that overexpression of cyclin Dl is associated with the pathogenesis of these diseases. Overexpression of cyclin Dl in rat embryo fibroblasts by retroviral transduction, resulted in a decrease in the duration of the Gl phase and decreased cell size. These cells produced tumors when injected into nude mice, but with a long latency period and perturbed the expression of several cellular growth-related genes, including c-myc, c-jun and cyclin A, but not cyclin D3.104 Furthermore, transfection of a Gl cyclin into fibroblasts or myeloid cell lines results in a shortening of Gl phase, but the total length of the cell cycle remains unchanged because of a compensatory prolongation of the S phase.105'106 Moreover, microinjection of cyclin Dl antibodies into fibroblasts arrests the cell at the Gl phase.107 The transforming activity of cyclin Dl has been shown in primary rat embryonic fibroblasts by co-transfection with c-myc or Ha-ras genes. Cyclin Dl, together with Ha-ras has been shown to transform primary cells and enable them to grow fibrosarcomas in nude mice.108 Cyclin Dl can also transform BRK cells in the presence of activated Ha-ras and an altered E1A protein.109 Strong evidence was provided, using osteosarcoma cells deficient for the retinoblastoma suppressing protein pRB, that all three D-type cyclins may exert their function as parts of a multiprotein complex involving interaction with pRB.110-113 It has been suggested that cyclin Dl functions by inactivating the inhibitory effect of Rb on cell-cycle progression. There is conflicting evidence, however, on the ability of cyclin Dl to phosphorylate Rb in vivo, in mammalian cells.110-111 The observation that Dtype cyclins contain the C-X-L-X-E motif, also found in the DNA viral oncoproteins SV40 T antigen, adenovirus El A and human papilloma virus E7, may provide a clue to the mechanism of interaction of cyclin Dl with Rb.114 This motif is required for the binding of cyclin Dl to Rb.110 The same regions of the Rb protein interact with the E2F transcription factor, which regulates the expression of several cellular genes involved in progression through the cell cycle.115 Cyclin Dl might affect the equilibration between the Rb-E2F complex and free E2F, acting as a dominant transcription represser.116 Overexpression of cyclin Dl would increase the amount of free E2F or decrease the amount of Rb-E2f complex,

t(14;18)and the fo/-2 oncogene 137

which might enhance the expression of several genes like c-myCy c-jun and cyclin A. This hypothesis is supported by the observation that transient overexpression of cyclin Dl decreases the amount of Rb-E2F complex in mammalian and insect cell systems.111,113 There is little evidence for alterations in the Rb gene in lymphomas. A comprehensive analysis of the Rb gene in a series of lowand high-grade lymphomas failed to reveal any mutations, although there was evidence for reduced levels of Rb protein in a few cases.117 The oncogenic potential of the cyclin Dl gene has been demonstrated in E|Ll-cyclin Dl transgenic mice that overexpress cyclin Dl, in B and T lymphocytes.118,119 The cell-cycle activity of these lymphocytes, their size and mitogen responsiveness are normal, but young transgenic animals contain fewer mature B and T cells. Although spontaneous tumors are infrequent, lymphomagenesis was more rapid in mice overexpressing cyclin Dl with c-Myc compared to mice expressing either transgene alone. Moreover, the spontaneous lymphomas of c-myc transgenic animals often expressed the endogenous cyclin Dl.118 Similarly, in another study, the cyclin Dl/N-myc or L-myc double transgenic mice developed clonal pre-B and B cell lymphomas. Furthermore, the crossing of cyclin Dl transgenic mice, with Eu/L-myc transgenics that overexpress L-myc in B and T cell populations, but predominantly develop T cell tumors, leads in double transgenics to B cell neoplasia. These findings establish cyclin Dl, as a proto-oncogene whose activity depends on a specific cell type as well as on a specific co-operating partner.119

t(14;18) AND THE bcl-2 ONCOGENE The t(14;18)(q32;q21) translocation, the most common translocation within human lymphoid malignancies,120,121 characterizes approximately 85 per cent of follicular and 20 per cent of diffuse B cell lymphomas.1,121,122 Molecular cloning of the t(14;18) breakpoint revealed a putative proto-oncogene, bcl-2 on chromosome 18q21,123~125 juxtaposed to one of the six immunoglobulin heavy-chain joining regions at 14q32. The bcl-2 gene consists of three exons. The first intron is 220 bp and a second intron of 370 kb separates the two coding exons II and III. Two proteins are potentially encoded from the 5.5 kb and the 3.5 kb mRNA transcripts: one encoding a 29 kDa 239 amino-acid bd-2a protein and the other a 205 aminoacid bd-2b protein that lacks a hydrophobic carboxyl tail, although this protein has never been seen in vivo in any appreciable amounts.126 The region of 19 hydrophobic amino-acids near the carboxyl terminus is followed by two charged residues that may serve to anchor the protein in membranes.127 The bcl-2 protein resides in the nuclear envelope, parts of the endoplasmic reticulum and outer mitochondrial membrane, but not in a variety

of other intracellular membrane compartments including the plasma membrane.127,128 In 60 per cent of cases the breakpoint on chromosome 18 falls in a 500 bp area in the 3' untranslated portion of the third exon of bcl-2 known as mbr (major breakpoint region)129,130 and in 25 per cent of cases it occurs 20 kb downstream in an untranscribed region known as mcr (minor cluster region).131,132 The breakpoints on chromosome 14 occur adjacent to the joining region of the immunoglobulin heavy-chain gene. Although the open reading frame of bcl-2 remains intact during the translocation, somatic mutations within it have been described.133 The t(14;18) is not confined to follicular lymphomas as it has also been reported in some highgrade lymphomas which appear to have transformed from low-grade follicular lymphomas,134 in a small percentage of B-CLL with breakpoints mapping between mbr and mcr,135 in de novo ALL of L2 or L3 FAB subtype,136'138 and in a number of cases of Hodgkin's disease.139-141 There are also conflicting reports about the detection of the t(14;18) in cases of benign follicular hyperplasia.142'143 Variant t(2;18)(pll;q21) and t(18;22)(q21;qll) translocations have also been described in B-CLLs144 and in follicular lymphomas.145'146 Molecular studies of these variant translocations have shown that the chromosomal breakpoints consistently map to the 5' region of the bd2 gene (known as the VCR region for variant cluster region) on chromosome 18 and within the K or A, lightchain loci on chromosomes 2 and 22, respectively.144'147'148 A variant t(2;18)(pll;q21) translocation was described in a follicular lymphoma resulting in the juxtaposition of a JK segment to a chromosome 18 transcriptional unit located 10 kb upstream of bcl-2, termed the FVT-1 (for follicular variant translocation) gene.149 Moreover, evidence has been found for multiple rearrangements affecting the mbr, mcr and VCR regions.150'151 The reciprocal partner on chromosome 14, the immunoglobulin heavy-chain locus (IgH) on the derivative 14 chromosome has been demonstrated to bear deletions in 76 per cent of follicular lymphomas, probably as a consequence of non-physiological activation of the recombinases involved in class switching.152 The lack of Ig detection, despite the mature origin of follicular lymphomas, may be explained in some of the cases by the inactivation of both IgH chain genes due to translocation of one allele in combination with deletions or defective rearrangements of the other allele.153 The tight clustering of breakpoints on chromosomes 14 and 18 during the translocation has allowed the use of the PCR technique for the detection of t(14;18)-bearing cells using genomic tumor DNA. The level of sensitivity obtained (up to 106) make this approach valuable for the detection of minimal residual disease.154-159 The presence of the translocation can be demonstrated also by Southern blotting using probes to various bcl-2 breakpoints, the main limitation being the requirement of

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frozen tissue for high molecular weight DNA extraction and the reduced sensitivity compared to PCR.159'160 Since PCR examines shorter lengths of DNA than Southern analysis, PCR-based tests may be more susceptible to microheterogeneity in breakpoint location.160 Most studies indicate the use of a combination of cytogenetics, Southern analysis and PCR for the most reliable detection of the t(14;18).160'162 Additionally, pulsed-field gel electrophoresis has proved to be the most informative process compared with standard methodology.163 The PCR technique has allowed the detection of t(14;18)-translocation-bearing cells in the peripheral blood or bone marrow in patients with localized (stage I and II) disease at diagnosis and in long-term remission after radiation therapy.164'165 Moreover, the presence of the t(14;18) translocation has been demonstrated at the completion of treatment as well as in long-term remission of advanced stage disease.166-169 The prognostic significance of the t(14;18) translocation has been the subject of controversy due probably to differences in the levels of sensitivity obtained by PCR. In some studies the presence of the t(14;18) translocation has been associated with a poor response to treatment and short survival,121 although for others the t(14;18) translocation and high bcl-2 protein expression did not correlate with clinical outcome.168-174 Other cytogenetic abnormalities such as chromosomal breaks higher than 6, abnormalities of chromosome regions lp21-22, 6q23—26 or 17p have been associated recently with short survival.174 The detection of the t(14;18) translocation in the reinfused bone marrow autograft in patients with follicular lymphoma treated with highdose treatment, is associated with shorter remission duration,175-177 and its presence at follow-up but probably not early after transplantation, is associated with a higher risk of relapse.177 The mechanisms by which these abnormalities influence survival in patients is unclear and may result from alterations in drug sensitivity and resistance due to kc/-2.178'180 It has been postulated that the t(14;18)(q32;q21) translocation event takes place in early B cells at the time of the D to J rearrangement. At the junction on both der!4 and derlS chromosomes, short segments of random insertions, up to 24 nucleotides in length, have been observed and considered to represent N insertions, normally found at the VD and DJ junctions after IgH rearrangement.130 This supports the hypothesis that VDI recombinase is involved in the generation of the breakpoints on chromosome 14.123 However the bcl-2 regions on chromosome 18 possess no combining heptamerspacer-nonamer motifs surrounding these breakpoints. The mbr region contains several sequence elements that could potentially infer genetic instability or facilitate homologous recombination. A polypurine-polypyrimidine stretch, with a potential to form alternative DNA structures (H-DNA or triplicates) is present in both the mbr and mcr regions. These polypurine tracts can act as

targets for mammalian endonucleases and are found around other genetic hot spots.181'183 Similar repeats of G-rich tetranucleotides have been implicated in immunoglobulin class switching.184'185 The mbr region contains a Chi-like octamer similar to the recombination signal in Escerichia coli and the human minisatellite core sequence, which could activate a Rec BCD-like mechanism.186"188 More recently, an SI nuclease-sensitive site was found that can be the target of an endogenous nuclease present in early B cells. A 45 kDa protein has been identified which binds to the Chi-like polypurine-polypyrimidine tract within mbr and mcr as well as to corresponding Ig sequences, and may play a role in homologous site-specific recombination.189 The juxtaposition of the bcl-2 oncogene with powerful enhancer elements within the IgH locus, markedly deregulates the gene by altering both its transcription and the efficiency of RNA processing, resulting in elevated amounts of bd-2/Ig chimaeric RNA, giving rise to overexpression of the bcl-2 protein.190'192 In normal lymph nodes the bcl-2 protein is most abundant in the long-lived recirculating B cells of the follicular mantle.192'194 bcl-2 is absent from the centroblasts and centrocytes destined to die within the dark zone and basal light zone. In parallel, surviving T cells within the medulla of the thymus demonstrate substantial bcl-2 staining while those in the cortex are negative.193'194 Overexpression of the bcl-2 protein has also been shown in follicular and diffuse B cell lymphomas without concurrent bcl-2 rearrangement in small lymphocytic, mantle zone lymphomas, CLL, plasma cell dyscrasias, chronic and acute myelogenous leukemia, and breast cancer, suggesting other mechanisms of deregulation of bcl-2.195~m As recently shown, the distribution of bcl-2 mRNA is roughly reciprocal to that of the protein with intense hybridization signal in germinal centers and almost absent in mantle zones. Discordant bcl-2 RNA and protein levels were also observed in tonsillar epithelial cells and cortical thymocytes. Importantly, follicular lymphomas and cell lines with the t(14;18) have concordant and abundant bcl-2 mRNA and protein expression, suggesting disruption of translational control mechanisms in follicular lymphomas.195 Overexpression of bcl-2 protein results in prevention of apoptosis or programmed cell death in selected hematopoietic cell lines following deprivation of IL-3, IL4 or granulocyte-macrophage colony stimulating factor (GM-CSF).199'203 Moreover studies of bcl-2 function in cultured postmitotic neurons have established a role for this gene in the suppression of apoptosis in complete absence of cell proliferation. Microinjection of bcl-2 expression plasmids into nerve growth factor (NGF)dependent neurons has been shown to delay markedly the rate of cell death that occurs upon removal of the neurotrophic factors from cultures.204 Overexpression of bcl-2 can block apoptosis induced by y-irradiation, glucocorticoids and a variety of chemotherapeutic

t(14;18)and the bc/-2 oncogene 139 agents.205 208 bcl-2 also blocks apoptosis that accompanies terminal differentiation of myeloid leukemic cell lines without affecting the differentiation process.209 bcl-2 has also been implicated in positive selection of thymocytes and in maintenance of B cell memory through its effect on survival at specific stages of lymphoid development and differentiation.210-212 A distinct biological effect of the bcl-2 protein in different cell types has been demonstrated by a paradoxical inhibition of cell growth in solid tumor cell lines.213 bcl-2 has also been implicated in the development of viral persistence and the pathogenesis of virus-associated malignancies as shown through induction of bcl-2 expression by the Epstein-Barr virus latent membrane protein 1, resulting in protection from apoptosis of B cells.214 Genetic analysis of apoptosis in the nematode worm C. elegans has identified three genes that regulate cell death, ced-3, ced-4 and ced-9. ced-9 suppresses apoptosis and has sequence similarity to bcl-2, and human bcl-2 can rescue ced-9 deficient worms.215'216 Thus some functions of bcl-2 are extremely well conserved throughout phylogeny. In contrast to ced-9 and bcl-2, ced-3 and ced-4 are involved in the initiation or execution of cell death, as loss of function mutations in these genes results in adult worms with additional cells.217 The oncogenic potential of the t(14;18) translocation and resulting bcl-2 overexpression have been demonstrated by transfection of bcl-2 constructs into NIH3T3 fibroblasts, which develop tumors when injected into mice with a latency period of approximately 4 weeks.218 Moreover &c/-2/IgH transgenic mice develop a polyclonal follicular lymphoproliferation of small resting IgM/IgD cells, which progress to immunoblastic lymphoma, by additional genetic alterations involving c-myc rearrangement.219-220 Most of the lymphomas developing in the E\Ji/bcl-2 transgene involve predominantly the B cell lineage and their immunophenotype (Sca-1, CD 4, Thy-1, CD 34, CD 45) is consistent with an origin very early in B lymphoid development.221 These observations suggest that the t(14;18) forms a basis for lymphomagenesis but is not sufficient itself to trigger the neoplastic process. In support of this hypothesis is the observation that the t(14;18) translocation can also be found in blood B cells of normal individuals, and that the frequency increases in the spleen and the blood with age, suggesting a multistep process of lymphomagenesis involving the t(14;18).222-223 In a bcl-2 transgenic line expressing high levels of bcl-2 protein in both cortical and medullary thymocytes, the immature thymocytes are resistant to apoptotic stimuli and have prolonged survival. It was also found that a proportion of thymocytes and peripheral T cells escape the process of negative antigenic selection, eliminating normally autoreactive T cells during thymocyte maturation.224 T cells in the peripheral lymphoid tissues are moderately elevated despite enhanced survival in vitro and there is a relatively high proportion of thymocytes with a mature

phenotype.225 Moreover, a bcl-2 transgene driven by the kk promoter results in mice that overexpress bcl-2 within the thymus and in the peripheral T cells, and which develop peripheral T cell lymphomas predominantly of diffuse large cell type at a mean age of 18 months.226 These data emphasize the tumorigenic potential of repression of cell death in multiple lineages. The role of bcl-2 in the normal control of tissue homeostasis was assessed in bcl-2 knockout mice, which complete embryonic development, but display growth retardation and early postnatal mortality. As expected differentiation of the lymphoid lineage is initially normal but thymus and spleen undergo massive apoptotic involution, resulting in lymphopenia. The animals die as a consequence of renal failure, the result of severe polycystic kidney disease and display hypopigmented hair, indicating a defect in redox-regulated melanin synthesis. The mechanism through which bcl-2 exerts its antiapoptotic function is not known but several possibilities have been explored. The localization of bcl-2 protein in the membranes of nuclear envelope and endoplasmic reticulum (ER) compartments in patches is highly reminiscent of nuclear pore complexes (NPCs),228 raising the possibility of a role for bcl-2 in some aspect of nuclear transport, NPC formation or nuclear envelope assembly and maintenance. The relevance of oxidative phosphorylation to the antiapoptotic function of bcl-2 has been assessed in human fibroblast cell lines lacking mitochondrial DNA. These experiments showed no requirement for oxidative phosphorylation for the induction of apoptosis or for the death represser activity of bcl-2.229 bcl-2 overproduction in a rat pheochromocytoma cell line, PC 12, did not correlate with the levels of ATP or oxygen consumption despite their resistance to apoptosis.230 However, bcl-2 overexpression and increased mitochondrial activity are closely related properties of cell lines resistant to apoptosis induced by glucocorticoids.231 Another important aspect is the role of Ca2+ in apoptosis, since Ca2+-dependent endonucleases may be involved in the internucleosomal DNA digestion typical of apoptotic cells, bcl-2 blocks Ca2+-ionophore-induced apoptosis in thymocytes, T cell leukemia lines and PC 12 cells. Overproduction of bcl-2, however, does not prevent rises in intracellular Ca2+, suggesting that bcl-2 blocks apoptosis downstream of this event. Moreover, lymphokine withdrawal, in IL-3-dependent cell lines results in gradual loss of Ca2+ from the ER and rise in the Ca2+ in the mitochondria. Overexpression of bcl-2 reverses these effects, suggesting that bcl-2 can influence Ca2+ partitioning.232 In favor of this hypothesis are the observations that glucocorticoid treatment of T cells results in massive loss of Ca2+ from the ER prior to apoptosis.233 and overexpression of an ER Ca2+-binding protein, calbindin-D, in glucocorticoid-sensitive T cells delays apoptosis, presumably by allowing ER to retain its Ca2+.234 Another attractive hypothesis is the role of oxidative injury in the

140 Molecular biology

induction of cell death, and the finding that bd-2 blocks the accumulation of lipid peroxides and possibly other reactive oxygen species in at least some settings.235 The concept of bd-2 regulating apoptosis through a dynamic process of positive and negative interactions with other proteins led to a search for other proteins with a structural similarity to bd-2. Viral bd-2 homologs, like the BHRF1 in the EBV236 and the LMW5HL in the African swine fever virus,237 can both prevent apoptosis, perhaps explaining the latency and persistence of some viral infections. However, cDNAs have been cloned recently for several novel human genes, revealing a family of bcl/-2-related members. One of these, called bax, has a six-exon structure and demonstrates a complex pattern of alternative RNA splicing that would encode several membrane and cytosolic proteins. Bax protein has been shown to homodimerize and heterodimerize with bd-2 in vivo. Bax overexpression accelerates apoptosis induced by cytokine deprivation in IL-3-dependent cell lines and counters the antiapoptotic function of bd-2. The ratio of bd-2 to Bax determines survival or death upon apoptotic stimuli.238 Another member of the family termed bd-x produces, by alternative splicing, two distinct bd-x mRNAs and encodes a 241 amino-acid protein with 74 per cent homology to bd-2. The protein product of the large mRNA, bd-xL, stably transfected into IL-3-dependent cell lines, inhibits cell death as effectively as bd-2. The second mRNA species, bd-xS encodes a protein that inhibits the ability of bd-2 to enhance the survival of growth-factordeprived cells.239 Other members of the family include the md-l gene and the Al gene isolated from cDNA libraries, derived from myeloid leukemic and normal cells, respectively.240-242 Additionally, the bad gene encodes a 204 amino-acid protein, which forms heterodimers with bd-2 and bd-xL. Its overexpression in IL-3dependent cells abolishes the protective effect of bd-xL upon IL-3 deprivation and promotes apoptosis, probably by competing with Bax for bd-xL, resulting in reduction of the bd-xL/Eax heterodimers and an increase in the amount of the death-accelerating protein Bax.243 Another new member of the bd-2 family is the bok gene, encoding a protein of 211 aminoacids, 25 per cent identical to bd-2. Three closely related bak genes exist: bak mapping to chromosome 6, bak-2 to chromosome 20 and bak-3 to chromosome 11. Like Bax, the Bak gene product enhances apoptosis following apoptotic stimuli and, unlike Bax, it inhibits cell death in an Epstein-Barr virus (EBV)-transformed cell line. The Bak protein can also bind to an apoptosis-inhibiting adenovirus protein E1B19K.244-246 In the emerging family of foc/-2-related proteins, two domains, termed bd-2 homology 1 and 2 (BH1 and BH2), have been identified.247 Site-specific mutagenesis of bd-2 established these two domains as novel dimerization motifs. Substitution of Gly 145 in the BH1 domain or Trp 188 in BH2 completely abrogates the

death represser activity of bd-2 upon apoptotic stimuli, such as IL-3 deprivation, y-irradiation and glucocorticoids. Mutations that affected the function of bd-2 also disrupted its heterodimerization with Bax while preserving its ability to form homodimers, suggesting that these domains are functionally important and that bd-2 exerts its function through heterodimerization with Bax.247

&c/-6//az-3 GENE REARRANGEMENTS The reciprocal translocation t(3;22)(q27;qll) was first identified248 in nine examples from a large lymphoma series (187 specimens). Most of these tumors had in common a diffuse morphology and predominantly a large cell type. Subsequent cytogenetic analysis confirmed249 and extended250 these results to include t(3;14)(q27;q32) and t(2;3)(p!2;q32) translocations. Molecular analysis with DNA probes from the IGH locus251 resulted in the identification of a gene at the breakpoint on chromosome 3 by four independent groups. This gene, which has been named bd-6252'253 kz-3254 and bd-52K contains a Kruppel-type COOHterminal Cys2-His2 zinc-finger region. This region has been shown to bind DNA and a consensus DNA binding sequence has been identified256 as (T/A)NCTTTCNAGG(A/G)AT, a sequence which can be found in the 5' region of certain genes, bd-6 also contains a NH2terminal region with significant homology252 to other zinc-finger transcription factors such as the ZFPJS protein, which regulates the major histocompatibility complex II promoter, the Tramtrack (ttk) and Broadcomplex (Br-c) proteins in Drosophila that regulate developmental transcription,257 the human KUP protein258 and the human PLZF protein, which is involved in the t( 11;17) variant translocation in acute promyelocytic leukemia.259 This evolutionarily conserved feature has been named the BTB domain and may be present in up to 40 different Drosophila genes.260 bd-6 mRNA has been detected in cell lines derived from mature B cells, but not from pro-B cells or plasma cells, T cells, other hemopoietic lineages or other tissues. This restricted range of normal expression has been taken252 to suggest that bd-6 is a transcription factor involved in the control of normal B cell differentiation and lymphoid organ development,261 and in the formation of germinal centers.262 The genomic structure of bd-6 encompasses about 26 kb263 and consists of nine exons. bd-6 rearrangements with IgH,251'264 IgK265 and IGX255 have now been molecularly analysed, and it is clear that all these events consistently break bd-6 in the same cluster region of about 10 kb at the 5' end of the gene. Breakpoints are clustered around the first exon and the putative regulatory region of the bd-6 gene is removed during translocation, leading to overexpression of the presumably intact coding region of the gene. Evidence has been found that

t(2;5)(p23;q35) translocation 141

biallellic rearrangements of bd-6 can occur.266 The fact that the IgH and IgA, rearrangements occur in the same region of bd-6 contrasts with the rearrangements affecting bd-2 and c-myc. IgH rearrangements occur 5' to c-myc and 3' to bd-2, whereas IgA rearrangements occur 3' to c-myc and 5' to bcl-2. Thus the configuration of both bd-2 and c-myc in relation to the Ig loci seems to be important, whereas the removal of the 5' untranslated region appears to be the important feature of bd-6 activation. It is now clear, however, that the bd-6 gene can be rearranged with not only the immunoglobulin loci but with a range of other chromosomal sites (Table 1221 '>267>268 Molecular analysis of the t(3;ll)(q27;q23) in a cell line has shown273 that this translocation results in a fusion between bd-6 and BOB1/OBF1, the B cell specific co-activator of octamer binding transcription factors. The regulatory regions upstream of the non-coding exon 2 of bd-6 are replaced by those of BOB1/OBF1, leaving the coding sequence of the bd-6 intact. Similar analysis of the t(3;4)(q27;qll) translocation in a cell line identified the gene product TTF267a fused to bd-6. TTF, which is only expressed in hemopoietic cells, has homology to the RAS superfamily and may define a new subgroup of RHO-like proteins. Sequence analysis of the bd-6 gene coding sequence in both rearranged and non-rearranged cases found no evidence that mutation plays a role in bd6 activation.274 A series of large-scale investigations of the incidence and clinical significance of bd-6 rearrangements in lymphoma has been reported.269,271,275 Approximately 15-20 per cent of all lymphomas were found to have bd-6 rearrangements, assessed by Southern analysis. As expected from previous cytogenetic studies, the greatest incidence (30 per cent,269 45 per cent275) was found in tumors classified as diffuse large cell lymphomas (DLCL). However, rearrangements have also been found in follicular lymphomas269,275 and in a case of CLL.271 In a study of 102 patients with DLLC, 23 cases with bd-6 rearrangements and 21 cases with bd-2 rearrangements Table 12.2

14q32 22q11 2p12 2q23 1q21 4p11 6p21 7p12 8q24 11q13 11q23 12q11 15q21

Chromosomal sites found rearranged with bd-6

IgH IgA IgK

TTF

BOB1

252, 269 252, 269 252, 269 252 252 269, 270 269, 271 269, 272 269 252 273 252 269

were found.276 From the clinical follow-up, it was concluded that rearrangement of bd-6 may be a favorable prognostic marker when compared to rearrangement of bd-2 in this series. The incidence of bd-6 rearrangements in AIDS-related lymphomas has also been investigated277 and these data showed that about 20 per cent of AIDS-DLCL carried rearrangements to bd-6.

t(2;5)(p23;q35) TRANSLOCATION Early cytogenetic investigations identified the t(2;5) translocation as a recurring event278 in tumors referred to as malignant histiocytosis.279 Subsequent analysis280"282 has shown that these tumors should be reinterpreted as large cell anaplastic lymphomas. A particular characteristic of this group is the presence of the Ki-1 (CD 30) surface antigen and it is now clear that a proportion of this group carry the t(2;5) translocation,283 particularly where there is evidence of T cell origin.284,285 Alternative cytogenetic abnormalities in CD 30-positive ALCL include t(2;2).286 Molecular analysis has resulted in the identification of the genes involved in the t(2;5) translocation. It has been shown287 that the translocation results in the in-frame fusion of a gene encoding a protein known as nucleophosmin (NPM) on chromosome 5 to a previously unknown tyrosine kinase gene (ALK) on chromosome 2. The normal ALK protein appears to be a membranespanning tyrosine kinase receptor, the fusion resulting in a chimeric NPM-ALK protein from which the membrane and putative extracellular domains have been lost. Reverse transcription PCR (RT-PCR) analysis of cells known to contain the t(2;5) translocation, including three cell lines and four examples of anaplastic large cell lymphomas (ALCLs), indicated that breakpoints occur in the same introns of the npm and alk genes, resulting in identical fusion junctions in the mRNA. The normal NPM protein is a nucleolar phosphoprotein, involved in the assembly of the small and large ribosomal subunits. NPM expression is cell-cycle regulated with a peak before entry into S phase. It has been postulated that, since the alk gene is normally silent in lymphoid cells, a critical consequence of its fusion to npm is the upregulation of an activated ALK tyrosine kinase domain.287 The availability of DNA probes and an RT-PCR assay for the t(2;5) translocation has facilitated molecular studies of its incidence in large cell anaplastic lymphomas and in related disorders.288 A DNA probe 5' to the npm gene was used289 in Southern analysis of a series of lymphomas. Rearrangements were found in 1/12 T cell ALCL and in 1/2 B cell ALCL. These data contrast with previous cytogenetic results which have suggested that most T cell ALCLs carry the t(2;5) translocation.290 Using RT-PCR291 a similar low incidence has been reported in a study in which a total of 6 of 37 cases of

142 Molecular biology

Ki-1 ALCLs were positive for the t(2;5) translocation. Within this study". 5/17 T cell ALCLs and 1/15 B cell ALCLs were positive. It was noted that the t(2;5) translocation may be strongly associated with pediatric Ki-1 lymphomas since two out of three in this study were positive. However, both studies taken together do not support the idea that there is a strong relationship between Ki-1-positive lymphomas and the t(2;5).291 It should be borne in mind that both strategies (RT-PCR and Southern blotting) may fail to detect rearrangements if breakpoints occur in different regions of either gene. Howevers the current evidence287 suggests that all breakpoints' occur at similar positions in both genes. The similarities between Ki-1-positive ALCL and Hodgkin's disease has prompted investigations of the occurrence of the t(2;5) translocation in the latter disease. Although an RT-PCR study292 indicated the presence of the t(2;5) in 11 of 13 patients with Hodgkin's disease, regardless of subtype, subsequent studies have failed to confirm this association.293294 Antibodies to the ALK protein have been developed and are useful diagnostically.295 These may be added to molecular probes in assessments of the prognostic significance of ALK protein and the NPM-ALK chimera. Current evidence suggests that these may be predictors of a good prognosis.296,297

11q23 ABNORMALITIES IN LYMPHOMA Abnormalities at chromosome band Ilq23 have been recorded in previous studies of lymphoma karyotypes. In a recent survey of 43 cases of non-Hodgkin's lymphomas, 3 out of 21 examples which lacked the t(14;18) translocation had abnormalities affecting Ilq23.298 Previous studies have found 2 out of 27 cases of large cell lymphoma with Ilq23 abnormalities299 and 2 out of 94 cases with the translocation t(ll;14)(q23;q32),300 which has also been noted in a single case report301 and in a lymphoma-derived cell line.302 Two examples of lymphoma subsequent to polycythemia vera have been reported to have Ilq23 abnormalities.303 A relatively high incidence of Ilq23 abnormalities has also been noted in Hodgkin's disease (6 out of 18 cases with abnormal metaphases),304 although subsequent studies have found different clonal abnormalities in Hodgkin's disease. Recently a cell line has been established from a pleural effusion of Hodgkin's disease and shown to contain Ilq23 abnormalities.305 The rck gene, known to be the target of the t(ll;14) translocation in the RCK-8 cell line306 has not yet been reported to be involved in other primary abnormalities at Ilq23. The hrx/mll gene, the target of chromosome translocation in acute leukemia, was investigated307 in 20 lymphoma samples with Ilq23 abnormalities and found to be rearranged in only three. It may therefore be concluded that a low but consistent

proportion of lymphomas have abnormalities to this cytogenetic region and that these events may target a gene other than rck or hrx/mll. Recently, two new genes have been identified as potential targets for translocation at Ilq23 in lymphomas. As discussed above, the bobl gene has been identified273 in a t(3;ll) translocation in a lymphoma-derived cell line resulting in a rearrangement with bcl-6. An example of the t(ll;14)(q23;q32) translocation has been molecularly cloned308 and the gene at Ilq23 identified as a new member of the proprotein convertase gene family (Ipc). The breakpoint was shown to lie within the 3' untranslated tail of the Ipc gene and therefore the breaks do not disrupt the coding region of this gene. It remains uncertain which of these genes, Ipc, bobl or rck are responsible for the majority of the Ilq23 abnormalities in lymphomas.

be/-10 AND MALT LYMPHOMA The molecular mechanisms that underlie lymphomatous progression at chronically inflamed sites, which results in mucosa-associated (MALT) lymphomas, remain poorly understood. However, cytogenetics identified abnormalities on chromosome Ip22 and a translocation t(l;14) as recurrent events309 and associations with more aggressive behavior in vivo and growth in vitro.310'311 The breakpoint of the t(l;14) translocation was cloned and found to exhibit a caspase recruitment domain suggesting a role in apoptosis and proapoptotic activity was seen in vitro.3n MALT lymphoma cells showed a frameshift truncating mutation, which lacked proapoptotic effects. This gene has been designated bcl-W and shows mutations in other cancers (colonic cancer, mesothelioma, germ cell tumors) and may have a role in carcinogenesis beyond that in this rare subtype of lymphomas.

GENE MUTATIONS IN LYMPHOMA Frequent and non-random chromosome 17p alterations and p53 mutations have been observed in patients with lymphoproliferative diseases, suggesting an important role in lymphomagenesis and disease progression. Thirty-seven per cent of patients with large cell lymphoma have been reported to have either loss of whole chromosome 17 or of part of 17 (17p-) or all of the short arm (i!7q).299 Other investigators have reported chromosome 17 abnormalities in 31-44 per cent of patients with large cell lymphoma300312 and such abnormalities were correlated with a grave prognosis and a short survival.313'314 Overexpression of p53 has been shown by immunostaining in 20-50 per cent of diffuse high-grade

Gene mutations in lymphoma 143

lymphomas.315 32° The incidence of mutations of the p53 gene varies from 20 to 30 per cent among different studies,320'323 but as recently shown, the percentage of p53 mutations in the group of high-grade non-Hodgkin's lymphomas is higher (45 per cent) if the analysis includes exons 2-11 and not only the 'hot spot' region (exons 5-8) where most mutations are known to occur.324 Moreover, staining for p53 is not predictive of mutations since cases overexpressing p53 in the absence of mutations have been described.324,325 Within the group of high-grade B cell lymphomas, the reported frequency of p53 mutations in Burkitt's lymphomas, varies between 35 and 45 per cent.325,326 Almost all cases of Burkitt's lymphoma have a translocation involving the c-myc gene, and therefore activation of both p53 and c-Myc may be critical in the development of these tumors. The coexistence of c-Myc and p53 alterations has also been shown in 3/8 and 1/11 diffuse large cell lymphoma cell lines and tumors, respectively.327 In Burkitt's lymphoma cell lines, a high frequency of p53 alterations (up to 60 per cent) has also been described.321,328-330 The majority of these cell lines contained only mutant versions of the p53 gene, and most of the mutations were missense and occasionally nonsense and frameshift. There was no correlation with the type of translocation, the ethnic origin of the patients or the EBV status. The expression of p53 in a group of 119 patients with high-grade B cell NHL has been shown to be an independent poor prognostic factor for survival. Simultaneous expression of bd-2 and p53 was associated with a poorer prognosis than p53 alone, particularly in the subgroup of nodal lymphomas.331 Detection of p53 mutation in bone marrow have been associated with histologic progression and transformation.332 A high frequency of p53 mutations has also been observed in patients with AIDS-related lymphomas. Although these patients have an increased incidence of B cell immunoblastic lymphoma, the incidence or type of p53 mutation does not differ when compared with B cell immunoblastic lymphomas in individuals without human immunodeficiency virus (HIV) infection.333 Interestingly, in other studies, overexpression of p53 was observed in 10 out of 45 of cases analysed, mainly clustering in the small non-cleaved cell and Ki-1 anaplastic large cell subtypes. A diffuse or clustered pattern of p53-positive neoplastic cells was seen in the small non-cleaved lymphomas, consequent upon p53 mutations. In contrast, in Ki-1 anaplastic large cell lymphomas, p53 immunohistochemical reactivity was limited to scattered tumor cells but no p53 gene alterations could be detected.334'335 Low-grade non-Hodgkin's lymphomas rarely have p53 alterations. Higher frequencies of p53 mutations have recently been shown in the splenic B cell leukemia/lymphoma of possible marginal origin, where p53 gene alterations involving exons 5, 6 and 8 were found in 40 per cent of cases examined. These mutations were missense or frameshift and the wild-type sequence

at the mutations site was barely visible, implying the loss of the normal p53 allele in leukemic cells.336 Most of the p53 alterations in the group of low-grade non-Hodgkin's lymphomas have been associated with progression to high-grade lymphoma. Serial biopsies of patients with follicular lymphoma who underwent histological transformation showed that a p53 mutation was observed in one-third of the transformed samples and this was not detected at the follicular stage of the disease.337 Another study revealed that four of five cases of follicular lymphoma transformed to diffuse large cell lymphoma were associated with p53 mutations.338 Interestingly, in one of these positive cases, the same mutation was also present in the pretransformation biopsy, correlating with the presence of diffuse-type areas within a predominantly follicular pattern.339 p53 immunoreactivity was observed in 50 per cent of low-grade non-Hodgkin's lymphomas and was higher in tumors of T cell origin.339 There was a positive association between p53 staining and the proliferation state as expressed by proliferating cell nuclear antigen (PCNA). Another study, however, revealed variable p53 immunostaining in follicular lymphomas, between biopsies and between individual follicles within the same tumor, with no correlation with the state of cell proliferation.340 Peripheral T cell lymphomas seem to have a low incidence of p53 mutations, ranging from 3 to 9 per cent of cases examined.321'341 p53 overexpression was observed in 50 per cent of the cases and did not correlate with cell proliferation as assessed by Ki-67 expression.341 However, within the group of peripheral T cell lymphomas, the adult T cell leukemia/lymphoma associated with human T cell leukemia virus type I (HTLV-1) infection, seems to have a much higher incidence of p53 gene alterations, ranging from 30 to 50 per cent in different studies.342'345 Based on the evaluation of at least 51 patients, it was postulated that p53 alterations represents one of the genetic changes responsible for the progression of the disease.342^345 The mutations found were mainly missense, nonsense, silent and frameshift, and the majority of those found in patients with the acute type of disease, occurred in highly conserved regions of p53. Moreover, cells carrying p53 mutations showed loss of the other p53 allele.342-345 p53 mutations correlated with an altered pattern of p53 expression as assessed by immunohistochemical staining.344,345 The frequency of p53 gene alterations in the acute phase of adult T cell leukemia/ lymphoma was significantly higher than that in the chronic type, suggesting a possible involvement of p53 gene alterations in the disease progression.346 Overexpression of p53 protein as assessed by immunohistochemical staining has been detected in about 60-80 per cent of cases with mixed cellularity and nodular sclerosing type of Hodgkin's disease.315,317,319,347 Immunoreactivity is localized to the nuclei of the Reed-Sternberg (RS) cells or its mononuclear variants, and the number of positive cells varies between 10 and 60 per cent of RS cells.

144 Molecular biology

Mutations of p53 have been detected in enriched RS cell preparations.348'349 No correlation has been found between EBV infection and p53 reactivity in RS cells. The background of small lymphocytes, plasma cells, eosinophils and histiocytes in Hodgkin's samples are unstained for p53. This finding supports the idea that the RS cell is the neoplastic component of Hodgkin's disease. Moreover, no p53 staining was observed in lymphocyte-predominant Hodgkin's disease, suggesting that this disease may be a form of B cell lymphoma rather than a subtype of Hodgkin's disease. Although the occurrence of p53 mutations in lymphoma has been the focus of many investigations, it remains possible that alterations to other genes may be equally important in lymphomagenesis. The murine double minute 2 (MDM2) gene encodes a protein that binds to and inactivates p53. Reports of MDM2 overexpression in lymphomas are contradictory. A Japanese study indicated that overexpression occurred mainly in low-grade lymphomas,350 whereas a UK study reported elevated MDM2 expression was primarily associated with highgrade disease.351 In the former case, the quantification was carried out by comparison with actin expression, but the expression of this gene is known to vary considerably between lymphoma samples.352 It has been suggested that accumulation of wild type (wt) p53 could promote the overexpression of the MDM2 gene product and that the ratio of MDM2/P53 could play a critical role in lymphoma progression.353 p53 is known to mediate expression of the P21 (p21wafl/cipl) gene whose protein product is involved in growth arrest. The coding sequence of P21 has been investigated for mutations in Burkitt's lymphoma samples. No mutations were found in the clinical samples but a mutation in Burkitt's cell line was found and shown to result in a loss of function of p21,354 The CDKN2 gene located on chromosome 9p21 encodes the cyclin-dependent kinase 4 inhibitor pi6. This gene is a putative tumor supressor because of its frequent alteration in many kinds of tumor cells. Several studies have investigated the prevalence of CDKN2 alterations and between 6 and 14 per cent of NHL samples have been shown to have acquired alterations.355'359 Selective hypermethylation of the gene is described.360 It is not yet possible to determine whether CDKN2 alterations are particularly associated with one subgroup or grade of lymphoma, although a high frequency of alteration (35 per cent) to CDKN2, and the neighboring gene MTS2 has been noted in T-ALL/lymphoblastic lymphoma361 and in low-grade lymphomas that have transformed to high grade.358,362

Mutations are seen in these factors in less than 10 per cent of lymphomas.1,364 and maybe pathogenetically significant in some cases.365 An example of gene amplification in lymphoma is described for the REL family in primary extranodal lymphomas and mediastinal lymphomas. Twenty-six out of 111 diffuse large cell lymphomas showed amplification to more than four copies and 19 of them were primary extranodal.366,367 Gene amplification, in general, in lymphoma is so far only found in a minority of cases.368 bd-3, the translocation breakpoint of the t(14;19) found in B-CLL and some B cell lymphomas, is a family member with positive regulation properties. It may be involved in upregulation of kappa B responsive genes,

CONCLUSION The molecular genetics of lymphoma has been one of the most exciting areas of biological advance in oncology during the 1990s. Basic mechanisms of lymphomagenesis have been partially explained and the knowledge acquired has already been applied in diagnosis and prognosis. Further advances and applications for classification, pathology and choice of therapy, and the identification of new targets for therapy are likely in the coming decade.

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GENE AMPLIFICATION, THE REL/NFk B TRANSCRIPTION FACTORS AND bcl-1 REL/NF kappa B transcription factors regulate many genes involved in the immune response and inflammation.363

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Introduction Descriptive epidemiology Analytic epidemiology

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INTRODUCTION Hodgkin's disease (HD) has been the focus of a substantial amount of epidemiologic research. This interest reflects the uniqueness of the disease in terms of its demographic patterns of occurrence, its risk factors suggestive of an infectious etiology, and its intimate relationship with the Epstein-Barr virus (EBV). This chapter reviews the features of the distribution of the disease within and between populations and the current knowledge of its risk factors. DESCRIPTIVE EPIDEMIOLOGY The incidence of HD is less than one-quarter that of the non-Hodgkin's lymphomas (NHLs), and among younger adults displays substantial international variation in magnitude (Fig. 13.1). Overall, the incidence rate generally increases with level of economic development. The disease is more common among men than women and, in affluent populations, generally more common in whites than among minority groups. The rates are lowest in Asian populations, regardless of level of economic development. In the USA in 1986-90, the age-adjusted incidence rate was 2.8 per 100 000 person-years with the age-adjusted mortality rate being only 0.6 per 100 000 person-years, reflecting the efficacy of treatment.1 Space-time clustering has been observed in HD.2'3 The relevance of such studies to possible infective etiologies is still uncertain. The distinguishing epidemiological feature of HD is its bimodal age-incidence curve (Fig. 13.2). This is most striking in economically advantaged populations. In such populations there are very few cases occurring

Summary References

165 166

among children, a rapid increase of incidence among teenagers peaking about age 25 and then a decrease to a plateau through middle age; after about age 55 years, rates increase with advancing age to the second peak. There is generally a male excess in both age peaks. Clemmesen4 has noted the existence of a 'secondary peak' among middle-aged males in economically advantaged populations. In a landmark study published in 1971, Correa and O'Connor5 noted that, among economically disadvantaged populations, a different age pattern is evident. In this case, there is an initial peak in childhood only for boys, relatively low rates among young adults followed by the late peak among those of advanced age. They noted that, with time, in parallel to economic development, there is a decrease in disease occurrence among children and a reciprocal increase among young adults. This evolution of the young adult peak is evident in birth cohort analysis of mortality from HD among British men in this century (Fig. 13.3).6 Within the same population, the age pattern will differ between population subgroups with major differences in socioeconomic level. At present, essentially all majority populations in Europe and North America have a well-defined 'developed' pattern of HD incidence. The height of peak occurrence in young adulthood varies within this set of countries, being higher in Canada, the USA, Switzerland and France, and lower in southern Europe. The pattern within the Eastern Block countries is variable. In general, the pattern in Asia and Africa is 'intermediate' or 'developing'.7'8 In contrast to the substantial variation of the magnitude of incidence in the younger adult peak in accord with socioeconomic conditions, the rates among older persons appear to be quite stable over time and between

162 Hodgkin's disease

Figure 13.1

Estimated

cumulative rate of Hodgkin's disease for age 15-54 years by sex: (a) women, (b) men. For description of method, see Chapter 9[7].

populations. This is more evident in recent data in which there is less misclassification between HD and NHL among older persons.9 A general observation is that HD cases occurring in economically developing populations and among lower social class groups in developed populations10 are predominantly of the mixed cellularity and lymphocyte depletion subtypes, indicative of more advanced disease. The explanation for this age-specific variation in geographic patterns was offered in 1957 by MacMahon, who proposed that the bimodality results from the overlap of

two disease distributions with differing age peaks. Specifically, he proposed that among young adults, HD is caused by a biological agent of low infectivity and that, among the elderly, the cause is probably similar to those of the other lymphomas.11 From social class-specific incidence data, there is evidence that rates of HD are elevated among young adults from higher social class. Henderson et al.12 computed histologic-specific incidence rates for HD in Los Angeles County from 1972 to 1975 by social class. This group found that the incidence of nodular sclerosis HD was

Analytic epidemiology 163

Figure 13.2 Age-specific incidence rate of Hodgkin's disease for men for 5-year age groups from 1983 to 1987.7

directly related to social class, but no consistent association for the other histological types was evident. This finding was corroborated by Cozen et a/.13 in the same population in a later time period and by Glaser14 in USA incidence data from 1969 to 1980. As part of a large population-based leukemia/lymphoma registry covering about half of the UK over a 5year period, Alexander and colleagues evaluated the characteristics of over 1800 HD cases by area-based socioeconomic and population density indices. They reported that, of the 486 cases diagnosed under age 25, incidence rates were significantly somewhat greater in the high socioeconomic areas, relative risk (RR) =1.2, and there was a significant trend in increase in areas closer to 'built-up areas' with mutual adjustment.15

Image Not Available

Figure 13.3 Age-specific mortality rates of Hodgkin's disease for successive 10-year birth cohorts of males in England and Wales. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., © 1977 from Gutensohn N, Cole P. Epidemiology of Hodgkin's disease in the young. Int J Cancer 7977; 19: 595-604.

The social class differences that are seen in the histologic presentation of HD may reflect a mix of agedependent host responses related to environmental exposures. These observations are consistent with an extension of the MacMahon hypothesis: that HD in young adults may develop as a rare consequence of a common lymphotropic infection with risk increased if infection is delayed until adolescence or young adulthood owing to better living conditions and reduced infectious exposures.6 With more clinically severe infection, which often occurs when 'childhood' infections are experienced in adulthood, the immunological control of a latent virus may be altered. In parallel, the disease seen among children reflects the effect of severe early infection. An interesting feature of the descriptive epidemiology of HD is the variation in sex ratio by age as discussed by Glaser.16 She notes that there appears to be a deficit of cases among women in their late thirties and forties in recent data from the USA and elsewhere. She proposes that this may represent a protective effect from childbearing, perhaps mediated by estrogens. However, a case-control study of 917 cases in the Swedish Cancer Register showed no significant difference between parous and non-parous women, and no link to the number of children. There was some evidence of a link between risk and later first birth.17

ANALYTIC EPIDEMIOLOGY

Socioeconomic status Analytic epidemiologic studies have confirmed that social class factors related to age of infection vary with age of diagnosis of HD through the first two-thirds of life.18 It appears that young children with HD tend to come from lower socioeconomic class and larger families, consistent with early infectious exposure. A shift in social class factors is then seen among young adult and middle-aged cases (aged 15-54 years), those who comprise the first major peak of disease. In this age group, the risk of HD has been found to be associated with a variety of risk factors associated with higher social class. As we have found in a population-based case-control study conducted in eastern Massachusetts (USA) in the 1970s, these factors include higher education, higher parental education (particularly maternal) and less dense housing in childhood.19 An exception to this statement is the observation of Alexander et al.20 in their large study in England, who reported that, while for cases aged less than 35 years at diagnosis there was a significantly positive association for social class, there was an insignificant negative association found for cases aged 35-49. A characteristic of HD occurring among young and middle-aged persons is its inverse association with sibship size, i.e. cases are more likely to come from small

164 Hodgkin's disease

families, and those from large families from the early birth orders. All of these factors foster susceptibility to late infections with the common childhood infections. For the middle-aged patients, this infectious exposure may come from their own children. Among the oldest persons, those in the second peak of HD incidence, the relationship between social class factors and risk of HD is not clear. In the Massachusetts population noted above, risk was not directly associated with social class.19 If anything, patients came from a somewhat lower social class than their controls. In the English study, there was a significant negative association with social class residence in cases aged 50-79 years.20 However, within an Israeli population, older cases appeared to come from somewhat higher social class as evidenced by level of education (RR = 2.1) and by the presence of a flush toilet in their childhood home (RR = 1.6).21 Whether these latter observations are confounded by the apparent generally increased risk of HD among adult Jews (see later) is unknown. In summary, children - particularly boys - living under relatively poor living conditions are at higher risk of HD than children elsewhere. For both young adult and middle-aged persons, there is evidence that HD may be the result of an age-related host response to a common infection. Among older persons, risk is not consistently related to social environment risk factors and shows minimal geographic variation.

Epstein-Barr virus The major candidate as an etiological infectious agent for HD is the ubiquitous herpesvirus, the Epstein-Barr virus.22 This association was first suggested by the virus's ability to transform B lymphocytes, the finding of Reed-Sternberg (RS) cells in lymphoid tissue of patients with infectious mononucleosis, and the consistent association found between history of infectious mononucleosis and HD.6 Multiple serologic studies revealed an invariable pattern of altered antibody responses to the EBV among HD patients in comparison to controls. In studies of more than 1900 HD cases of all ages, the proportion who have antibodies indicative of prior infection has been quite similar to that of controls. However, the cases consistently have higher mean immunoglobulin G (IgG) antibody titers to the EBV viral capsid antigen (VGA) than controls. Further, more of the cases have antibodies (as well as higher titers) against the early antigen (EA) of EBV, indicative of viral replication.23 Since these results were based on blood specimens collected after the diagnosis of the disease, the findings may simply reflect the reactivation of latent EBV as a result of the immune dysfunction characteristically seen in HD. However, these findings have been confirmed in two nested case-control studies that used blood specimens obtained from populations followed prospectively for

the diagnosis of HD.24,25 In both studies, the risk of HD was also associated with high antibody titers against the EBV nuclear antigen complex (EBNA). These observations imply that, for a subset of cases, the development of HD is preceded over an extended period of time by an increased level of EBV activation. Of note, the joint pattern of elevated EBV antibodies of both those of replication (anti-VGA and anti-EA) and that of latency (anti-EBNA) is not seen in normal populations.26 With the advent of highly sensitive molecular probes, striking evidence that EBV is directly related to the pathogenesis of HD has been found. These data began with the initial observation of Weiss et a/.27,28 that monoclonal episomal EBV was detectable in HD tissue and localized to the RS cells in 4 out of 21 specimens tested. This discovery has been confirmed in a large number of subsequent reports and the detection rate increased with the use of more sensitive methods.18 Overall, the findings suggest that about one-third to one-half of HD cases are EBV-genome positive. Pallesen et a/.29 further demonstrated that the EBV genome present in RS express a restricted latent phenotype of LMP1+/EBNA2-, both viral gene products normally being coexpressed in latently infected lymphocytes. This important finding has also been confirmed by many subsequent investigators.18 The consistency of the finding of clonal episomal EBV of a unique latent phenotype expressing LMP1 with its oncogene-like properties in a substantial proportion of HD cases in many patient populations throughout the world argues strongly for a causal role of the virus in these cases.30,31 The EBV-genome positivity rate is higher in mixedcell and lymphocyte-depleted HD, the subtypes associated with more advanced disease, and lower in nodular sclerosis; that for lymphocyte predominance appears to be none or extremely low, although the data are sparse and somewhat inconsistent.3 In a combined analysis of data from 14 studies involving more than 1500 HD cases, Glaser et al. evaluated the characteristics of patients with EBV-positive tumors. They found that having EBVpositive HD was associated with being male; being Hispanic; and among children, coming from less economically developed populations.32 These observations suggest that the factors affecting or reflecting immune competency are associated with EBV-genome status. In this light, a report by Frisan et al. suggests that tumor-associated suppression of EBVspecific T cell responses may play a role in EBV-positive HD. These investigators assessed the presence of HLA class I restricted EBV-specific reactivities within the tumor-infiltrating lymphocytes. Of six EBV-positive tumors tested, none had EBV-specific cytotoxic T lymphocytes (CTLs) compared to 3 of 3 EBV-negative tumors [P=0.003].33 These paradoxical findings raise a number of questions. Is the EBV involved in the pathogenesis of all HD, but the viral episome is somehow lost in persons with strong EBV-specific CTLs?34 Is

Summary 165

EBV-negative HD due to infection with another, unidentified virus?35

Immune dysfunction There is some evidence that risk of HD is increased among patients with certain primary immunodeficiencies. These cases account for about 9 per cent of all malignancies reported among these patients. HD does not appear to occur excessively among organ transplant recipients.36 It is of interest that HD is now recognized to be a part of the spectrum of opportunistic malignancies occurring in the natural history of human immunodeficiency virus-I (HIV-I) infection,37 particularly among intravenous drug abusers.38 Hessol et al. have reported a significant excess of HD in a cohort of homosexual men with HIV infection (RR = 5.0).39 Among these acquired immunodeficiency syndrome (AIDS)-related cases, the proportion that is EBV-genome positive is extremely high. In general, these HIV-I-infected patients present with advanced HD and exhibit a poor prognosis. In many, HD appears to spread non-contiguously - without mediastinal or splenic involvement.40 This alteration in the clinical behavior of HD in AIDS has been attributed to the loss of T-helper cells.

Genetic factors Several investigators have dealt with the question of whether genetic factors play a role in the etiology of HD as reviewed by Grufferman and Delzell.41 As in other hematopoietic malignancies, there is evidence for increased risk among relatives of cases. Two unusual observations warrant attention. The first is that of Grufferman et al42 who found 13 sibling cases of a total of 1577 cases in a population-based incidence survey. They reported that siblings of a young adult with HD have, overall, a roughly seven times higher risk than do members of the general population. Of note, their findings suggest that the excess risk among siblings is concentrated among those of the same sex as the first affected. That is, if a male is affected, his brothers have about a nine-fold increased risk, while his sisters have a five-fold increased risk. If a female is affected, the reverse applies. This finding was confirmed in a literature review.43 This observation argues against the theory that genetic factors play a major role in the etiology of HD, since it may be explained by childhood environmental exposures that are more likely to be shared by siblings of the same sex. In contrast, Mack et al. have recently reported that, among 366 sets of twins in which at least one was diagnosed with HD, the risk of HD in both twins was many times greater among the 179 monozygotic than among the 187 dizygotic sets.44

An unexplained observation is the consistent finding of increased risk among Jews.11,13,45 We found this also in our population-based case-control study in eastern Massachusetts. This association was not explained by social class correlates, such as family size. With control for all such factors, the increased risk was about twofold.19

Other exposures Concerning occupational exposures as risk factors for HD, only two have been found to be related with the disease in a number of studies: wood and chemicals; for neither are the data consistent. Grufferman and Delzell41 have been reviewed these reports in detail. In our study in the Boston-Worcester area (Matte and Mueller, unpublished) no association with occupation was found overall. There was an association with self-reported exposure to dust or sawdust, which increased with age (for subjects aged 15-39 years: RR = 1.1; 40-54 years, 2.1; > 55 years, 2.7). However, no dose response was evident. Turning to occupational exposure to chemicals, the findings are also quite varied. Early reports of an association of HD with herbicide exposure (primarily chlorophenols) have not been supported in a large casecontrol study in Kansas (USA).46 There are general findings of increased risk with employment in the rubber, plastics or synthetics industry and paper mill workers, but no specific exposures are evident.18 It is of interest that HD is one of the handful of malignancies that is not related to radiation exposure.47,48 This observation underscores the notion that the pathogenesis of HD is unique among the malignancies.

SUMMARY Much of the epidemiological and molecular biological evidence points to dysfunctional immunological control of latent EBV infection. The epidemiological evidence points to age at infection as an important modifier of risk. However, the current evidence does not fit together easily. What is needed is epidemiological research that concurrently integrates the molecular, serological and risk factor data. The possibility that a second virus is involved warrants consideration. Smithers49 has postulated a mechanism by which chronic antigenic stimulation could act in the pathogenesis of HD. He commented that'... we are bound to look at the evidence for the effect of prolonged pressures on the cell-mediated arm of the immune system and for feed-back failure of restraint in influencing the development of this disease.' It may be that, in HD, an alteration in gene expression occurs as a consequence of continuing antigenic stimulation from a chronically expressed

166 Hodgkin's disease EBV infection. However, in this case, the gene involved is not one controlling proliferation, but rather one controlling the expression of the normal, functionally active mediators released by antigen-stimulated cells. The alteration of gene expression may be quantitative change, resulting in a greatly amplified message. Alternatively, it may be that the gene product that normally shuts down the messages by feedback inhibition is underexpressed or dysfunctional. The result would be an immune system that is continually 'turned on', that is, an immune system that is perpetually mobilized in response to a chronic antigen and thus unable to respond to others. This hypothesis can be used to explain the biological paradox of HD: the malignant properties reflect the underlying genetic changes, the histological features reflect the response of normal immune cells to the perpetual stimulation, and the immune defects reflect the resulting imbalance in the immune response system.50

REFERENCES 1. Miller BA, Ries LAG, Hankey BF et al., eds. SEER cancer statistics review: 1973-1990. Washington DC: National Cancer Institute, NIH Publ. no. 93-2789,1993. 2. Evans AR, Hancock BW, Brown MJ, Richmond J. A small cluster of Hodgkin's disease. Br Med J 1977; 1: 1056-7. 3. Mueller N, Grufferman S. The epidemiology of Hodgkin's disease. In: Mauch P, Armitage JO, Diehl V, Hoppe RT, Weiss LM, eds Hodgkin's disease. Philadelphia: Lippencott Williams &Wilkins 1999; 61-78. 4. Clemmesen J. To the epidemiology of Hodgkin's lymphogranulomatosis.y Beige Radiol 1981; 3: 263-71. 5. Correa P, O'Connor GT. Epidemiologic patterns of Hodgkin's disease. Int J Cancer 1971; 8:192-201. 6. Gutensohn (Mueller) N, Cole P. Epidemiology of Hodgkin's disease in the young. Int J Cancer 1977; 19: 595-604. 7. Parkin DM, Muir CS, Whelan SL et al., eds. Cancer incidence in five continents, Vol. VI. IARC publication no. 120. Lyon: IARC, 1992. 8. Stiller CA. What causes Hodgkin's disease in children? Eur J Cancer 1998; 34: 523-8. 9. Glaser SL, Swatz WG. Time trends in Hodgkin's disease incidence: the role of diagnostic accuracy. Cancer 1990; 66: 2196-204. 10. Hu E, Hufford S, Lukes R, etal. Third-world Hodgkin's disease at Los Angeles County-University of Southern California Medical Center. J Clin Oncol 1988; 6:1285-92. 11. MacMahon B. Epidemiology of Hodgkin's disease. Cancer Res 1966; 26: 1189-2000. 12. Henderson BE, Dworsky R, Pike MC, et al. Risk factors for nodular sclerosis and other types of Hodgkin's disease. Cancer Res 1979; 39: 4507-11. 13. Cozen W, Katz J, Mack T. Risk patterns of Hodgkin's disease in Los Angeles vary by cell type. Cancer Epidemiol Prevent 1992; 1:261-8.

14. Glaser SL. Regional variation in Hodgkin's disease incidence by histologic subtype in the US. Cancer 1987; 60: 2841-7. 15. Alexander FE, Ricketts TJ, McKinney PA, et al. Community lifestyle characteristics and incidence of Hodgkin's disease in young people. IntJ Cancer 1991; 48: 10-14. 16. Glaser SL Reproductive factors in Hodgkin's disease in women: a review. Am J Epidemiol 1994; 139: 237^6. 17. Lambe M, Hsieh CC, Tsaih SW, Adami J, Glimelius B, Adami HO. Childbearing and the risk of Hodgkin's disease. Cancer Epidemiol Biomarkers Prev 1998; 7: 831-4. 18. Mueller N. Hodgkin's disease. In: Schottenfeld D, Fraumeni J Jr, eds Cancer epidemiology and prevention, 2nd edn. New York: Oxford University Press, 1996: 893919. 19. Gutensohn (Mueller) N. Social class and age at diagnosis of Hodgkin's disease: new epidemiologic evidence on the 'two-disease' hypothesis. Cancer Treatment Rep 1982; 66: 689-95. 20. Alexander FE, McKinney PA, Williams J, et al. Epidemiological evidence for the 'two-disease hypothesis' in Hodgkin's disease. IntJ Epidemiol 1991; 20: 354-61. 21. Abramson JH, Pridan H, Sacks Ml, etal. A case-control study of Hodgkin's disease in Israel.) Natl Cancer Inst 1978;61:307-14. 22. Evans AS. The spectrum of infections with Epstein-Barr virus: a hypothesis. J Infect Dis 1971; 124: 330-7. 23. Evans AS, Gutensohn (Mueller) N. A population-based case-control study of EBV and other viral antibodies among persons with Hodgkin's disease and their siblings. Int J Cancer 1984; 34:149-57. 24. Mueller N, Evans A, Harris NL, et al. Hodgkin's disease and Epstein-Barr virus: altered antibody pattern before diagnosis. N Engl J Med 1989; 320: 689-95. 25. Lehtinen T, Lumio J, Dillner J, et al. Increased risk of malignant lymphoma indicated by elevated Epstein-Barr virus antibodies - a prospective study. Cancer Causes Control 1993; 4:187-93. 26. Rocchi G, Tosato G, Papa G, et al. Antibodies to Epstein-Barr virus-associated nuclear antigen and to other viral and non-viral antigens in Hodgkin's disease. /Art7 Cancer 1975; 16: 323-8. 27. Weiss LM, Strickler JG, Warnke RA, et al. Epstein-Barr viral DNA in tissue of Hodgkin's disease. Am J Pathol 1987; 129:86-91. 28. Weiss LM, Movahed LA, Warnke RA, etal. Detection of Epstein-Barr viral genomes in Reed-Stern berg cells of Hodgkin's disease. N Engl J Med 1989; 320: 502-6. 29. Pallesen G, Hamilton-Dutoit SJ, Rowe M, etal. Expression of Epstein-Barr virus latent gene products in tumour cells of Hodgkin's disease. Lancet 1991; 337: 320-2. 30. Knecht H, Brousset P, Bachmann E, etal. Latent membrane protein 1: a key oncogene in EBV-related carciogenesis?/4rto Hematol 1993; 90: 167-71. 31. Herbst H, Niedobitek G. Epstein-Barr virus and Hodgkin's disease. IntJ Clin Lab Res 1993; 23:13-16.

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32. Glaser SL, Lin RJ, Steward SL, et al. Epstein-Barr virus-

42. Grufferman S, Cole P, Smith PG, et al. Hodgkin's disease

associated Hodgkin's disease: epidemiologic characteristics in international data. Int J Cancer 1997: 70: 375-86. 33. Frisan T, SjbbergJ, Dolcetti R, etal. Local suppression of

in siblings. N Engl J Med 1977; 296: 248-50. 43. Grufferman S, Barton JW III, Eby NL. Increased sex concordance of sibling pairs with Behcet's disease, Hodgkin's disease, multiple sclerosis and sarcoidosis. Am

Epstein-Barr virus (EBV)-specific cytotoxity in biopsies of EGV-positive Hodgkin's disease. Blood 1995; 86:1493-501. 34. Mueller NE. Epstein-Barr virus and Hodgkin's disease: an epidemiological paradox. Epstein-Barr Virus Rep 1997; 4: 1-2. 35. Jarrett RF. Epstein-Barr virus and Hodgkin's disease. Epstein-Barr Virus Rep 1998; 5: 77-85. 36. Mueller N. Overview of the epidemiology of malignancy in immune deficiency. JAIDS 1999; 21: S5-S10. 37. Goedert JJ, Cote TR, Virgo P, et al. Spectrum of AIDSassociated malignant disorders. Lancet 1998; 351:1833-9. 38. Roithmann S, Tourani J-M, Andrieu J-M. Hodgkin's disease in HIV-infected intravenous drug abusers. N Eng J MedWW; 323:275-6.

J Epidemiol 1987; 126: 365-9. 44. Mack TM, Cozen W, Shibata DK, et al. Concordance for Hodgkin's disease in identical twins suggesting genetic susceptibility to the young-adult form of the disease. N EnglJ Med 1995; 332: 413-18. 45. Bernard SM, Cartwright RA, Darwin CM, et al. Hodgkin's disease: case control epidemiological study in Yorkshire. BrJ Cancer W87; 55:85-90. 46. Hoar SK, Blair A, Holmes EF, et al. Agricultural herbicide use and risk of lymphoma and soft-tissue sarcoma.y/AM/4 1986; 256: 1141-7. 47. Hainan, KE. Failure to substantiate two cases of alleged occupational radiation carcinogenesis. Lancet 1988; 1: 639.

39. Hessol NA, Katz MH, Liu JY, et al. Increased incidence of

48. Boice JD Jr, Land CE, Preston DL. Radiation. In:

Hodgkin's disease in homosexual men with HIV infection. Ann Intern Med 1992; 117: 309-11. 40. Knowles DE, Chamulak GA, Subar M, et al. Lymphoid neoplasia associated with the acquired immunodefi-

prevention 2nd edn. New York: Oxford University Press 1996; 319-54. 49. Smithers D. On some general concepts in oncology with

ciency syndrome (AIDS): the New York University Medical Center experience with 105 patients (1981-1986). Ann Intern Med 1988; 108: 744-53. 41. Grufferman S, Delzell E. Epidemiology of Hodgkin's disease. Epidemiol Rev 1984; 6: 76-106.

Schottenfeld D, Fraumeni J, eds Cancer epidemiology and

special references to Hodgkin's disease. Int J Radial Oncol Biol Phys 1983; 9: 731-8. 50. Mueller NE. The epidemiology of Hodgkin's disease. In: Selby D, McElwain TJ, eds Hodgkin's disease Oxford: Blackwell Scientific Publications, 1987; 68-93.

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14 Non-Hodgkin's lymphoma RACARTWRIGHT

Introduction Descriptive epidemiology Analytic epidemiology

169 170

The future References

174 174

172

INTRODUCTION The epidemiology of non-Hodgkin's lymphoma (NHL) presents serious difficulties. As a result there are still many gaps in our knowledge of the distribution and causes of these conditions. There are several reasons for this. The classification systems have been in flux for many years. As opinions about the disease have changed, so a series of classifications have been produced. This had led to problems for epidemiologists who collect routine and often historical information from cancer registries or from other special studies. All the various classifications, dating back over 30 years, have been used by epidemiologists at one time or another, many of which are regarded as out of date by contemporary histopathologists. Two aspects of these classifications should be noted: what is included or excluded as 'NHL', and the internal subtypes of the disease. Both have changed and these changes vary from country to country. Thus comparisons over time and/or internationally are fraught with difficulties of interpretation. Classification errors might account for 10-15 per cent of wrongly associated cases.1 This has led many epidemiologists simply to avoid the issue of the need to account for or incorporate subtypes of NHL in their studies. They have assumed NHL to be one cohesive pathological entity. This is nowadays at odds with the concepts of the histopathologists whose classification strategies have gradually shifted from those which purely reflected disease outcome to those more truly in line with the recognized pathogenic processes. In addition, most epidemiologists have tended to ignore the site of origin of the NHL. A further noteworthy event has been that the use of cell-surface markers has led to more undifferentiated tumors being classified as NHL.

A related difficulty lies in the pathological status of Hodgkin's disease (HD). Originally regarded as distinct entities, the pathological boundaries between HD and NHL have become increasingly blurred. This is particularly true in the older, non-nodular sclerosing cases where a decline in case numbers has been interpreted as a possible diagnostic artefact of a tendency to classify more such cases as NHL. Further, many risk factors for HD, particularly, but not exclusively, in older cases, are similar to those for NHL. The boundaries between chronic lymphocytic leukemia (CLL) and multiple myeloma (MM) are also blurred from an epidemiological viewpoint, although they are relatively clear diagnostically. The relatively rare lymphoblastic lymphoma is regarded as part of the acute lymphoblastic leukemia (ALL) spectrum and is not referred to in this chapter, along with CLL and MM. In summary, because of the chaos of classification and the limitation of many earlier epidemiological studies, much of the descriptive epidemiology of NHL is difficult to interpret, and could be full of spatial and temporal artefacts. Some of the earlier epidemiological attempts to find causal links may also be seriously flawed as a consequence of the pooling of all NHL cases together or the inappropriate use of systems of classification. This could mean that highly significant risk factors have been diluted or completely lost. Although most of these challenges are now being addressed by epidemiologists, the data from this new generation of studies are just becoming available. However, the reader must still interpret epidemiology data with caution. For example, Anderson et al. found substantial differences in the geographical distribution of NHL subtypes (by the Revised European-American Classification).2

170 Non-Hodgkin's lymphoma

DESCRIPTIVE EPIDEMIOLOGY

Rates by classification of NHL by all type and all sites In view of the difficulties noted in the introduction, only the recently available data are supplied. Table 14.1 gives incidence rate data by age and sex for recently acquired information from parts of the UK, collected as a result of a special study spanning 1984-1993.3 These rates are typical of many European populations in that they are greater in males at all ages and show a steadily increasing incidence in both sexes with the highest rate being in the elderly.

Internationally, however, there are greater differences and some selected populations are given in Table 14.2 to reflect this. These are taken from data computed by the International Agency for Research on Cancer4 and roughly represent cases occurring between the years 1982 and 1989. Higher childhood rates are seen in certain countries, such as in parts of sub-Saharan Africa, where it is largely due to the Burkitt-type lymphoma.5 Asian children living in the UK may have a higher NHL rate than in the white population.6 This is also true in some Arab children.7 Generally, Middle Eastern and Caucasian populations have the highest rates of NHL in all older age groups. There is some slight evidence to suggest rates in Europe are higher in the north and central parts than in the far south.4

Table 14.1 Age-specific incidence rate (x per 100 000 per year) for cases of NHL collected from geographically defined areas of the UK 1984-1993 inclusive based on 13 901 cases

0-4 10-14 20-24 30-34 40-44 50-54 60-64 70-74 80-84 90+

0.61 1.07 1.56 2.93 7.22 1449 23.34 41.85 48.02 47.92

0.46 0.35 0.82 2.21 5.03 9.54 16.97 28.07 31.26 20.00

Rates by all histological types by site until recently mere nas been very little systematic data reported by the site of origin of the NHL. A recent special collection from the UK3 has allowed this to be rectified. Table 14.3 gives the relative proportion of the various sites based on the first histopathology report in each case. The 'skin' site includes mycosis fungoides and Sezary's syndrome. Table 14.4 gives some age-specific incidence rates for these sites. The rarity of some sites is noteworthy as is the brief span of risk for others, e.g. the testes.

0.54 0.72 1.20 2.58 6.13 12.01 20.01 33.98 36.79 25.55

Table 14.2 Age-specific incidence rates in selected populations

South America Columbia

1.0

0.7

2.1

0.9

1.7

2.9

10.1

9.6

19.0

32.9

North America Connecticut whites Connecticut blacks

0.8 1.4

1.5 0.0

0.8 1.5

0.6 1.6

4.3 3.4

2.4 4.5

16.0 11.2

14.2 6.7

79.0 44.2

58.0 21.6

Asia India - Bombay

0.8

0.3

1.1

0.3

1.5

1.0

5.9

5.6

19.9

15.5

Israel Jews

1.6

0.9

1.9

0.3

3.3

3.6

15.5

18.3

5.6

Japan Miyagi

0.7

0.7

3.0

1.4

1.8

1.2

5.0

3.3

33.3

19.5

Europe Finland Belarus Soab- Basque

1.3 1.3 1.1

0.6 0.9 2.3

1.8 1.3 1.6

0.5 0.9 3.4

3.1 1.6 2.6

1.7 1.1 1.3

14.9 4.2 8.0

10.0 2.2 6.6

48.5 12.5 38.8

38.2 6.4 19.4

Australasia New South Wales

1.2

0.6

1.0

0.5

4.5

2.3

18.0

14.7

63.1

46.5

44.4

Descriptive epidemiology 171

Table 14.3 Site of origin of non-Hodgkin's lymphoma in cases aged 0-79 based on 12 033 cases collected 1984-1993

Lymph node, marrow, blood, tonsils Gastrointestinal tract Skin Bone, orbit, jaw Spleen Liver Central nervous system Testes Breast Other

80.00 8.35 6.12 1.37 1.15 0.98 0.11 0.07 0.05 1.80

Seascale near British Nuclear Fuels Ltd, Sellafield.17 The inclusion in such studies of NHL in both children and young adults (under age 25) is controversial, as they are pooled with ALL cases. It is unlikely that the NHL cases have all been of the lymphoblastic type. The major type of 'clustering' occurs within families. Secular trends

Variation in rates in the UK by all histological types and sites The use of panel-reviewed data has enabled local variation to be examined in the UK at various geographical levels from that of administrative county to the small electoral wards. This highlights various features, particularly a non-random distribution of cases between both counties and administrative districts, with an excess of cases in the south of England compared to the north.3 This has been confirmed in a mortality study.8 Further, the data confirm an excess of cases in predominantly rural areas, an observation made also in North America.9 At the electoral ward level, a non-random and unusual case distribution has been described in parts of the UK,10,11 suggesting local rural excesses. Local case clusters have also been described for the disease in Africa, owing to Burkitt's lymphoma and its links with the EpsteinBarr virus (EBV) and malaria.12 Post hoc clusters in neighborhoods have been described occasionally in various countries.13-16 However, the number of reports are limited compared to HD or leukemia, for example. It should also be noted that NHL in young people has been associated with the 'cluster' reports relating to nuclear power plants of various kinds in the UK, e.g.

One of the most remarkable features of NHL epidemiology is the increase in recorded rates of the condition over the years. This increase is true for most age groups over 30 years of age and for both sexes. No study has shown any increasing trend in childhood NHL.18 This is particularly so for Caucasian populations, and has been recorded from Europe, North America and Australasia. The increase is also seen in black populations in the USA but at a lower rate, and is not seen in African or southwest Asian peoples.19 The same trends have also been seen in UK populations.20 In a series from Yorkshire utilizing a reviewed histopathology panel dataset for 1977-1992, the increase is a remarkable 5 per cent per annum21 but this has been exceeded by a series from France.22 NHL sited in the central nervous system (CNS) has been shown to be on the increase in London.23 However, a Danish study has shown no increase in NHL of the gastrointestinal tract.24 There is no doubt that the trends exist. The controversy revolves around the reasons for it. Because of the problems outlined in the introduction, it has long been argued that the increases are artefactual and the result of increased diagnostic acumen, an increased biopsy rate and the improved ability to distinguish NHL from other tumors. This could, for example, account for some increase in CNS lymphomas due to the advent of better imaging techniques.23,25 To investigate one aspect of this, two series of nodal tumors were abstracted from the same geographical area some years apart and all were reviewed again by a panel. The results showed a uniform increase in incidence in all ages over 30 for NHL, whilst HD only showed an increase in the elderly. The latter

Table 14.4 Age-specific incidence (x per 100000 per year) of NHL non-Hodgkin's lymphomas of all histopathological types by site (sexes pooled where appropriate)

Lymph node, marrow, blood, tonsils Gastrointestinal tract Skin Bone, orbit, jaw Spleen Liver Central nervous system

Testes Breast

0.28 0 0.02 0 0 0.2 0 0 0

0.37 0.07 0.01 0 0 0.01 0.01 0.04 0

1.65 0.12 0.19 0.05 0 0.01 0.02 0 0.09

9.44 0.98 0.83 0.12 0.08 0.11 0.14 0.08 0.05

28.22 2.77 2.22 0.38 0.44 0.33 0.33 0.61 0.25

172 Non-Hodgkin's lymphoma

could be due to increased or more thorough investigations, whilst the former argues for a biological and not a spurious phenomenon.26 Nowadays the consensus is for the existence of a real 'biological' increase but of unknown causation (see later). Some attempts have been made to examine which, if any, subtypes are increasing. Some studies have suggested a general increase using various classification systems but one has implied that large cell disease is responsible.27 If the rates of increase continue, varying between 3 and 10 per cent per annum, NHL will be amongst the commonest cancers in Europe in the next few years.28

ANALYTIC EPIDEMIOLOGY Given the caveats noted in the introduction, piecing together the jigsaw of published studies can be difficult, in some cases, to the point of speculation. However, it is apparent when reviewing the literature that the attention of research workers has fallen into three broad categories: aspects of altered immunity (using its broadest interpretation), occupational studies, and a ragbag of 'lifestyle' studies. The most plausible area of research is that dealing with aspects of immune competence.

Studies of altered immunity INHERITED SYNDROMES AND SUSCEPTIBILITY VIA INDIVIDUAL INHERITED GENETIC SEQUENCES

Several studies have suggested that a slight excess of lymphoma cases occur in blood relatives. The significance of this is not yet known; however, there are a range of generally rare, but well-defined and usually simply inherited conditions that have an excess of NHL as part of a syndrome. Such conditions are typified by ataxia telangiectasia. This is an autosomal recessive condition due to a gene deficit on chromosome 1 lq.29 The syndrome gives a progressive ataxia, many infections and progeria. Immunologically, there are a complex array of deficits, including impaired synthesis of immunoglobulin A (IgA).30 A wide range of cancers occur in these individuals but these include NHL probably more frequently than any other.31 Although such a condition is very rare, theoretically the unaffected heterozygotes could occur quite commonly in the population and it is thus a question of great significance to learn of the health of such individuals. So far only studies of the parents of cases (who are necessarily heterozygotes) have been published, with a suggestion of excess cancers but with such small case numbers that the results are difficult to interpret.32 However, the same argument would be true of all the other autosomal recessive and sex-linked conditions of impaired immunity.

These would include Chediak-Higashi syndrome,33 Wiskott-Aldrich syndrome,34 Bloom's syndrome,35 common variable immunodeficiency, the various agammaglobulinaemias and the severe combined immunodeficiency disorder.36 If the Hardy-Weinberg law of population genetics holds for all these very rare homozygous or sex-linked conditions, the frequency of the heterozygotes in the general population would be quite common. It will be necessary to identify the molecular characteristics of the gene sites in order to identify the carriers and then to determine the status of such people as possibly susceptible to NHL. The potential underlying genetic defects could represent a major initiating cause of NHL, although it would be unlikely to be the only step required to manifest the disease in these heterozygotes. IMMUNODEFICIENCY DUE TO PAST MEDICAL HISTORY

There is an excess of various cancers in patients following organ transplantation, consistent with the intensity of the immunosuppressive regimen.37 The risk of NHL in such patients can be very high, between 20- and 60-fold, but varying from study to study. One other consistently common secondary malignancy is skin carcinoma.38 Some series suggest that extranodal NHL of the CNS is particularly common. Individuals receiving immunosuppressive therapy without transplantation also have a risk of NHL;39 for rheumatoid arthritis cases the risk is roughly ten-fold. There is, however, a problem with all these studies. This is highlighted by more recent reports, which recognize the existence of post-transplant lymphoproliferative disease,40 the diagnosis of which may have been confused in earlier studies, with the contemporary understanding of NHL. Even if this is the case, some underlying risk must exist for NHL in those immunosuppressed by drug therapy. A further complexity in interpreting this outcome for conditions such as rheumatoid arthritis is that the condition itself, not necessarily with the use of immunosuppressive therapy, may have an excess of NHL,41-43 although only a 2-4-fold excess has been observed. This may also apply to other chronic conditions associated with altered immunity such as systemic lupus.44 VIRAL IMMUNOSUPPRESSION

The role of EBV in African Burkitt's lymphoma and in nasopharyngeal carcinoma, in concert with other chronic parasitic infections, is well recognized.45,46 The role of EBV in other NHL types is less well understood, although a small number of cases do have active EBV involvement. However, in most instances, EBV does not appear to be a significant pathogenic factor in the majority of NHL cases. The role of human immunodeficiency

Analytic epidemiology 173

virus (HIV) as an immune depleting agent, is much clearer, however, both from studies of HIV in the general public and in hemophiliacs given HIV-positive Factor VIII preparations. As far as acquired immunodeficiency syndrome (AIDS) cases are concerned, roughly 3 per cent acquire some type of NHL. This equates to a 60-fold risk when cases are contrasted with the general unaffected population.47 Of the NHL in a series from the USA, nearly 60 per cent were described as 'immunoblastic', approximately 20 per cent as primary CNS tumors and approximately 20 per cent as 'Burkitt' in type. The risk in a series of purely HIV-infected hemophiliacs was half that of the AIDS study noted above. Almost all such cases were described as extranodal but for a very wide range of sites, including gastrointestinal tract, skin and CNS.48 The relationship between human T-cell lymphotropic virus type 1 (HTLV-1) and the development of acute T cell leukemia/lymphoma is now much clearer in the endemic areas of Japan and the Caribbean. In Jamaica the risk of NHL in those infected with HTLV-1 is roughly 10-fold.49 Most HTLV-1 infections are a result of vertical transmission and thus the condition lends itself to public health measures. Other HTLV-1 endemic areas have been identified in Africa50 and the USA51 and South America.52 The role of needle transmission and the status of HTLV-2 are still under investigation. The newly identified herpes-like agent associated with Kaposi's sarcoma may also have a role in NHL.53 Known or unknown viruses have also been postulated to account for the excess of NHL found in blood transfusion recipients.54 CHEMICALLY INDUCED IMMUNOSUPPRESSION

Many of the chemicals possibly linked to NHL are thought to have immunosuppressive qualities.55

for in the calculation. These could be the mundane explanation as to why NHL excesses occur quite commonly in this type of literature. The links with occupations have been extensively reviewed elsewhere56 and the salient results are listed below. AGRICULTURE

Various occupations related to agriculture have been associated with an excess risk of NHL.57 Overall, at least 20 studies have seen statistical excesses in farmers, horticulturists and contract applicators.56 In addition, a lowgrade NHL excess is seen in farm animal breeding workers.58 However, a large study of herbicide production workers showed no NHL excess,59 nor has any study of dioxin-exposed workers shown any NHL excess, although the general population of Seveso does show a statistical excess but only for males.60 Attention has been given to the particular exposures of farmers themselves and what substances, if any, might be responsible. One review suggested that 2;4D is significantly involved,61 while another study has incriminated atrazine.62 In a more recent workers-exposure study, no significant excess of NHL emerged for any subtype of phenoxyherbicides, chlorophenols or dioxins with only a minor possible effect of usage of the insecticide lindane.63'64 No firm biological evidence has so far been found to support causal links between NHL and any such substances. It has been clearly demonstrated that veterans of the Vietnam war show an excess of NHL.65 This remains unexplained but it has been suggested that the phenomenon may be a result of exposure to defoliants. However, close examination of the data show this excess is confined to naval veterans. Studies of possible links between Agent Orange and contaminants with NHL and sarcoma are ongoing.66

Occupational links PETROCHEMICAL INDUSTRY

The risks associated with NHL's links with immune alterations range from four-fold rising to roughly 60fold. The occupational risks, however, are very different, with risks being four-fold at most but usually far smaller. Despite this, the literature on this aspect of etiology is very large. This should not be taken as a sign that occupations are deemed to be particularly significant in the pathogenesis of these conditions. Occupational cohort and other studies 'turn up' statistically significant results, a proportion at random, and there are large numbers of such studies. Secondly, the calculation of'expectated case numbers' in these studies is made on a basis of known national rates. In the case of NHL, these may be too low, owing to the problems of basic ascertainment (see 'Introduction'), that is, the comparison between a wellinvestigated cohort and national rates are inappropriate. Also the increasing trends in incidence are not accounted

At least four studies have shown a statistical excess of NHL with the petrochemical industry.56 However, two cohort studies were negative.67,68 This indicates the risk may be weak or of uncertain significance. OTHER INDUSTRIES

A wide variety of other industries have been named sporadically as having an excess risk of NHL. These include, firefighters,69 flour industry workers,70 asbestos exposed workers,71,72 dry cleaners,73 nickel refinery workers,74 carpenters, painters, plasterers and others in the wood and building trades.75-77 All the risks are either very low or based on very small numbers and, with a few exceptions, have little support from biological studies.78 Most of these observations are unsupported by independent studies.

174 Non-Hodgkin's lymphoma

Lifestyle and other exposures

REFERENCES

Most studies have shown little statistically significant relationship between NHL and cigarette smoking. There are, however, studies showing, albeit weak, risks and some evidence of a dose response relationship and a relationship of risk to age.79-81 Attempts to analyse the relationship between smoking and different subtypes of NHL are fraught with difficulty, the association with follicular lymphomas possibly being the strongest.82 The evidence for a relationship with exposure to ionizing irradiation is equally sparse, amounting to very little risk consequential on the atomic bomb explosions83 or from diagnostic X-rays,84 but the results from alphairradiation via the use of diagnostic thorotrast demonstrate a definite risk, although this is difficult to quantify.85 Despite this, there are no unequivocal data available to suggest a simple relationship in risk between NHL and these two acknowledged human carcinogens. This maybe due to the protean nature of NHL, with possibly a strong risk with some subtypes of NHL only, or perhaps because lymphomagenesis is solely dependent on chronic immune interference. As to other exposures, there is in general no convincing aspect of dietary exposure linked to risk of NHL,86-87 including non-alcoholic beverages88 and alcohol.89 In some populations, data suggested a possible link to meat intake.90 It has been suggested that the use of hair colorants gives a risk of NHL91 but this has been challenged.92 Attempts have been made to associate residential proximity to industrial sites with the risk of NHL in adults or children, with varying success and little by way of convincing results.93-95

1. Palackdharry CS. The epidemiology of non-Hodgkin's lymphoma: why the increased incidence? Oncology 1994; 8: 67-75. 2. Anderson JR, Armitage JO, Weisenburger DD, for the NonHodgkin's Lymphoma Classification Project. Epidemiology of the non-Hodgkin's lymphomas: distribution of the major subtypes differ by geographical locations. Ann Oncol 1998; 9: 717-20. 3. Cartwright RA, McNally RJQ, Rowland DJ, etal. The descriptive epidemiology of leukaemia and related conditions in parts of the United Kingdom 1984-1993. London: Leukaemia Research Fund, 1997. 4. Parkin DM, Muir CS, Whelan SL, eds. Cancer incidence in five continents, Vol. VI. IARC Scientific Publications 120. Lyon: IARC, 1992. 5. Stiller CA, Parkin DM. International variations in the incidence of childhood lymphomas. Paediat Perinatal Epidemiol 1990; 4: 303-24. 6. Powell J, Parkes SE, Cameron AH, et al. Is the risk of cancer increased in Asians living in the UK? Arch Disease Childhood 1994; 71: 398-403. 7. Revesz T, Mpofu C, Oyejide C. Ethnic differences in the lymphoid malignancies of children in the United Arab Emirates. A clue to aetiology? Leukemia 1995; 9:189-93. 8. Swerdlow A, Silva Ide S. Atlas of cancer incidence in England and Wales 1968-85. Cancer Research Campaign. Oxford: Oxford University Press, 1993. 9. Pickle LW, Mason TJ, Howard N, et al. Atlas of US cancer mortality among whites: 1950-1980. DHHS Publ No. (NIH) 87-2900. Washington, DC: US Government Printing Office, 1987. 10. Eddington GM. The Burkitt lymphoma in the Northern Savannah of Nigeria. Prog Clin Biol Res 1981; 53: 133-49. 11. Barnes N, Cartwright RA, O'Brien C, et al. Variation in lymphoma incidence within Yorkshire health region. BrJ Cancer W87; 56:169-72. 12. Smith PG. Current assessment of 'case clustering' of lymphomas and leukaemias. Cancer 1978; 42:1026-34. 13. Schimpff SC, Schimpff CR, Brager DM, et al. Leukaemia and lymphoma patients interlinked by prior social contact. Lancet 1975; i: 124-9. 14. Dowsett EG. Leukaemia in Kingston, Surrey, 1958-64: an epidemiological study. BrJ Cancer 1966; 20:16-31. 15. Mainwaring D, Martin J. Leukaemia and reticuloses. Br Med J 1968;ii:702. 16. Kolandaivelu G. A cluster of non-Hodgkin's lymphoma. Indian Paediat 1988; 25: 583. 17. Draper GJ, Stiller CA, Cartwright RA, et al. Cancer in Cumbria and in the vicinity of the Sellafield nuclear installation, 1963-1990. BrMedJ 1993; 306: 89-94. 18. Blair V, Birch JM. Patterns and temporal trends in the incidence of malignant disease in children: I. Leukaemia and lymphoma. EurJ Cancer 1994; 30A: 1490-9. 19. Devesa SS, Fears T. Non-Hodgkin's lymphoma time

THE FUTURE A close reading of the preceding chapter will have suggested ways in which epidemiological studies of NHL can be improved and indeed some such studies are now underway, with better diagnostic and exposure markers. The problems as to how to subdivide the disease and why the condition is increasing so much and in such a widespread fashion, however, still remain. Common sense would suggest that the pathways of greatest influence upon lymphomagenesis are through the many areas of immune depletion. Unless major selective pressures exist, the gene pool of immune deficiency syndrome heterozygotes is unlikely to be increasing disproportionately to the total population. Further, whatever is causing an increase must be very common. It has been argued that this could be due to the immune modifying effects of sunlight,28 but other models based on antibiotic usage and traffic pollution also exist. Given the future potential burden of the disease on society, studies to address these and related issues are necessary.

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72. Gerber MA. Asbestosis and neoplastic disorders of the hematopoietic system. AmJClin Pathol 1969; 53: 204-8. 73. Blair A, Stewart PA, Tolbert PE, et al. Cancer and other causes of death among a cohort of dry cleaners. BrJ Indust Med 1990; 47:162-8. 74. Egedahl RD, Carpenter M, Homik R. An update of an epidemiology study at a hydrometallurgical nickel refinery in Fort Saskatchewan, Alberta. Health Rep 1993; 5:291-302. 75. Edling C, Jarvholm B, Andersson L, et al. Mortality and cancer incidence among workers in an abrasive manufacturing industry. BrJ Indust Med 1987; 44: 57-9. 76. Scherr PA, Hutchison GB, Neiman RS. Non-Hodgkin's lymphoma and occupational exposure. Cancer Res 1992; 52: 5503s-9s. 77. Perrson B, Dahlander A-M, Fredriksson M, et al. Malignant lymphomas and occupational exposures. BrJ Indust Med 1989; 46: 516-20. 78. Garry VF, Danzl TJ, Tarone R, et al. Chromosome rearrangements in fumigant appliers: possible relationship to non-Hodgkin's lymphoma risk. Cancer Epidemiol Biomarkers Prevent 1992; 1: 287-91. 79. Brown LM, Everett GD, Gibson R, et al. Smoking and risk of non-Hodgkin's lymphoma and multiple myeloma. Cancer Causes Control 1992; 3: 49-55. 80. Linet MS, McLaughlin JK, Hsing AW, et al. Is cigarette smoking a risk factor for non-Hodgkin's lymphoma or multiple myeloma? Results from the Lutheran Brotherhood cohort study. Leak Res 1992; 16: 621-4. 81. Freedman DS, Tolbert PE, Coates R, Brann EA, Kjeldsberg CR. Relation of cigarette smoking to non-Hodgkin's lymphoma among middle-aged men. Am J Epidemiol 1998;148:833-41. 82. Herrinton LJ, Friedman GD. Cigarette smoking and risk of non-Hodgkin's lymphoma subtypes. Cancer Epidemiol Biomarkers Prev 1998; 7: 25-8. 83. Nishiyama H, Anderson RE, Ishimaru T, et al. The incidence of malignant lymphoma and multiple myeloma in Hiroshima and Nagasaki atomic bomb survivors. Cancer 1973; 32:1301-9. 84. Boice JD, Morin MM, Glass AG. Diagnostic X-ray procedures and risk of leukemia, lymphoma and multiple myeloma. JAMA 1991; 265:1290-4. 85. Visfeldt J, Andersson M. Pathoanatomical aspects of malignant haematological disorders among Danish patients exposed to thorium dioxide. Acta Pathol Microbiol Immunol Scand 1995; 103: 29-36. 86. Ward MH, Zahm SH, Wisenburger DD, et al. Dietary factors and non-Hodgkin's lymphoma in Nebraska (United States). Cancer Causes Control 1994; 5: 422-32. 87. Scott D. Nutritional factors and the development of nonHodgkin's lymphoma: a review of the evidence. Cancer Res 1992;52:5492s-5s. 88. Tavani A, Negri E, Franceschi S, et al. Coffee consumption and risk of non-Hodgkin's lymphoma. EurJ Cancer Prevent 1994; 3: 351 -6.

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PART

Clinical Management

Hodgkin's disease: clinical features Imaging of lymphoma Localized Hodgkin's disease Localized non-Hodgkin's lymphoma Advanced Hodgkin's disease Aggressive non-Hodgkin's lymphoma Lymphoblastic lymphoma in adults Follicular lymphoma Other low-grade non-Hodgkin's lymphomas High-dose therapy AIDS-related lymphoma Cutaneous lymphomas Pediatric lymphomas Lymphoma in the elderly Infections Long-term problems The way forward

181 205 221 247 269 287 299 309 325 331 351 359 371 385 399 421 437

4

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15 Hodgkin's disease: clinical features PWM JOHNSON, PJ SELBY AND BW HANCOCK

Introduction

181

Prognostic factors

Presenting features of Hodgkin's disease

181

Diagnosis and staging

184

Patterns of recurrence Hodgkin's disease in special situations

Paraneoplastic manifestations of Hodgkin's disease

188

Contrasts with non-Hodgkin's lymphoma

Clinical approach to the patient with Hodgkin's disease

188

References

INTRODUCTION Thomas Hodgkin first described the 'morbid appearances of the absorbant glands and spleen' in six patients with lymph node enlargement at Guy's Hospital in London in January 1832.1 Samuel Wilks in 1865 first used the term 'Hodgkin's disease' in describing a condition involving bulky lymphadenopathy and 'a deposit of a morbid kind in internal viscera, more especially in the spleen'.2 Sternberg3 and Reed4 later identified the characteristic giant cells now given their names. Such cells had also been mentioned by Olivier and Ranvier,5 Tuckwell,6 Langans,7 Greenfield8 and Gowers.9 Treatment with radiotherapy began with Pusey10 in 1902 and was developed by Gilbert in 1939," leading to the work of Peters in Toronto,12 and major contributions at Stanford University by Henry Kaplan.13,14 Single-agent chemotherapy began in the 1940s,15 and this was followed 20 years later by useful combination chemotherapy16 and then effective quadruple combination chemotherapy.17,18 It is perhaps surprising that with such a long history there still seems to be a great deal to learn about the clinical features of Hodgkin's disease. Understanding of these features, their prognostic significance and their biological basis continues to develop. The subject is still in evolution, and thinking around the clinical features is adapted to changing concepts of histopathology and pathogenesis. Treatment decisions continue to be based predominantly upon anatomical staging of the disease and simple indicators of its severity, but there is some dissatisfaction with the lack of predictive power in this approach, particularly its inability to pick out those for

191 194 195 196 198

whom conventional therapy is likely to fail. It is to be hoped that novel methods of prognostic division may emerge in the next few years to overcome this deficiency.

PRESENTING FEATURES OF HODGKIN'S DISEASE The clinical features of Hodgkin's disease have probably changed little despite changing interpretations. The epidemiology of the disease has been discussed in Chapter 13 but certain aspects are relevant to the patterns of presentation. The illness is more common in males, particularly among cases occurring in childhood. The well-known bimodal age incidence varies according to the geographical location, with more childhood and adolescent patients in less developed countries, and a generally higher peak age at presentation in the Western world.19 The clinical pattern of the disease at presentation also varies between units and hospitals and trials groups. Patients with localized disease are seen more often in radiotherapy centers, and advanced systemic disease may lead to a referral to a medical oncology unit. This largely explains the wide variations between reported series. Table 15.1 contains the clinical features of patients who presented to three different research groups in the UK during the last three decades: the Royal Marsden Hospital, the United Kingdom Central Lymphoma Group and the British National Lymphoma Investigation. These show considerable variation in the gender ratio, presence of systemic symptoms, clinical

182 Hodgkin's disease: clinical features

Table 15.1 Clinical features of Hodgkin's disease at presentation

Sex Male Female

77 152

33.6 66.4

148 79

65.2 34.8

182 122

59.9 40.1

172 117

59.5 40.5

117 112

51.1 48.9

79 148

34.8 65.2

84 220

27.6 72.4

87 202

30.1 69.9

27 89 64 49

11.8 38.9 27.9 21.4

13 78 77 54

5.9 35.1 34.7 24.3

10 71 121 93

3.3 23.4 42.6 30.7

8 58 135 88

2.8 20.1 46.7 30.4

10 12 70 137

4.4 5.2 30.6 59.8

11 20 50 135

5.1 9.3 23.2 62.5

5 2 47 250

1.6 0.7 15.5 82.2

2 6 54 227

0.7 2.1 18.7 78.6

193 36

84.3 15.7

198 20

90.8 9.2

273 31

89.8 10.2

250 39

86.5 13.5

139 90

60.7 39.3

172 47

78.5 21.5

246 58

80.9 19.1

220 69

76.1 23.9

117 112

51.1 48.9

81 145

35.8 64.2

103 198

34.2 65.8

95 186

33.8 66.2

171 58

74.7 25.3

193 33

85.4 14.6

281 20

93.4 6.6

252 29

89.7 10.3

197 32

86.0 14.0

230 23

89.8 10.2

220 9

96.1 3.9

173 20

89.6 10.4

199 30

86.9 13.1

191 36

84.1 15.9

B symptoms

No Yes Clinical stage

I II III IV Histology

LD LP MC NS Involvement of: Liver

No Yes Spleen

No Yes Mediastinum

No Yes Bulky mediastinum

No Yes Lung

No Yes Marrow

No Yes Inguinal nodes

No Yes

The authors are grateful to Dr Gillian Vaughan Hudson (BNLI) and Dr Michael Cullen (CLG) for provision of the data included in the table from Hancock et al.20 and Cullen et al.21 BNLI = British National Lymphoma Investigation, CLG = Central Lymphoma Group, LD = lymphocyte depleted, LP = lymphocyte predominant, MC = mixed cellularity, NS = nodular sclerosing.

stage, histologic subtypes, and involvement of various visceral and lymph node sites. This reflects selective referral patterns and differences in investigation policies. The National Survey of Patterns of Care for Hodgkin's Disease of the Commission on Cancer of the American College of Surgeons reported findings in 9482 patients from 611 geographically scattered hospitals (Fig. 15.1).

The authors estimated that this series included some 45 per cent of the US annual incidence during the study period, and it represents a useful unselected description of the clinical features of the disease.22 Painless enlargement of lymph nodes, usually in the neck, but occasionally in the axilla or inguinal region, is the most common presentation. Spontaneous waxing

Presenting features 183 Table 15.3 Stage distribution at presentation24

Image Not Available

IA IB AIM

11 0.8 12

20

HA IIB IIAE IIBE

29 10 5 2.8 47

} 4 I 26

All II IMA IIIB IIIAE IIIBE

All III Figure 15.1 Clinical examination findings at presentation. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., from Kennedy BJ, et a I. National survey of patterns of care for Hodgkin's disease. Cancer 7985; 56: 2547-56. © 7985 American Cancer Society.

and waning of nodes is well recognized. Systemic symptoms, such as, fever, night sweats, weight loss or itching, occur in about one-third of patients initially. In a few patients pain is experienced in the nodes, often in the chest, after drinking alcohol - a symptom usually associated with nodular sclerotic histology.23 Table 15.2 gives an overall impression of the pattern of Hodgkin's disease at presentation from across the literature. There are still few examples of detailed studies that add much to this general understanding. The outstanding early work at Stanford24 is summarized in Table 15.3. It is derived from Table 15.2 Sites of involvement with Hodgkin's disease at presentation

Right neck nodes Left neck nodes Mediastinum Axillary nodes Hilar nodes Para-aortic nodes Iliac nodes Inguinal and femoral nodes Mesenteric nodes Splenic hilar, celiac, portal nodes Spleen Liver Lung Bone Bone marrow

55-60 60-70 60-65 20-25 10-25 25-35

10-15 5-15 5-10 10-20 30

5-15 10-20 5-15 5-15

5 10 2 5 <1 <1 <1 <5 <1 <1 <1 <1 <1 <1 <1

IVA IVB

16 11 1.5 2.3 30

I J

1-7

20

All IV

3.2 7.4 11

13

Not given

0

21

PS = pathological stage.

a consecutive series of unselected patients all of whom underwent staging laparotomy and bone marrow biopsy. There is a close association between stage and systemic symptoms that was also shown in the later Stanford series25 (Fig. 15.2). Involvement of particular lymph node groups in the absence of disease elsewhere may carry special prognostic significance. Isolated high cervical lymph nodes are a preferential site of involvement by the lymphocytepredominant histologic type and usually carry a favorable prognosis.26 By contrast, infradiaphragmatic Hodgkin's disease presenting with inguinal lymphadenopathy alone carries an unfavorable prognosis.27

Figure 15.2 symptoms.

Relationship of stage to occurrence of systemic

184 Hodgkin's disease: clinical features

This pattern accounts for about 10 per cent of patients who present with localized disease, and is associated with male gender, more advanced age, a higher incidence of systemic symptoms and with lymphocyte-depleted and mixed cellularity histology.28,29 Nodular sclerosis histologic types tend to present with central lymph node enlargement, usually in the chest, whereas the less favorable histologic types more often involve the abdomen and extranodal sites. Splenic involvement is usually in association with lymphadenopathy on both sides of the diaphragm, and is the sole site of abdominal disease in less than 10 per cent of those with thoracic disease. Isolated extranodal presentations are rare: less than 5 per cent of cases. Pulmonary and endobronchial lesions, liver infiltration, cortical bony deposits, gastrointestinal tumors, bone marrow and meningeal deposits are all described as the sole site of disease in a few cases, but all are very uncommon. When Hodgkin's disease is found in an isolated extranodal site, the diagnosis requires careful and critical review; non-Hodgkin's lymphomas are much more often the cause of such presentations. Extranodal involvement in association with disseminated disease is found in 10-20 per cent of cases. The most commonly affected sites are the lung, liver, cortical bone and bone marrow. Definite diagnosis of extranodal involvement is not always straightforward. Pleural effusions may occur due to either lymphatic obstruction in the mediastinum or direct pleural infiltration. Similarly liver blood tests may be abnormal in the absence of radiologic liver lesions or histologic involvement. Bone marrow infiltration may be inhomogeneous. A variety of paraneoplastic phenomena occur and may occasionally be the cause of presentation. These include: anemia, which may be normochromic/normocytic or due to autoimmune hemolysis; nephrosis, which may also be due to immune complexes or to amyloidosis; skin manifestations, such as, erythema multiforme, icthyosis, hyperpigmentation or urticaria, and hypercalcemia.

DIAGNOSIS AND STAGING In over 90 per cent of all cases the diagnosis is made by lymph node biopsy.22 Needle aspiration cytology may have a minor role in the diagnosis of recurrence30 but is no substitute for adequate surgical biopsy, preferably of a whole node, at the time of presentation. The early work of Kaplan and colleagues31 in California and of Sir David Smithers32'33 at the Royal Marsden Hospital examined the location of nodal and extranodal involvement by Hodgkin's disease, and emphasized the distinctly non-random pattern of spread. Smithers postulated that there might be a continuous movement of Hodgkin cells through lymph nodes and through the bloodstream, but that there may

be intrinsic differences in the susceptibility of different lymph node chains; Kaplan believed that spread was contiguous. The Harvard group have recently analysed their cases to examine patterns of spread34 and certain trends are discernible: supraclavicular nodes are associated with mediastinal disease much more than high neck nodes; mediastinal and hilar nodes are associated; and abdominal nodes are associated with splenic involvement. It is upon the relatively orderly anatomic pattern of disease progression that the various staging systems have been based, influenced also by the diagnostic and therapeutic approaches available at the time. The Hodgkin's Disease Staging Committee meeting at Ann Arbor established the basis of the current staging system35 (Table 15.4). The limitations of the Ann Arbor system were recognized to be the lack of information on several prognostically important criteria, in particular the number of lymph node sites and the bulk of the tumor, particularly in the mediastinum.36 It also ignored recent advances in imaging, including computed tomography (CT) and magnetic resonance imaging (MRI). This led to modification of the Ann Arbor staging at a meeting in the Cotswolds in England, which has subsequently become the basis of the Cotswold staging system37 (Table 15.5). In both staging systems, classifications apply only to the patients at the time of disease presentation and prior to definitive therapy. Each stage is subdivided into A and B categories - A for those without defined systemic symptoms, B for those with one or more of the following: (a) unexplained weight loss of more than 10 per cent of the body weight in the 6 months previous to presentation, (b) unexplained fever with temperatures above Table 15.4

Ann Arbor staging system for Hodgkin's disease

Stage I Involvement of a single lymph region (I) or of a single extralymphatic organ or site (IJ. Stage II Involvement of two or more lymph node regions on the same side of the diaphragm (II) or localized involvement of an extralymphatic organ or site and of one or more lymph node regions on the same side of the diaphragm (llE). An optional recommendation is that the numbers of node regions involved be indicated by a subscript (e.g. II3). Stage III Involvement of lymph node regions on both sides of the diaphragm (III), which may also be accompanied by localized involvement of an extralymphatic organ or site (IIIE), or by involvement of the spleen (Ills) or both (IIIJ. Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs or tissues with or without associated lymph node enlargement. The reason for classifying the patient as stage IV should be identified further by defining site by symbols.

Diagnosis and staging 185

Ta ble 15.5 The Cotswold staging classification for Hodgkin 's disease Stage I Involvement of a single lymph region or a lymphoid structure (e.g. spleen, thymus, Waldeyer's ring). Stage II Involvement of two or more lymph node regions on the same side of the diaphragm (i.e. the mediastinum is a single site, hilar lymph nodes are lateralized). The number of anatomic sites should be indicated by a subscript (e.g. II2). Stage III Involvement of lymph node regions or structures on both sides of the diaphragm: III, with or without splenic hilar, celiac or portal nodes III2 with para-aortic, iliac, mesenteric nodes Stage IV Involvement of extranodal site(s) beyond that designated E: A B X

No symptoms Fever, drenching sweats, weight loss Bulky disease > 1/3 the width of the mediastinum > 10 cm maximal dimension of nodal mass E Involvement of a single extranodal site, contiguous or proximal to a known nodal site CS Clinical stage PS Pathological stage

The following notation is used in further description of pathologic stage: N+ or NH+ or HS+ or SL+ or LM+ or MP+ or P0+ or 0D+ or D-

For other lymph node, positive for disease or negative by biopsy For liver, positive or negative by liver biopsy For spleen, positive or negative following splenectomy For lung, positive or negative by biopsy For marrow, positive or negative by biopsy or smear For pleura involved, or negative by biopsy or cytological examination For osseous involvement or negative by biopsy For skin involvement or negative by biopsy

38°C; and (c) drenching night sweats. Neither pruritus alone nor a short, febrile illness associated with a known infection qualifies for B classification. A distinction is made in both staging systems between clinical and pathologic staging. Clinical staging (CS) is determined by history, physical examination, radiological studies, isotopic scans, laboratory tests of urine and blood, and the initial biopsy results. Whilst the clinical stage derives from the clinical findings and non-invasive tests, the pathologic stage (PS) is based upon further biopsies taken subsequent to the initial diagnosis, either at laparotomy or by some other invasive procedure, such as liver or bone marrow biopsy. Some care must be exercised in the use of the term

'pathological staging'. Comprehensive pathological staging involves laparotomy and splenectomy, but the term is allowed for less extensive biopsy procedures, such as percutaneous liver biopsy. The use of the PS notation does not by itself indicate that a splenectomy has been carried out. Lymphatic Hodgkin's disease The lymphatic structures are defined as the lymph nodes, spleen, thymus, Waldeyer's ring, appendix and Peyer's patches. The lymph node regions accepted as single groups are shown in Table 15.6. Figure 15.3 shows the characteristic appearances of Hodgkin's disease in the mediastinum. Radiologic enlargement alone is insufficient to diagnose splenic involvement; clinically detectable splenomegaly or focal defects on scans are required (Fig. 15.4). In patients subjected to staging laparotomies, only 60 per cent of spleens that were enlarged clinically or radiographically were found to be involved on histological examination.24,38,39 This figure rose to 70-80 per cent in Table 15.6 Lymph node groups classified separately for staging Cervical, supraclavicular, occipital and preauricular (all one) Infraclavicular Axillary and pectoral Mediastinal, including thymus Hilar Para-aortic Mesenteric Iliac Inguinal and femoral Splenic Popliteal Epitrochlear Waldeyer's ring

Figure 15.3

Computed tomographic scan showing mediastinal

involvement by Hodgkin's disease.

186 Hodgkin's disease: clinical features

Figure 15.4

Figure 15.5 Computed tomographic scan showing pulmonary involvement by Hodgkin's disease.

Computed tomographic scan showing

involvement of the liver and spleen by Hodgkin's disease. 25

the presence of involved infradiaphragmatic nodes. Conversely, 30 per cent of spleens that were thought to be normal were found to be involved. Clinical assessment is therefore misleading. The main factors that indicate an increased probability of splenic involvement are mixed cellularity histologic subtype, para-aortic lymph node involvement, systemic symptoms and a large number of nodal sites above the diaphragm. Epitrochlear lymphadenopathy is uncommon, even when Hodgkin's disease is widespread, and is probably found in less than 2 per cent of cases.40,41 There are a few cases of epitrochlear disease as the presenting feature of Hodgkin's disease in the absence of any other disease on full investigation.42 Involvement of Waldeyer's ring is very uncommon and was found in 3.7 per cent of 750 patients in one series.43 It is usually found in the tonsil or nasopharynx, and is associated with upper cervical or pre-auricular nodal disease in around half the cases.44 Mixed-cellularity histology is over-represented at this site.

Extranodal Hodgkin's disease Table 15.2 gives an indication of frequency of involvement at extranodal sites. LUNG

About 10-20 per cent of patients have lung disease at presentation45 (Fig. 15.5). Older series recorded that up to 40 per cent involved the lung at some phase of the illness,46,47 but this has become less common with increasingly successful treatment. Over 50 per cent may have involvement at autopsy.48 Hodgkin's disease in the lung is usually associated with lymphadenopathy in the mediastinum or hilar regions, and is most common with nodular sclerosing histology. Relapse in lung may occur in the absence of regrowth of the lymph nodes in patients who have been treated for intrathoracic lymphadenopathy by radiotherapy. Primary intrapulmonary Hodgkin's disease without

lymphadenopathy has been described in occasional case reports (see reviews49,50). The commonest pattern of lung involvement is direct spread of tumor from the mediastinum into the lung parenchyma. The X-rays may, on the other hand, show large lung nodules, multiple small nodules, or coarse and fine reticular shadows. PLEURA

Pleural effusion in Hodgkin's disease may be the result of tumor invasion of the pleura or may be secondary to obstruction of lymphatic drainage by mediastinal disease. The presence of an effusion is not necessarily indicative of extranodal Hodgkin's disease. Distinguishing between these two processes is of some clinical importance and may be difficult. Malignant cells may be seen on cytological examination of the pleural fluid or on needle biopsy of the pleura. If the pleural surfaces are involved with tumor the protein content of the fluid will usually be high, but this is not invariably the case. When radiotherapy was the only curative treatment available, patients were subjected to thoracotomy in order to distinguish the cause of pleural effusion. In more modern practice, since even non-malignant effusions are usually associated with bulky mediastinal lymph nodes, which are best treated by chemotherapy, such invasive methods are no longer required.51 ENDOBRONCHIAL DISEASE

Although involvement of the distal bronchiole is not uncommonly found at autopsy in patients with advanced pulmonary Hodgkin's disease, it is unusual to find Hodgkin's disease as an endobronchial lesion. Harper et al. have reviewed 13 such cases, most of which had lobulated masses on bronchoscopy.52 SUPERIOR VENA CAVAL OBSTRUCTION

Although Hodgkin's disease commonly involves the mediastinum, superior vena caval obstruction is rare, and less frequent, for instance, than in small cell lung

Diagnosis and staging 187

cancer or aggressive non-Hodgkins lymphoma.53 Its clinical and radiological features are not specific to Hodgkin's disease and it is usually associated with nodal disease in the neck, biopsy of which will yield the diagnosis. Dexamethasone allows substantial relief of symptoms and some regression of the mass. Since the disease is usually bulky, combination chemotherapy is the treatment of choice, and works as quickly as radiotherapy. LIVER

The reported incidence of liver involvement at presentation ranges from 3 to 24 per cent, reflecting the selection of patients and the extent of investigation.51,54 The mixedcellularity and lymphocyte-depleted histologic types are the most common in this site. The diagnosis of hepatic Hodgkin's disease may present several problems. Jaundice is usually only found in very advanced cases, and there is little correlation between liver size and the presence of Hodgkin's disease histologically. Liver function tests may be deranged in Hodgkin's disease in the absence of histological involvement of the liver.55,57 Imaging scans of the liver lack sensitivity, whether by CT, isotope imaging scans, ultrasound or any of the newer methods now available. In a study of 215 patients, Fabian et al.58 found 24 per cent positive liver biopsies (laparotomy, peritonoscopy or percutaneous) in patients with stage IIIA-IVB disease with an increasing rate in higher stages (15 per cent in CSIIIA; 48 per cent in CSIVB). Twenty-nine patients had a negative percutaneous biopsy followed by a laparotomy at which 8/29 had liver disease on wedge biopsy. Nine patients had negative peritonoscopy and only 1/9 had a positive wedge biopsy. In the absence of a satisfactory diagnostic method for liver Hodgkin's disease, the presence of two substantially abnormal liver function tests, or one abnormal test plus hepatomegaly, or an abnormal liver scan plus one abnormal enzyme were previously used as criteria (Ann Arbor criteria35). Unfortunately these criteria were not accurate: in the study of Fabian et al.,58 56 per cent of patients with a positive biopsy were negative by Ann Arbor criteria and 21 per cent of patients with normal liver biopsies had Ann Arbor criteria liver disease. The Cotswold staging system therefore dispensed with the liver blood tests as a means of determining stage, relying instead upon radiology and specialized scans. The finding of focal defects in the liver on CT scan is taken as evidence of involvement provided it is confirmed by a second imaging technique, such as ultrasound or isotope scanning. Hepatitis, hepatic failure, cholestatic jaundice and granulomatous hepatitis have all been described.59-63Liver granulomas are found in 5-10 per cent of patients at staging laparotomy for known Hodgkin's disease.60 However, in a small number of cases, hepatic granulomas may precede the diagnosis of Hodgkin's disease by several years, and be associated with hepatosplenomegaly and fever.61 Hodgkin's disease should be considered in the differential

diagnosis of'idiopathic' hepatic granulomas. Cholestatic jaundice may occur in the absence of detectable liver involvement59,63 either with advanced disease or localized supradiaphragmatic lymph node disease. In that case, the jaundice may resolve after mantle radiotherapy.63 BONE

As with other visceral sites of disease, there is a very wide range of reported findings from different centers (6-19 per cent in series after 1960), but if these are taken together the average is 12 per cent in 2991 patients.51 Bone disease may or may not be painful, but can be associated with alcohol-induced pain. It may be lytic or sclerotic, and may result from hematogenous spread or direct extension into bone, for example, the lumbar spinal vertebrae from para-aortic nodes or the sternum from mediastinal nodes. The spine is the commonest site of involvement.23,64 SPINAL CORD COMPRESSION

Extradural spinal cord compression is an unusual manifestation of advanced Hodgkin's disease65,66 or a rare presentation of localized bony disease. There may be associated bony destruction or it may occur in the absence of obvious bony abnormality, by extension from nodal disease through the intervertebral foramina or from meningeal deposits. The clinical features of cord compression in Hodgkin's disease are similar to those from other causes. Unlike other malignant processes that cause cord compression, Hodgkin's disease is usually very sensitive to treatment by radiotherapy and chemotherapy. The results are best when treatment is given immediately and patients who have good neurological function at the time of treatment usually make excellent recoveries. Spinal laminectomy may be required to make the diagnosis in a few patients.51 CENTRAL NERVOUS SYSTEM

Intracranial Hodgkin's disease is uncommon.67,68 The disease tends to involve midline structures at the base of the brain, including brain stem and cerebellar vermis, and causes cranial nerve palsies, weakness, headache, and seizures. It carries a grave prognosis, particularly when associated with resistant disease elsewhere, and median survival is less than 6 months, with only about 20 per cent of patients surviving 2 years. Leptomeningeal Hodgkin's disease has been the subject of sporadic case reports,69,70 and Hodgkin's disease is one of the least frequent causes of meningopathy. When encountered, it maybe treated with intrathecal methotrexate and whole-brain irradiation, and occasionally useful remissions may result.70 BONE MARROW

Involvement of bone marrow is found in between 5 and 15 per cent of patients. It is closely associated with symptoms

188 Hodgkin's disease: clinical features

and advanced stage, being found in less than 2 per cent of IA and IIA patients, and it is less common in nodular sclerotic subtypes.71 Alkaline phosphatase is commonly raised and marrow involvement confers a relatively poor prognosis, even within patients with advanced disease.71,72 HODGKIN-CELL LEUKEMIA

Hodgkin-cell leukemia is rare and is usually associated with very advanced disease.73 In such cases, the distinction from lymphoid and myeloid leukemia may be difficult. Linch et al. have analysed one such case, found the cells to be derived from the B cell lineage and have postulated an association with the lymphocyte-depleted form of nodular sclerotic Hodgkin's disease.74 PERICARDIAL DISEASE

Paracardiac nodal disease is visible in 2 per cent of patients at presentation75 but may be more important at relapse after mantle irradiation, which may not include nodes in the cardiophrenic angle.76 Pericardial effusions are rare at the time of presentation but may be a feature of very advanced mediastinal disease. SKIN AND SUBCUTANEOUS DISEASE

The cutaneous manifestations of Hodgkin's disease are pruritus, urticaria, erythema multiforme, eczema, herpetic infections, ichthyosis, alopecia, oedema, erythema nodosum, toxic epidermal necrolysis and infiltration. The findings at involved sites are usually multiple dermal or subcutaneous erythematous nodules and extension from involved lymph nodes may be a feature. GASTROINTESTINAL TRACT

Gastrointestinal involvement with Hodgkin's disease is distinctly rare, although sporadic case reports have been made for most parts of the gastrointestinal tract.25,51 There are no specific clinical syndromes, and the diagnosis in any of these sites should be regarded with suspicion, since non-Hodgkin's lymphomas are a much commoner cause of gut involvement. OTHER SITES

Rare cases of Hodgkin's disease are described in extranodal sites, including thyroid, presenting as a 'cold' nodule,77 larynx,78 kidney,79 bladder, adrenal, and ovary and endometrium.25'80 Thyroid involvement usually results from direct spread from contiguous nodes.

PARANEOPLASTIC MANIFESTATIONS OF HODGKIN'S DISEASE Skin manifestations, such as erythema multiforme or nodosum, are recognized paraneoplastic phenomena in

Hodgkin's disease, which may give rise to several different cutaneous effects as listed above. Nephrotic syndrome has been described in cases without perirenal or intraabdominal Hodgkin's disease.81,82 This manifestation has been associated with immune complexes in the glomeruli and improves on treatment of the underlying Hodgkin's disease. Hypercalcemia is described in Hodgkin's disease but is uncommon. Intrathoracic Hodgkin's disease may be associated with hypertrophic osteoarthropathy.83 Neurologic syndromes, including progressive multifocal leukoencephalopathy, subacute motor neuropathy, cerebellar degeneration, myelopathy, anterior horn cell degeneration and diffuse reticular cerebral infiltration, have all been described occasionally in association with Hodgkin's disease. The occurrence of any neurological syndrome in association with Hodgkin's disease is an immediate indication for detailed neurological examination and investigation. CT and MPJ scanning and careful examination of the cerebrospinal fluid are all required. In addition to specific involvement by Hodgkin's cells and to the various paraneoplastic syndromes, a careful search should be made for evidence of opportunist infection.

CLINICAL APPROACH TO THE PATIENT WITH HODGKIN'S DISEASE History As with all lymphoma patients, the initial approach to those with Hodgkin's disease involves a careful history, seeking evidence of systemic symptoms. The performance status of the patient may constitute useful prognostic information and should be recorded. There is a spectrum of severity in systemic symptoms. Sweats may be drenching and obvious with patients frequently changing their night attire or sheets, or they may be less prominent. Fever may be a high swinging fever, sometimes in the Pel-Epstein pattern, which is intermittent occurring every 3 or 4 days. Weight loss may be profound or minor. To be characterized as a significant symptom, the weight loss must be unexplained and of more than 10 per cent of the body weight in 6 months. Fever has to be more than 38°C; night sweats are not defined in severity but unexplained night sweats sufficient to cause a change of night attire is a useful criterion to use. Careful evaluation of a patient's emotional state is necessary, as well as a social and family history, which will influence the impact of treatment. It is important to know whether a patient has completed their family in order to judge the need for gamete cryopreservation. Physical examination Examination will involve all lymph node areas, including Waldeyer's ring, attention to hepatosplenomegaly and a

Clinical approach to the patient 189

general examination of cardiovascular, respiratory and neurologic systems.

Investigations

Table 15.7 Investigations for newly diagnosed patients with Hodgkin's disease Blood tests Blood count: Hemoglobin White blood cell count Lymphocyte count Platelet count Erythrocyte sedimentation rate Biochemistry Electrolytes Urea Creatinine Urate Calcium Liver blood tests (bilirubin, alkaline phosphatase, transaminases) Lactate dehydrogenase Albumin [32 microglobulin

Laboratory investigations in all cases involve a full blood count and differential. The absolute lymphocyte count may have prognostic significance and should be recorded. The erythrocyte sedimentation rate (ESR) should be measured. Biochemical tests will include assessments of hepatic, renal and bone metabolism. Liver tests to be measured include particularly alkaline phosphatase, transaminases, lactate dehydrogenase, bilirubin and albumin. The renal function tests should include serum urate concentration and the serum calcium should be recorded.b2 microglobulin is increasingly reported as a prognostic factor and should also be measured prospectively.84 All patients require chest X-rays, and CT scans of the chest, abdomen and pelvis with oral and intravenous contrast. Bipedal lymphangiography, which was widely used for staging in the past, is now largely supplanted by the less invasive procedure of CT scanning. The latter investigation has the additional advantage of visualizing the celiac axis, mesenteric, portal and splenic hilar nodes, which are poorly demonstrated if at all by lymphangiography. Involvement of lymph nodes that are of normal size cannot be detected by CT scanning, ultrasonography or MRI at present. Investigations that may contribute more information include gallium scanning85-88 and positron emission tomography.89 The place of each of these investigations is reviewed by Sandrasegaran et al. in Chapter 16. Bone marrow biopsy has been widely used in the staging of Hodgkin's disease, mainly because of its recognition as an unfavorable prognostic marker.90 More recently it has been shown that bone marrow findings rarely alter the clinical management or survival, so that the procedure may no longer be recommended as part of the routine staging.91 If there is a case to be made for bone marrow biopsy, it might be for those patients with stage I/IIA, where a positive biopsy would mandate systemic rather than local therapy;92 however, since the positive yield in this group is less than 1 per cent this is difficult to justify clinically. The recommended staging investigations for newly diagnosed patients are given in Table 15.7.

marrow infiltration.95 Coomb's positive hemolytic anemia is rare and associated with advanced symptomatic disease.96,97 Leucocytosis with a total white cell count exceeding 10 x 109/1 is found in about a quarter of patients, whereas leucopenia with white cell counts of less than 5 x 109/1 occurs in less than 10 per cent. Lymphopenia with counts less than 1.0 x 109/1 is seen in about 20 per cent of cases and is associated with advanced stage.25 Eosinophilia is occasionally present but is probably of no special significance. In a few patients, thrombocytopenia has been the first manifestation of the disease.98,99 Most commonly, this appears to be due to platelet consumption by immune mechanisms, although the alternative explanation of heavy bone marrow infiltration has to be considered. Autoimmune neutropenia has been described.100

HEMATOLOGY

BIOCHEMISTRY

Hematological tests may be normal. An elevation of the ESR is commonly found in patients with advanced disease or systemic systems, and confers a relatively poor prognosis.93,94 Severe anemia (<9 g/dl) at diagnosis is uncommon and may be multifactorial, owing to hemodilution, hemolysis, iron utilization block and occasionally

Abnormalities in liver function tests may be seen in patients with Hodgkin's disease in the absence of liver infiltration56,57 (see later) or because of liver involvement. The lactate dehydrogenase level has emerged as an important prognostic factor and is often elevated in advanced disease.101 Hypercalcemia is rare and associated

Radiology Chest X-ray Computed tomography (chest, abdomen, pelvis) Bone marrow biopsy Optional Under special circumstances Ultrasound scanning Magnetic resonance imaging Gallium scanning Technetium bone scanning Computed tomography scanning of the brain

190 Hodgkin's disease: clinical features

with extensive involvement of bones. In occasional patients, abnormalities of vitamin D metabolism have been demonstrated.102 Renal function must be checked, because of the risk of renal damage by hyperuricemia or infection. Urinalysis occasionally reveals proteinuria. ALTERNATIVE MARKERS OF THE SEVERITY OF HODGKIN'S DISEASE

Although the staging procedures described above yield useful prognostic information for the whole population of patients with Hodgkin's disease, the relatively crude techniques of anatomical localization ignore the heterogeneity of behavior of the illness in different patients. The different histopathologic subtypes may give some help in this respect, but they remain broad categories within which differing patterns of disease are observed. Because of this, different assays have been tested in the hope of identifying measurements that might better reflect the course of the illness. b2 microglobulin has already been mentioned as one such measurement, but a variety of others are under active investigation. Among these, cytokines and their receptors, and adhesion molecules appear most promising. There is now emerging evidence from the literature that measurement of several cytokines may correlate with the severity of Hodgkin's disease. This is in spite of the fact that many studies are based on small numbers of patients with only a few cytokines examined in each and it is often difficult to compare results between studies owing to differences in the assays used. Conflicting results have come from studies relating interleukin-6 (IL-6) concentrations to survival and the presence of B symptoms. IL-6 has been found to be elevated in between 50 and 75 per cent of patients at presentation compared with controls.103-106 In some studies, IL-6 concentration did not relate to histological subtype, stage or the presence of B symptoms, and was no longer detectable in the majority of patients following therapy, even in the presence of progressive disease.103-105 However, a strong correlation between serum IL-6 concentrations and the presence of B symptoms has been found in later studies.106-107 In addition, higher concentrations of IL-6 were related to poorer survival.106-107 The reasons for these discrepancies are unclear but may be related to assay differences in some cases, different detection limits, and the mixture of untreated and treated patients in some studies. More recently, IL-10 has been identified as another potential prognostic marker. A study of 85 patients at the MD Anderson Cancer Center showed IL-10 and serum lactate dehydrogenase levels to be independent predictors of failure-free survival in a multivariate analysis: among 54 patients with normal levels of both markers, failure-free survival (FFS) was 78 per cent whilst among 23 patients with elevated levels of both, FFS was only 22 per cent.108

Elevated soluble IL-2 receptor (sCD 25) concentrations are seen in the great majority of patients - 93 per cent in one study.109 Levels have been related to disease stage, B symptoms and disease status106,110,111 with lower levels relating to better survival.111,112 A multivariate analysis of sCD 25 levels among 127 previously untreated patients demonstrated an independent correlation with survival.113 A further study used a panel of soluble antigens as biomarkers: the combination of elevated sCD 8, sCD 25, sCD 30 and sCD 54 at diagnosis in 18 of 80 patients was found to predict a group with only 33 per cent disease-free survival at 5 years.109 The same study found that 37 per cent of patients acheiving clinical complete remission retained at least one elevated marker, and that this also correlated with the probability of recurrence. Between 22 and 87 per cent of newly diagnosed patients have been reported as having elevated levels of sCD 30111,114,115 with the wide range ascribed to differing assay sensitivity. Correlations with the presence of B symptoms, stage and tumor burden have all been reported. In addition, sCD 30 was of prognostic use with higher levels being associated with poorer survival111,114,116 and correlated with disease activity and treatment response suggesting a possible use in longitudinal monitoring. Significantly elevated concentrations of soluble p55 TNF receptors have been found in Hodgkin's disease compared with controls117,118 with correlations to disease stage, B symptoms and complete response rate. Significantly higher sICAM-1 concentrations have been found in patients with Hodgkin's disease compared to controls.116,119,121 Levels were related to stage of disease, B symptoms and response rate. sICAM-1 appears to offer prognostic information for disease-free and overall survival, but these findings require amplification in larger series. STAGING LAPAROTOMY

Prior to the development of accurate cross-sectional imaging and the analysis of clinical data to predict intraabdominal involvement, complete staging of Hodgkin's disease apparently restricted to the upper body required a staging laparotomy with sampling of multiple node groups, liver biopsy and splenectomy. A series of studies in the late 1970s demonstrated the correlation between clinical features, such as number of sites of involvement, size of the largest tumor mass, pathologic subtype and ESR, and the finding of abdominal disease at laparotomy.122,124 These findings allowed application of chemotherapy for patients with adverse prognostic features. This, together with the success of 'salvage' therapy for patients with progressive abdominal disease following extended field radiotherapy to the chest, and concerns about the higher numbers of patients developing secondary leukemia following splenectomy,125 all

Prognostic factors 191

contributed to the decline of staging laparotomy. A randomized trial demonstrated the equivalent survival of patients staged by laparotomy or clinically when subtotal nodal irradiation was used,126 and such results appear to have been sustained in the long term.127 The staging laparotomy is therefore no longer used in the great majority of centers worldwide.

PROGNOSTIC FACTORS Many attempts have been made to predict the outcome of treatment for patients with Hodgkin's disease. A wide range of descriptive studies have identified features of the illness that predict for remission, freedom from relapse and overall survival, along the lines of the factors described above. These fall broadly into three groups, with obvious areas of overlap: 1 Factors relating to the extent of the disease, such as stage, number of sites of involvement, bulk of tumor mass, lactate dehydrogenase (LDH), b2 microglobulin and cytokine levels. 2 Factors reflecting the state of the patient and the effect of the illness, such as performance status, age, gender, albumin, hemoglobin and white blood cell count. 3 Factors reflecting the aggression of the malignancy such as histologic type, systemic symptoms and ESR.

and most studies have identified age as prognostic in both univariate and multivariate analyses (see also Chapter 28). GENDER

Women with Hodgkin's disease are more likely than men to survive. Attention has been drawn to this over many years25 and a survival advantage overall of about 10 per cent after 5 years for all patients is estimated. This remains true in the International Database study, the effect being most prominent in patients with advanced stage disease. The causes of this difference are not known. STAGE Stage is an important predictor of survival in population-based studies22 (Fig. 15.7). The more recent and extensive collection of data into the international Hodgkin's disease database also confirms that stage is an important predictor of freedom from failure, which was the principal end point of that analysis.130 The presence of B symptoms also has a highly significant impact on prognosis.25,130,131 The impact of B symptoms is probably less in modern series of patients treated with state-of-the-art chemotherapy than in early series. Although it remains the custom to consider systemic symptoms to be of prognostic significance according to the criteria set out in the Ann Arbor staging system

This latter category has appeared to lose some significance as the efficacy of therapy has increased. The different factors have been used in analyses of increasing complexity, usually multivariate models of proportional hazards128 or multiple regression. The most pressing application for such models is to identify in advance the minority of patients poorly served by conventional therapy who might be most likely to benefit from alternative approaches such as early high-dose chemotherapy. The largest such analysis to date was that of the International Database on Hodgkin's Disease, which included over 5000 patients with advanced disease from 22 study groups in Europe and North America.129 Despite this, it was not possible to identify a large subgroup with a 5-year progression-free survival of less than 50 per cent: the failure of therapy was distributed across prognostic categories in too diffuse a manner. This work continues but so far it has proved a difficult challenge and no good predictive model exists. Individual prognostic factors

AGE Age is a major determinant of survival even when deaths due to causes other than Hodgkin's disease are excluded from the analysis. The population-based study of cases in the USA22 very clearly demonstrates this (Fig. 15.6),

Figure 15.6 Age as a prognostic factor in cause-specific survival. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., from Kennedy BJ, et a I. National survey of patterns of care for Hodgkin's disease. Cancer 7985; 56. 2547-56. © 1985 American Cancer Society.

192 Hodgkin's disease: clinical features

paragranuloma patients (10 per cent only). Patients with lymphocyte-rich classical Hodgkin's disease did not differ significantly in clinical features from those with nodular sclerotic histology. Patients with nodular paragranuloma showed a particular pattern of outcome. Overall survival was favorable at 95 per cent at 10 years. However, there was a continuing pattern of recurrence with only 50 per cent of patients free from disease after 15 years. Late recurrence was common up to 20 years (Fig. 15.8). Some patients had multiple recurrences extending over 15 years but still a good overall outcome in terms of survival. There were 103 deaths among 478 patients in the study as a whole. Among 83 for whom the cause of death was known, 41 were due to Hodgkin's disease, four were treatment related, 19 were due to secondary neoplasia including ten non-Hodgkin's lymphomas, six solid tumors and three acute leukemias. Deaths from Hodgkin's disease occurred relatively early with 50 per cent between 2 and 4 years from diagnosis. Deaths from non-Hodgkin's lymphomas and acute leukemia occurred between 2 and 8 years, and from solid tumors between 4 and 14 years.54 NUMBER OF NODAL SITES

HISTOLOGICTYPE

In patients presenting with supradiaphragmatic Hodgkin's disease, an increasing number of involved nodal sites is known to indicate an increased risk of infradiaphragmatic disease. Accordingly there is an increased probability of abdominal relapse if such supradiaphragmatic disease is treated with radiation alone. In the Harvard Joint Centre for Radiotherapy series124 the number of nodal sites predicted powerfully for pathological upstaging after laparotomy. Seventeen per cent of patients with one lymph node site had their stage increased after laparotomy whereas 27 per cent of patients with two or more lymph node sites were similarly upstaged (P < 0.01). The presence of inguinal lymphadenopathy predicts for worse progression-free survival on both univariate and multivariate analysis.130

The association between histology and prognosis in Hodgkin's disease is described in detail in Chapter 2. In the context of clinical features, it is possible to identify a distinctive pattern of disease, particularly for the lymphocyte-predominant type. A recent international collaborative study examined the characteristics of 201 cases in which the pathology was reviewed. Of these, 54.7 per cent were reclassified into nodular paragranuloma (nodular lymphocyte-predominant Hodgkin's disease) and 28.4 per cent into lymphocyte-rich classical Hodgkin's disease. The patients with nodular paragranuloma differed from patients with classical nodular sclerosing or mixed cellularity Hodgkin's disease in a number of important respects. Nodular paragranuloma patients were younger (average 30 years vs 37 years), more often male (74 vs 49 per cent), and more often had early-stage disease (74 vs 57 per cent). Mediastinal disease was less frequent with nodular

Figure 15.8 Survival (SV) and freedom from treatment failure (FFTF) in lymphocyte-predominant Hodgkin's disease.

Figure 15.7 Stage as a prognostic factor. Reprinted by permission of Wiley-Liss, Inc., a subsidiary of John Wiley & Sons, Inc., from Kennedy BJ, et al. National survey of patterns of care for Hodgkin's disease. Cancer 7985; 56:2547-56. © 7985 American Cancer Society.

(weight loss, night sweats and fever), more detailed analysis132 suggests that weight loss, significant fevers and severe pruritus are associated with a poorer prognosis on univariate and multivariate analysis, whereas night sweats, minor fever, minor degrees of weight loss and mild pruritus had no influence.

Prognostic factors 193

MEDIASTINAL DISEASE

Mediastinal involvement is associated with a relatively young population of patients and with nodular sclerotic histology. Small-volume mediastinal disease probably has little influence on survival or on probability of relapse after radiotherapy. However, when a mediastinal mass is bulky (mass diameter to thoracic width ratio of > 33 per cent), most authors find a higher risk of relapse after radiotherapy than for patients without such bulk.133-137 There are, however, some analyses that do not show this effect, probably as a result of differences in radiotherapy technique.138-139 The high relapse rate, which is seen in many centers after radiotherapy alone, is reduced by the addition of combination chemotherapy.140 However, presence of a very bulky (> 45 per cent thoracic diameter) mediastinal mass remains a significant predictor of treatment failure even after modern chemotherapy.130 FAMILIAL LONGEVITY

Bjorkholm et al 141 showed that parental longevity influenced the outcome of 98 patients with Hodgkin's disease. Although patients aged less than 50 at the time of diagnosis were not affected, patients more than 50 years old had a better outlook if their parents had been long lived. There was a significant excess of death from tuberculosis in the parents of patients who did badly with Hodgkin's disease. The authors postulated that this observation might be explained by a familial deficiency in T cell immunity. PERSONALITY

A single study has been reported, which investigated the relation between personality and outcome in malignant lymphoma. Sixty-three newly diagnosed patients were graded by the Personality Inventory questionnaire at the time of diagnosis and the L-score was found to be an independent predictor for survival in multivariate analysis, as was the Hospital Anxiety and Depression score.142

Multivariate analysis and models Many different prognostic models and indices have been proposed for Hodgkin's disease. Some of these are

described in Table 15.8. Four of these models were evaluated in a study of 344 patients with advanced Hogdkin's disease included in the Groupe d'Etudes des Lymphomes de 1'Adulte (GELA) study.145 Patients with at least three adverse factors according to the Memorial Sloan-Kettering Cancer Centre or the European Bone Marrow Transplant criteria had a higher risk of failing with conventional treatment; however, based on survival rate, no very high risk group could be identified. For such models, three features can be used to describe their utility. These are the statistical significance of the factors included, the fit of the data to the chosen model and the predictive power of the model. Most reports of prognostic models describe their statistical significance and goodness of fit. Until recently, no good method was available to evaluate predictive power in survival time models. The predictive power of a set of prognostic factors is their ability on average to make accurate predictions of what will happen to patients. If a model is fitted well by the data, it does not necessarily imply that, for an individual patient, the prediction will be precise. Without quantification of the predictive power, highly significant P values of covariates in an adequate fitting model may give a misleading impression of accuracy and utility.146 As an example of this problem, data have been analysed from over 1000 patients treated in the UK in the Royal Marsden Hospital series, the United Kingdom Central Lymphoma Group and the British National Lymphoma Investigation.20,21,147 The data were used to evaluate the meaning of prognostic factors for complete remission, recurrence and survival. The data on log rank results for the entire database are shown in (Table 15.9). After Cox proportional hazards analysis independent prognostic factors were age, clinical stage IV, mediastinal bulk and albumin. In this analysis, choice of chemotherapy was also significant, with poorer results for patients receiving only alkylating agent-based combinations compared to those who received alternating regimens including doxorubicin and etoposide. In this analysis, the ability of the prognostic factors to predict patient outcome was examined. The proportion of variance that was explained by the best prognostic factor analysis was surprisingly small for the prediction of complete remission (7 per cent of variance explained), survival to 5 years (9 per cent of variance explained) and estimated survival probability (10-14

Table 15.8 Prognostic models in Hodgkin's disease factors found predictive of outcome in multivariate analysis 132

Gobbi (1988) Wagstaff (1988)143 Proctor (1991 )144 Hasenclever(1996)129 Sarris (1996)108

586 301 92 validated in 455

1618 155 validated in 226

Age, stage, gender, histology, erythrocyte sedimentation rate, albumin Age, stage, gender, lymphocyte count Age, stage, hemoglobin, lymphocyte count Age, stage, gender, white blood cell count, hemoglobin, albumin Age, lactatedehydrogenase, (32 microglobulin

194 Hodgkin's disease: clinical features Table 15.9 Analysis of prognostic factors in a combined UK series of patients

Sex

Male

654

73.9

Female

395

73.3

0.1

0.814

367 682

79.2 70.7

4.8

0.28

I, II, III

759

77.8

IV

284

62.4

27.7

< 0.001

Involvement of: Liver No 914 Yes 126

75.3 60.6

15.9

< 0.001

Spleen No Yes

74.8 69.7

3.7

0.53

B symptoms

No Yes Clinical stage

Mediastinum No Yes

777 264

PATTERNS OF RECURRENCE 396 641

73.7 73.4

0.8

0.362

Bulky mediastinum No 897 Yes 140

74.4 67.9

1.5

0.222

Lung No Yes

77.3 64.3

2.8

0.094

Marrow No

400 55

393

76.2

29

61.2

3.1

0.078

Inguinal nodes No Yes

390 66

78.5 59.8

10.7

0.001

Age < 45 >45

790 259

78.4 59.0

59.2

< 0.001

463 319

82.0 62.3

33.5

< 0.001

585 229

78.1 62.9

15.?

< 0.001

Yes

Albumin

> 36 <36 Hemoglobin

>11 <11

possible in 64 per cent of cases; with the addition of the best statistical model derived from the patient database, the proportion of patients with the correct prediction rises to only 67 per cent. For prediction of survival at 5 years, in the absence of a model, prediction would be correct in 74 per cent of cases and, with the best model (excluding information on remission status), this rises to 76 per cent. Even when the retrospective information that complete remission is attained is included in the model, the proportion of correct predictions rises only to 81 per cent. It is apparent from this analysis that the prognostic factors currently available are very limited in their discriminatory power. The implication of this is that there is a need for new prognostic factors that might more accurately reflect the behavior of the illness. This implies a better understanding of the biological factors predicting for outcome and, when possible, for evaluation of chemosensitivity.

per cent variance explained). Further analyses have considered the ability of prognostic factors to predict the outcome of individual patients. (If the probability of remission or survival was estimated by the model to be > 50 per cent, this was scored as a prediction.) These analyses are also disappointing. Without using the statistical model, prediction of complete remission is

Following radiotherapy for localized disease, the factors predicting risk of recurrence are well documented. When patients are carefully selected, surgically staged and treated with extended-field radiotherapy, the recurrence rate is less than 20 per cent. However, unselected clinical stage I and II patients may have relapse rates of over 50 per cent.148 Most such recurrences occur in lymph nodes lying outside the radiotherapy field. Recurrence after chemotherapy occurs in 20-40 per cent of cases and in the great majority this is at sites of previous disease. In the remainder it is generally in closely related sites.149 Most recurrences occur within 3 years of the end of treatment. However, late recurrences are well recognized up to 20 years.150 In one large series of 1360 patients from Stanford University, the actuarial risk of recurrence after 3 years was 12.9 per cent, and 52 patients suffered recurrences between 3 and 15 years.151 Most recurrences of Hodgkin's disease are diagnosed clinically or on chest X-ray. In the Stanford series it is notable that only 13 patients of 52 called attention to their relapse (three by palpating their own nodes; ten by reporting systemic symptoms). The remainder were diagnosed by physicians at follow-up. In the Christie Hospital, Manchester, UK, among 135 relapses, 113 patients reported lumps or systemic symptoms themselves. However, in 22 cases the recurrence was detected by physical examination or tests (most commonly chest X-ray).152 Most recurrences will be detected if patients are asked to return if they have symptoms. A few more will be found by examination and investigations. Frequent, detailed follow-up is unlikely to have a large impact on outcomes.

Hodgkin's disease in special situations 195

HODGKIN'S DISEASE IN SPECIAL SITUATIONS

Hodgkin's disease in pregnancy (see also Chapter 19)

Fertility in Hodgkin's disease

Being a condition predominantly affecting young adults, Hodgkin's disease is occasionally diagnosed during pregnancy, at a rate of between 1 in 1000 and 1 in 6000.165 In fact, some large-scale epidemiologic studies have suggested a protective effect with increasing parity, although it is possible that confounding factors may be responsible for the association.166 In such cases, decisions regarding investigation and therapy are clearly complicated.167,168 The balance between effective treatment of the mother and the potential effects upon the fetus will differ considerably according to the maturity of the gestation and the extent of the disease. While it is necessary to consider each individual case with great care, certain general statements may be made. The first of these is that the prognosis of Hodgkin's disease diagnosed during pregnancy does not appear to differ greatly from that diagnosed at other times, in retrospective series.165,169 The pattern of disease is similar and metastatic involvement of the placenta or fetus is extremely rare.170 The need to limit radiation exposure to the fetus throughout gestation restricts the staging investigations that may be used. Whilst chest X-rays may be performed in the third trimester, the use of CT results in too high an exposure and is not employed. Ultrasound examination or MRI may provide alternative methods, but often staging is incomplete and treatment must be given on a pragmatic basis with limited information. For early pregnancy (up to 20 weeks), limited radiotherapy to sites in the chest may be used, although a full mantle field is thought too likely to result in fetal damage, particularly neurological. Chemotherapy is very rarely used during the first trimester, owing to the very high incidence of malformation or abortion.171 For those mothers presenting during early pregnancy with advanced disease requiring treatment, termination of pregnancy may be the only option offering a reasonable prospect of a cure. In later pregnancy, the options are greater; in some cases, it may be possible to defer full staging and therapy until the fetus reaches adequate maturity and can be delivered. For mothers with localized disease, radiotherapy is an option and the risks of mantle irradiation appear to be acceptable.169 For those with advanced disease there is some information to suggest that chemotherapy may be given relatively safely,171 although growth retardation is commonly seen and the long-term sequelae have not been characterized. Theoretical considerations of germ cell damage make the use of alkylating agents inadvisable.

In males, oligozoospermia, poor motility and an increased proportion of abnormal forms are commonly found at presentation, particularly in patients with advanced disease,153,154 and histopathological changes may be seen in the testes of such patients. In females, although the effects are less well documented, disturbances of menstrual function may occur. Chemotherapy, particularly with alkylating agents, can directly damage spermatogenesis and this damage may be permanent.155,58 Early in the course of treatment with MOPP-like regimens, irreversible azoospermia is seen; this also applies to alternating and hybrid regimens (e.g. MOPP/ABVD, LOPP/EVAP, ChlVPP/EVA, ChlVPP/PABlOE, see Chapter 19). Where alkylating agents are avoided (e.g. in anthracycline-based regimens, such as ABVD) fertility is usually preserved.159 In females, chemotherapy progressively damages and irreversibly destroys ovarian follicles; this manifests as oligomenorrhea or amenorrhea and a reduced reproductive span. These changes occur more often in older women and are again particularly a feature of alkylating agent-based regimens.158,,60-163

Exposure of both male and female gonads to therapeutic radiotherapy results in severe damage to these organs; radiation effects are dose related but the threshold dose for damage may be as low as 0.5 Gy. A dose of 4 Gy will produce permanent infertility in a third of even young women and prolonged, possibly irreversible, sterility in men. The likely effects of treatment with chemotherapy or radiotherapy should be discussed with patients. For males, sperm banking should be offered whenever possible. For females, effective techniques for oocyte or ovarian tissue preservation are desirable; as yet, however, these available remain experimental and not generally available. Embryo storage is generally precluded by the need to stimulate the ovaries artificially for some weeks prior to harvesting of oocytes and subsequent fertilization, thus causing unacceptable delays in starting treatment. For patients remaining fertile after treatment, it is prudent to delay starting a family for at least a year; not least because it is during this time that the risk of relapse is highest but also because of the theoretical risk of mutagenesis. However, children successfully conceived after treatment do not appear to have an increased incidence of congenital or later-onset medical problems.164 Males remaining sterile after chemotherapy do not suffer androgen lack. In females, estrogen production is affected and, where premature menopause is confirmed, hormone replacement therapy should be given.

HIV-related Hodgkin's disease Epidemiologic studies have indicated an increased incidence of Hodgkin's disease among the HIV-positive

196 Hodgkin's disease: clinical features

population. One such study yielded an odds ratio of 36.6 (95 per cent confidence limits 0-78.12).172 Several series of cases have been reported in the literature and, in all, the clinical characteristics among HIV-positive patients show a bias towards unfavorable features. These include a higher frequency of mixed cellularity histology, systemic symptoms, stage IV disease and extranodal involvement, particularly of the bone marrow.173,176 The finding of Epstein-Barr virus involvement is universal174,175177,178 and the prognosis is generally reported as poor, with median survival between 1 and 2 years.175,179 As for non-Hodgkin's lymphomas, the prognosis correlates to some extent with the severity of HIV-disease, being worse in those with a low CD 4+ count. In one series no patient with initial CD 4 count below 300/ml survived 2 years.173

CONTRASTS WITH NON-HODGKIN'S LYMPHOMA The clinical features and investigation of nonHodgkin's lymphomas (NHLs) are described fully in Chapters 18, 20-23. However, some general comments can be made to highlight important differences from Hodgkin's disease. NHLs are commoner than Hodgkin's disease in the UK in the ratio of 3.5 to I.180 Their incidence is increasing, whereas that of Hodgkin's disease seems stable. The NHLs are a heterogeneous group of malignancies whose behavior varies from indolent to rapidly lethal; high-grade tumors arise in all age groups although their incidence increases with age, while low-grade tumors are generally confined to later life. They are only marginally commoner in men than women and there is a marked geographical variation in incidence. Their presentation is variable; localized lymphadenopathy particularly in the neck is common, as in Hodgkin's disease, but in contrast unusual nodes may be involved, or there may be more generalized bulky and 'centrifugal' lymphadenopathy. Over one-quarter start outside the classic lymph node areas - most often the gut and Waldeyer's ring but almost any tissue can be affected (Table 15.10) - an extreme rarity in Hodgkin's disease. Knowing the stage of the patient's disease is not so important nowadays for determining treatment but it still has a bearing on prognosis. The Ann Arbor criteria are still useful, although sometimes not entirely appropriate because of the protean patterns of nodal and extranodal spread. For example, NHL starting in the Waldeyer's ring is nowadays generally described as being 'extranodal', which is at variance with the original Ann Arbor definitions. This may in part account for the different recorded incidence rates for 'extranodal' lymphoma. In addition, some series report all cases where

the primary presentation is believed to be extranodal, including disseminated disease. The extent of investigation will be determined largely by the clinical status of the patient and the histopathological subtype. In general, full hematological and biochemical investigation is necessary, and radiological investigations must include, at the very least, chest X-ray to detect mediastinal and hilar lymphadenophathy and some investigation to establish the presence or not of abdominal disease. In the past this was often lymphangiography; current 'state of the art' CT scanning has made this redundant, particularly since it is now evident that, unless the lymphoma is truly localized (an uncommon situation), chemotherapy is likely to be needed as part of the planned treatment. Clinical staging tends to underestimate the incidence of systemic disease. Bone marrow biopsy should be assessed, since marrow involvement will be found in over 30 per cent of cases and, in certain forms with a poor prognosis, particularly of the lymphoblastic type, cerebrospinal fluid should be cytologically examined. The clinicopathological heterogeneity of the NHLs makes it very difficult to define prognostic factors. Perhaps the best researched group is that of the diffuse large cell lymphomas. For example, major centers treating this subtype, which accounts for over a third of NHLs, have collaborated to develop an International Prognostic Index (IPI). Based on data from over 3000 patients, this index clearly distinguishes subgroups that differ in terms of tumor response, relapse and overall survival.186 The IPI is based on straightforward clinical and biological data (age, Ann Arbor stage, serum LDH level, performance status and number of extranodal sites of disease). In its age-adjusted simplified version, it enables clinicians to make appropriate choices of treatment, and can be used to select and stratify patients entering prospective clinical trials. Such factors may vary during the course of the disease and in a study of such variations (involving 1271 patients on GELA trials), it was concluded that, while IPI factors are relevant to short-term follow-up, only performance status was predictive of patients' ability to tolerate induction chemotherapy and only tumor stage was predictive of long-term survival.187 Unfortunately, with several other putative prognostic indices, the number of patients assessed is not large enough to give statistically relevant guidelines. Relatively simple predictors of adverse prognosis which merit further study include the following: • • • •

T cell immunophenotype;188 low serum albumin;189,190 raised ferritin;191 raised b2 microglobulin.192

Other more sophisticated but generally expensive and time-consuming investigations take into account the intrinsic biological characteristics of lymphoma cells.193

Contrasts with non-Hodgkin's lymphoma 197

Table 15.10 The incidence of extranodal lymphoma

All NHL Extranodal NHL

8767 1467(17%)

Gastrointestinal Stomach 346 (23.5%) Small intestine 110(7.5%) Large intestine 82 (5.5%) Head and neck Tonsil Nasopharynx Tongue Nose Salivary gland Thyroid Other Skin

142 (9.5%) 37 (2.5%) 20(1.0%) 33 (2.0%) 69 (4.5%) 36 (2.5%) 48 (3.5%) 110(7.5%)

1257 463(37%)a,b

580 236(41 %)a

832 299 (36%)a

2007 394(20%)

87(17.0%) 41 (8.0%) 11 (2.0%)

54 (23.0%) 13(5.5%) 16(6.5%)

46(15.5%)' 56(18.5%)f 16(5.5%)'

53(13.5%) 25 (6.5%) 16(4.0%)

d

25(10.5%) 11 (4.5%) 5 (2.0%) 3(1.0%) 3(1.0%) 4(1.5%) 2(1.0%)

28 (9.5%) 26 (8.5%)

2 (0.5%)

47 (12.0%) 15(4.0%) 5(1.5%) 20 (5.0%) 16(4.0%) 27 (7.0%) 13 (3.5%)

12 (4.0%)

33 (8.5%)

d d

17(3.5%) 17(3.5%) 25 (5.0%) 3 (0.5%)

e

4(1.5%)

56(11.0%)

4(1.5%)

Connective tissues 90 (6.0%)

12 (2.5%)

5 (2.0%)

6 (2.0%)

11 (3.0%)

Bone

69 (4.5%)

41 (8.0%)

6 (2.5%)

19(6.5%)

19(5.0%)

Lung

53 (3.5%)

24 (5.0%)

11 (4.5%)

7 (2.5%)

3(1.0%)

Breast

33 (2.0%)

6(1.0%)

5 (2.0%)

—

5(1.5%)

Testis

23(1.5%)

15(3.0%)

4(1.5%)

1 (0.5%)

14 (3.5%)

Orbit (and eye)

32 (2.0%)

4(1.0%)

7 (3.0%)

7 (2.5%)

31 (8.0%)

c

8

Central nervous system

23(1.5%)

33 (6.5%)

15(6.5%)

3(1.0%)

34 (9.0%)

Marrow

—

89(17.5%)

33 (14.0%)

—

—

Liver

6 (0.5%)

27 (5.0%)

—

—

1 (0.5%)

Female genital

16(1.0%)

6(1.0%)

1 (0.5%)

2(0.5)

2(0.5)

Others

89 (6.0%)

29 (5.5%)

9 (4.0%)

64(21.5%)

4(1.0%)

a b c d e f g

Including disseminated disease at presentation. Including cases with more than one presenting site. Including orbital connective tissue. Excluding Waldeyer's ring. Excluding mycosis fungoides. Excluding 47 cases of gastrointestinal presentation where the origin is uncertain or multiple. Brain only.

Although numbers of patients studied are small, the following predictive factors have been reported: • • •

•

genetic abnormalities - a number of these have been described (see Chapter 9); abnormalities in cell cycle regulation - in general high proliferative activity adversely affects survival;194-197 pattern of expression of adhesion molecules - variably reported to be predictive of outcome, but CD 44 (hyaluronate receptor) expression in particular seems to be an adverse marker;198-199 cytokine levels - poor outcome has been described

•

with elevated levels of IL-6, IL-10 and tumor necrosis factor oc (TNFa); 200-202 lymphoma cell chemosensitivity indicators - MDR and bcl-2 expression at diagnosis are unfavorable prognostic factors.203,204

The shortcomings of the Ann Arbor staging classification are particularly well demonstrated with the follicular lymphomas. In a study of 398 patients entered into British National Lymphoma Investigation trials between 1974 and 1980, the Ann Arbor system fared poorly as a prognostic indicator; most powerfully significant factors

198 Hodgkin's disease: clinical features

for cause-specific survival were the number of lymph node regions involved, splenomegaly, constitutional symptoms and age. With the exception of splenomegaly, other studies have shown similar findings.205,208 The factors described above for aggressive NHLs186 may also be relevant to the follicular lymphomas,209 and likewise molecular and cytogenetic markers may be of prognostic value. However, it is still difficult to pick out a group of patients with such adverse features as to warrant more intensive (or experimental) treatment at presentation.

16.

17.

18.

19.

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References 203 164. Swerdlow AJ, Jacobs PA, Marks A, et al. Fertility, reproductive outcomes, and health of offspring, of patients treated for Hodgkin's disease: an investigation including chromosome examinations. BrJ Cancer 1996; 74: 291-6. 165. Lishner M, Zemlickis D, Degendorfer P, Panzarella T, Sutcliffe SB, Koren G. Maternal and foetal outcome following Hodgkin's disease in pregnancy. BrJ Cancer 1992; 65:114-17. 166. Kravdal 0, Hansen S. Hodgkin's disease: the protective effect of childbearing. IntJ Cancer 1993; 55: 909-14. 167. Sutcliffe SB. Treatment of neoplastic disease during pregnancy: maternal and fetal effects. Clin Invest Med 1985; 8: 333-8. 168. Doll DC, Ringenberg QS, Yarbro JW. Management of cancer during pregnancy. Arch Intern Med 1988; 148: 2058-64. 169. Woo SY, Fuller LM, Cundiff JH, Bondy ML, Hagemeister FB, Mclaughlin P. Radiotherapy during pregnancy for clinical stages IA-IIA Hodgkin's disease. IntJ Radial Oncol Biol Phys 1992; 23: 407-12. 170. Rothman LA, Cohen CJ, Astarloa J. Placental and fetal involvement by maternal malignancy: a report of rectal carcinoma and review of the literature. AmJObstet Gynecol 1973; 116:1023-34. 171. Yahalom J. Treatment options for Hodgkin's disease during pregnancy. Leuk Lymphoma 1990; 2: 151-61. 172. Serraino D, Pezzotti P, Cozzi-Lepri A, Grigoletti E, Tirelli U, Rezza G. Incidence of Hodgkin's disease in a cohort of HIV seroconverters. Proc ASC01996.15: a847. 173. Levy R, Colonna P, Tourani JM, Gastaut JA, Brice P, Raphael M. Human immunodeficiency virus associated Hodgkin's disease: report of 45 cases from the French registry of HIV-associated tumors. Leuk Lymphoma 1995; 16:451-6. 174. Bellas C, Santon A, Manzanal A, et al. Pathological, immunological, and molecular features of Hodgkin's disease associated with HIV infection: comparison with ordinary Hodgkin's disease. AmJSurg Pathol 1996; 20: 1520-4. 175. Levine AM. HIV-associated Hodgkin's disease: biologic and clinical aspects. Hematol Oncol Clin North Am 1996; 10:1135-48. 176. Errante D, Zagonel V, Vaccher E, Serraino D, Bernardi D, Sorio R. Hodgkin's disease in patients with HIV infection and in the general population: comparison of clinicopathological features and survival.Ann Oncol 1994; 2: 37-40. 177. Gloghini A, Boiocchi M, De RV, etal. High incidence of monoclonal EBV episomes in Hodgkin's disease and anaplastic large-cell Ki-1-positive lymphomas in HIV-1positive patients. IntJ Cancer 1993; 54: 53-9. 178. Herndier BG, Sanchez HC, Chang KL, Chen YY, Weiss LM. High prevalence of Epstein-Barr virus in the Reed-Stern berg cells of HIV- associated Hodgkin's disease. Am J Pathol 1993; 142:1073-9.

179. Tirelli U, Errante D, Dolcetti R, Gloghini A, Serraino D, Vaccher E. Hodgkin's disease and human immunodeficiency virus infection: clinicopathologic and virologic features of 114 patients from the Italian Cooperative Group on AIDS and Tumors. J Clin Oncol 1995; 13:1758-67. 180. Leukaemia Research Fund Centre for Clinical Epidemiology. An Atlas of Leukaemia and Lymphoma. London: Leukaemia Research Fund, 1990: 81-9. 181. Freeman C, Berg JW, Cutler SJ. Occurrence and Prognosis of Extranodal Lymphomas. Cancer 1972; 29: 252-60. 182. d'Amore F, Christensen BE, Brincker H, et al. Clinicopathological features and prognostic factors in extranodal non-Hodgkin lymphomas. EurJ Cancer 1991; 27:1201-8. 183. Otter R, Gerrits WBJ, Sandt MMVD, et al. Primary extranodal and nodal non-Hodgkin's lymphoma. A survey of a population-based registry. EurJ Cancer Clin Oncol 1989; 25:1203-10. 184. Modan B, Shani M, Goldman B, et al. Nodal and extranodal malignant lymphoma in Israel: an epidemiological study. BrJ Haematol 1969; 16: 53-9. 185. Dobson LS, Hancock H, Bright N, Robinson MH, Hancock BW. Localised non-Hodgkin's lymphoma: the Sheffield Lymphoma Group experience (1970-1995). Int JOncol1998;13:1313-18. 186. The International Non-Hodgkin's Lymphoma Prognostic Factors Project. A predictive model for aggressive nonHodgkin's lymphoma. N EnglJ Med 1993; 329: 987-94. 187. Mounier N, Morel P, Haioun C, et al. fortheGroupe d'Etudes des Lymphomes de'Adulte: a multivariate analysis of the survival of patients with aggressive lymphoma. Cancer 1998; 82:1952-62. 188. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms. A proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 189. Cowan RA, Jones M, Harris M, et al. Prognostic factors in high and intermediate grade non-Hodgkin's lymphoma. BrJ Cancer 1989; 59: 276-82. 190. Coiffier B, Gisselbrecht C, Vose JM, et al. Prognostic factors in aggressive malignant lymphomas. Description and validation of a prognostic index that could identify patients requiring a more intensive therapy. J Clin Oncol 1991; 9: 211-19. 191. Hancock BW, May K, Bruce L, et al. Haematological and immunological markers in malignant lymphoma. TumourDiagWSQ; 1:140-4. 192. Johnson PWM, Whelan J, Longhurst S, et al. b-2 Microglobulin: a prognostic factor in diffuse aggressive non-Hodgkin's lymhomas. BrJ Cancer 1993; 67: 792-7. 193. Salles G. Towards new prognostic factors in diffuse large cell non-Hodgkin's lymphoma. Ann Oncol 1996; 7: 993-6. 194. Cowan RA, Harris M, Jones M, et al. DNA content in high and intermediate grade non-Hodgkin's lymphoma. Prognostic significance and clinicopathological correlations. BrJ Cancer 1989; 60: 904-10.

204 Hodgkin's disease: clinical features 195. Akerman M, Brandt L, Johnson A, et al. Mitotic activity in non-Hodgkin's lymphoma. Relation to the Kiel classification and to prognosis. BrJ Cancer 1987; 55: 219-23. 196. Joensuu H, Ristamaki R, Sbderstrom KO, et al. Effect of treatment on the prognostic value of S-phase fraction in non-Hodgkin's lymphoma. J Clin Oncol 1994; 12: 2167-75. 197. Miller TP, Grogan TM, DahlbergS, et al. Prognostic significance of the Ki-67 associated proliferative antigen in aggressive non-Hodgkin's lymphomas: a prospective Southwest Oncology Group trial. Blood 1994; 83: 1460-6. 198. Jalkanen S, Joensuu H, Soderstrom KO, et al. Lymphocyte homing and clinical behaviour of nonHodgkin's lymphoma.y Clin Invest 1991; 87:1835-40. 199. Salles G, Zain M, Jiang WM, et al. Alternatively spliced CD44 transcripts in diffuse large-cell lymphomas: characterization and comparison with normal activated B-cells and epithelial malignancies. Blood 1993; 82: 3539-47. 200. Seymour JF, Talpaz M, Cabanillas F, et al. Serum interleukin-6 levels correlate with prognosis in diffuse large-cell lymphoma.J Clin Oncol 1995; 13: 575-82. 201. BlayJ-Y, Burdin N, Rousset F, et al. Serum interleukin-10 in non-Hodgkin's lymphoma: a prognostic factor. Blood 1993;82:2169-74. 202. Salles G, Bienvenu J, Bastion Y, et al. Elevated circulating alpha-TNF and soluble TNF-receptor levels

203. 204.

205.

206.

207.

208. 209.

are associated with adverse prognostic factors and poor outcome in lymphoma patients. BrJ Haematol 1996; 93: 352-9. Yuen AR, Sikic Bl. Multidrug resistance in lymphomas. J Clin Oncol 1994; 12: 2453-9. Hill ME, Maclennan KA, Cunningham DC, et al. Prognostic significance of BCL-2 expression and bcl-2 major breakpoint region rearrangement in diffuse large cell non-Hodgkin's lymphoma-a British National Lymphoma Investigation study. Blood 1996; 88: 1046-51. Boiocchi M, De RV, Bloomfield CD, Goldman A, Dick F, et al. Multivariate analysis of prognosis factors in the nonHodgkin's malignant lymphomas. Cancer 1974; 33: 870-9. Gospodarowicz MK, Bush RS, Brown TC, et al. Prognostic factors in nodular lymphomas: a multivariate analysis based on the Princess Margaret Hospital experience. Int J Radial Oncol Biol Phys 1984; 10: 489-97. Romaguera JE, McLaughlin P, North L, et al. Multivariate analysis of prognostic factors in stage IV follicular lowgrade lymphoma: a risk model.J Clin Oncol 1991; 9: 762. Coiffier B, Bastion Y, Berger F, et al. Prognostic factors in follicular lymphomas. Semin Oncol 1993; 20(suppl 5): 89. Lopez-Guillermo A, Montserrat E, Bosch F, et al. Applicability of the international index for aggressive lymphomas to patients with low-grade lymphoma.y Clin Oncol 1994; 12:1343-8.

16 Imaging of lymphoma K SANDRASEGARAN, PJ ROBINSON AND A SPRIGG

Introduction Imaging characteristics of nodes Chest Abdomen and pelvis Skeletal system Head and neck Central nervous system

205 205 206 207 210 211 213

INTRODUCTION Hodgkin's disease (HD) is primarily a nodal disease, with extranodal involvement being rare at presentation. Extension of nodal involvement is typically by a contiguous pattern, for example, supraclavicular to anterior mediastinal nodes. The Ann Arbor classification, which is described elsewhere, is used for staging disease extent and for grading prognosis. Non-Hodgkin's lymphoma (NHL) presents with extranodal disease in 20-40 per cent of cases. Nodal involvement is typically more bulky than in HD, with more widespread and non-contiguous disease being common at presentation. The Ann Arbor classification is less useful in NHL, with disease bulk, histology and biochemical markers being important prognostic factors. Differences between HD and NHL in pathology, clinical presentation and in the natural history of the disease are sufficiently great to require different imaging strategies during staging and follow-up. In this chapter, we will first discuss the imaging of nodal and extranodal disease in various sites. Specific requirements for the imaging of pediatric andacquired immunodeficiency syndrome (AIDS)-related lymphomas are described, and strategies are suggested for the selection and timing of follow-up imaging. IMAGING CHARACTERISTICS OF NODES The recognition of disease in nodes depends on their enlargement; involvement of normal-sized nodes cannot

214 214 216 216 217 218

Breast Lymphoma in patients with AIDS Lymphoma in children Imaging in the follow-up of lymphoma New imaging techniques in lymphoma References

be detected by computed tomography (CT), ultrasonography (US) or magnetic resonance imaging (MRI) at present. Discrimination between minor nodal enlargement by lymphoma, and reactive or inflammatory enlargement is also impossible by current imaging methods. Nodes are readily distinguished from surrounding fat on CT and appear as masses of uniform attenuation similar to that of muscle. Groups of nodes appear lobulated, and necrosis or calcification is rare unless there has been previous treatment. Nodes typically show little enhancement after contrast medium injection, although moderate enhancement may be seen in nodular sclerosing HD. They rarely cause invasion of surrounding tissue, but often displace or compress adjacent structures. There is considerable normal variation in the size of nodes. Table 16.1 indicates the size criteria for enlargement of nodes in various anatomic sites.1,2 Subcarinal nodes measuring 10 mm are usually normal Table 16.1 Maximum normal sizes of lymph nodes on computed tomography

Mediastinal and hilar Axillary Paracardiac Para-aortic Retrocrural Portocaval Mesenteric Iliac and inguinal

10 10 8 10 6 8 8 10

206 Imaging of lymphoma

unless there is also involvement of tracheobronchial nodes. In the abdomen the maximum size of normal nodes increases with distance from the diaphragm and decreases with age. Normal nodes cannot usually be differentiated from surrounding fat on US. Enlarged reactive and lymphomatous nodes are echopoor without distal enhancement. Malignant nodes tend to be more rounded but it is not usually possible to distinguish them from benign enlargement. On Tl-weighted magnetic resonance (MR) images, lymph nodes have low signal and contrast well against the high signal of surrounding fat. On Tl-weighted images, nodes have a homogeneously high signal. A mixed high and intermediate signal on T2-weighted images is occasionally seen in untreated nodular sclerosing HD, but is typical after treatment. Gallium localizes in viable tumor cells to a degree, which varies with histologic grading and with disease activity. Gallium uptake is highest in HD and high-grade NHL. Since gallium is taken up by normal liver and bone marrow, and is partly excreted via the bowel, interpretation of planar images of the abdomen is more difficult than in the chest. With optimum technique, gallium-67 scanning has been claimed to have greater than 90 per cent sensitivity, specificity and accuracy in detecting active disease in the thorax.3

CHEST Intrathoracic involvement at the time of initial presentation is found in 65-85 per cent of patients with HD and 25-40 per cent of patients with NHL.4,5 In HD, mediastinal lymphadenopathy is common and typically affects paratracheal and anterior mediastinal nodes (Fig. 16.1). Posterior mediastinal nodes are rarely involved. In the absence of mediastinal disease, hilar adenopathy is uncommon and involvement of the lung

Figure 16.1 CT scan at the level of the aortic arch showing enlarged axillary, anterior mediastinal and azygous nodes in Hodgkin's disease.

parenchyma rare in HD, unless there has been previous radiotherapy to the mediastinum. The pattern is less predictable in NHL and isolated pulmonary disease may occur. The thymus is considered to be a lymphatic organ and so there is little need to determine whether an anterior mediastinal mass is of thymic or nodal origin. Thymic enlargement is seen on CT in 30-50 per cent of patients with HD.6 The thymus remains enlarged in about a third of cases after treatment. Lung manifestations include direct extension from involved nodes, pulmonary nodules with or without cavitation, collapse from bronchial infiltration by tumor or obstruction by nodes and, rarely, interstitial infiltration. CT is the staging method of choice. When the above changes are seen in the untreated patient, pulmonary involvement can be diagnosed with confidence.7 In the treated patient, however, biopsy may be needed to differentiate pulmonary relapse from infection, radiation pneumonitis or drug-induced lung disease. Pleural effusions are seen in 7-10 per cent of untreated adult patients. They are not of prognostic importance, unless associated with a pleural mass, since they rarely contain malignant cells and usually resolve on treatment of adenopathy. Invasion of the chest wall may occur in NHL with involvement of internal mammary nodes and the thoracic spine may be involved by extension from posterior mediastinal nodes. Cardiophrenic nodes (Fig. 16.2) may produce diaphragmatic invasion (Fig. 16.3). Histologic evidence of pericardial invasion is rarely obtained but about 5 per cent of patients have pericardial effusions on CT at the time of presentation.7 Myocardial involvement is rare and has a poor prognosis.

Figure 16.2 CT scan at the level of the right hemidiaphragm showing enlarged nodes in the right cardiophrenic angle and adjacent to the apex of the heart. Histology: NHL

Abdomen and pelvis 207

value in initial diagnosis or staging. The role of positron emission tomography (PET) in staging lymphoma appears promising but still needs further investigation (see later).

ABDOMEN AND PELVIS

Figure 16.3 CT through the superior part of the liver showing a large non-enhancing mass of lymphoma arising in the left hemidiaphragm infiltrating the left lobe of the liver and other adjacent viscera. Histology: NHL

Staging of thoracic lymphoma In addition to initial chest X-ray, thoracic CT should be routinely performed in all lymphoma patients. Scans should be examined with lung windows as well as soft tissue windows. The routine use of intravenous contrast enhancement is not necessary in adults but may be useful in cases where there is difficulty in interpretation, e.g. in patients with aberrant mediastinal vessels or in the absence of intrathoracic fat. If the results of CT are doubtful or inconclusive, MRI may be helpful to improve the definition of chest wall or mediastinal disease (Fig. 16.4). Where cardiac involvement is suspected, echocardiography can be added to detect small pericardial effusions. Gallium-67 single photon emission computed tomography (SPECT) should detect the presence of active disease in patients with residual masses after treatment of mediastinal HD,8 but has little

Figure 16.4 ~[2-weighted MRI scan through mid-thorax showing a multinodular mass of fairly high signal intensity surrounding the great vessels (areas of signal void) and invading the right anterior chest wall. A large right pleural effusion is present. Histology: NHL

Lymphoma should be considered in the diagnosis of any unusual mass within the abdomen. Lymphoma can involve nodes in the retroperitoneum, mesentery, porta hepatis, splenic hilum, around the pancreas or the major vascular bundles. CT is the first-line imaging technique (Fig. 16.5). Where there are no superficial nodes available for excision biopsy, CT- or US-guided fine-needle aspiration is usually adequate to arrive at a diagnosis of NHL. In HD, a core specimen is normally required. The relatively rare condition of primary splenic lymphoma typically presents with single or multiple masses in the spleen.9 Much more frequently the spleen is involved concurrently with nodal lesions elsewhere; in such cases, splenic disease is typically diffuse with only a small minority of cases showing nodules larger than 1 cm in size. The problem of detecting secondary splenic involvement in lymphoma is still largely unsolved. Staging laparotomy has shown that, at the time of the presentation, the spleen is infiltrated in about 30-40 per cent of patients with Hodgkin's disease and in 10-40 per cent of those with NHL.10~12 In 10 per cent of patients presenting with thoracic HD, splenic involvement is the sole site of infradiaphragmatic disease13 so detection of splenic disease changes both staging and treatment. In patients with disease above and below the diaphragm, the additional detection of splenic disease does not often change staging but may indicate a different treatment plan. The size of the spleen is not much help, since diffuse infiltration may be present in spleens of normal size, while mild to moderate reactive splenomegaly occurs in

Figure 16.5 CT at the level of L1/2 showing multiple enlarged para-aortic and mesenteric nodes surrounding the inferior vena cava, aorta and left renal vein.

208 Imaging of lymphoma

about 30 per cent of patients with HD and up to 70 per cent of those with NHL; however, marked splenomegaly in NHL almost always indicates infiltration. Diffuse infiltration of the spleen cannot be reliably detected by ultrasound, by CT, or by unenhanced or gadoliniumenhanced MRI. Discrete nodules, when large enough to be visible, are hypoechoic on ultrasound and show low attenuation with reduced contrast enhancement compared to normal splenic tissue on CT (Fig. 16.6). On MRI, the lesions are hypointense or isointense on Tlweighted MRI images, hyperintense on 77-weighted images and show reduced enhancement after gadolinium compared to normal spleen (Fig. 16.7). The presence of enlarged nodes at the splenic hilum may be taken as an indicator of parenchymal involvement of the spleen. Sensitivity of ultrasound and CT in detecting splenic disease is about 35 per cent.14 CT following intravenous or intra-arterial iodized oil has been reported to improve the detection of diffuse hepatosplenic lymphoma15 but the side effects of the contrast agent have prohibited its widespread adoption. Superparamagnetic iron oxide particles are ingested by

Figure 16.6 Unenhanced CTscan through the upper abdomen showing multiple low-attenuation lesions in both liver and spleen. Note also the enlarged retrocrural lymph nodes. History: Hodgkin's disease.

Figure 16.7 Abdominal MRI in NHL (a) Transverse T2weighted scan through upper abdomen showing multiple lesions of increased signal intensity in liver and spleen, (b) Coronal STIR images showing one of the larger liver lesions with high signal and also multiple bone deposits showing areas of high signal affecting most of the vertebral bodies, (c) Transverse T2-weighted scan through the renal areas showing multiple splenic lesions of increased signal, together with numerous enlarged para-aortic nodes. (Courtesy of DrAlan Chalmers.)

Abdomen and pelvis 209

normal reticuloendothelial cells and produce a marked reduction in signal intensity on both Tl- and Unweighted MRI. Initial trials suggest that diffuse lymphomatous involvement of the liver or spleen might be detected even in organs of normal size.16 Further experience with this technique is needed. Primary hepatic lymphoma is a very rare tumor of middle-aged whites that is occasionally associated with cyclosporin treatment. It presents as a solitary mass involving Kupffer cells, sometimes with lymph nodes at the porta hepatis. Secondary hepatic lymphoma is associated with lymph node disease and at presentation is seen in 5-10 per cent of NHL patients and 10-20 per cent of HD patients.11,12,15 The liver is never involved in the absence of splenic disease (except possibly in some patients with AIDS), whereas the spleen is often involved without the liver being affected. As with splenic disease, involvement is diffuse in 90 per cent of cases17 and not reliably detectable on US, CT or MRI. Nodular disease in the liver looks similar to that in spleen (Fig. 16.6 and 16.7). Hepatomegaly in NHL is likely to signify liver involvement but is non-specific in HD. Disease of the bile ducts and gall bladder is rare but has been described in AIDS-related lymphoma. Parenchymal involvement of the pancreas occurs in 0.5-2 per cent of NHL patients12,18 and develops in association with disease in adjacent nodes. The incidence is higher in patients with high-grade histology, particularly Burkitt's lymphoma. Appearances on US, CT and MRI may be indistinguishable from those of pancreatic carcinoma except that dilatation of the pancreatic and biliary ducts is relatively uncommon. It may be difficult to differentiate peripancreatic lymphadenopathy from pancreatic disease. Percutaneous needle biopsy has been reported to be diagnostic in 95 per cent of cases.18 Renal lymphoma is usually an incidental finding on CT. It is often a late manifestation, being seen at initial staging in only 3-6 per cent of cases. Bilateral disease is rare initially but commonly develops in the late stages.19,20 Intravenous urography is frequently normal, whereas US usually shows single or multiple hypoechoic foci without distal acoustic enhancement.20 Occasionally echogenic nodules or multiple cystic lesions are seen. The typical appearance on CT is that of multiple intrarenal nodules with attenuation similar to or less than that of normal renal cortex. The nodules show less enhancement than normal renal tissue after intravenous contrast injection. Most cases are associated with lesions in the retroperitoneal nodes, liver or spleen. When renal lymphoma is suspected, contrast-enhanced CT is required for staging. When there is evidence of lymphoma at other sites, typical CT appearances may be taken to indicate renal involvement (therefore Stage IV disease) but, in the minority of cases presenting with primary renal lymphoma, a guided biopsy is required. Ultrasound may be used for following up those lesions that are clearly visible by this technique.

Adrenal involvement occurs in 1-4 per cent of patients with lymphoma21,22 and in the majority of cases is associated with retroperitoneal lymphadenopathy. The usual appearance is that of homogenous enlargement of one or both glands, which typically resolves with treatment. A solitary adrenal mass without retroperitoneal lymphadenopathy in a lymphoma patient does not necessarily signify adrenal infiltration since incidental non-functioning adenomas are relatively common, particularly in older patients. Bladder involvement is usually asymptomatic and is most often picked up on staging CT. The appearances are those of a large multinodular intramural mass or widespread thickening of the bladder wall. Most cases of prostatic lymphoma are intermediate or high-grade NHL. There is usually extensive involvement of the whole gland and adjacent tissue. NHL of prostate is typically associated with disease in bone, Waldeyer's ring, liver, mesenteric and inguinal nodes. The prognosis is very poor.22 Primary testicular lymphoma accounts for one-third of testicular tumors presenting in patients aged over 50 years. It is always due to intermediate- or high-grade NHL; bilateral disease is present in 10-25 per cent of cases.23 Primary imaging is by ultrasound, which usually shows well-defined homogeneous masses with reduced echogenicity in an enlarged testis. The appearances are characteristic given the age of patient. Staging is crucial since the 2-year survival of Stage I-II patients is 45 per cent compared with 1 per cent for Stage III-IV.24 Testicular lymphoma is typically associated with involvement of the central nervous system (CNS), Waldeyer's ring and the lungs. Staging may include sonography of both the testes, abdominal CT, chest X-ray, lumbar puncture and clinical examination with endoscopic biopsy of the nasopharynx.23 Ovarian lymphoma, which is typically solid homogeneous masses of NHL with low vascularity on ultrasound, usually presents late and has a poor prognosis, whereas lymphoma of the uterus more commonly has an earlier presentation with a 73 per cent 5-year survival for Stage I-II disease.22 Staging should include pelvic ultrasound and abdominopelvic CT. In gastrointestinal (GI) lymphomas, the clinical stage affects the prognosis more than histology or location.23,25 Regional lymph node involvement implies significantly worse prognosis. HD rarely involves the GI tract, whereas in NHL the GI tract is the commonest extranodal site of disease with involvement in 5-15 per cent of patients at the time of presentation.25 The stomach is affected in about half of these cases [including those arising in mucosa-associated lymphoid tissue (MALT) which have similar imaging appearances], the small bowel is affected in a third, and large bowel involvement accounts for the remainder. NHL is the cause of 2-5 per cent of gastric tumors.26 Radiologic appearances include enlarged gastric rugae, ulceration, aneurysmal dilatation

210 Imaging of lymphoma

Figure 16.8 CT through the upper abdomen showing extensive gastric wall thickening. Histology: NHL.

and multiple polyps. It may be impossible to differentiate from adenocarcinoma on CT, but lymphoma is suggested if there is gross thickening of the entire stomach wall, clear separation between stomach wall and adjacent organs, lymphadenopathy above and below the renal hilum, or extension across the pylorus into the duodenum (Fig. 16.8). Because the lesion infiltrates the submucous gastric wall, endoscopic biopsies may miss the pathology in up to 20 per cent of cases.26 Lymphoma is probably the commonest primary tumor of small bowel, accounting for about 20 per cent of cases. Typically it shows a constrictive, nodular or ulcerative appearance on barium studies, and associated mesenteric nodes may be shown by CT. Multiple lesions occur in about 10 per cent of cases.25 The rare primary lymphoma of large bowel usually affects either cecum or rectum. Secondary spread is associated with multiple lesions affecting any part of the colon. The incidence is highest in AIDS patients and in those with poorly differentiated NHL.

Staging of abdominal lymphoma CT is usually the initial mode of investigation. Where only lymph node disease is expected, oral contrast is used and there is no necessity for intravenous contrast. Contrast-enhanced images are useful if extranodal involvement is suspected. Lymphangiography (LAG) and gallium-67 scanning probably make no additional contribution to the staging of abdominal NHL. In early HD, LAG has historically been thought to be superior to CT in staging para-aortic nodes27 but other authors have recently found no advantage.28 MRI can detect retroperitoneal and pelvic nodal disease as sensitively as CT. Mesenteric nodes are not well seen due to the mobility of the bowel. GI lymphoma is usually diagnosed on endoscopy or barium studies, but CT is also required for staging. In patients presenting with lymphoma elsewhere, barium

studies are not routinely required to look for GI involvement, except in those with NHL of Waldeyer's ring, who have a 6-15 per cent probability of asymptomatic GI disease.29 The use of laparotomy has declined considerably in the last decade. It is inappropriate in patients with NHL and Stage III/IV HD. HD patients with Stage I or II and features suggesting a poor prognosis, e.g. bulky tumors or B symptoms, now receive chemotherapy without laparotomy. Those with very good prognosis, i.e. single site, small tumor load and no symptoms, will probably be cured by radiotherapy alone without laparotomy, and even if they relapse will be salvaged by chemotherapy. Consequently, staging laparotomy is reserved for an ever-decreasing group of HD patients with intermediate prognosis. In the absence of axillary or inguinal nodes that can easily be biopsied surgically, CT- and US-guided core biopsies performed with spring-loaded firing devices have an important role in the diagnosis and staging of lymphoma. The role of fine-needle aspiration biopsy (FNAB) in this situation is controversial. The development of ancillary diagnostic techniques, such as immunologic markers and cytogenetics, has increased the specificity and accuracy of FNAB in diagnosis of high-grade NHL. Accuracies of up to 90 per cent have been quoted.30,31 However, the exclusion value of a negative FNAB remains low in patients with HD and intermediate-grade lymphoma.32 FNAB, however, has a useful role in the assessment of residual masses following treatment (see later).

SKELETAL SYSTEM It is important to differentiate between bone marrow and osseous involvement. At presentation, bone marrow involvement is rare in HD but is found in 20-40 per cent of NHL patients;11,12,33 this indicates Stage IV disease and is associated with worse prognosis than involvement of liver, lung or osseous bone. Bone marrow aspirates are relatively late indicators of marrow involvement. In a large study of NHL patients, marrow biopsy increased the staging in 32 per cent of cases, mostly from Stage II to Stage IV.33 The performance of bilateral bone marrow biopsies increases the pick-up rate of positive cases by 10 per cent to 40 per cent compared with single site biopsies.34 Bone marrow involvement in low-grade NHL is typically diffuse but in intermediate- to high-grade NHL and in HD marrow disease is likely to be focal. Bone scintigraphy and CT are not accurate in assessing marrow disease. On MRI, tumor deposits have a low signal on Tl -weighted images and a high signal on T2weighted sequences. Tumor deposits down to 3 mm in size can be detected as having a high signal on short-tau inversion recovery (STIR) sequences.

Head and neck 211

Osseous involvement occurs in 1-2 per cent at presentation and 5-15 per cent during the course of the disease35 in adult lymphoma patients. The incidence is much higher in children. Primary bone lymphoma (also termed reticulum cell sarcoma or histiocytic lymphoma) is another rare form of NHL. By definition there is no lymphadenopathy and a single bone, typically femur or pelvis, is involved, so the lesion is automatically classified as Stage I. Secondary bone lymphoma is seen in NHL and HD, and tends to involve the axial skeleton, especially the spine. Spread may be hematogenous (Stage IV) or from adjacent lymphadenopathy. In either case the prognosis is relatively favorable; the survival with hematogenous bone involvement is 50 per cent at 10 years. Abnormal biochemistry is a poor predictor of bone involvement. Plain radiographs may show a permeative or moth-eaten appearance. Periosteal reaction is more common in HD. Pelvic bone lesions often have soft tissue extension. Sclerotic lesions are more frequent in HD and following treatment. Primary bone lesions usually show reduced signal intensity on Tl -weighted MRI but their appearance on T2-weighted imaging is variably isointense or hypointense.36'37.

Staging of lymphoma of osseous bone and marrow Skeletal radiographs need only be performed in those with bone or joint pain, and in areas of bone disease suspected by CT, chest X-ray or bone scintigraphy. Bone scintigraphy has a sensitivity and accuracy of 95 per cent in detecting bone involvement35 but it is not routinely indicated, since most cases of bone lymphoma are revealed on initial chest X-ray and CT. It is used for patients who have localized skeletal symptoms and those with known bone involvement for staging and followup. CT or MRI is valuable in assessing soft-tissue extension of lymphoma. Currently, iliac crest biopsy to detect marrow disease is routine, although PET using 2-[18F]fluoro-2-deoxy-Dglucose (FDG) may provide a less invasive alternative because it samples the whole skeleton and is probably at least as accurate.38,39 A case can also be made for the use of MRI (Tl-weighted and STIR sequences) of the pelvis, spine and proximal femora in patients with negative marrow biopsies who would otherwise be candidates for radiotherapy, e.g. Stage I high-grade NHL. In such patients a positive MR study may be followed by appropriately sited biopsy.

per cent of all HD cases, including those without throat symptoms or radiological evidence of disease, have positive nasopharyngeal biopsies and some authors advocate nasopharyngeal biopsy as part of routine staging of HD.40 About a third of patients with clinical Stage I or II disease will have infradiaphragmatic disease, so abdominal CT is mandatory. Abdominal disease is particularly likely in those with bulky supraclavicular lymphadenopathy or bilateral neck disease, and in those with mixed cellularity on histology. With NHL, the head and neck is a primary site for involvement in about 10 per cent of patients and about half of these will also have systemic involvement.41,42 NHL is limited to nodes in a third of head and neck cases, with deep lymphatic chains being the most common sites. Extranodal tissue such as Waldeyer's ring and paranasal sinuses account for the majority of head and neck NHL. The nasopharyngeal adenoids together with oropharyngeal, faucal and lingual tonsils make up the Waldeyer's ring of extranodal lymphatic tissue. It is the commonest site of NHL in the head and neck region (Fig. 16.10). In 6-15 per cent of cases, there is coexistent disease of the GI tract (most often stomach) and barium studies are indicated even in the absence of symptoms.43 On CT, head and neck lymphoma typically is homogeneous, has similar attenuation to muscle and shows little enhancement. On MRI it is of low signal on Tl-weighted images and intermediate signal on T2-weighted images. There is moderate enhancement with gadolinium.

HEAD AND NECK HD of the head and neck is typically limited to lymph nodes; extranodal disease is manifest clinically in less than 1 per cent of cases (Fig. 16.9). However, about 20

Figure 16.9

CT scan through the level of the hyoid showing a

lymph node mass compressing the right submandibular gland. Histology: Hodgkin's disease.

212 Imaging of lymphoma

Figure 16.10 C7 scan through the level of the angle of the mandible showing an ill-defined soft tissue mass extending into the oropharynxfrom the right tonsillar fossa. Histology: NHL

Tonsillar lymphoma is frequently associated with widespread nodal disease and prognosis is consequently poor. Recurrence after treatment usually occurs within a year and tends to involve bone marrow, the GI tract or the CNS. After squamous cell carcinoma, NHL is the second

Figure 16.11 Transverse Tl-weighted (a) and T2-weighted (b) MRI scans through the orbits showing an extensive tumor mass with moderately high signal intensity on both T7 and T2 scans enveloping the anterior and lateral aspects of the left globe together with the lacrimal gland. Histology: NHL. (Courtesy of Dr Ashley Guthrie.)

most common tumor of the paranasal sinuses. Extension into the infratemporal fossa and cheek may occur without visible bone destruction. Clinically and radiologically lymphoma can mimic squamous carcinoma, although bone destruction is usually not as extensive as in carcinoma, and lymphadenopathy tends to be bilateral, without calcification or necrosis. Lymphoma is also suggested if nodes are large and in atypical sites, such as retropharyngeal, submental, submandibular or posterior triangle chains. Occasionally it may be difficult to differentiate tumor mass from retained secretions on CT and, in these cases, T2- weigh ted MRI or Tl- weigh ted sequence with gadolinium should allow discrimination. Primary orbital NHL is the commonest orbital malignancy in adults and is bilateral in up to 40 per cent of cases.42 Most cases are associated with systemic disease, which may present up to 5 years later.41 NHL may resemble reactive lymphoid hyperplasia, but homogeneity and bone destruction are indicative of the former, while scleral thickening and infiltration of retro-orbital fat are suggestive of the latter.44 Either CT or MRI can be used to demonstrate disease in the retrobulbar space, around the globe, optic nerves and muscles, and within the lacrimal glands (Fig. 16.11 and 16.12). The examination protocol should include the neck to evaluate cervical nodal disease and, if CT is used, images with bone windows should be included. Intraocular involvement is rare and is almost always associated with CNS involvement. NHL of salivary gland is rare and, although it is usually part of widespread disease, the prognosis is good.43 The parotid gland is the most frequently affected. The tumor can usually be distinguished from adjacent parotid tissue and fat on CT or MRI; the imaging features are similar to those of lymphoma elsewhere in the head and neck region. Single lymphomatous masses can-

Central nervous system 213

studies of the upper GI tract and small bowel. In patients with paranasal sinus lymphoma, ideally both CT and MRI with axial and coronal sections as well as intravenous contrast enhancement are necessary to delineate extension of the tumor. CT shows bone destruction better, while MRI is superior in delineating soft tissue and intracranial extension. These patients also have a high risk of associated meningeal disease so cerebrospinal fluid (CSF) sampling may be helpful.

CENTRAL NERVOUS SYSTEM

Figure 16.12 CT through orbits showing obliteration of the contents of the left orbit by infiltrating tumor. Histology: NHL Note the spread of the tumor into the infratemporal fossa on the left and previous surgery to right globe. (Courtesy of Dr Ashley Guthrie.)

not be distinguished from the more common pleomorphic adenoma. Multiple NHL masses may look similar to Warthin's tumor or metastasis, but bilaterality and the presence of periparotid lymphadenopathy are suggestive of lymphoma. Thyroid NHL occurs more commonly in females, is associated with chronic thyroiditis and is bilateral in half the cases. Ultrasound is sensitive but not specific for diagnosing NHL. A variety of patterns have been reported, including discrete hyperechoic nodules, multiple lesions of complex echogenicity, diffusely hypoechoic goitre or even thyroid enlargement with normal echopattern.45 On CT, the typical appearance is a low attenuation nodular mass with extracapsular spread and adjacent nodal involvement. Unlike anaplastic carcinoma, necrosis and calcification are rare. In the absence of nodal involvement, the prognosis is good (80 per cent - 5-year survival) but it is much worse with nodal disease (30 per cent - 5-year survival).46

Lymphomas account for about 2 per cent of primary brain tumors. Brain involvement occurs in 10-15 per cent of NHL47 at some time but, of those presenting initially with CNS involvement, the vast majority (over 90 per cent) are primary lymphoma.41 Brain involvement in HD is so rare that a space-occupying lesion in the brain of a patient with known HD should suggest a second diagnosis. Primary brain lymphoma has been previously termed reticulum cell sarcoma, microglioma and round cell sarcoma. Most cases present as solitary masses, which, unlike gliomas, tend to affect central sites, particularly the periventricular areas, basal ganglia, corpus callosum and thalamus. With disease progression, 30 per cent of patients will develop multifocal involvement and about 10 per cent will develop diffuse parenchymal infiltration. On CT, about two-thirds of the lesions are hyperdense and less than 10 per cent are hypodense.48 Surrounding edema and central necrosis are much less commonly seen than with gliomas. Homogeneous enhancement with contrast is typical, although patchy or peripheral enhancement may occur. Non-enhancement and the presence of edema are associated with a poorer prognosis. On Tl -weighted MR images, parenchymal lesion are isointense or hypointense compared with gray matter and show enhancement with gadolinium. The lesions are hyperintense or isointense to gray matter on T2weighted images, which also show the presence of edema. Leptomeningeal spread is seen in both NHL and HD (Fig. 16.13).

Staging of head and neck NHL Staging of CNS lymphoma Where extranodal disease is suspected, CT is required for anatomic definition and radiotherapy planning. All patients with head and neck NHL should have abdominal CT because of the high prevalence of coexisting infradiaphragmatic disease. If CT is equivocal, e.g. with dental artefacts and in the difficult supraclavicular region, MRI may be helpful; we would recommend coronal STIR and transverse T2 -weighted sequences. In Stage I and Stage II disease, bone marrow biopsy should be carried out since these procedures result in upstaging in about 15 per cent of cases. Patients with Waldeyer's ring involvement, as already mentioned, should have barium

CT and MR are equally effective in detecting primary brain lymphoma.48 Meningeal deposits are best seen on gadolinium-enhanced Tl-weighted MRI, which is considerably more sensitive than contrast-enhanced CT. Coronal sections are recommended. Lymphoma of the spinal cord and meninges is rare, and both CT and MRI are recommended in staging. Tumor in the spinal cord, meninges, paraspinal soft tissue and vessels is well shown by MRI (Fig. 16.14). CT is superior in showing the extent of cortical bone destruction. In the absence of neurological symptoms, CNS

214 Imaging of lymphoma

2 those who are immunocompromised, especially with AIDS, in whom the risk of CNS involvement is increased by a factor of 500; 3 those with diffuse NHL, and with involvement of testes or bone marrow, who have a 25 per cent risk of developing CNS involvement.49

BREAST

Figure 16.13 Transverse T2-weighted MRI scan through mid-brain and posterior fossa, showing multiple areas of high signal intensity on the surface of the cerebellar hemispheres. Histology: NHL (Courtesy of Dr Keith Blanshard.)

Primary lymphoma accounts for 0.1-0.5 per cent of breast tumors with a disproportionate (6 per cent) of cases occurring in males and on the right side.50 The mammographic appearance is usually that of a welldefined mass (Fig. 16.15) with minimal irregularity of contour and no microcalcification. Fibrous reaction distorting the breast architecture and nipple retraction are rare. Diffuse or localized skin thickening may occur due to lymphatic obstruction. Occasionally there is diffuse increase in breast density. Ipsilateral axillary lymphadenopathy is seen in 35-40 per cent of cases and is associated with poor prognosis. The mammographic appearances overlap with those of carcinoma but the presence of bilateral lymphadenopathy is suggestive of lymphoma. Staging procedures for breast lymphoma should include chest radiograph and thoracoabdominal CT. The roles of ultrasound and MRI are not yet clear.

LYMPHOMA IN PATIENTS WITH AIDS screening is not required in routine staging of lymphoma, except in the following patients, who should have lumbar puncture and, if possible, MRI of brain and spinal cord: 1 those with very high grade histology, i.e. lymphoblastic lymphoma and small cell non-cleaved (Burkitt's and non-Burkitt's) lymphoma;

Figure 16.14 Transverse T2-weighted MRI scan through the mid-thoracic spine showing intradural, but extra medullary infiltration by tumor spreading from the paraspinal muscles on the left and also extending into the left subpleural space. Histology: NHL. (Courtesy of DrAlan Chalmers.)

AIDS-related lymphomas have several features that are distinct from lymphoma in other patients. Peripheral lymphadenopathy is relatively uncommon and the diagnosis of lymphoma often depends on guided biopsy of liver or para-aortic nodes.

Figure 16.15 CT through the mid-thorax showing a large homogenous tumor in the left breast. Histology: NHL.

Lymphoma in patients with AIDS 215

Hodgkin's disease in AIDS patients HD is increasingly recognized as a complication of human immunodeficiency virus (HIV) infection although at present it is not one of the major diagnostic criteria for defining a diagnosis of AIDS in HIV-positive patients. The distinctive features of HD in AIDS patients include the following:51-53 1 most patients present at Stage III or Stage IV; 2 there is a high incidence of bone marrow involvement even in the absence of splenic disease; 3 mesenteric nodes are involved in 20 per cent of cases; 4 nodal disease is often non-contiguous, e.g. pelvic and mediastinal lymphadenopathy occur without paraaortic disease.

Non-Hodgkin's lymphoma in AIDS patients Like HD, NHL in AIDS patients shows many unique features:54-56 1 the signs and symptoms are non-specific, e.g. CNS lymphoma often presents with altered personality, which is also a feature of other CNS complications of AIDS; 2 peripheral lymphadenopathy is absent in half of cases; 3 high-grade B cell type histology occurs in over 50 per cent of cases compared with less than 5 per cent in the general population; 4 involvement of multiple extranodal sites occurs in 75-95 per cent of cases; 5 primary brain lymphoma accounts for about 25 per cent of AIDS-related lymphoma (ARL), whereas only 2 per cent of non-AIDS NHL presents in this way. 6 median survival is very poor, being less than 6 months compared to 40 per cent 5-year survival of Stage III and IV NHL in the general population.

Imaging features of ARL Mediastinal and hilar node lesions are less bulky and less commonly found than in non-AIDS patients. Mediastinal nodes measuring 5-10 mm in diameter must be regarded with suspicion and larger intrathoracic lymph nodes are more likely to be caused by fungal or mycobacterial infection than lymphoma. Fineneedle aspiration biopsy with the appropriate immunochemistry is usually adequate for diagnosis in NHL, whereas in HD, because of the importance of structural elements in the histology, a cutting needle sample or open biopsy is better. CNS lymphoma in AIDS tends to be multifocal with lesions smaller than 2 cm in size. Subarachnoid invasion is seen in a quarter of the cases48 with epidural involvement in 6 per cent. With larger lesions, central necrosis is

common, so a rim enhancement pattern is seen on CT or gadolinium-enhanced MRI. Neither technique can differentiate this appearance from infective complications, such as toxoplasmosis and biopsy may be required for firm diagnosis. However, recent radionuclide SPECT studies using either thallium-201 or technetium-99mlabeled methoxyisobutyl nitrile (MIBI) have made this distinction by showing focal uptake in areas of tumor, whereas infective lesions showed little or no concentration of the tracer.57,58 MRI is more sensitive than CT in detecting parenchymal and leptomeningeal disease, and is the imaging method of choice. AIDS-related NHL occasionally presents with multiple discrete intramedullary spinal masses. About a quarter of AIDS-related lymphomas include bowel lesions,55 typically the mouth, rectum and terminal ileum. The barium findings are similar to those of lymphoma in non-AIDS patients. CT is necessary to demonstrate the full extent of bowel wall thickening and to detect mesenteric disease. It may be difficult to differentiate rectal lymphoma from inflammatory perirectal disease seen in homosexual men. Occasionally lymphoma may present as diffuse peritoneal nodularity without visible lymph node enlargement, mimicking carcinomatosis. Abdominal and pelvic lymphadenopathy in AIDS may be due to several causes. AIDS-related complex (a syndrome seen in HIV-positive patients without overt neoplasia) may cause generalized enlargement of nodes up to 1.5 cm. Nodes larger than this are abnormal, the likely causes being lymphoma, Kaposi's sarcoma, or Mycobacterium avium intracellulare (MAI) infection. Kaposi's sarcoma generally spares mesenteric nodes and causes less bulky lymph node enlargement. MAI typically produces bulky nodes with central low density due to necrosis. Ultrasound or CT-guided biopsy is recommended in order to distinguish these conditions from NHL. Focal lesions in the liver are more common (25-50 per cent) than in lymphomas in other patients (5-10 per cent).51,53 Appearances on CT and ultrasound are similar to those of lymphoma nodules in non-AIDS patients. Ultrasound and CT are both fairly insensitive in detecting diffuse liver and spleen involvement, and needle biopsy is usually required.51 The incidence of renal involvement is about 7-11 per cent.52 The typical appearance is that of multiple focal lesions, which are of low attenuation on CT and are hypoechoic on ultrasound. Diffuse enlargement of both kidneys in AIDS is more likely to be due to AIDS-related glomerular disease, which is a focal and segmental glomerulosclerosis manifest by renal failure and proteinuria.

Staging of ARL Lymphoma affects the chest much less frequently than infections, which may mimic it. Definitive diagnosis

216 Imaging of lymphoma

requires bronchoscopic biopsy or lavage in cases of diffuse disease and percutaneous biopsy with localized disease. CT may be useful in assessing mediastinal lymphadenopathy prior to a transcarinal needle biopsy. Since abdominal node disease tends to be bulky, there is a case for using ultrasound, which is comparable with CT in detecting liver lesions, as the initial screening investigation. If ultrasound is negative, or where involvement of bowel or other extranodal organs (e.g. psoas muscle) is suspected, CT is required. Lumbar puncture is required in all ARL cases. With positive CSF assay or clinical signs of CNS involvement, MRI should be carried out because its sensitivity is greater than that of CT in detecting brain and meningeal lymphoma. Bone marrow aspiration is required routinely owing to the high incidence of marrow lesions.

ographs are required prior to anesthesia, since large anterior mediastinal masses may compress the trachea in a sedated child lying supine. A nasogastric tube may be used to give sedation and oral contrast. At the end of the scan, residual contrast is aspirated from the stomach. We routinely use a clip-on transcutaneous oxygen saturation monitor (pulse oximeter) on sedated children. Mediastinal sonography is useful for follow-up of lymph node masses in the mediastinum or abdomen and planning biopsy. Bone marrow biopsies, preferably following MRI of the pelvis and femurs, are routine. CNS staging is usually performed by assaying CSF. Cranial MRI or CT, with contrast, are reserved for those with appropriate symptoms.

IMAGING IN THE FOLLOW-UP OF LYMPHOMA LYMPHOMA IN CHILDREN The principles of diagnosis and staging of lymphoma in the pediatric population are the same as those for adults. Hodgkin's disease accounts for 40 per cent of childhood lymphomas and has a peak incidence in teenagers. Childhood NHLs tend to be of high-grade histology. T cell histology is found in 30 per cent of pediatric NHL and presents with thoracic disease. Mediastinal lymphadenopathy may be large enough to cause dysphagia or superior vena caval obstruction. On the other hand, B cell NHL presents with extranodal disease in the abdomen or head and neck region. Burkitt's lymphoma is an unusual form of high-grade B cell NHL that occurs in an epidemic form in tropical Africa and New Guinea. Involvement of the maxilla or mandible is found in 60 per cent of these patients and the abdomen is affected in a similar proportion. American or European Burkitt's lymphoma is sporadic and is less strongly associated with the Epstein-Barr virus. In pediatric B cell NHL gastrointestinal disease tends to occur in the ileocecal region and intussusception may be the mode of presentation. Disease of the pancreas, kidneys, mesentery, ovaries and thyroid glands are common. Ascites and occasionally pleural effusion are present. Lymphadenopathy in the thorax or abdomen is unusual and, when present, is confined to the iliac and inguinal regions. There is an increased frequency of involvement of the CNS (20 per cent) and bone marrow (20 per cent). Staging pediatric lymphoma

In all cases CT of the chest and abdomen is performed as a baseline study. Intravenous contrast is routinely used. Good bowel opacification is also vital. Those under 2 years of age usually need sedation. This is best done in the presence of an anesthetist during a dedicated pediatric scanning session. Frontal and lateral chest radi-

Assessment of response to treatment In the phase of active treatment, imaging is used as a guide to therapeutic response. This is particularly true with cyclical chemotherapy, which should be discontinued or changed if the patient fails to show objective evidence of response. If there is visible intrathoracic disease, chest X-ray should be repeated at each clinic visit, which typically is monthly. CT may be repeated after each two cycles of chemotherapy, which usually means a gap of 6-8 weeks between scans. In our institution, chest, abdominal and pelvic scans, without intravenous contrast enhancement, are performed in all follow-up patients referred for CT, although there may be a case for a study limited to the regions showing disease on initial staging in NHL patients treated with chemotherapy.59 Also, a less detailed and frequent follow-up has been advocated for patients with HD (see Chapter 15).

Assessment of a residual mass Imaging is also used to confirm remission. The definition of complete remission requires that all previously abnormal investigations, including imaging studies, are repeated and found to be normal. In practice, residual mediastinal masses are common in HD or T cell NHL. Continuing regression of a mass with treatment implies persistence of active disease. Once the mass has reached a stable minimum size, further investigation may be necessary if there is clinical doubt about its activity (Fig. 16.16). Serial CT scans are the usual method of assessing the status of a residual mass and are performed every 2-3 months. Up to 15 per cent of residual masses may show a change in attenuation but an increase in size is highly suspicious of relapse. Masses that remain static after 1 year's follow-up can be considered inactive residue. Using gallium-67 imaging with SPECT, sensitivity and

New imaging techniques in lymphoma 217

Figure 16.16 Resolution of lymph node disease with treatment. Unenhanced CTscans through upper abdomen before (a) and after (b) treatment for abdominal Hodgkin's disease.

specificity of over 80 per cent has been quoted in assessing the activity of residual mediastinal masses.60 In HD, 67 Ga is fairly sensitive in detecting active disease residues after treatment but a negative result is less reliable in defining remission.61 Some histological subtypes of NHL and many necrotic tumors do not take up gallium and the accuracy of this method is lower for abdominal disease. On MRJ carried out 6-12 weeks after treatment, a reduction in the signal on a T2-weighted sequence usually means replacement of tumor by mature fibrosis. However, persistence of high signal is not specific to tumor and can be caused by inflammatory edema, cyst formation or partial volume averaging with fat. A change in signal from low to high on serial T2-weighted MRI is highly suggestive of relapse. There may be a role for MRI in predicting the size of a residual mass by measurement of T2-weighted signal intensities on the pre- and posttreatment scans.62 Fine-needle aspiration biopsy can be performed if there is clinical or radiological doubt of the activity of the residual mass. The accuracy of FNAB in the followup situation is good, and complications are rare even when biopsies of deep mediastinal structures are performed. If FNAB is negative, when there is strong clinical suspicion of relapse, a cutting needle or surgical biopsy is indicated. Detection of late relapse

The third function of follow-up is to detect relapse, which occurs in 10-40 per cent of patients with HD and in up to 60 per cent of NHL patients. Over 85 per cent of HD patients who relapse do so within 3 years of treatment.63 The timing of radiological reassessment depends on the clinical context. If a residual mass of uncertain significance exists, it should be assessed as above. If

remission has been complete, then 6-monthly CT scans during the first 3 years are sufficient. There are no clear rules for the length of long-term follow-up. In most institutions follow-up spans at least 10 years. A shorter follow-up may be reasonable for high-grade NHL, which can be considered to be cured if the patient survives for 5 years. Most late relapses are diagnosed clinically or with simple tests such as blood counts and chest X-rays, so after 3 years of treatment expensive imaging techniques, such as CT scans, should only be performed if there is clinical suspicion of relapse.

NEW IMAGING TECHNIQUES IN LYMPHOMA

Positron emission tomography Several studies have shown that PET with FDG is useful in staging64-66 and predicting response to therapy67 in lymphoma. PET has been shown to be at least as sensitive as CT in detecting disease in lymph nodes and extranodal sites.65-66-68 PET may also be useful in predicting the behavior of a residual mass after treatment.65,69 Further studies have suggested that it may be possible to differentiate cerebral lymphoma from infective lesions in HIV-positive patients.70 FDG uptake is related to histological grading, so PET may be negative in low-grade NHL71 and MALT lymphomas,'68 whilst false-positive results have been found in cases of rebound thymic hyperplasia,72 infection, fractures and other metabolically active benign lesions. PET using 11C-labeled methionine has also been found to be sensitive for detecting lymphoma lesions but less clearly related to histological grading and prognosis than FDG.73

218 Imaging of lymphoma

Somatostatin receptor scintigraphy

12. Chabner BA, Johnson RE, Young RC, et al. Sequential nonsurgical and surgical staging of non-Hodgkin's

The accuracy of somatostatin receptor scintigraphy with 11 'In-labeled octreotide (DTPA-pentetriotide) in staging and restaging of lymphoma has been tested in several trials.74-76 In general, the sensitivity is better for head and neck or thoracic tumors than for disease in the abdomen.74-75 This would in part explain the greater sensitivity of this technique in detecting the tumor site in Hodgkin's disease compared to non-Hodgkin's lymphoma.76 The place of this method in staging of lymphoma remains to be confirmed. Immunoscintigraphy with radiolabeled antibodies is undergoing early trials and results of controlled studies are awaited.

lymphoma. Ann Intern Med 1976; 85:149-54. 13. Reznek H, Richards MA. The radiology of lymphoma. Clin Haematol 1987; 1:77-107. 14. Castellino RA, Hoppe RT, Blank N, et al. Computed tomography, lymphography and staging laparotomy: correlation in initial staging of Hodgkin's disease. Am J Roentgenol 1984; 143: 37-41. 15. Thomas JL, Bernadino ME, Vermess M, et al. EOE-13 in the detection of hepatosplenic lymphoma. Radiology 1982; 145: 629-34. 16. Weisslander R, Elizondo G, Stark DD, et al. The diagnosis of splenic lymphoma by MR imaging: value of superparamagnetic iron oxide. AmJ Roentgenol 1989; 152: 175-80. 17. Zornoza J, Dood GD. Lymphoma of the gastrointestinal

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diagnosis and treatment? Ann Surg 1989; 209: 25-30. 19. Heiken JP, Gold RP, Schnur MJ, King DL, Bashist B, Glazer HS. Computed tomography of renal lymphoma with ultrasound correlation. J ComputAssist Tomog 1983; 7:245-50. 20. Horii SC, Bosniak MA, Megibow AJ, Raghavendra BN, Subramanium BR, Rothberg M. Correlation of CT and ultrasound in the evaluation of renal lymphoma. Urol Radiol 1983; 5: 69-76. 21. Moulton JS, Moulton JS. CT of adrenal glands. Semin Roentgenol 1988; 23: 288-303. 22. Charnsangavej C. Lymphoma of the genitourinary tract. Radiol Clinics North Am 1990; 28: 865-77. 23. Bragg DG, Colby TH, Ward JH. New concepts in the non-Hodgkin's lymphomas: radiologic implications. Radiology 1986; 159: 289-304. 24. Duncan PR, Gowing NFC, McElwain TJ, Peckham MJ. Extranodal non-Hodgkin's lymphoma presenting in the testicle: a clinical and pathological study of 24 cases. Cancer 1980; 45:1578-84. 25. Lewin KL, Ranchod M, Dorfman RF. Lymphomas of the gastrointestinal tract: a study of 117 cases presenting with gastrointestinal disease. Cancer 1978; 42: 693-707. 26. Dragosick SB, Bauer P, Radaszkiewicz TUS. Primary gastrointestinal non-Hodgkin's lymphomas: a retrospective clinico-pathologic study of 150 cases. Cancer 1984; 152: 291-6. 27. Castellino RA, Hoppe RT, Blank N, et al. Computed tomography, lymphography and staging laparotomy: correlation in initial staging of Hodgkin's disease. AmJ Roentgenol 1984; 143: 37-41. 28. Stomper PC, Cholewinski SP, ParkJ, Bakshi S, Barcos MP. Abdominal staging of thoracic Hodgkin's disease: CTlymphangiography-Ga-67 scanning correlation. Radiology 1993; 187: 381-6. 29. Saul SC, Kapaida SB. Primary lymphoma of Waldeyer's ring. Clinicopathologic study of 68 cases. Cancer 1985; 56:157-66.

References 219 30. Carter TR, Feldman PS, Innes DJ, Frierson HF, Frigy AF. The role of fine needle aspiration cytology in the diagnosis of lymphoma. Acta Cytol 1988; 32: 848-53. 31. Pontifex AH, Klimo P. Application of aspiration biopsy cytology to lymphomas. Cancer 1984; 53: 553-6. 32. Cafferty LL, Katz RL, Ordonez NG, Carrasco CH, Cabanillas FR. Fine needle aspiration diagnosis of intraabdominal and retroperitoneal lymphomas by a morphologic and immunocytochemical approach. Cancer 1990; 65: 72-7. 33. Pond GD, Castellino RA, Horning S, Hoppe RT. NonHodgkin's lymphoma: influence of lymphography, CT and bone marrow biopsy on staging and management. Radiology 1989; 170:159-64. 34. Coller BS, Chabner BA, Gralnick HR. Frequency and patterns of bone marrow infiltration in non-Hodgkin's lymphomas: observations on the value of bilateral biopsies. Am] Haematol 1977; 3:105-19. 35. Anderson KC, Kaplan WD, Leonard RCF, Skarin AT, Canellos GP. Role of 99mtechnetium-methylene diphosphonate bone imaging in the management of lymphoma. Cancer Treat Rep 1985; 69:1347-51. 36. Hermann G, Klein MJ, Abdelwahab IF, Kenan S. MRI appearance of primary non-Hodgkin's lymphoma of bone. Skeletal Radiol 1997; 26: 629-32. 37. White LM, Schweitzer ME, Khalili K, Howarth DJ, Wunder JS, Bell RS. MR imaging of primary lymphoma of bone: variability of T2-weighted signal intensity. AmJ Roentgenoll998; 170:1243-7. 38. Carr R, Barrington SF, Madan B, etal. Detection of lymphoma in bone marrow by whole-body positron emission tomography. Blood 1998; 91: 3340-6. 39. Moog F, Bangerter M, Kotzerke J, Guhlmann A, Frickhofen N, ReskeSN. 18-F-fluorodeoxyglucose-positron emission tomography as a new approach to detect lymphomatous bone marrow. J Clin Oncol 1998; 16: 603-9. 40. Biorklund A, Cavallin-Smith E, Landberg T, Lindberg LG, Akerman M. Biopsy of the nasopharynx as a staging procedure in Hodgkin's disease. Acta Radiol 1976; 15: 387-93. 41. Bragg DG. Radiology of the Lymphomas. Curr Probl Diagnos Radiol 1987; 16:183-206. 42. Harnsberger RH, Bragg DG, Osborn AG, et al. NonHodgkin's lymphoma of the head and neck: CT evaluation of nodal and extranodal sites. Am J Neuroradiol 1987; 8: 673-9. 43. Cobleigh MA, Kennedy JL Non-Hodgkin's lymphoma of the upper aerodigestive tract and salivary glands. Otoloaryngol Clinics North Am 1986; 19: 685-710. 44. Westacott S, Garner A, Moseley IF, Wright JE. Orbital lymphoma versus reactive lymphoid hyperplasia: an analysis of the use of computed tomography in differential diagnosis. BrJ Ophthalmol 1991; 75: 722-5. 45. Chisin R, Weber AL. Imaging of lymphoma manifestations in the extracranial head and neck region. Leuk Lymphoma 1994; 12:177-89. 46. DePena CA, Van Tassel P, Lee Y-Y. Lymphoma of the head and neck. Radiol Clin North Am 1990; 28: 723-43.

47. Herman TS, Hammond N, Jones SE, Butler JJ, Byrne GE, McKelvey EM. Involvement of the CNS by non-Hodgkin's lymphoma. The south-western oncology group experience. Cancer 1979; 43: 390-7. 48. Hochberg FH, Miller DC. Primary central nervous system lymphoma. J Neurosurg 1988; 68: 835-53. 49. Young RC, Howser DM, Anderson T, et al. Central nervous complications of non-Hodgkin's lymphoma: potential role for prophylactic therapy. AmJ Med 1979; 66: 435-43. 50. Schouten JT, Weese JL, Carbonne PP. Lymphoma of the breast. Ann Surg 1981; 194: 749-53. 51. Townsend RR, Laing FC, Jeffrey RB, Bottles K. Abdominal lymphoma in AIDS: evaluation with US. Radiology 1989; 171:719-24. 52. Nyberg DA, Jeffrey RB, Federle MP, Bottles K, Abrams Dl. AIDS-related lymphomas: evaluation by abdominal CT. Radiology 1986; 159: 59-63. 53. Jeffrey RB, Nyberg DA, Bottles K, et al. Abdominal CT in acquired immunodeficiency syndrome. Am J Roentgenol 1986; 146: 7-13. 54. Nyberg DA, Federle MP. AIDS-related Kaposi sarcoma and lymphomas. Semin Roentgenol 1987; 22: 54-65. 55. Ziegler JL, Beckstead JA, Volberding PA, et al. NonHodgkin's lymphoma in 90 homosexual men. N EnglJ Med 1984; 311:565-70. 56. Lowenthal DA, Strauss DJ, Campbell SW, Gold JWM, Clarkson BD, Koziner B. AIDS-related lymphoid neoplasia. Cancer 1988; 61:2325-37. 57. Lorberboym M, Wallach F, Estok L, et al. Thallium-201 retention in focal intracranial lesions for differential diagnosis of primary lymphoma and nonmalignant lesions in AIDS patients. J Nucl Med 1998; 39:1366-9. 58. Naddaf SY, Akisik MF, Aziz M, et al. Comparison between 201 TI-chloride and "Tc(m)-sestamibi SPET brain imaging for differentiating intracranial lymphoma from nonmalignant lesions in AIDS patients. Nucl Med Commun 1998; 19: 47-53. 59. Thomas JL, Barnes PA, Bernadino ME, Hagemeister FB. Limited CT studies in monitoring treatment of lymphoma. AmJ Roentgenol 1982; 138: 537-9. 60. Front D, Israel 0, Epelbaum R, et al. Ga-67 SPECT before and after treatment of lymphoma. Radiology 1990; 175: 515-19. 61. BogartJA, Chung CT, Mariados NF, et al. The value of gallium imaging after therapy for Hodgkin's disease. Cancer 1998; 82: 754-9. 62. Nyman R, Rehn SM, Glimelius BLG, et .al. Residual mediastinal masses in Hodgkin's disease; prediction of size with MR imaging. Radiology 1989; 170: 435-40. 63. Herman TS, Hoppe RT, Donaldson SS. Late relapse among patients treated for Hodgkin's disease. Ann Intern Med 1985;102:292-7. 64. Newman JS, Francis IR, Kaminski MS, Wahl RL. Imaging of lymphoma with PET with 2-[F-18]-fiuoro-2-deoxy-Dglucose: correlation with CT. Radiology 1994; 190: 111-16.

220 Imaging of lymphoma

65. Stumpe KD, Urbinelli M, Steinert HC, Glanzmann C, Buck

71. Goldberg MA, Thrall JH, Alpert NM, Mueller PR, Fischman

A, von Schulthess GK. Whole-body positron emission

AJ, Lee MJ. Fluorodeoxyglucose PET of abdominal and

tomography using fluorodeoxyglucose for staging of lymphoma: effectiveness and comparison with computed tomography. EurJ Nucl Med 1998; 25: 721-8. 66. Rodriguez M. Computed tomography, magnetic resonance imaging and positron emission tomography in non-Hodgkin's lymphoma. Acta Radiol 1998; 417 (suppl): 1-36. 67. Okada J, Arimizu N, Imaseki K, et al. FDG-PET for predicting the prognosis of malignant lymphoma. Ann Nucl Med 1994; 8:187-91. 68. Rodriguez M, Glimelius B, Hagberg H, et al. [18F]FDG PET in gastric non-Hodgkin's lymphoma. Acta Oncol 1997; 36: 577-84. 69. De Wit M, Hossfeld DK, Clausen M, Herbst K, Beyer W, Bumann D. Whole-body positron emission tomography (PET) for diagnosis of residual mass in patients with lymphoma. Ann Oncol 1997; 8 (suppl): 57-60. 70. Villringer K, Schwaiger M, Pfister HW, et al. Differential

pelvic neoplasms: potential role in oncologic imaging. Radiographics 1993; 13:1047-62. 72. Weinblatt ME, Kochen J, Babchyck B, Belakhlef A, Zanzi I. False-positive FDG-PET imaging of the thymus of a child with Hodgkin's disease.) Nucl Med 1997; 38: 888-90. 73. Nuutinen J, Leskinen S, Lindholm P, et al. Use of carbon11 methionine positron emission tomography to assess malignancy grade and predict survival in patients with lymphomas. EurJ Nucl Med 1998; 25: 729-35. 74. Cerulus G, Leonard JP. A comparison of 111ln-octreotide and 67 Ga scintigraphy in malignant lymphoma. Nucl MedCommun 1997; 18: 616-22. 75. Ivencevic V, Emrich D, Hiddemann W, et al. Somatostatin receptor scintigraphy in the staging of lymphomas. Leuk Lymphoma 1997; 26:107-14. 76. Van den Anker-Lugtenburg PJ, Krenning EP, Lamberts SW, Lowenberg B. The relevance of somatostatin receptor

diagnosis of CNS lesions in AIDS patients by FDG-PET. 7

expression in malignant lymphomas. Metabolism 1996;

Comput Assist Tomogr 1995; 19: 532-6.

45 (suppl 1): 96-7.

17 Localized Hodgkin's disease SB SUTCLIFFE,AR TIMOTHY AND MH ROBINSON

Introduction

221

Management of Stage MIA Hodgkin's disease

222

Side effects of radiation therapy Conclusion

Localized disease and the determination of prognostic factors Radiation therapy for localized Hodgkin's disease Systemic therapy for localized Hodgkin's disease

226 234

INTRODUCTION The prognosis for patients with Hodgkin's disease has improved dramatically over the past 30 years. This is well illustrated by examination of incidence and mortality rates for Hodgkin's disease from a population database of approximately 10 million individuals within the Province of Ontario, Canada (Fig. 17.1). Incidence has remained fairly constant with a rate of approximately 2.85 per 100000 persons. It is noteworthy that, unlike non-Hodgkin's lymphoma, the incidence rate is not rising and there has been no identification of predetermining conditions, e.g. congenital, iatrogenic

Figure 17.1

Incidence and mortality rates for Hodgkin's

disease, male and female, Province of Ontario, Canada 1969-1992 (age adjusted to the world standard population). Data kindly provided by the Ontario Cancer Registry.

References

236 237 239 240

or acquired immunodeficiency states, Helicobacter pylori infection and gastric mucosa-associated lymphoid tissue (MALT) lymphoma, chronic immunoproliferative conditions (Sjogren's disease, Hashimoto's disease). Furthermore, the demographics of Hodgkin's disease and the bimodal incidence relative to age remain constant. Mortality, however, has declined substantially from a rate of approximately 1.46 (1965) to 0.47 per 100000 persons in 1992. In this context, mortality should be considered as a 'cause-specific' survival end point inasmuch as the information is derived from death certificate data - deaths from causes other than Hodgkin's disease will not necessarily be included in the analysis of Hodgkin's disease mortality. Important components of interpretation would include the continuous decline in mortality throughout the 30-year period, a mortalityrincidence ratio of approximately 50 per cent prior to the advent of four-drug combination chemotherapy (Fig. 17.1)1 and a current mortaliry:incidence ratio of approximately 17 per cent. Throughout the past 30 years, the prevailing philosophy of management has focused upon the highest overall and cause-specific survival rates, and the highest progression-free or relapse-free rates with individual or combined modality therapy. More recently, this philosophy has been tempered as it is increasingly recognized that: • the most important end point is overall survival, i.e. all causes of death must be considered, given the increasing recognition of treatment-related causes of death offsetting incremental cause-specific survival gains;

222 Localized Hodgkin's disease

• the most effective treatment strategy is that which achieves the highest overall survival with the least amount of therapy and the greatest functional integrity. Several developments have taken place in management of Hodgkin's disease over the last three decades: • the determination of prognostic factors, i.e. the identification of determinants of treatment and outcome, including stage of disease (clinical or pathological); • the role of radiation therapy, i.e. the selection of patients for whom radiation therapy alone results in the highest level of disease control and the definition of late radiation-related morbidity and mortality; • the role of chemotherapy, either alone or in combination with radiation therapy, and the identification of the most effective regimens with the least associated morbidity and mortality. For each of these developments, the extent to which they have contributed to overall survival, i.e. procedure, treatment and disease-related causes of death, is an important consideration with respect to further improvements in patient management. The relationship of treatment efficacy to treatment-related morbidity and mortality, particularly in early-stage Hodgkin's disease, will in large measure determine current and future therapeutic practice.

LOCALIZED DISEASE AND THE DETERMINATION OF PROGNOSTIC FACTORS The definition of early, or localized, Hodgkin's disease has developed along two lines: the description of disease extent, and the definition of prognostic factors.

Description of disease extent

Table 17.1

Ann Arbor classification for staging of Hodgkin's

disease. Reproduced from Sutcliffe SB. Hodgkin's disease: chemotherapy method. In: Raquel RE, ed. Conn's current therapy. Philadelphia: W.B. Saunders Co., 1995

I II III

IV

Fever Night sweats Weight loss

Single lymph node region Two or more lymph node regions on the same side of the diaphragm Lymph nodes on both sides of diaphragm (the spleen is considered a lymph node in this classification) Disseminated involvement of one or more extralymphatic organs or tissue, with or without associated lymph node involvement

>38.4°C; repeat episodes; no documented infectious cause Repeated episodes, sufficient to moisten night attire or bed linens >10+% body weight in 6 months prior to diagnosis, in absence of other identifiable cause

a All stages can be A (asymptomatic) or B (symptomatic). Stage III can be subdivided into III, (involvement of upper abdomen, i.e. spleen, splenic hilar, celiac or porta hepatis nodes) or III2 (involvement of lower abdomen, i.e. para-aortic, mesenteric, pelvic or inguinofemoral nodes). Stage IV, disseminated involvement, is distinguished from E disease (applicable to Stages l-lll), in which extension into an extranodal site occurs contiguous with adjacent nodal disease. The distinction of E disease from Stage IV disease is therapeutically valid only if the extranodal extension can be encompassed with the nodal disease and relevant lymphatic pathways in an appropriate irradiation field to the full therapeutic radiation dose. b If any or all symptoms are present, disease is classified as B; if all symptoms are absent, disease is classified as A. Other relevant symptoms/history include lassitude, anorexia, generalized pruritus, alcohol-induced pain and immunodeficiency state (congenital or acquired, e.g. HIV infection or predisposition; therapeutic immunosuppression).

This is the determination of the anatomic distribution of disease according to the Ann Arbor classification2 (Table 17.1) and subsequent refinements.3 The principal purpose of staging is to establish the most appropriate selection for localized therapy (radiotherapy), systemic therapy (chemotherapy), or both, and to categorize patient groups reproducibly to allow comparison of outcomes between different treatments and treating institutions. The approach to staging has evolved through the following.

resonance imaging and radioscintigraphy (gallium scans, bone scans). Bone marrow aspiration and biopsy evaluation have traditionally been a component of clinical staging, although current practice would probably limit its application to those with advanced clinical stage, adverse prognostic factors or abnormal hematology. Furthermore, a positive study would constitute a pathological stage.

CLINICAL STAGING

SURGICAL (OR PATHOLOGICAL STAGING)

This is the description of disease extent by history, including the evaluation of systemic symptoms, physical examination, hematological and biochemical parameters, imaging studies including plain radiographs, computerized tomography, lymphography, magnetic

Staging laparotomy with splenectomy, liver biopsy(ies) and lymph node mapping was introduced by the Stanford group in the late 1960s as a means of more accurately denning those with localized disease as defined by the Ann Arbor classification, and thereby

Determination of prognostic factors 223

more appropriately defining the extent and configuration of irradiation fields.4 Twenty-five years of experience with surgico-pathological staging has established the following benefits. 1 Staging laparotomy and splenectomy remains the most accurate means of evaluating the abdomen in Hodgkin's disease. In those with supradiaphragmatic clinical Stage I and II disease, it is the only certain way to establish the approximately 25-30 per cent of otherwise unselected patients, or the 15-20 per cent of patients selected by other clinical prognostic factors, who have occult abdominal disease.4-8 Likewise, splenectomy remains the only reliable means of assessing splenic disease below the threshold of clinical detection.9 2 The probability of occult intra-abdominal disease and the patterns of intra-abdominal involvement have been defined as a result of surgical staging. The spleen, the splenic hilar and the celiac axis nodes are me most likely sites of involvement in those with clinical Stage I and II supradiaphragmatic disease. Mesenteric and porta hepatic nodes are very rarely involved, and liver involvement rarely, if ever, occurs without splenic disease and correlates with the extent of splenic involvement. Para-aortic node involvement is commonly associated with splenic involvement. 3 Aspects of the pathobiology of disease have been defined, e.g. the variation in histology from presentation site to lesser areas of involvement defined at laparotomy and the lympho-depleting character of the ongoing natural history of disease. In addition, the origins of the disease in T celldependent areas of lymphoid tissue (the paracortex of lymph nodes and the periarteriolar sheath within the spleen) were defined by examination of grossly uninvolved tissues sampled at laparotomy. 4 The sensitivity and specificity of imaging and percutaneous biopsy procedures have been defined, and their limitation with respect to disease distribution and mass size characterized. 5 Clinical characteristics at presentation and related prognostic factors can be correlated with the probability of abdominal disease, its distribution and the likelihood of single versus multiple sites of involvement.6,7 6 Oophoropexy can be performed for those who would receive lower abdominal or pelvic irradiation. 7 Abdominal radiation fields may be minimized to avoid unnecessary exposure to organs that would otherwise be included in fields determined according to clinical staging practices, e.g. the exposure of the left lower lobe of the lung, upper half of left kidney, and portions of stomach and bowel within fields designed to irradiate the spleen, splenic hilar nodes and lymphatic pathways along the splenic artery.

8 Hematological tolerance to chemotherapy or to total nodal irradiation may be enhanced, although this remains a controversial issue.10,11 9 Laparotomy findings have prognostic relevance beyond documentation of involvement, e.g. pathological Stage III A, versus IIIA2,12 number of sites of involvement in pathological Stage IIIA, and splenic involvement and the probability of liver disease.13 There are also several important adverse issues relating to surgical staging. These are listed below. 1 The procedure has a recognized sampling error, particularly in the upper abdomen in the mid-line between T12 (celiac axis node level and a common site of involvement) and L 2/3 [the root of the mesentery and the superior (L 1/2) and inferior mesenteric (L 2/3) nodal levels]. 2 The spleen must be removed to be properly assessed, thereby conferring the hazards of the postsplenectomy state. 3 The procedure has a small mortality rate (less than 1 per cent), but a significant morbidity rate, including bowel obstruction, deep vein thrombosis, urinary tract infections and wound dehiscence.14 4 Postsplenectomy myocardial infarction possibly related to thrombocythaemia and altered coagulability states. 5 Controversy relating to an increased risk of acute leukemia in patients treated for Hodgkin's disease following splenectomy.15,16 While there appears to be no increased risk of acute leukemia following splenectomy for traumatic rupture and other benign and malignant causes,17 other factors are also of relevance in the Hodgkin's disease population, e.g. immune dysfunction postsplenectomy and possible increased dosages of chemotherapeutic agents in splenectomized versus non-splenectomized patients. 6 Costs and delay in therapy associated with a major surgical procedure and any associated complications. 7 With selection using multiple favorable prognostic factors at presentation, the probability of having abdominal disease defined by laparotomy is less than 20 per cent.7 Accordingly, some 80 per cent of patients are exposed to a major non-therapeutic procedure that is unlikely to influence management or outcome. Given that staging laparotomy and splenectomy is a well-characterized procedure with highly reproducible findings between similarly selected patients within and between institutions, the question as to the impact of surgical versus clinical staging upon overall survival is important. Has any of the improvement in survival for patients with Hodgkin's disease over the past 25 years been due to surgical staging and the increased accuracy of definition of disease extent it offers?

224 Localized Hodgkin's disease

Firstly, would it be expected that improvements in staging technology would influence survival? This has been addressed by Bradford-Hill ('the fallacy of attribution'18 and Bush ('stage migration')19 - the apparent improvement in overall survival by improving the staging methodology. As shown in Fig. 17.2, various subgroups of patients, all equal in number, are characterized by a survival probability that becomes progressively less according to a stage designation shown above the boxes. The overall survival of the group is 50 per cent. A more refined description of stage is employed as shown beneath the boxes. The reclassification into new stages affects survival by stage, even though the overall survival (50 per cent) is unchanged. Expressed more simply, the outcome depends upon the available therapy and not upon the description applied to the disease, unless the staging procedure, in and of itself, modifies the natural history of the disease. Secondly, is there any historical precedent for the view that surgically staged patients fare better than clinically staged patients during the same era of treatment? While this evidence is circumstantial given the retrospective nature of the data, a comparison of survival in a large cohort from Stanford University (predominantly surgically staged) and from Princess Margaret Hospital, Toronto (clinically staged) between 1968 and 1977 revealed no difference in outcome between the two groups.20 Finally, the most compelling evidence derives from the analysis of prospective randomized trials in early-stage Hodgkin's disease conducted by the European Organisation for Research and Treatment of Cancer (EORTC). In the H-2 study, a comparison of two differing radiation techniques according to whether laparotomy and splenectomy was performed revealed no difference in survival rates in the total cohort or the subset receiving no additional maintenance chemotherapy.21 The H-6 study, involved a randomization of'favorable' patients as judged by presentation prognostic factors, between surgical staging and clinical staging (H6-F group). Surgically staged patients were treated with mantle radiation or combined modality therapy, with clinically

staged patients receiving subtotal nodal irradiation encompassing the spleen. No difference in cause-specific survival was noted between the two trial arms, but overall survival by 10 years of follow-up was actually worse in the laparotomy arm due to an excess of both early and late deaths, including a small number of postlaparotomy myocardial infarctions.22 It is also pertinent to ask which groups of patients derive a benefit from laparotomy and splenectomy. By conventional wisdom, it would seem to be those who have a negative procedure (pathological Stage I-II) in whom radiation is deemed appropriate therapy, or those with a positive result (pathological Stage III-IV) in whom chemotherapy is the most appropriate treatment. A theoretical analysis is presented in Fig. 17.3 based upon anticipated results of performing laparotomy and splenectomy in clinical Stage I and II patients, and applying optimal therapeutic outcomes as defined in the literature. The analysis indicates that the proportion of patients with unselected clinical Stage I and II disease who can remain disease-free following radiation therapy alone is approximately 60 per cent. This figure is in accordance with the 61 per cent relapse-free rate reported in a series of 252 patients with clinical Stage I and II Hodgkin's disease treated with radiation therapy alone between 1968 and 1977.23 Thus, the proportion of patients who remain permanently relapse-free following radiation is the same whether laparotomy is employed or not; the radiocurable population exists more as a function of radiation fields employed than as a consequence of surgical staging. The real population deriving benefit from laparotomy are those who are found to have occult intra-abdominal disease and receive chemotherapy. Paradoxically, laparotomy is selecting for benefit from chemotherapy, not from radiation therapy.

Definition of prognostic factors While improvements in therapy have been such as to minimize the impact of prognostic factors defined prior

Figure 17.2 Diagram illustrating how the results in each stage can be improved by 'improving' the staging methods. Reproduced with permission from Bush RS. Malignancies of the ovary, uterus and cervix: the management of malignant disease series; 2. Peckham MJ, Carter RL, gen. eds. London: Edward Arnold, T 979:34.

Determination of prognostic factors 225

Figure 17.3

Theoretical

analysis of treatment outcome for 100 patients with clinical stage I and II Hodgkin's disease based on anticipated surgical staging results. PS = pathological stage, XRT = radiotherapy, CT = chemotherapy.

to therapy as a means of estimating survival, these factors have become increasingly incorporated into decision making with regard to optimal therapy. As many of these factors are inter-related, multivariate analyses are required to establish independent determinants of outcome. Even so, the variation in patient assessment, therapy, prognostic factors examined and the differing methods of assigning values, and the differing types of statistical analyses used render exact comparison and uniform conclusions difficult. Three general questions may be asked of prognostic factors: 1 What are the independent determinants of prognosisf For what endpoints or outcome do they predict? With what disease or treatment-related process do they correlate? Recent reviews have addressed the first two questions.24-25 In the absence of definitive information on the biology of treated and untreated disease, answers to the third question are purely speculative. The principal prognostic factors for localized Hodgkin's disease are shown in Table 17.2. Systemic symptoms are recognized in the Ann Arbor classification (Table 17.1). A recent re-evaluation of systemic symptoms indicates that severe pruritus, a symptom not incorporated in the Ann Arbor classification, also confers an adverse prognosis.26,27 Systemic symptoms confer an adverse prognosis in relation to primary disease control and cause-specific survival28 and are correlated strongly with extent of disease defined by stage or total tumor burden.28,29 The prognostic significance of anatomical stage as described by the Ann Arbor classification has been confirmed repeatedly over the last three decades. However,

clinical experience has indicated that subgroups of patients with widely differing prognoses exist within individual Ann Arbor stages. Specific examples would include: the favorable prognosis of isolated unilateral high cervical nodes or unilateral inguinal or femoral nodes within Stage I disease; the adverse prognosis of bulky mediastinal disease (see section on 'Mediastinal adenopathy' later); the adverse impact of IIIAj versus III A2 disease;12,13 the extent of splenic involvement;30 inguinal adenopathy in advanced stage disease;31 and bone marrow involvement in Stage IV disease.32 Agreement exists that both anatomic stage and volume of disease (total tumor burden), whether considered separately or in conjunction, constitute highly significant independent prognostic determinants.33 The principal

Table 17.2 Prognostic factors in Stage I and II Hodgkin's disease.

Factor

Variables

Stage Symptoms

I v II Ann Arbor classification Fever (>38.5°C), weight loss (>10%), night sweats, severe pruritus LPand NSvsMCand LD NS types I and II > 3 sites vs < 3 Bulk and number of sites None or small vs large > 50 years vs < 50 years Male vs female >50 mm/h vs<50

Histological type Number of sites involved Tumor burden Large mediastinal mass Age Gender Sedimentation rate

LP = Lymphocyte predominant, NS = nodular sclerosis, MC = mixed cellularity, LD = lymphocyte depleted.

226 Localized Hodgkin's disease

impact of stage or tumor burden is upon primary disease control, relapse distant to irradiation fields and causespecific survival. An important exception, however, is bulky mediastinal disease, where the adverse impact upon locoregional control and local relapse-free rate following radiation alone does not appear to have as established adverse impact upon overall or cause-specific survival. Histological subtyping according to the Rye classification34 has proved to be prognostically sensitive, although this is largely expressed in patients with localized disease receiving radiation therapy alone.7,23,35 Patients with mixed-cellularity and lymphocyte-depleted histology have a worse prognosis with a poorer cause-specific survival. Histology is, however, strongly correlated with age, gender and extent of disease, and its independent significance is controversial. The prognostic implications of subdivision of nodular sclerosing histology into lymphocyte-rich (type I) or lymphocyte-depleted (syncytial variant - type II) is also a continuing source of debate.36-39 The independent adverse prognostic impact of older age (>40 years or >50 years) has been defined in numerous reports. This is expressed upon primary disease control, survival after relapse and cause-specific survival.7,23,40-42 While a reduced ability to tolerate treatment in older patients is often cited, this is probably a consequence of more aggressive disease biology. Gender, independent of other prognostic factors, appears to have minimal, if any, impact upon outcome or treatment allocation. A number of hematologic and biochemical parameters have been shown to have an adverse impact upon prognosis, including elevated sedimentation rate,28,40,43,44 lymphocytopenia and severe anemia in advanced disease. In early stage disease, abnormalities of serum copper, ceruloplasmin, ferritin, b2 microglobulin, serum albumin, lactic dehydrogenase and soluble CD 30 are unusual, and their prognostic utility is not established. Characterization of tumor cell populations by phenotypic, flow cytometric, genotypic or karyotypic attributes has provided information relevant to diagnostic accuracy and insights into tumor cell biology, but none has yet been shown to be of prognostic value. Similarly, HLA characterization has provided no clinically applicable prognostic information.39

RADIATION THERAPY FOR LOCALIZED HODGKIN'S DISEASE The evolution of curative radiation therapy for Hodgkin's disease has largely been established on two constructs: the radiation dose required to control disease within the radiation field, and the radiation volume(s)/ [field disposition(s)] required to control both clinically

apparent disease and adjacent regions with a high probability of occult involvement.

Radiation dose, fractionation and tumor control Peters reported in 1966 the difference in survival between 'high'- (>2500 roentgen) and 'low'-dose radiation.1 However, the first definitive analysis of a dose control relationship was presented by Kaplan in 1966.45 This retrospective analysis of data from predominantly kilovoltage therapy proposed a linear relationship with a 22 per cent control rate with <1000 roentgen and a 98.6 per cent control rate at 4400 roentgen. Fletcher and Shukovsky subsequently reinterpreted the Kaplan analysis and presented a sigmoid dose-response relationship with control rates of 93 per cent and 97 per cent at 3000 roentgen, and between 3101 and 4000 roentgen.46 Further analyses incorporating current patient cohorts treated with megavoltage beams have largely confirmed Fletcher and Shukovsky's report. Vijayakumar and Myrianthopoulos cite a 98 per cent in-field control rate for 4117 sites at risk with a tumor dose of 37.5 Gy, and a relationship with tumor bulk (<6 cm; >6 cm) with 98 per cent in-field control rates for subclinical, <6 cm and >6 cm disease at tumor doses of 32.4 Gy, 36.9 Gy and 37.4 Gy.47 A reanalysis of the Vijayakumar data set by Brincker and Bentzen, however, failed to demonstrate any dose-response relationship above 35 Gy, nor was there any evidence of a requirement for doses higher than 32.5 Gy for bulkier disease.48 The absence of an incremental dose control relationship above 30 Gy has also been reported in the Patterns of Care Outcome Studies49 and from the Medical College of Wisconsin data.50 Gospodarowicz et al. reported a 95 per cent infield control rate with 35 Gy.43 The current evidence would appear to be fairly uniform in establishing that doses in excess of 35 Gy result in no gain in local control, that in-field relapse at this dose is low (<5 per cent), the majority of failures are either 'marginal' or distant to the radiation field, and that doses in excess of 35 Gy can only contribute to enhanced treatment morbidity. Indeed, in the German Hodgkin's Study Group's randomized study of extended field radiotherapy of 40 Gy compared with extended field radiotherapy of 30 Gy followed by involved field radiotherapy of 10 Gy, it was concluded that subclinical disease could be sufficiently treated with 30 Gy.51 Data relating to overall treatment time, including the continuous or split course regimens reported by Johnson et al.52 have been reviewed by Brincker and Bentzen.48 No major effect of overall treatment time up to 7 weeks was defined. Despite a paucity of reports of differing fraction size, sensitivity to change in dose per fraction appears to be low within the range of daily fraction size of 1.5-2.0 Gy,48,50 while morbidity is increased with increasing dose per fraction (>2.5 Gy).

Radiation therapy 227

matic and infradiaphragmatic presentation of Stage I and II Hodgkin's disease.

Field size (radiation volume) The importance of including adjacent, clinically uninvolved regions within the radiation field encompassing the involved presentation site was recognized by Finzi53 and demonstrated by Gilbert, Desjardins, Peters and Middlemiss, and Easson and Russell.54-57 However, Specht et al, in their meta-analysis of 1974 patients in eight randomized trials of more versus less expensive radiotherapy, showed that while more extensive fields had a large effect on disease control, there was only a small effect on overall survival.58 Management considerations differ for supradiaphrag-

SUPRADIAPHRAGMATIC DISEASE

The results of radiation therapy for control of Stage I and II Hodgkin's disease are shown in Table 17.3-17.6 according to the use of staging laparotomy and splenectomy and radiation fields confined to one side of the diaphragm or to both mantle and abdominal fields. The data are largely single-arm, consecutive patient experience and encompass a time period of more than two decades, during which management was influenced by surgical staging, radiotherapeutic technique and elabo-

Table 17.3 Relapse rates following extended-field mantle irradiation" for clinical Stage I and II Hodgkin's disease. Reproduced with modifications with permission from Timothy AR, VanDykJ, Sutcliffe SB. Radiation therapy for Hodgkin's disease. In: Selby P, McElwain TJ, eds. Hodgkin's disease. Oxford: Blackwell Scientific Publications, 1987:184-7

a

83

ns

Mantle

53/83 (63%)

Transdiaphragmatic failure rate (62%) Local relapse (14%)

Rubin et al. (1974)59

45

36/4-6

Mantle

17/45(38%)

13 of 15 lymph node extension below diaphragm IB + IIB Mantle and PA field MC + LD

StoffelandCox(1977) 60

32

35/4

Mantle

IA (29%, ii = 15) HA (5896, n = 14) IIB(66%,n = 3)

152

40/4

Mantle ± inverted

88/152(58%)

Local relapse (11%) Non-irradiation area (28%) Extranodal relapse (19%)

Tubiana et al. (1979)62

64

30-38/3-4

Mantle

37/64 (58%)

Local relapse (17%) Transdiaphragm (33%)

Liew et al. (1983)63

130

35/4

Mantle

IA (29%, n - 37) MA (46%, A7 = 84) IB + IIB (33%, i? = 9)

521

35/4

Involved

42.7% (1968-72)'

Mantle

30.3% (1973-7)

Mantle

29.0% (1978-82)

Mantle

20% (1978-86) ,

Timothy et al. (1978)61

Sutcliffe et al. (1985)23

Gospodarowicz(1992)43 OS - 87.2%, 77.6% and 63% @ 5,10 and 20 years CSS - 89.6%, 86.7% and 83.3% @ 5,10 and 20 years RFR - 70.1%, 65.8% and 63.7% @ 5,10 and 20 years Low risk (CS I + MA, < 50 years, LP/NS ESR < 40, no large mediastinal mass no 'E' lesions)

35

40/4

Mantle

0/35

Very favorable subgroup - H-7 total OS -100% @ 3 years FFS - 82% @ 3 years

Noordijk(1994)64

24

35/4 (+ 5/3 boost)

Mantle

9/24

CS IA + B RFR > 60%

Ganesan (1990)6 15 years

Radiation confined to nodal sites on one side of the diaphragm. OS = overall survival, RFR = relapse-free rate, ns = not specified, MC = mixed cellularity, LD = lymphocyte depleted, PA = para-aortic, LP = lymphocyte predominant, NS = nodular sclerosis, ESR = erythrocyte sedimentation rate, CS = clinical stage, CSS = cause-specific survival

228 Localized Hodgkin's disease

ration of prognostic factors predictive for local and distant relapse following radiation. Several general statements can be drawn from the data. 1 In otherwise unselected patients with clinical Stage I and II Hodgkin's disease, the overall progression rate following radiation confined to supradiaphragmatic nodes (mantle) is of the order of 45-60 per cent (Table 17.3). The substantial majority of postradiation failures will be in the non-irradiated area, most commonly in the abdomen in patients treated with mantle irradiation alone for supradiaphragmatic disease. The pattern and magnitude of disease progression risk are not surprising given that staging laparotomy results indicate an advance to pathological Stage III or IV disease in at least 25 per cent of unselected patients with clinical Stage I and II disease. 2 In otherwise unselected patients with pathological Stage I and II disease, the overall progression rate following mantle radiation is commonly in the range of 30-35 per cent (Table 17.4). Again, the most common site of failure is in non-irradiated areas, usually in transdiaphragmatic regions. That this pattern of rate of failure exists despite surgical staging is somewhat surprising; however, staging laparotomy and splenectomy is subject to sampling error, the examination of excised tissue is subject to Table 17.4

sampling variation and observer interpretation, and the pathobiology of early disease may not be adequately represented by surgically derived, histopathologically examined material. 3 The use of mantle and abdominal irradiation in otherwise unselected patients with clinical Stage I and II disease results in progression rates of approximately 30-40 per cent. Failures are commonly distant to the radiation field, but can occur both within and beyond the treated volume. It may reasonably be assumed that some of the risk of 45-60 per cent failure with radiation fields confined to only one side of the diaphragm would be reduced by treating the predictable sites of abdominal disease with radiation in the absence of confirmation by laparotomy. 4 Mantle and abdominal irradiation fields for otherwise unselected patients with pathological Stage I and II disease again show a progression rate of approximately 25-35 per cent (Table 17.6). Failure is usually beyond the radiation field. 5 The results reported above draw attention to the limitation of staging laparotomy and splenectomy to describe disease extent adequately, given that a significant relapse rate exists despite negative abdominal surgical staging, the use of radiation fields that encompass the regions sampled at laparotomy, and the high rate of local disease control within the radiation field.

Relapse rates following extended-field mantle irradiation" for pathological Stage I and II Hodgkin 's disease.

Reproduced with modifications with permission from Timothy AR, VanDykJ, Sutcliffe SB. Radiation therapy for Hodgkin's disease. In: Selby P, McElwain TJ, eds. Hodgkin's disease. Oxford: Blackwell Scientific Publications, 1987:184-7

36/4-6

Mantle

9/17(53%)

39

35/4

Mantle

IA(0%,n = 17) MA (30%, n = 19) IIB (33%, n = 3)

17

40/4

Mantle

4/17(23%)

66

30-38/3-4

Mantle

22/66 (33%)

Liew et al. (1983)63

55

35/4

Mantle

16/55(29%)

Anderson et al. (1984)67

46

40/4

Mantle

5/46 (all patients)

2/23 (prospective study)

66

a

StoffelandCox(1977) 60

17

35/4 (+ 5/3 boost)

Mantle (62) Inverted Y(4)

9/66

IB+IIB MC + LD

Mantle ± PA

Timothy et al. (1978)61

I and II non-mediastinal presentation only

Hagemeister et al. (1982)6

Patients selected by NS and LP, 'A', Mauch (1995)6 disease above carina, negative lap.

OS -100% @ 4 years FFR- 83% @ 4 years

CS IA + B RFR-80%@15years

Ganesan (1990)6

Radiation confined to nodal sites on one side of the diaphragm. MC = mixed cellularity, LD = lymphocyte depleted, NS = nodular sclerosis, LP = lymphocyte predominant, OS = overall survival, FFR = freedom from relapse, RFR = relapse-free rate.

Radiation therapy 229 Table 17.5 Relapse rates following supradiaphragmatic and infradiaphragmatic irradiation for clinical Stage I and II Hodgkin's disease. Reproduced with modifications with permission from Timothy AR, VanDykJ, SutcliffeSB. Radiation therapy for Hodgkin's disease. In: Selby P, McElwain TJ, eds. Hodgkin's disease. Oxford: BlackwelI Scientific Publications, 1987:184-7

32/50 laparotomy staged but outcome Rubin et al. (1974)5 according to clinical stage presented Local relapse (14%) Transdiaphragm (0%) Dissemination/extranodal relapse (14%)

50

ns

14/50 (28%) Total nodal irradiation (no spleen radiotherapy if splenectomy)

24

36/4-6

Mantle PA + spleen

4/24(17%)

IB + IIB Total nodal irradiation MC+ LD

156

40/4

Mantle PA + spleen

44/156(28%)

Patients with MC + LD randomized to Tubiana et al. (1981)21 two chemotherapy schemes (n = 48) Local relapse (10%) Non-radiotherapy area (6%) Extranodal relapse (12%)

51

35/4

Mantle upper abdomen

IA (66%, n = 3) Spleen radiotherapy < 25 Gy in 36/52 IIA(24%, n - 38) patients IB + IIB (50%, n = 10)

128

40/4

STNI + spleen 24/128(19%)

250

35/4

Mantle + UA

28.4% @ 8 years CS I and MA, non-bulky mediastinum and no E lesion

88

35/4

Mantle + UA

Gospodarowicz(1992)43 12.7% @ 8 years Low risk (CS I and IIA, < 50 years, LP/NS ESR < 40, no large mediastinal mass, no E lesion)

130

40/4

STN I + spleen 14/130

H=6 favorable - CS I and CSII2 no bulky mediastinum A and ESR < 50 or B and ESR < 30

Favorable subgroup - H-7 trial OS - 99% @ 3 years FFS-81%@3years

StoffelandCox(1977) 6

Sutcliffe et al. (1985)23

Carde(1993)2

Noordijk(1994)64

ns = not specified, PA = para-aortic, STNI = subtotal nodal irradiation, UA = upper abdomen, MC = mixed cellularity, LD = lymphocyte depleted, ESR = erythrocyte sedimentation rate, LP = lymphocyte predominant, NS = nodular sclerosis, OS = overall survival, FFS = freedom from relapse.

6 Several investigators from the early 1980s onwards established prognostic determinants, other than clinical and surgical stage, to characterize relapse risk following radiation therapy. There is substantial agreement on the nature and predictive role of these prognostic factors that include age, systemic symptoms, Stage I vs II, histology, number of involved nodal sites, mediastinal mass (size or ratio) and sedimentation rate.7,23,40,77,78 In addition, evidence has been presented relating the probability and extent of abdominal involvement with clinically derived prognostic factors.7,6 The impact of prognostic attributes other than stage alone on treatment outcome after radiation is illustrated by relapse-free rates in excess of 80 per cent for favorably selected clinical Stage I and II patients43 treated with mantle or subtotal nodal fields22,43,64 or favorably selected patients with pathological Stage I and II disease treated with mantle irradiation alone.77

7 This experience would indicate that, by patient selection according to clinically determined prognostic parameters with or without surgical staging, relapsefree rates in excess of 80 per cent following radiation can be achieved. The more rigorous application of prognostic parameters for selection of patients results in fewer patients receiving radiation alone, but a higher relapse-free rate and, the logical corollary, more patients with Stage I and II disease receiving chemotherapy as part of initial management. Despite the evolution of an effective strategy for obtaining high relapse-free rates without the need for surgical staging and by the definition of optimum radiation volumes, the following points are salutary. 1 The mortality rate for late effects of treatment wholly or, in part, attributable to radiation now exceeds the mortality rate attributed to Hodgkin's disease in those with clinical Stage I and II disease.68,79 While

230 Localized Hodgkin's disease

Table 17.6 Relapse rates following supradiaphragmatic and infradiaphragmatic irradiation for pathological Stage I and II Hodgkin's disease. Reproduced with modifications with permission from Timothy AR, VanDykJ, SutcliffeSB. Radiation therapy for Hodgkin's disease. In: Selby P, McElwain TJ, eds. Hodgkin's disease. Oxford: Blackwell Scientific Publications, 1987:184-7

59

36/4-6

Mantle

9/59(15%)

IB + IIB

StoffelandCox(1977) 60

MC + LD)TNI 41

40/4-5

Mantle + PA

14/41 (34%)

PA treated only med. +ve

Wierniketo/. (1979)69

65

40/4 involved 30/4 non-involved

Mantle + PA

22/65 (34%)

I and II (all)

Hagemeister ef al. (1982)70

94

40/4

Mantle + PA

27/94 (29%)

109

40-50/4-6

STNI TNI

25/109(23%)

I and II (al

Hoppeefo/. (1982)71

233

36-44/4-6

STNI

(16%)

I and MA only

Mauchefo/. (1982)72

128

37/4-5

STNI TNI

28/128 (22%)

Supradiaphragm only 'E' lesions excluded

Nissen and Nordentoft (1982)73

45

40-44/4

Mantle + periaortic

12/45 (27%)

OS - 93% @ 8 years FFP-76%@8years RFS-70%@8years

fttietal.

51

45/4

STNI

17/51 (35%)

OS - 76% @ 10 years (all) Longo et al. (1991)75 - 85% @ 10 years (bulky med. and IIA1 excluded) DFS - 60% @ 10 years (all) - 67% @ 10 years (bulky med. and IIIA1 excluded)

88

40-44/4

STN1 (85% of patients)

30/83 (36%)

RFS - 69% and 62% @ 5 and Brusamolino (1994)76 10 years

Tubiana et al. (1981)21

(1992)74

MC = mixed cellularity, LD = lymphocyte depleted, STNI = subtotal nodal irradiation, TNI = total nodal irradiation, PA = para-aortic, OS = overall survival, med. = mediastinum, FFP = freedom from progression, RFS = relapse-free survival, DFS = disease-free survival.

modifications to radiation technique and treatment volumes could potentially reduce the incidence of treatment-related second malignancy or heart disease, the magnitude would probably be small (Fig 17.4). 2 Although radiation treatment volume clearly has a bearing on relapse rate, the only circumstance where this has a survival impact is in patients who receive no therapy other than radiotherapy prior to death. In practice, radiation field size has no bearing on overall survival in an era of successful salvage of disease progression by chemotherapy. 3 Given that radiation field size has no bearing on overall survival other than in those treated solely by radiation, and that radiation is a significant contributor to the cumulative incidence of 25 per cent non-disease-related mortality at 20 years of follow-up,80 the benefits of attempting to achieve higher relapse-free rates with radiation are uncertain and not measurable in terms of survival unless they are associated with a reduced treatment-related mortality. 4 Finally, if the evolution of practice is to define an

ever-diminishing population of patients with Stage I and II Hodgkin's disease with a very high relapse-free rate with radiotherapy in whom the only impact upon survival can be the reduction in treatmentrelated mortality, the major question becomes whether any radiation is required. If chemotherapy abrogates the survival impact of varying radiation parameters (or surgical staging), it is a logical question to ask whether any radiation has relevance in an era of effective chemotherapy. It is important to note, however, that this reasoning is based only on consideration of overall survival, i.e. the impacts of radiation therapy or chemotherapy on disease and treatment-related mortality. It does not take into account other aspects of therapeutic choice that might include patient preference, acute side effects, gonadal impacts, psychosocial impacts of relapse probability and therapy, and access and availability to high-quality radiation therapy.81-83 Accordingly, the future role of radiation therapy in the management of early-stage Hodgkin's disease will be determined more by comparative morbidity and mortality impacts (quality of life, incidence and causes of

Radiation therapy 231

Figure 17.4

Cumulative incidence of death - early-stage

Hodgkin's disease (n = 9041). HD - Hodgkin's disease related death (1242 cases). Other causes (715 cases). Reproduced with permission from Treatment strategy in Hodgkin's disease. Proceedings of the Paris International Workshop and Symposiumjwfle 28-30, 7990:409. Somers R, Henri-Amar M, MeerwaldtJH, Carde P, eds. London: John Libbey& Co. Ltd (Eurotext).

death) than by the traditional determinant, relapsefree rate. This rationale underlies the current EORTC H-8 trial and the National Cancer Institute (Canada) HD-6 study.

1 For patients with peripheral clinical Stage I disease, the probability of advancing stage by performing through laparotomy and splenectomy is approximately 10 per cent, and sites would include retroperitoneal nodes (despite negative lymphogram) or spleen. Such patients have commonly received inverted Y fields with or without splenic coverage with a relapse rate not exceeding 20 per cent. Supradiaphragmatic nodal areas constitute the most frequent relapse sites. 2 Patients with symptomatic clinical or pathological Stage II disease have a very high failure rate with extended field radiation. 3 Other than for clinical or pathological Stage IA disease, confined to inguinal or femoral nodes, where extended field radiation is an appropriate therapy with a relapse risk of 20 per cent, patients with infradiaphragmatic disease [clinical stage (CS) + pathological stage (PS) IIA/B and IISA/B] should receive chemotherapy as part of initial management. Given the relative infrequency of patients with infradiaphragmatic disease and the small subset with central abdominal presentation, most investigators have failed to define an adverse prognostic effect of infradiaphragmatic disease on overall survival, although Specht and Nissen90 determined an inferior disease-free survival in this group.

INFRADIAPHRAGMATIC PRESENTATION

Infradiaphragmatic Hodgkin's disease is uncommon and accounts for approximately 10 per cent of clinical Stage I and II presentations.23,84-90 Most frequently, patients present with peripheral disease in the femoral, inguinal or superficial iliac region. Approximately 20 per cent of infradiaphragmatic patients present with deep iliac or abdominal disease. This may be manifest initially as symptoms (fever, sweats, weight loss, etc.), paravertebral mass with pain or nerve root symptomatology, splenomegaly, autoimmune hemolytic anemia, or thrombocytopenia or an abdominal mass. Patients presenting with abdominal, as opposed to peripheral, disease tend to be older, more frequently symptomatic, have bulkier disease, and mixed cellularity or lymphocytedepleted histology.91 Nodular sclerosis histology is less represented in infradiaphragmatic presentations. Patients with lymphogram-negative, clinical Stage I infradiaphragmatic disease rarely have more extensive disease defined at laparotomy. This also applies in the very rare circumstance of bilateral inguinal/femoral disease (clinical Stage I) with a negative lymphogram. A positive lymphogram predicts for more extensive disease with a high correlation with splenic involvement and a lower probability of liver disease.86,88,91 Treatment approaches have varied from involved field irradiation to combined modality therapy based on small numbers of patients treated over a long time period. The following guidelines can be derived.

MEDIASTINAL ADENOPATHY, HILAR ADENOPATHY AND EXTENSION OF MEDIASTINAL DISEASE

Mediastinal adenopathy occurs in approximately 70 per cent of all patients with Hodgkin's disease. Whilst the description of bulk varies, most series define massive mediastinal adenopathy as >l/3 of the transthoracic diameter on a posterio-anterior radiograph or > 10 cm by direct measurement of the maximal mediastinal contour. The importance of the definition of bulky (massive) mediastinal disease derives from the high intrathoracic failure rate with conventionally planned radiation fields.71,75,92-98 Such failures are usually within field, marginal and within the thoracic cavity, including lung, pleural, chest wall, pericardial, pleural or pericardial effusions or any combination of the above. The pattern of failure of massive mediastinal disease treated by conventional radiation technique almost certainly has less to do with tumor bulk than with the lymphatic anatomy of intrathoracic structures, and the limitations posed upon the concept of prophylactic or extended fields by the limiting radiation tolerance of the lungs.98,99 The lymphatic network of the lungs comprises superficial lymphatics draining from the visceral pleural surface and the alveoli to a deep lymphatic plexus following the bronchioles and bronchi to the hilar nodes. Nodes are located at second- and first-order

232 Localized Hodgkin's disease

bronchi, and communicate within pulmonary hilar and mediastinal nodes. Non-encapsulated lymph follicles do not occur distal to the bronchioles but small aggregates of lymphocytes occur in loose connective tissue throughout the lung. The parietal pleura drains through intercostal lymphatics anteriorly to internal mammary nodes and posteriorly to intercostovertebral nodes. The lower portion of the parietal pleura interconnects with diaphragmatic lymphatics. Lymphatics of the pericardium drain inferiorly to the diaphragmatic network, superiorly to the brachiocephalic nodes and the anterior and posterior mediastinal nodes. Extensive mediastinal disease may exist as discrete clusters of enlarged nodes or as conglomerate masses that may result in: • extension to the internal mammary nodes and anterior chest wall with intercostal spread, parietal pleural masses, paravertebral mass formation or pleural effusion; • extension along bronchi resulting in extensive interstitial spread with or without endobronchial disease; • direct lung infiltration; • pneumonic infiltration from bronchovascular spread with consolidation and, less commonly, cavitation; • extension through the pericardium and myocardium with costophrenic adenopathy, pericardial effusion and/or diaphragmatic involvement. The patterns of intrathoracic spread have previously been described from historic clinical series and autopsy reports, but may now be much more clearly appreciated with the routine use of computerized tomography (CT) and magnetic resonance imaging (MRI). With the use of conventionally applied radiation fields, full-thickness lung shields are used to minimize lung dose. Even with such shielding, the lung scatter dose approximates 20 per cent of the tumor dose with allowance for lung density. Lung blocks are also planned according to the radiological mediastinal contour, as defined at simulation, with a margin of approximately 1 cm around soft-tissue contours and with acknowledged shielding of intercostal lymphatics, a large part of the pericardium and most of the diaphragm. Even if'shrinking field' techniques are employed for bulky mediastinal disease to allow redesign of lung blocks as the radiological mediastinal contour recedes, it does not follow that all original disease recedes with the radiologic contour, thereby introducing the risk of dose heterogeneity throughout the tumor volume. Most importantly, disease can change in size but necessarily in anatomic position, e.g. hilar nodes, E-lesions, lung extensions. The problem of massive mediastinal disease is that of including all known disease and lymphatic channels involved by contiguous or retrograde spread within a radiation field that can be treated to a tumoricidal dose given the limiting tolerance of the lung and, to a lesser

extent, the entire pericardium. Support for this hypothesis is evident from the change in overall and intrathoracic recurrence patterns using either whole thoracic radiation with lung dose attenuation100 or combined modality therapy.101 In current practice, combined modality therapy is the standard approach for patients with bulky mediastinal disease. Staging laparotomy adds nothing to the management plan. Chemotherapy is the initial therapy and, given a high probability of response, permits a more optimal radiation volume to be defined. Split-course therapy, choice of chemotherapy regimen, number of cycles of therapy, chemotherapy end-point (partial or complete response), radiation as therapeutic or adjuvant modality, and radiation dose and field arrangement are all variables of the combined modality approach. Notwithstanding these variations, the probability of relapse with radiation of 40-70 per cent, depending on mass size, may be improved to 15-25 per cent with combined modality therapy. Despite this improvement in progression-free rate, the choice of initial therapy has no bearing on overall survival.71,72,75,92,102 An additional consideration for patients with large mediastinal disease is the interpretation of the mediastinal contour following therapy. A persisting abnormal mediastinal contour is quite common.103-105 Important interpretational features include the stability of the radiological appearance, comparison of pre- and post-treatment gallium studies, and CT and MRI characteristics. Alternate pathologies, e.g. thymic cysts, should also be considered.106 While the majority of situations of stable, gallium-negative residual abnormality do not constitute active disease based on longer term follow-up observation, no clear unambiguous management guidelines exist. Given that the further therapeutic options could range from observation to radiation to high-dose therapy with marrow/stem cell transplantation, guided thoracoscopic mediastinal biopsy(ies) may be appropriate. It is also probable that functional or biological evaluation through modalities such as positron-emission tomography may help further in the interpretation of residual mediastinal abnormalities post-therapy.

Technical aspects of radiation therapy The preceding sections on supradiaphragmatic disease and infradiaphragmatic presentation have established that the control of localized Hodgkin's disease is dependent on two factors: a tumoricidal radiation dose, and the inclusion of the known extent of disease and adjacent clinically non-involved areas and their lymphatic connections within the irradiated volume. As noted previously, 'in-field' failure is extremely uncommon when tumoricidal doses of radiation are achieved uniformly throughout the radiation field. The vast majority of radiation 'failures' occur distant to the radiation field and

Radiation therapy 233

reflect the clinical expression of occult disease that is not incorporated into the treatment plan. The important technical aspects of radiation relate mainly to the following: • the achievement of a uniform tumoricidal radiation dose throughout a large treatment volume; • the complicated, irregularly shaped fields resulting from the spatial relationship between the treatment volume and adjacent normal tissues; • the limiting tolerance of critical normal structures within, or close to, the treatment volume; • the variation in external surface contour and internal tissue densities within the irradiated volume, and their impact upon dose homogeneity; • the variable depth of involved tissues within the treatment volume from superficial nodal sites to mid-thoracic or abdominal regions; • the need to achieve a reproducible, accurate and consistent treatment over the duration of a fractionated daily treatment program.107,408 Most commonly 'mantle' and 'inverted Y' fields are treated with a parallel-pair technique using megavoltage photon beams in the range of 4-18 MV. Optimal beam energy is largely determined by maximum patient separation, or thickness, within the treatment field. Depth dose characteristics increase as a function of increasing photon energy - 60Co beams may result in an uneven dose distribution with unacceptably high maximum to mid-plane dose unless used at an extended skin-surface distance. High-energy photon beams (> 10 MV) will have minimal dose variation at a depth beyond the maximum dose (Dmax) but may have a dose 'build-up' zone, which could result in 'underdose' to superficial nodal regions. This 'sparing' of superficial tissues is favorable in terms of skin reaction, but unfavorable if superficial nodes are also 'spared'. In this circumstance, bolus (tissue equivalent material) may be used to bring the maximum dose closer to the skin surface, but with resultant loss of skin sparing and enhanced acute skin reaction. The treatment geometry is dependent on the required field size, the desired penumbra width and the treatment unit characteristics. Given the treatment source-patient distance and the necessity for interposed beammodifying devices (blocks, attenuators, compensators, etc.), rigorous attention to the daily reproduction of treatment geometry is essential. Ideally, isocentric megavoltage units will be used to treat anterior and posterior fields on a daily basis with the patient in a supine or prone position to avoid variation that might otherwise result from supine and prone setups with fixed units. To confirm the suitability of the planned treatment volume in relation to disease distribution and to achieve a technically reproducible setup on a daily basis, patients should undergo simulation prior to therapy. All subsequent procedures are referenced to the simulation process, which includes the validation of treatment vol-

ume, the position of beam-modifying devices, and contour characterization and placement of reference points or tattoos for reproducible positioning. Any simulation errors will be reproduced throughout the treatment, thus emphasizing the need for accurate simulation and verification of daily reproducibility of technique through the use of portal images or treatment check films.109,110 The Patterns of Care Study110 clearly established the unacceptably high in-field and marginal failure rates associated with inadequately planned or unreproducible treatment techniques. Patient immobilization devices, shielding blocks for critical normal tissues, compensators to adjust for surface contour irregularity and attenuators to deliver modified dosage to regions of limited tolerance are required to establish reproducible, uniformly distributed irradiation to the desired treatment volume. Special consideration is required when matching supra and infradiaphragmatic fields to avoid areas of 'overdosage' to critical normal tissue, e.g. spinal cord, or 'underdosage' within areas that may harbor overt or occult disease. The construction of such junctions is dependent on technique and may involve the use of customized shielding, junction wedges or 'moving' field borders. Dose uniformity throughout the radiation field and daily fraction size have an important bearing not only on local tumor control but also on normal tissue morbidity. Of particular importance are: the use of beams of appropriate photon energy to avoid significant maximum dose versus tumor dose/mid-plane dose differences; equally weighted beams from anterior and posterior to avoid inappropriately high anterior or posterior dose within the treatment volume; planning techniques that achieve dose homogeneity across the treatment volume; and fractionation techniques that treat both anterior and posterior portals each treatment day to achieve an individual fraction dose of 175-185 cGy. The importance of irradiation technique cannot be overemphasized. Radiation results in very high levels of local disease control when appropriately planned and executed. Radiation also contributes to late morbidities, which have a mortality rate in excess of the mortality rate of the disease for those presenting with Stage I and II disease.79 The morbidity of radiation, and hence the mortality, has an important relationship with radiation dose - both 'intended' dose and actually delivered dose. It is salutary to note that radiation field size does not influence survival given the availability of effective chemotherapy111 but does influence survival as a function of late, radiation-related mortality.

Radiation therapy for salvage of locally recurrent disease Local in-field recurrence following appropriate radiation therapy is uncommon. Retreatment with radiation with

234 Localized Hodgkin's disease

curative intent is rarely feasible in the original field given the limiting tolerance of normal tissues within the proposed retreatment volume. Chemotherapy is the standard and practical treatment of choice. Localized radiation for recurrence distant to the irradiation field is also rarely attractive from a theoretical consideration, i.e. the concept of accuracy of knowledge of disease extent given recurrence in sites of previously occult involvement despite wide field irradiation, or from a practical consideration, e.g. normal tissue tolerances, extranodal disease, low probability of salvage with radiation, and availability of effective chemotherapy with high potential for cure. Isolated local recurrence may occur, however, in a small proportion of patients treated initially with chemotherapy alone for unfavorable local disease or advanced disease. Experience with radiation therapy for salvage in this setting is limited by its relative rarity, differences in patient identification and selection, literature availability and reporting bias. It is clear, however, that a small number of patients with locally recurrent disease postchemotherapy may achieve long-term disease-free survival after salvage radiation.112-115 Factors that are most likely to have a bearing on the success of salvage radiotherapy are those that relate to the success of radiation as sole therapy, e.g. absence of symptoms, localized Stage I and II with a limited number of nodal sites, age, histology, erythrocyte sedimentation rate (ESR) and non-bulky mediastinum. A disease-free interval between local recurrence and prior chemotherapy of greater than 12 months has also been noted to be associated with a higher probability of salvage by radiation therapy.115 The importance of defining this small and highly selected cohort of patients derives from the desirability of avoiding intensive chemotherapy salvage with autologous marrow or stem-cell transplantation with its associated morbidity and mortality, if lesser therapy with radiation can achieve long-term disease control.

SYSTEMIC THERAPY FOR LOCALIZED HODGKIN'S DISEASE

Combined modality therapy versus radiation therapy The beneficial impact of adjuvant chemotherapy following radiation has long been established in the context of disease-free survival, particularly in populations selected according to unfavorable presentation characteristics. Thus, the evolution of practice from the late 1970s and early 1980s acknowledged the higher recurrence rates following radiation for symptomatic patients with more advanced or bulky localized disease, and established an improved relapse-free rate with subsequent adjuvant chemotherapy. The logical progression was the primary

use of chemotherapy with adjuvant radiation, thereby rendering 'unfavorable' presentations 'favourable' for conventionally applied radiation, or for fields more restricted in size or dose. The two principal questions relating to combined modality therapy versus radiation therapy as optimal initial treatment for early stage Hodgkin's disease - is there a significant improvement in disease-free survival and also in overall survival? - have been addressed in a number of randomized clinical trials. In the EORTC HI trial, otherwise unselected clinical Stage I and IIA+B patients were randomized to mantle irradiation with adjuvant maintenance vinblastine for 2 years for those with mixed cellularity and lymphocyte-depletion histology.62 At 12 years of follow-up, disease free rates of 38 per cent and 58 per cent characterized the radiation-only versus radiation plus chemotherapy arms, respectively, but overall survival rates were 58 per cent and 65 per cent. Nissen and Nordentoft73 compared subtotal nodal irradiation versus mantle plus MOPP chemotherapy in patients with PS I/IIA+B disease. At 6 years of follow-up, disease-free survival rates were 68 per cent and 95 per cent, respectively, but overall survival was no different (92 per cent and 88 per cent). Mantle radiation was compared with mantle and MVPP chemotherapy in PS I/II A+B patients by Anderson et al.67 Disease-free rates at 5 years were 69 per cent and 93 per cent, respectively, with overall survival rates of 94 per cent and 91 per cent. A chemotherapy regimen modified to avoid the gonadal and late second cancer risks of MOPP - vinblastine, bleomycin and methotrexate (VBM) - was combined with involved field radiation and compared with subtotal nodal irradiation in patients with PS I/II A+B and IIIA Hodgkin's disease by Horning et al.116 A significant difference in disease-free survival was noted with the combined modality therapy (97 per cent versus 72 per cent) but overall survival was equivalent (100 per cent and 97 per cent). A single arm confirmatory study of effectiveness of VBM plus involved field radiation has been reported but with reservations regarding treatment morbidity.117 In the EORTC H5 trial, patients with clinical Stage I and II unfavorable disease were randomized between subtotal nodal irradiation versus 'sandwich' MOPP.118 At 9 years of follow-up, disease-free survival differences were 66 per cent and 83 per cent, respectively, with a non-significant difference in overall survival (73 per cent and 88 per cent). The EORTC #7 trial has examined subtotal nodal irradiation compared with EBVP (epirubicin, bleomycin, vinblastine and prednisone) with involved field radiation in 254 patients with favorable clinical Stage I/II Hodgkin's disease. At 3 years of follow-up, failure-free survival rates of 81 per cent and 79 per cent, and overall survival rates of 99 per cent and 100 per cent, respectively, have been recorded.64 The German Hodgkin's Study Group has conducted a randomized study in patients with CS/PS I, II and IIIA disease with risk factors (mediastinal mass, extranodal

Systemic therapy 235

lesions, splenomegaly) comparing low-dose (20 Gy) versus high-dose (40 Gy) radiation in various field dispositions with all patients receiving eight-drug combination therapy. To date, this study, last updated through presentation at the Third International Symposium on Hodgkin's Lymphomas in Cologne 1995, has yielded no differences in overall survival or freedom from treatment failure for any group.119,120 However, interim analysis of their more recent study suggests that two cycles of ABVD plus radiotherapy is better than radiotherapy alone in extending the duration of freedom from treatment failure in early stage (I, II) Hodgkin's disease.121 In an attempt to establish whether the failure of all randomized studies to demonstrate a difference in overall survival related to sample size and statistical power, Specht reported a meta-analysis of all randomized trials, published or unpublished, of radiation therapy and combined modality therapy.33 She concluded that combined modality therapy was associated with a proportional reduction of approximately 15 per cent in the hazard of death, but that this reduction was not statistically significant. There was no additional indication that combined modality therapy differed in impact according to age, stage or presence of symptoms. In a more recent meta-analysis of 1688 patients in 13 trials of radiotherapy plus chemotherapy alone, Specht et al concluded that the addition of chemotherapy to radiotherapy has a large effect on disease control but only a small effect on overall survival.58

Chemotherapy versus radiation therapy Two randomized studies have addressed the issue of chemotherapy versus radiation therapy. The Italian study compared a random allocation to mantle followed by para-aortic radiation with six cycles of MOPP therapy in a total of 89 adult patients with PS I/IIA Hodgkin's disease. Initial disease control was achieved in all radiation patients (n = 45) and 40 of 44 receiving chemotherapy. At an 8-year median follow-up, overall survival was significantly higher in the radiation (93 per cent) compared with the chemotherapy group (56 per cent). Freedom from progression rates (76 per cent and 64 per cent) and relapse-free survival rates (70 per cent and 71 per cent) were not significantly different. Eight patients (of 44 treated with MOPP) died of Hodgkin's disease and three additional MOPP-treated patients died of a second cancer.74 The National Cancer Institute (NCI) study compared radiation alone (predominantly subtotal nodal) with MOPP chemotherapy in patients with Stage I/II A+B and IILAj disease.75 Over the time course of the study initiated in 1978, the majority of patients were surgically staged, those with bulky mediastinal masses were excluded in 1981 and those with Stage IIIA1 disease in 1983. Of the 51 patients receiving radiation, the pro-

jected 10-year disease-free survival and overall survival rates were 60 per cent and 76 per cent compared with 86 per cent and 92 per cent for the 54 patients randomized to MOPP. With exclusion of patients with large mediastinal masses and Stage IIIA1 disease, features recognized to be unfavorable for radiation therapy alone, disease-free and overall survival rates for radiation and chemotherapy were 67 per cent and 82 per cent, and 85 per cent and 90 per cent, respectively, with no significant difference between the two arms. These two studies, apparently with differing conclusions, raise questions relating to the relatively poor performance of the MOPP regimen in the Italian study and the unexpectedly high cause-specific and overall mortality with chemotherapy, and the relatively poor performance of the radiation therapy arm in the NCI study. They would also indicate that the superiority of radiation or chemotherapy, based upon random allocation in appropriately selected cohort Stage I and II Hodgkin's disease patients, remains to be determined and that overall survival remains the single most important end point, given both disease and treatment-related mortality. Non-randomized studies of chemotherapy alone for management of early-stage Hodgkin's disease have been reported, with somewhat variable results. Expected high remission rates with relapse rates up to 30 per cent have been reported by Ziegler et a1., Olweny et al, Lauria et al. and Bubman et al.122-125 Colonna and Andrieu126 reported a low complete remission rate in a small series of clinically staged patients with adverse prognostic factors in Algeria. Al-ldrisse and Ibrahim83 reported a more favorable experience from Saudi Arabia in patients with adverse prognostic factors characteristic of non-Western patient populations. These studies highlight the differing distribution of prognostic factors in patient populations with earlystage disease in Western and non-Western countries, and the practical and pragmatic considerations that influence treatment choice given limited access to radiation therapy appropriate to the technical complexity and quality assurance required for optimal radiation for Hodgkin's disease.81,83

Chemotherapy versus combined modality therapy Chemotherapy alone (cyclophosphamide and vinblastine on day 1, and procarbazine and prednisone on days 1-14 on a 28-day cycle for six cycles - CVPP) was compared with the same regimen with radiation therapy (30 Gy) delivered to involved node areas between cycles three and four of chemotherapy by Pavlovsky et al.127 in patients with CS I/II Hodgkin's disease. A significant difference in disease-free survival was evident with the CVPP + radiotherapy arm (71 per cent versus 62 per cent) but no overall survival difference was apparent

236 Localized Hodgkin's disease

(89 per cent and 82 per cent). Subset analysis by favorable versus unfavorable attributes (age >45 years, >2 involved nodal areas, or bulky disease) revealed no difference in disease-free or overall survival by treatment arm for the favorable group (77 per cent versus 70 per cent, and 92 per cent versus 91 per cent, respectively). Radiotherapy plus CVPP was a more effective therapy for the unfavorable group (disease-free survival 75 per cent versus 34 per cent, and overall survival 84 per cent and 66 per cent, respectively). The broader applicability of this study has been tempered by the limited usage of the CVPP regimen, particularly in the low dose-intensive manner employed, and more specifically for those with unfavorable prognostic factors at presentation.

In any combined modality program, where both treatments are known to have effects on cardiorespiratory function and an independent risk for second malignancy, the degree to which modification in one or both therapies modifies the late effect risk is largely unknown. Given the lack of an established overall survival benefit with combined modality therapy, the independent contribution of both radiation and chemotherapy and the unknown, but probably enhanced, interaction between the two modalities for late malignancy risk, the increasing use of combined modality therapy in early stage Hodgkin's disease requires careful examination.

MANAGEMENT OF STAGE IIIA HODGKIN'S DISEASE

Choice of chemotherapy regimen Systemic therapy for advanced Hodgkin's disease is addressed in Chapter 19. While the principle of employing regimens of established efficacy in advanced Hodgkin's disease has most commonly been applied for those with unfavorable early-stage disease, the following modifications have been introduced. 1 The cumulative amount of chemotherapy has been reduced, particularly with the MOPP regimen or its variants, to reduce gonadal impacts.128 2 The ABVD regimen (Adriamycin, bleomycin, vinblastine, imidazole carboxamide) has become a preferred regimen to MOPP, given equivalent or superior efficacy and significantly less gonadal morbidity and second tumor risk. 3 The radiation volumes and doses have been modified to minimize acute single modality effects, diminish enhanced morbidity of combined modality therapy and minimize late complications. 4 New regimens have been developed to minimize gonadal and late second malignancy risks of combined modality therapy, e.g. the ABVD regimen, the VBM regimen,116 the VAPEC-B regimen;129 the EBVP regimen (epirubicin, bleomycin, vinblastine and prednisone) has been demonstrated to be equivalent to subtotal nodal irradiation when combined with involved field radiation in favorable CS I/II patients, but it has been established to be less effective than MOPP/ABV with involved field radiation in those with unfavorable CS I/II disease.64 In the design of combined modality regimens, two inter-related considerations are paramount. (1) Is the regimen of equal efficacy to existing regimens? In this consideration, both disease control and overall survival end points are mandatory. (2) Given equal efficacy, does the combination result in lesser acute or late complications, particularly those that compromise function or result in treatment-related death?

The management of Stage IIIA Hodgkin's disease has evolved over the past 25 years through a more detailed understanding of intra-abdominal disease distribution achieved through staging laparotomy, derivation of prognostic factors adverse for control with radiation alone and through the increasing use of chemotherapy with curative intent. As defined in the Ann Arbor classification, Stage III disease includes disease on both sides of the diaphragm confined to nodes and/or spleen, with or without extranodal extension (E. lesions) but without extranodal dissemination (Stage IV disease). Definition of clinical Stage III disease may be achieved through a positive lymphogram (pelvic or retroperitoneal lymphadenopathy imaged via the bipedal route to approximately the second lumber vertebral level), palpable splenomegaly (acknowledged to be unreliable unless the spleen size is greater than 500 g or approximately three times normal size), imaging evidence of intra-abdominal or pelvic adenopathy, e.g. CT, ultrasound, MRI or gallium imaging (recognizing the sensitivity and specificity limitations of these examinations for nodes that are not grossly enlarged or non-gallium avid), or evidence of splenic deposits through CT or MRI evaluation. Notwithstanding the method of disease definition, radiation therapy alone is an inappropriate treatment for clinical Stage IIIA or IIIB disease based on disease progression rates exceeding 50 per cent.130,131 Although higher control rates with radiation alone have been cited in clinical Stage IIIA disease,132 chemotherapy is currently considered standard management of clinical Stage IIIA/B disease. The initial heterogeneity of experience with radiation therapy alone for clinical Stage IIIA was put into perspective with the routine practice of staging laparotomy, and splenectomy in patients with supradiaphragmatic clinical Stage I and II disease. Both the reliability of a positive lymphogram to describe retroperitoneal and pelvic disease, and the unreliability of clinical investigation of the upper abdomen to define nodal or splenic

Side effects of radiation therapy 237

disease were established. The important distinction of upper abdominal disease in spleen or nodal sites (pathological Stage IIIAJ from lower abdominal disease (nodal involvement below the level of the superior mesenteric artery - IIIA2) was defined by Desser et al.12 The high relapse rate with radiation alone for those with PS IIIA2 compared with PS IILA1 disease was subsequently demonstrated.13,131,133 Further refinements included the description of extent and bulk of splenic disease, its correlation with liver involvement, and the lesser probability of disease control with radiation alone for those with more extensive splenic disease,30 with splenic and nodal disease30,134 or with a greater number of involved intraabdominal sites of disease.13 This cumulative experience has indicated that the role of radiation therapy in Stage IIIA disease should, at best, be reserved solely for those with PS IIIA1 disease with minimal splenic, splenic hilar or celiac axis adenopathy. For this surgically defined subgroup, relapse-free rate with radiation alone (subtotal nodal irradiation) may exceed 70 per cent.135 In parallel with this experience, two other considerations have arisen: • the examination of prognostic factors other than anatomical stage, their correlation with the probability and extent of occult intra-abdominal disease, and the derivation of successful management protocols with radiation alone or chemotherapy/combined modality therapy based on clinical staging methods without a requirement for staging laparotomy and splenectomy; • recognition that chemotherapy/combined modality therapy can achieve high overall survival and relapsefree rates in those with PS IIIA disease with adverse prognostic factors (extensive splenic involvement, IIIA2 disease, splenic and nodal disease and >5 sites of involvement).30,135-137 In summary, it is well established that the majority of patients with clinical Stage IIIA disease have an unacceptably high progression rate when treated with radiation alone, and should be managed with a chemotherapy or combined modality approach. Radiation therapy alone is only an appropriate consideration for those with minimal upper abdominal disease (IIIAj) defined by laparotomy and splenectomy.

SIDE EFFECTS OF RADIATION THERAPY

Acute

and fractionation schemes. Their impact is a consequence of reduced functional integrity in tissues with a high renewal capacity, e.g. hematological, gut, mucous membrane, skin, hair, etc. As dose-fractionation schemes are generally within tolerance for critical normal tissues, acute effects are commonly transient with a return to normal, or satisfactory, function. SUPRADIAPHRAGMATIC IRRADIATION

Fatigue Cumulative fatigue is common during therapy and patients may take several weeks to recover. Dry mouth, altered taste perception, parotid swelling and dental hygiene

Radiation field borders at the base of the skull encompass sublinguinal, submental and a portion of the parotid glands, and, depending on the superior extent of the field, some of the minor salivary glands in the mucosa of the floor of the mouth. During therapy, saliva consistency becomes thicker and more viscous, and a reduction in salivary flow with a more viscous character may persist as a more chronic side effect. Taste sensation is commonly altered, and contributes to anorexia and weight loss. Oral hygiene, and more particularly, assiduous dental care is necessary given the accelerated caries associated with the dry mouth. Dental consultation and advice on maintenance of oral care is an essential part of therapy. Nausea, emesis and weight loss

Many factors contribute to nausea and emesis, including physical effects of radiation, psychological components, including anxiety and anticipatory nausea, dry mouth and altered taste perception, fatigue and the necessity for daily therapy over 4 weeks. The use of agents such as dimenhydrinate, phenothiazine antiemetics, steroids or 3HT3 antagonists will usually allow maintenance of ambulatory therapy with minimal impairment of nutritional intake. Skin reaction

With megavoltage radiation therapy and appropriate attention to technique, skin reaction should be minimal. Techniques employing bolus (tissue equivalent material) applied to the skin to compensate for surface contour or separation variances will result in full dose on the skin surface, with consequent hyperpigmentation, and dry or moist desquamation in flexural areas. Avoidance of skin abrasion, e.g. wet shaving, the use of scents or deodorants, and sun exposure, minimizes any radiation-related acute skin effects. Dysphagia and mucositis

The acute side effects of radiation therapy occur during and up to 6-8 weeks following completion of treatment. They occur reproducibly in all patients and reflect dose-volume considerations, technical aspects of therapy

A sense of 'a lump in the throat' progressing to a severe sore throat is common during mantle therapy. Attention to food preparation, additives and meal frequency, and the use of topical or systemic analgesics can help to

238 Localized Hodgkin's disease

reduce the effect of these symptoms. The introduction of a posterior cervical cord shield and an anterior larynx shield during therapy will ameliorate this symptom, and full recovery can be expected 1-2 weeks post-therapy. Excessive laryngeal mucous production is common resulting in persistent 'clearing of the throat' and occasional retching. Any acute voice change through laryngitis or laryngeal edema is fully reversible. Alopecia and facial hair loss

Epilation occurs within the irradiated volume. This usually results in occipital hair loss and loss of beard hair within the field. Regrowth of hair occurs following therapy. Dry shaving is preferable during therapy to avoid skin abrasion. Hematological suppression

Mantle irradiation alone rarely causes hematological suppression of concern. It is extremely unusual to require any blood component support or management of neutropenia. Hematologic suppression is not uncommon, however, in combined modality therapy, and with subtotal nodal or wide-field abdominal irradiation. Regular blood count supervision and either hematologic support, or treatment delay, should be exercised as necessary. INFRADIAPHRAGMATIC IRRADIATION

Upper abdominal or inverted Y ± spleen/splenic pedicle fields result in fatigue and hematological consequences as described in mantle fields. Gastrointestinal effects

Nausea, emesis and weight loss characterize wide-field irradiation, and are managed with dietary modifications, antiemetics, sedatives and hydration as necessary. Increased bowel motility is common with bowel cramps, flatulence, borborygmi and diarrhea. Milk products may exacerbate these symptoms owing to the acute effects of bowel mucosal injury on lactose tolerance. Agents to reduce bowel motility and good dietary management are usually effective in allowing completion of therapy without interruption.

Chronic side effects of radiation therapy Chronic or delayed side effects of therapy reflect permanent loss of functional integrity in tissues due to epithelial or stromal vascular injury and, as such, are irreversible. Chemotherapy, when combined with radiation therapy, may have an exacerbating role. Pulmonary

Symptomatic acute pneumonitis is rarely encountered unless large volumes of lung are included in the irradiation field, or concurrent chemotherapy with adriamycin and/or bleomycin is administered. Manifest clinically as dyspnea with a dry, unproductive cough,

fever and as patchy infiltrates within the radiation volume on X-ray, the situation may be improved with high-dose steroids. In a prospective study of pulmonary effects of therapy, Horning et al.138 defined three cohorts of patients - mediastinal radiotherapy, mediastinal radiotherapy plus bleomycin, and bleomycin alone. A decrease in forced vital capacity and diffusing capacity was noted in the majority of patients over the first 15 months after therapy with recovery by 36 months posttreatment. At 3 years or more post-therapy, approximately one-third of patients receiving radiation had forced vital capacity (FVC) values of <80 per cent predicted and 7 per cent had diffusion across lung of carbon monoxide (DLCO) values of <80 per cent predicted. Bleomycin appeared to contribute relatively little to the pulmonary effects of mediastinal irradiation. Pulmonary fibrosis on X-ray is readily seen following irradiation in the areas receiving a full tumor dose. Upper lobe fibrosis, paramediastinal contour irregularity and architectural distortion of the mediastinal and hilar structures are common, although they are not usually associated with clinical symptoms. These changes are more apparent with combined modality therapy with ABVD compared with MOPP. Cardiac

Radiation therapy effects on the heart have traditionally been described in terms of radiation-related pericarditis, pericardial effusion, constrictive pericarditis or cardiomyopathy. Established precedents for such effects139,140 and for a dose-complication relation exist.141,142 The volume of heart irradiation, dose, fractionation and technique108 are all established determinants of late cardiac injury. The overall impact of cardiac injury is, however, increasingly recognized in the context of late cardiac mortality.28,79,143 In patients with early-stage Hodgkin's disease, cardiac mortality is the second most common non-disease-related cause of death after second malignancy and, in total, non-disease-related mortality approximates disease-related mortality.143 Excess mortality from coronary artery disease following irradiation to the mediastinum has been noted by Boivin and Hutchinson144 with an increase risk (risk ratio = 2.56) in their more recent longer follow-up studies.145 Others have confirmed these observations.146,148The majority of the cardiac mortality risk is believed to be attributable to the late vascular effects of irradiation. Thyroid function

The majority of patients receiving radiation therapy will develop compensated biochemical hypothyroidism, i.e. an elevated thyroid stimulating hormone level (TSH) in the presence of normal thyroid indices and no evidence of clinical hypothyroidism. The role of lymphography or iodine contrast-based imaging as a goitrogenic stimulus prior to radiation has been implicated in the high incidence of compensated thyroid dysfunction. Regular

Conclusion 239

evaluation of TSH constitutes good practice, and supplementation with exogenous L-thyroxine to achieve a euthyroid state with suppression of elevated TSH levels is appropriate to avoid both benign and malignant thyroid disease. Renal

Upper abdominal irradiation in a non-splenectomized patient necessitates the inclusion of the spleen, nodes along the splenic artery, the celiac axis, and the superior and inferior mesenteric nodes. The upper half of the left kidney and a portion of the stomach are inevitably included in this field to the full tumor dose. At 3-5 years post-radiation, no changes in blood pressure, biochemistry or urinalysis have been recorded, despite renal cortical atrophy and decreased uptake, and abnormal glomerular and tubular function within the radiation field.149 Osteonecrosis

A rare, but recognized, late complication of therapy is osteonecrosis, most commonly of the femoral heads, but also involving other joints, e.g. humeral heads. Manifest as pain, the earliest imaging changes are provided by MRI and can be distinguished from bone involvement by Hodgkin's disease. The incidence of osteonecrosis is 1-3 per cent of patients, occurring about 70 months post-therapy. Treatment with radiation and/or steroids has been implicated, and the predilection for femoral joints has suggested a role for mechanical stress and weight bearing. The condition is commonly progressive with increasing pain and reduction of movement; it may be managed by total joint replacement.150,151 Testes The radiation dose to the testis is dependent on the relative depth of the testis and the distance from the edge of the radiation beam. With megavoltage beams, testicular doses of up to 10 per cent of tumor dose may be expected with an inverted Y radiation field, and 4-9 per cent from a large abdominopelvic field without additional testicular shielding. These doses would result in azoospermia, either prolonged or permanent. Appropriately designed testicular shielding devices may result in a reduction of 75 per cent of the radiation dose to the testis, thereby enhancing the probability of germinal epithelial recovery.152 Ovary

Radiation dose to the ovary is an important consideration with inverted Y fields. In an unmodified position, the ovaries are exposed to the full tumor dose and ovarian failure will ensue. Transposition of the ovaries to the mid-line behind the uterus with subsequent external shielding153,154 or to the lateral abdominal wall155 will result in a dose reduction compatible with preservation of ovarian function. Ovarian transposition carries a small (about 10 per cent) risk of vascular compromise to the ovary and, given the rare need for pelvic irradiation in patients with supradiaphragmatic presentations of

Hodgkin's disease, routine transposition of the ovaries should not be performed without due consideration of the management plan by surgeon and oncologist. Psychosocial and psychosexual function

Patients with Hodgkin's disease experience the threats common to all patients receiving therapy for malignancy - many at a younger age, when education, employment status, insurability and fertility are paramount concerns. Psychosocial morbidity has been identified by a number of investigators, most commonly in those receiving chemotherapy or combined modality therapy, and includes psychological distress, career and financial problems, denial of life and health insurance, sexual problems, conditioned nausea and negative socioeconomic effects.156-161 Recognition of subgroups with particular vulnerability, and incorporation of information, counselling and support of the patient, family and/or partners are an important part of continuing management. Second malignancy

Second malignancy as a late complication of treated Hodgkin's disease is discussed in Chapter 30. The development of a second malignancy represents the most significant and extensively documented late complication of curative therapy for Hodgkin's disease. In the International Database on Hodgkin's Disease series, the 10-year, 15-year and 20-year cumulative incidence rates of second primary cancer were 6.4, 11.2 and 18.6 per cent, respectively.162 For acute leukemia, non-Hodgkin's lymphoma and solid tumors, the cumulative incidence rates were 2.4, 3.2 and 13.6 per cent by 20 years. There is general agreement that the incidence rate of acute leukemia plateaus by 12-15 years, while that of solid tumors continues to increase. Factors associated with increased leukemia risk include MOPP or MOPP-like regimens (as opposed to ABVD), prolonged or repeated exposure to chemotherapy regimens, older age at treatment and advanced stage of disease. The role of prior splenectomy is noted,162-164 although splenectomy for trauma does not appear to be associated with leukemogenic risk.17 Second solid tumor risk increases with increasing age, extended field radiation and combined modality therapy. The significant association of prior radiotherapy and subsequent lung cancer163,165,166 have endorsed the principles of lifestyle adjustment, e.g. cigarette smoking, and preventive health measures (regular follow-up, breast self-examination, mammography, etc.). It has recently been confirmed that there is a dramatically increased risk of breast cancer for young women treated with radiotherapy.167

CONCLUSION While radiotherapy alone has been the traditional and highly successful mode of treatment for localized

240 Localized Hodgkin's disease

Hodgkin's disease, it is now evident that other treatment options may be more appropriate. The main aim must be to achieve a balance between excellent overall survival and late radiation toxicity. Meta-analyses confirm that, while combined modality does not improve overall survival, disease control is better. Using 'neoadjuvant' chemotherapy, perhaps in abbreviated regimens, should allow reduction of the extent and dose of radiotherapy, and hence of late toxicity. Randomized clinical trials are underway to confirm this.

14. Jockovich M, Mendenhall NP, Sombeck MD, et al. Longterm complications of laparotomy in Hodgkin's disease. Ann Surg 1994; 219: 615-24. 15. Van Leeuwen F, Somers R, Hart A. Splenectomy in Hodgkin's disease and second leukemias (letter). Lancet 1987;25:210-11. 16. Dietrich P-Y, Henry-Amar M, Cosset JM, et al. Second primary cancers in patients continuously disease-free from Hodgkin's disease: a protective role for the spleen? Stood 1994; 84:1290-1315. 17. Mellemkjaer L, Olsen JH, Linet MS, etal. Cancer risk after splenectomy. Cancer 1995; 75: 577-83.

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107. Carmel RJ, Kaplan HS. Mantle irradiation in Hodgkin's disease. An analysis of technique, tumor eradication, and complications. Cancer 1976; 37: 2813-25. 108. Timothy AR, VanDyk J, Sutcliffe SB. Radiation therapy for Hodgkin's disease. In: Hodgkin's disease. Selby P, McElwain TJ, eds. Oxford: Blackwell Scientific Publications, 1987; 216-35. 109. Marks JE, Haus AG, Sutton HG, Griem ML. The value of frequent treatment verification films in reducing localization error in the irradiation of complex fields. Cancer 1976; 37: 275-61. 110. KinzieJJ, Hanks GE, MacLean CJ, Kramer S. Patterns of care study: Hodgkin's disease relapse rates and adequacy of portals. Cancer 1983; 52: 2223-6. 111. Specht L. Oral presentation. Third International Symposium on Hodgkin's Disease, Cologne, Germany, 1995. 112. Diehl LF, Perry DJ, Terebelo H, et al. Radiation as salvage therapy for patients with Hodgkin's disease relapsing after MOPP (mechlorethamine, vincristine, prednisone, and procarbazine) chemotherapy. Cancer Treat Rep 1983; 67: 827-9. 113. Leigh BR, Fox KA, MackCF, et al. Radiation therapy salvage of Hodgkin's disease following chemotherapy failure. Int J Radiat Oncol Biol Phys 1993; 27: 855-62. 114. Uematsu M, Tarbell NJ, Silver B, et al. Wide-field radiation therapy with or without chemotherapy for patients with Hodgkin's disease in relapse after initial combination chemotherapy. Cancer 1993; 72: 207-12. 115. O'Brien PC, Parnis FX. Salvage radiotherapy following chemotherapy failure in Hodgkin's disease - what is its ro\e?Acta Oncol 1995; 34: 99-104. 116. Horning SJ, Hoppe RT, Hancock SL, Rosenberg SA. Vinblastine, bleomycin, and methotrexate: an effective adjuvant in favorable Hodgkin's disease. J Clin Oncol 1988;6:1822-31. 117. Bates NP, Williams MV, Bessell EM, et al. Efficacy and toxicity of vinblastine, bleomycin, and methotrexate with involved-field radiotherapy in clinical stage lAand IIA Hodgkin's disease: a British National Lymphoma Investigation pilot study.) Clin Oncol 1994; 12: 288-96. 118. Carde P, Burgers JM, Henry-Amar M, et al. Clinical stages I and II Hodgkin's disease: a specifically tailored therapy according to prognostic factors. J Clin Oncol 1988; 6: 239-52. 119. Diehl V, Pfreundschuh M, Loffter M, et al. Chemotherapy of Hodgkin's lymphoma with alternating cycles of COPP (cydophosphamide, vincristin, procarbazine, prednisone) and ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine). Results of the HD1 and HD3 trials of the German Hodgkin Study Group. Med Oncol Tumor Pharmacother 1989; 6: 155-62. 120. Diehl V. Update: Third International Symposium on Hodgkin's Disease, Cologne, Germany, 1995. 121. Tesch H, Sieber M, Ruffer JU, et al. Two cycles ABVD plus radiotherapy is more effective than radiotherapy alone

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18 Localized non-Hodgkin's lymphoma SBSUTCLIFFE, MK GOSPODAROWICZ AND MH ROBINSON

Introduction Localized disease and the determination of prognostic factors Staging classification Prognostic factors and patterns of failure Principles of treatment Surgery

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INTRODUCTION The management of patients with non-Hodgkin's lymphoma (NHL) is primarily influenced by histology and stage. While radiation therapy can establish high levels of local tumor control irrespective of histology and may be a curative modality for those with truly localized disease, histology is the main determinant of potential curability of NHL with chemotherapy. Because of differences in treatment options, especially the usefulness of chemotherapy, it is useful to consider two main groups of lymphoma: (1) B cell lymphomas of lymphocytic, follicular center cell, lymphoplasmacytoid, marginal zone (mucosa-associated lymphoid tissue; MALT) type and mantle zone type, for which there is no evidence of chemocurability; and (2) diffuse lymphomas of large cell, immunoblastic Burkitt and non-Burkitt type, for which evidence for chemocurability exists. Patients with Stage I and II disease constitute only a minority of those with lymphoma. Although radiation has traditionally been the treatment of choice for localized disease and remains the principal curative modality for those with localized low-grade (indolent) disease, combined modality therapy has become the standard approach for patients with localized intermediate and high-grade lymphomas. The management of patients with low-grade lymphoma remains a significant challenge, given that the majority of patients progress despite local control of presenting tumor with radiation and that no curative systemic therapy currently exists.

Radiation therapy Chemotherapy and combined modality therapy Assessment of response and follow-up Management of primary extranodal lymphoma Mediastinal (thymic) large cell Summary References

249 250 251 251 262 262 263

LOCALIZED DISEASE AND THE DETERMINATION OF PROGNOSTIC FACTORS The evaluation of the extent of disease is one of the most important steps in selecting appropriate therapy. Routine staging investigations include: • history of symptoms of disease, including B symptoms, i.e. weight loss, fever and night sweats; • full physical examination, including all node-bearing areas and Waldeyer's ring; • complete blood count and erythrocyte sedimentation rate (ESR); • liver function tests; • serum lactate dehydrogenase (LDH); • bone marrow biopsy; • imaging tests - minimum includes chest X-ray and computed tomography (CT) of the abdomen and pelvis; • appropriate imaging tests to delineate the extent of disease, tumor site, invasiveness and the effect on other organs; cytologic examination of an effusion; needle biopsy of any other suspicious lesions; magnetic resonance imaging (MRI); gallium scan; cerebrospinal fluid (CSF) examination, if indicated by history, physical examination or risk factors; • immunophenotyping and molecular analyses of biopsies.

248 Localized non-Hodgkin's lymphoma

Traditionally, bipedal lymphangiogram (LAG) has been useful in assessing pelvic and para-aortic lymph nodes. The specificity and sensitivity of LAG in expert hands have been reported to exceed that of CT.1 However, with improvements in CT technology and the increased use of chemotherapy in early-stage disease, the overall value of LAG has diminished. In addition, the marked decline in the use of LAG in other tumors has resulted in decreased numbers of radiologists with expertise in its interpretation. MRI is useful to delineate the extent of disease in soft tissues, especially in illustrating the extent of bone, extradural and central nervous system (CNS) involvement. The use of gadolinium enhances MRI imaging in the CNS. Gallium scanning, especially high-dose gallium (10 mCi), is a useful general screening tool for malignant lymphoma and is also valuable in assessing response to therapy.2-4 The presence of asymptomatic gastrointestinal (GI) tract involvement should be considered in patients with primary lymphoma of Waldeyer's ring or thyroid gland.

STAGING CLASSIFICATION The Ann Arbor staging classification has been used for non-Hodgkin's lymphoma for over 20 years.5 In the Ann Arbor classification, Waldeyer's ring, thymus, spleen, appendix and Peyer's patches of the small intestine are considered as lymphatic tissues and involvement of these areas does not constitute an 'E' lesion, originally defined as extralymphatic involvement. However, most clinicians, recognizing the unique pathological and clinical characteristics of primary lymphoma affecting these organs, consider them as separate entities. The limitations of the Ann Arbor system have been previously recognized. In the spectrum of non-Hodgkin's lymphoma, the classification differentiates locoregional from widespread lymphoma, documents anatomic extent of disease and B symptoms. However, it is not optimal for describing the extent of local disease, invasion of adjacent organs, tumor bulk or multiple sites of involvement within one organ, e.g. the skin and GI tract. Modifications to the Ann Arbor classification have been proposed in the past. In head and neck lymphoma, the size of the primary tumor has been classified according to the TNM classification for squamous cell carcinoma of that region. In gastric lymphoma, substaging of Stage I to reflect the depth of the stomach wall penetration has been suggested. In Stage II disease, distinction of involvement of the immediate nodal region versus more extensive regional lymph node involvement has been found to be of prognostic significance.6,7 Currently, the Ann Arbor classification, supplemented by description of other prognostic factors, including tumor bulk, hematologic and biochemical parameters, sites of involvement, and pathology, remains the foundation for patient assessment.

PROGNOSTIC FACTORS AND PATTERNS OF FAILURE Although the anatomic extent of disease indexed by Ann Arbor stage is an important prognostic factor, other factors are known to influence the outcome in patients with non-Hodgkin's lymphomas. These include histologic type,8 phenotype (B cell vs T cell), tumor bulk, number of involved sites and proliferation indices (S-phase fraction, Ki-67 antigen)9 as well as age, gender and performance status.10 Additional prognostic factors related to tumor bulk and extent of disease include hemoglobin and albumin levels, LDH, ESR, b-2 microglobulin level and interleukin-6 levels.11-15 The impact of these factors on prognosis has been validated by the development of the International Prognostic Index (IPI). IPI is based on the patient's age, serum LDH, performance status and number of involved extranodal sites.15 Patients are grouped according to the number of adverse factors, i.e. age over 60 years, Stage III or IV, LDH greater than normal, unfavorable performance status, and more than one involved extranodal site. Patients in the low-risk group (0-1 adverse factors) treated with doxorubicin-based chemotherapy and/or radiation therapy (RT) had a 73 per cent 5-year survival; in the low intermediate group (two adverse factors) - 51 per cent; in the high intermediate group (three adverse factors) - 46 per cent; and in the high-risk group (four or five adverse factors) - a 26 per cent 5-year survival.15 A similar pattern of decreasing survival with a number of adverse factors can be observed in younger patients. The usefulness of IPI in low-grade lymphoma and T cell lymphoma has also been documented.16-18 In addition to the above factors, the presenting site of extranodal lymphoma has further prognostic implications, e.g. lymphomas presenting in the testis, ovary, eye, CNS and liver have a particularly adverse prognosis. Prognostic factors are particularly relevant in primary extranodal lymphomas, where stage, although important, plays a lesser role than histology or tumor bulk. Knowledge of patterns of failure has an additional impact on management. Lymphomas presenting in the testis are associated with failure in the brain or meninges, as may be the case with lymphomas presenting in the paranasal sinus and other parameningeal sites. In MALT lymphoma, recognition of the association of GI, thyroid and Waldeyer's ring involvement has led to a more appropriate patient assessment. Furthermore, the association of Helicobacter pylori infection and gastric lymphoma has had an impact on the therapeutic approach. Efforts to eradicate treatable causes of the inflammatory process underlying lymphoma may improve the outcome in MALT lymphomas. Primary head and neck lymphomas, thyroid lymphomas and gastrointestinal lymphomas may present with massive, locally extensive tumors invading adjacent organs and compromising vital functions, such as vision,

Radiation therapy 249

respiration or renal function. An intensive approach with chemotherapy and radiotherapy, and achievement of local control are essential in these cases, since local failure, a most common pattern of relapse in such cases, is largely not salvageable with additional therapy.

PRINCIPLES OF TREATMENT In most situations patients with localized non-Hodgkin's lymphoma are treated with curative intent. A palliative approach is used in situations where, owing to the condition of the patient or the extent and/or location of the disease, a radical treatment carries no chance of cure. The perception that low-grade lymphomas always present with generalized disease and are associated with prolonged survival has limited the use of curative treatment strategies in patients with localized lymphoma. Knowledge of histology, extent and pattern of disease is essential to select the appropriate treatment strategy. Local therapy is routinely used, both for cure and local control. However, the recognition of occult distant disease mandates the use of chemotherapy in a large proportion of patients. The main modalities used in treatment programs for non-Hodgkin's lymphoma are radiation therapy and chemotherapy, although surgery is used in diagnosis and management of selected cases. The initial decision for patients treated with curative intent is the use of local treatment alone - surgery, RT, or both, versus the local and systemic approach - surgery and chemotherapy, chemotherapy and RT, or all three modalities. The choice is pragmatic and predicated upon the potential for local control, inherent risk of occult distant disease and availability of curative chemotherapy. All of these factors are based on clinical observations and past experience, rather than the knowledge of basic genetic or biologic factors.

SURGERY The role of surgery in the management of nonHodgkin's lymphoma is poorly defined. Many case series identify a few patients with Stage I primary extranodal lymphoma cured with surgery alone; indeed, one recent report suggests that surgery alone may be sufficient for selected high-grade nodal lymphomas.19 In general, however, surgical cure is infrequent, although resection of the primary tumor may be helpful, e.g. GI lymphoma, especially localized intestinal disease, and testis lymphoma.20-22 However, since treatment also involves radiation therapy and chemotherapy, very aggressive surgical approaches requiring sacrifice of cosmesis or function are not indicated. There are no indications for amputation in primary bone lymphoma, mastectomy in breast lymphoma or cystectomy in bladder lymphoma.

Accordingly, preoperative or intraoperative diagnosis is essential. For example, in the approach to treatment of parotid tumors, where radical surgical resection carries a risk of nerve injury, early diagnosis of lymphoma may prevent unnecessary sacrifice of the facial nerve.

RADIATION THERAPY The principles of radiation therapy are to deliver an adequate radiation dose to the target volume including the full extent of disease with appropriate margins. The proper design of RT plans takes into consideration all staging data, awareness of normal anatomy, familiarity with common routes of lymphatic spread, and appreciation of the radiation tolerance of normal organs and tissues. The correct application of dose and fractionation schedules should assure local control with acceptable acute toxicity and minimization of late complications. The technique should guarantee reproducibility of treatment on a daily basis. Current RT techniques infer the use of custom-designed fields that conform to individual patients' anatomy and tumor location. The application of radiation fields varies from parallel opposed fields to three or four field techniques with the intent of providing a homogeneous distribution of radiation dose within the target area. The dose of RT required to achieve local control varies depending on histologic type and tumor bulk.13 Low-grade lymphomas are more responsive to RT, and doses of 20-35 Gy delivered in 10-20 fractions over 2-4 weeks result in local control rates in excess of 95 per cent.23-25 Lower RT doses are sufficient to secure local control, especially in low bulk disease. There are no prospective randomized trials designed to determine the optimal RT dose and, with current excellent results and few complications, it is unlikely that such trials will be undertaken. Reports of treatment of localized (Stage I and II) lowgrade lymphoma, including small lymphocytic, follicular small cleaved and follicular cleaved histology, demonstrate a 10-15 year relapse-free rate of approximately 50 per cent and cause-specific survivals of 70-75 per cent.13,23-29 The long-term results of involved field RT in 285 patients treated at the Princess Margaret Hospital between 1967 and 1986 showed an overall survival rate at 10, 15 and 20 years of 65, 57 and 44 per cent, causespecific survivals of 77, 71 and 61 per cent, and relapsefree rates of 52, 47 and 47 per cent respectively.13,29 In a prospective randomized trial with limited numbers of laparotomy Stage I and II patients, no significant difference was found in the rates of freedom from relapse for involved, extended field or total lymphoid radiation. A number of institutions employing involved and extended radiation fields in clinical Stage I and II lowgrade lymphoma have reported that approximately 50 per cent of patients with localized Stage II and 65-85 per

250 Localized non-Hodgkin's lymphoma

cent of patients with Stage I disease remain disease free at 10 years. Whereas the overall survival was between 60 and 80 per cent at 10 years, most relapses occurred in unirradiated sites within the first 5-6 years.13,23-29 Similar results were reported by the British National Lymphoma Investigation (BNLI) in 1994. Overall 78 per cent of patients treated with doses of less than 25 Gy achieved local control, compared to 91 per cent of patients treated with doses greater than 25 Gy.30 Prior to the late 1970s, most patients with Stage I and II intermediate grade lymphoma were treated with RT alone. Overall, RT was curative in 40-50 per cent of all patients.31,32 Adverse factors for failure following RT included Stage II disease with more than two sites of involvement or non-contiguous involvement, tumor bulk > 2-3 cm, age over 60 years, B symptoms, and extranodal sites other than stomach, thyroid or Waldeyer's ring.13,33,34 A small group of patients, comprising those with asymptomatic Stage I and II localized disease, over 60 years, small bulk (< 2-2.5 cm) achieved 70-80 per cent relapse-free rates following treatment with involved field RT alone.13 However, even in this highly selected group, 1 in 3-5 patients relapsed following treatment with RT alone. The use of pathological staging helped to select a group suitable for RT alone but, with the success of chemotherapy and RT, this approach is no longer appropriate.35 Large cell lymphomas are said to be less sensitive to RT; however, their response is dependent on the bulk of disease. For small tumors, excellent local control rates are achieved with RT doses of 35-40 Gy or 30-35 Gy when combined with chemotherapy.

CHEMOTHERAPY AND COMBINED MODALITY THERAPY There are many reasons to consider chemotherapy in the management of localized non-Hodgkin's lymphoma. The experience with local therapy alone has documented a high risk of distant failure, especially in those with intermediate or high-grade lymphoma, older patients and those with bulky disease.33 The risk of occult disease in distant sites is also high in patients with non-MALT-related lymphoma.33,36 Chemotherapy, especially doxorubicin-based combinations, such as CHOP, ProMACE, MACOP-B, M-BACOD, etc. (see Chapter 20), has been documented to cure patients with lymphoma, principally those with diffuse large cell lymphoma, and there is currently no known advantage to any one of these drug combinations.37,38 The choice of chemotherapy regimen is based on histology, irrespective of the site of disease. In most instances, where chemotherapy and RT are combined, chemotherapy is given first. This allows the assessment of response to chemotherapy and the reduction of dis-

ease bulk, thereby allowing the use of a lower RT dose. Such an approach has been shown to improve local control over that obtained with RT alone and to reduce distant relapse rates. The use of chemotherapy and RT in presentations with high distant failure rates, such as most intermediate- and high-grade lymphomas, has resulted in improved relapse-free and overall survival.39 Currently, patients with Stage I and II extranodal lymphoma without poor prognostic features, such as large tumor bulk (> 10 cm), high LDH, high-grade histology or T cell phenotype, who are able to complete therapy, achieve an 80-90 per cent 5-year survival. Several phase II trials have suggested an improved relapse-free survival, but no overall survival benefit for patients with Stage I and II low-grade lymphoma treated with chemotherapy and RT 23,40,41 The use of chemotherapy in MALT-related lymphomas, where the primary tumor can be controlled with local treatment methods, is less well defined. The relative morbidity and long-term effects of each approach should be considered. Although several trials have documented improved disease-free and overall survival with combined chemotherapy and radiation, the evidence for benefit of combined RT and chemotherapy over chemotherapy alone was absent until recently. In 1995, Glick et al. reported the results of a phase III Eastern Co-operative Oncology Group (ECOG) trial of CHOP alone versus CHOP plus RT for intermediate-grade Stage I and II non-Hodgkin's lymphoma.42 Overall, 345 previously untreated patients with bulky or extranodal Stage I and II disease were treated with CHOP chemotherapy. Patients achieving complete response with eight courses of CHOP were randomized to consolidation RT or observation. The 6-year disease-free survival was 58 per cent in CHOP arm, and 73 per cent in the CHOP and RT arm (P = 0.03). The overall survival was 70 per cent for CHOP, and 84 per cent for CHOP and RT (P = 0.06). All patients achieving partial response to CHOP received RT, and their 6-year disease-free survival was 54 per cent and the overall survival 64 per cent. This trial confirmed the benefit of involved field radiation in patients with Stage I and II intermediate-grade lymphoma receiving CHOP chemotherapy. The Southwest Oncology Group (SWOG) subsequently completed a phase III trial (SWOG 8736) of CHOP (three cycles) followed by involved field RT or CHOP alone (eight cycles). The overall survival favored CHOP and RT with 82 per cent versus 72 per cent 5-year survival (P = 0.01 ).43 Lifethreatening toxic effects were less in the CHOP/RT group; in particular left ventricular function was unaffected whereas it was decreased in seven patients who received CHOP alone. However, the dose of radiotherapy required for intermediate and high-grade tumors is uncertain. Conventional RT involves delivering a dose of 35-45 Gy to the involved site with a margin including the uninvolved local nodes.

Management of primary extranodal lymphoma 251

ASSESSMENT OF RESPONSE AND FOLLOW-UP The key determinant of cure is the ability to eradicate disease - the attainment of complete remission. In patients treated with RT alone, response is usually assessed 4-6 weeks following the completion of therapy. Since the RT dose-fractionation schedule is determined prior to treatment, and is usually based on information regarding dose-response relationship and tolerance of tissues within the treatment volume, the presence of residual disease at the end of the treatment course is not an indication for additional radiation. The assessment of response includes examination of the organ of presentation and follow-up general assessment to rule out disease progression. In patients treated with chemotherapy or combined modality therapy, where chemotherapy is used first, the response is assessed following one or two courses of chemotherapy and every 1-2 months thereafter. Chemotherapy is complete when two courses are delivered following attainment of clinical remission. A gallium scan 1-2 months following completion of chemotherapy is useful in determining completeness of response of previously gallium-avid tumor. Remission assessment comprises the demonstration of disease-free status on general assessment and also at an organspecific level. Issues that require special consideration include the following. 1 Knowledge of the pattern of relapse is helpful in planning follow-up procedures. In situations where local relapse is uncommon, as in orbital lymphoma, completely resected gastric lymphoma or small bulk Waldeyer's ring lymphoma, long-term repeated imaging or endoscopic examination of the presenting site is not indicated. However, follow-up should include a complete physical examination with particular attention to any new adenopathy or unusual symptomatology. Patients with low-grade lymphomas, especially non-MALT-associated diseases, are at prolonged risk of relapse. Although most recurrences in patients with intermediate-grade lymphoma occur within 2-3 years following the diagnosis, late relapse occurs. Accordingly, prolonged follow-up is indicated in all patients. 2 Evaluation of an organ or tissue that is anatomically or architecturally abnormal as a result of prior involvement by lymphoma, e.g. CNS lymphoma. 3 Primary bone lymphoma will present persisting radiological and MRI abnormalities post-treatment, and bone scan will almost certainly identify changes that cannot distinguish active disease from bone healing and remodeling. Resolution of gallium activity may be helpful in such cases. 4 The evaluation of paired organs/sites, e.g. testis, kidney, salivary and lacrimal glands, eye and orbit, lung, ovary, particularly when one organ has been the primary site of disease and may have been

removed as part of initial therapy. The increased risk of disease recurrence or progression in the paired 'normal' organ is well established. Following establishment of complete remission, the schedule of follow-up assessment will reflect the expectation of events and their time course. Consideration must be directed to the following. 1 Histology - recurrence risk is expressed in the majority of patients with intermediate-grade and high-grade lymphoma within a 3-5 year period following therapy. For patients with localized lowgrade lymphoma, there is probably no period when there is no risk of relapse; there is also no strong predictive probability of relapse related to time period of observation, although the frequency of relapse becomes less after 8-10 years. 2 Organ of presentation - certain primary extranodal lymphomas recur locally or within the tissues of origin with a much higher probability than at remote sites, e.g. primary CNS lymphoma. 3 Bulk of disease at presentation site and the use of locoregional irradiation in the treatment plan. Tumor bulk in a non-resected organ predicts for both local and distant relapse. Local disease control in sites receiving a tumoricidal dose of RT is expected unless substantial tumor bulk was present at the time of RT. Management of relapse usually involves chemotherapy. However, in patients who relapse with localized disease, repeat chemotherapy and RT may offer a higher chance of prolonged disease control. In selected circumstances of low-grade lymphoma recurring with localized small bulk disease, RT alone may offer lengthy disease control.

MANAGEMENT OF PRIMARY EXTRANODAL LYMPHOMA

Introduction Primary extranodal non-Hodgkin's lymphomas with their propensity to present with localized disease are especially important to radiation oncologists.44-46 Lymphomas presenting in extranodal sites account for approximately 20-45 per cent of all lymphomas.45,47-51 Primary extranodal lymphomas account for approximately 50 per cent of Stage I and II lymphomas.52 From an epidemiologic, etiologic and management point of view, they are a heterogeneous group of neoplasms. The majority of studies focusing specifically on extranodal NHLs are retrospective and based on archival material frequently collected over decades in the face of changing understanding of pathology and variations in treatment approaches.47,48,52-57

252 Localized non-Hodgkin's lymphoma

The criteria for the diagnosis of primary extranodal lymphoma have been proposed by Dawson for GI lymphomas,58 and further refined by Lewin and Herrmann.59-60 The original Dawson criteria stipulated that the primary extranodal lymphomas present with main disease manifestation in an extranodal site, may only have regional lymph node involvement, no peripheral lymph node involvement, and no liver or spleen involvement. Later these criteria were relaxed to allow for contiguous involvement of other organs (e.g. liver, spleen) and allowed distant nodal disease, providing that the extranodal lesion was the presenting site and constituted predominant disease bulk.60 The designation of Stage III and IV lymphomas as primary extranodal lymphomas is debatable, and with variable reporting, it is difficult to establish the true incidence of localized extranodal lymphomas. Extranodal involvement occurring in the presence of predominantly nodal or disseminated disease is considered secondary. In many developed countries, a 2-4 per cent rise per year in the incidence of NHL has been observed over the last four decades. Surveillance, epidemiology and end-results (SEER) data indicate a proportionately greater increase in the incidence of extranodal lymphomas than nodal lymphomas (3.0-6.9 per cent vs 1.7-2.5 per cent); a similar increase in extranodal lymphomas has been observed in the UK.50,61 Despite an increasing body of knowledge regarding genetic and phenotypic events underlying the development and progression of NHL, the exact etiologic agent has not been identified in the majority of cases. The etiology of many primary extranodal lymphomas has been associated with chronic antigenic stimulation. Examples include the association of thyroid lymphomas with Hashimoto disease, salivary gland lymphomas with Sjogren's syndrome and enteropathy-associated T cell intestinal lymphoma with celiac disease. Helicobacter pylori has been identified as a causative agent in gastric lymphoma and possibly other gastrointestinal lymphomas.62-66 Epstein-Barr virus (EBV) infection has been linked with primary natural killer (NK)-cell nasal lymphomas.67 The identification of causative agents offers a unique opportunity to implement preventive measures and hope of lowering the incidence of this disease in the future. The histologic spectrum of extranodal lymphomas is different from nodal lymphomas, with a predominance of diffuse large cell lymphomas, the occurrence of MALT lymphomas, a distinct group of lymphomas with homing properties, and a paucity of follicular lymphomas. Recent identification of a mucosal homing receptor, a4b7 integrin, that binds to MadCAM, a vascular recognition addressin selectively expressed on mucosal endothelium, supports the unique character of GI and other MALT lymphomas.68 Although lymphomas occurring in some sites have consistent histology, e.g. diffuse large cell in the testis, other sites have a spectrum of disease entities, e.g. intestinal lymphomas, where T cell lymphomas, MALT

lymphomas and mantle cell lymphomas occur. The other site with a spectrum of histologies is the breast. Primary lymphoma of the breast occurring in young women and associated with pregnancy is commonly a high-grade lymphoma, while later in life MALT lymphomas and diffuse large cell lymphomas, possibly of the transformed MALT type, occur. The full spectrum of lymphomas also occurs in the skin, with low-grade T cell lymphomas, Ki-1-positive large cell lymphomas, lowgrade B cell lymphomas, peripheral T cell lymphomas and large B cell lymphomas all seen. Although the histology is diverse, many primary skin lymphomas exhibit homing properties to the skin, regardless of histologic type. Histologic type is the main determinant of prognosis in both nodal and extranodal lymphomas but the specific presenting site is also of importance in extranodal lymphomas. For example, the prognosis of Stage I primary brain lymphoma or testis lymphoma is different from Stage I primary bone lymphoma in spite of the other prognostic factors being equal. The spectrum of presenting sites is vast, but in all comprehensive reports primary lymphomas affecting stomach and Waldeyer's ring are the most common (see Table 15.9). In the classic report by Freeman of the SEER experience from 1950 to 1964, stomach lymphoma was most common, followed by intestine, tonsil, and skin.49 Waldeyer's ring lymphomas are frequently considered as nodal presentations and therefore are not included in extranodal lymphoma statistics. The recent SEER report found stomach, skin, intestine and brain to be the most common sites of extranodal lymphoma.50 In a population-based study from Denmark, d'Amore found stomach, intestine, skin, and bone to be the most common sites of presentation. The referral patterns may affect institutional experience with primary extranodal lymphoma.48 In the experience of the Sheffield Lymphoma Group, the commonest sites were the head and neck, GI tract, skin and CNS accounting for 87 per cent of patients.51 In the Princess Margaret Hospital experience, Waldeyer's ring lymphoma (mostly tonsil) and stomach lymphoma were consistently the most common extranodal sites over the last 30 years.56 However, in the last 10 years, fewer stomach and intestinal lymphomas were seen, while proportionately more primary bone and extranodal lymphomas were seen and treated at the PMH. Less common, but distinct primary extranodal lymphomas, include other head and neck sites (salivary gland, paranasal sinus lymphoma, gingiva, nose), orbit, thyroid, breast, lung, female genital tract (ovary, cervix, uterus), genitourinary tract (testis, bladder, prostate) and soft-tissue lymphomas. The least common sites of primary extranodal lymphoma include the heart, muscle, kidney, pleura, adrenal gland and dura. It has been a matter of some controversy as to whether extranodal presentations have a worse prognosis than those with localized nodal disease. However, in the large

Management of primary extranodal lymphoma 253

Danish48 and Dutch69 population-based studies, there was a significant survival difference in favor of the nodal cases. Certainly, the clinical behavior is different, but analyses should become more meaningful when recent developments in histopathological and biological markers begin to be implemented.

Gastrointestinal tract This is one of the commonest sites of extranodal lymphoma. They occur most frequently in the stomach (approximately 60 per cent of cases), followed by small intestine (30 per cent), colon and rectum (10 per cent). Primary gastrointestinal lymphomas account for at least 15 per cent of all non-Hodgkin's lymphomas and maybe increasing in incidence. Overall survival is variously reported as between 34 and 57 per cent in populationbased series,7,70,71 being better for stomach than for intestine. Approximately three-quarters of patients present with intermediate- or high-grade histology. Primary T cell lymphomas in the GI tract are very rare and are usually associated with enteropathies. The use of refined immunocytochemistry and molecular biology has helped to define the MALT lymphomas. Most of these arise in the stomach and are associated with Helicobacter pylori infection. The traditional therapeutic strategies in gastric lymphoma include a complete surgical resection with postoperative RT, chemotherapy, or chemotherapy plus RT. Surgery alone, employing partial or total gastrectomy, has been reported to cure a small proportion of patients.22 Such treatment has been commonly offered to patients with a low-grade lymphoma. However, surgery alone requires careful follow-up, since low-grade MALTassociated lymphoma is a multifocal disease. Most studies with long-term follow-up report relapse-free rates and survival inferior to those where adjuvant therapy has been used. D'Amore, in a retrospective review of the Danish Lymphoma Study Group experience, found that patients with gastric lymphoma who received RT as part of their therapy had a reduced relative risk of relapse.6 In the Princess Margaret Hospital experience, patients with Stage IA and IIA gastric lymphoma treated with complete gross surgical resection and low-dose (20-25 Gy) postoperative RT had an 86 per cent 10-year relapse-free survival.72 In this favorable group of patients, the depth of stomach wall invasion did not affect the outcome. Others have shown good results in patients with complete resection of tumor followed by chemotherapy alone or combined modality therapy.73 It is uncertain whether the favorable outcome in these reports was the effect of surgery itself, or the low tumor bulk allowing for complete surgical resection. Surgical resection is associated with a significant morbidity and mortality, and its use in an unselected patient population may have an adverse effect on outcome.

Recently, several reports have suggested that treatment with chemotherapy alone or chemotherapy followed by RT may produce similar results to those obtained with surgery.74 Maor reported a series of 34 patients treated with chemotherapy and RT without gastrectomy. Six patients died of recurrent disease and two of treatment toxicity. Of the 26 surviving patients, 24 did not require gastrectomy.75 Taal and colleagues from Amsterdam reported a 64 per cent disease-free survival at 4 years in patients treated with RT alone without prior tumor resection. The updated experience treating gastric lymphoma with chemotherapy and RT, or RT alone, without an attempt at surgical resection, revealed a 5-year relapse-free survival of 85 per cent in Stage I and 58 per cent in Stage II patients.76,77 Although these reports suggest that a successful therapeutic approach does not have to include surgical resection of the primary tumour, they have to be interpreted with caution. Chemotherapy alone is curative in only a proportion of patients with diffuse large cell lymphoma and there is no evidence for cure of low grade lymphoma. Excellent results have recently been reported for low-dose radiotherapy alone in patients with low-grade MALT stomach lymphomas without Helicobacter pylori infection, or persisting after antibiotic therapy.78 However, the use of RT in lieu of surgical resection has to be considered in the context of its toxicity. Although moderate dose RT (35-45 Gy) will produce high local control rates, the dose required to control unresected disease is higher than that used in an adjuvant setting (25 Gy). In most instances where RT is used to treat gastric lymphoma, the left kidney is exposed to a radiation dose in excess of tolerance levels. The long-term morbidity of strategies, including chemotherapy alone, or RT and chemotherapy without surgical resection, has not been compared to those including resection. In cases where resection of the primary tumor is not feasible, combined modality including doxorubicin-based (e.g. CHOP) chemotherapy followed by RT is recommended. However, the reported ultimate local control and survival rates in such cases have been lower. Regression of primary low-grade B cell gastric MALT lymphoma following treatment with antibiotics has raised the possibility that eradication of Helicobacter pylori may be sufficient therapy for selected patients with early low-grade lymphoma of the stomach. Several case reports and small series of patients have suggested a high rate of disappearance of MALT gastric lymphoma after treatment with antibiotics.79-81 Recommended antiHelicobacter therapy includes metronidazole, ampicillin and omeprazole or clarithromycin, timidazole and omeprazole. The expected rates of eradication of Helicobacter are 75-90 per cent. Although eradication of Helicobacter may be documented within a month of the completion of antibiotic therapy, complete disappearance of lymphoma may take several months. Clearly much is still to be learned regarding patient selection for

254 Localized non-Hodgkin's lymphoma

conservative management with antibiotics, response rates and duration of response. Intestinal lymphoma is diagnosed most commonly at laparotomy and surgical resection is standard. In advanced disease, where resection is not technically feasible, treatment comprises doxorubicin-based chemotherapy followed by RT. Our own policy has been to treat low-grade intestinal lymphoma with surgical resection followed by adjuvant whole abdominal RT (20-25 Gy in l-1.25Gy daily fractions). In intermediate-grade lymphoma, surgery followed by chemotherapy is recommended. If a short course of chemotherapy is used, whole abdominal RT is added. In patients where complete tumor resection is not feasible, chemotherapy followed by RT is recommended.72,82 However, in the absence of randomized trials, the optimal treatment strategy is uncertain. The outcome reported in the literature varies depending on the extent of disease and histology. In a large series of intestinal lymphomas, Domizio documented a 75 per cent 5-year survival for patients with low-grade B-cell lymphomas and only a 25 per cent 5-year survival for those with T cell tumors.83 The poor outcome of patients with intestinal T cell lymphomas has also been documented in the BNLI84 and Danish experience.6 The site of involvement was also of prognostic significance with lesions in the terminal ileum having the best survival. Other prognostic factors in primary intestinal lymphoma include age, performance status, B symptoms and mesenteric lymph node involvement (Stage II disease).6,84 Immunoproliferative small intestinal disease (IPSID), alpha heavy-chain disease, and Mediterranean lymphoma all refer to various manifestations of B cell lymphoma affecting the small intestine.85 Patients present with poor performance status and severe malabsorption, and frequently cannot tolerate standard therapy. Overall survival is poor. Several authors have reported that treatment with the tetracycline group of antibiotics can produce clinical, histologic and immunologic remissions. Remissions have also been described following chemotherapy. The role of RT and surgical resection remains to be defined. Despite several available treatments, IPSID is a highly lethal disease with survival rates being as low as 23 per cent at 5 years.86 Patients with resectable Stage I and II, disease have a 5-year survival of 40-47 per cent compared with 0-25 per cent for unresectable or Stage II2 disease. Rectal presentations are less common than other sites in the lower intestinal tract. Diffuse small non-cleaved cell lymphoma is the most common, although diffuse large cell lymphomas also occur. Treatment usually includes chemotherapy and RT (30-40 Gy in 1.5-2 Gy daily fractions) for patients presenting with bulky lesions and/or intermediate-grade lymphoma. Involved field RT alone (30-35 Gy in 1.5-1.75 Gy daily fractions) has been successful in providing long-term disease control for MALT lymphoma of the rectum. Abdominoperineal

resection should be discouraged as there is no evidence that it improves local control or survival.

Waldeyer's ring (tonsil, base of tongue, nasopharynx) The Waldeyer's ring, and particularly the tonsil, is in most series the commonest site for extranodal lymphoma of the head and neck.87 The disease occurs most frequently after 50 years of age. Dysphagia, airway obstruction, Eustachian tube blockage, mass lesion or neck adenopathy are the common modes of presentation depending on the principal site of the tumor. The lesion may be visible by examination and may be effectively imaged for site, size, local extension and neck adenopathy by CT or MR imaging. Multiple sites of involvement may be apparent within the tissues of Waldeyer's ring. Traditionally, most experience has reflected the use of local RT with high local control rates using involved field techniques and moderate radiation doses (35-50 Gy). Overall survival rates of 50-60 per cent for Stage IE lesions, and 25-50 per cent for IIE lesions have been recorded.88,89 Following RT, the majority of failures occur distant to the radiation field indicating a high risk of occult systemic disease with apparently localized Waldeyer's ring presentations. The overall relapse rate and the pattern of failure following RT strongly indicate the need for effective therapy for both local tumor and occult systemic disease. For patients with Stages I-IIE disease there is no indication for CNS prophylaxis. With combined modality therapy, local control rates in excess of 80 per cent and overall survival rates of 60-75 per cent depending on the bulk and nodal extent of the presenting lesion have been recorded.90,91 A prospective randomized trial by Aviles et al. demonstrated the superiority of combined modality therapy with 5-year failure-free survivals of 48 per cent for RT alone, 45 per cent for CT alone, and 83 per cent for combined modality therapy (P < 0.001).92

Paranasal sinuses and nasal cavity Tumors occur more commonly in males and in those over 50 years of age. Important differences in clinical features, phenotypic and genotypic characteristics, and prognosis are apparent between Western and Oriental populations presenting with nasal fossa and midline sinus lymphomas. Common presenting features include painless nasal obstruction, nasal discharge, nasal hemorrhage, 'tearing' of the eye(s), facial swelling or palatal lesions with dental effects. In Orientals, a destructive, erosive lesion (polymorphic reticulosis/lethal mid-line granuloma) may be a more characteristic presentation. Examination may define the lesion by anterior or posterior rhinoscopy. Lesions within the maxillary sinus may

Management of primary extranodal lymphoma 255

impact upon the nasal fossa, orbit, palate/buccogingival recess or anterior facial integrity (facial swelling, asymmetry, loss of nasolabial fold). Tumor extent is most effectively documented by CT or MRI evaluation, taking account of soft tissue swelling and bone destruction. Tumors are most commonly of diffuse, large-cell type including immunoblastic lesions. Both B and T cell tumors are seen: B cell tumors are more common in Western populations, although the T:B ratio is higher than for nodal lymphoma; in Oriental populations, T cell tumors predominate and show the characteristic features of angioinvasion, necrosis and epitheliotropism within the spectrum of angiocentric, immunoproliferative disease. Low-grade tumors are rare. A recent workshop characterized the nasal T/NK cell lymphoma as a distinct clinicopathological entity highly associated with the Epstein-Barr virus. Tumors with an identical phenotype and genotype may occur in other extranodal sites, most commonly in the skin, subcutis and GI tract, although referred to as nasal-type T/NK cell lymphomas.93 With RT alone, using involved field techniques and moderate dosage (35-45 Gy), high local control rates may be achieved.94 In Western populations, the systemic failure rate is substantial (50 per cent) following RT alone, thereby establishing the current practice of combined modality therapy (anthracycline-based chemotherapy with adjuvant radiation) for lymphoma presenting in the nasal fossa and paranasal sinuses. The systemic failure is also significant with angiocentric, immunoproliferative T cell disease.95,96 For Western populations, overall 5-year survival rates of 60-70 per cent should be achieved. Information is also now becoming available to characterize optimal therapy and prognosis for patients with T cell lymphoma of nasal fossa and sinuses.97,98

Salivary gland The parotid gland is the site of occurrence in approximately 80 per cent of cases, followed by the submandibular salivary gland. Sublingual or minor salivary glands are rarely the presentation site of clinically manifest lymphoma. Presentation is usually with an asymptomatic salivary gland mass. Lymphoma of the salivary gland is most commonly seen in patients with Sjogren's syndrome. Myoepithelial sialoadenitis (MESA), considered part of the spectrum of MALT lymphoma, is also characteristic of Sjogren's syndrome. Other low-grade B cell lymphomas arising in the salivary glands include mantle cell and lymphoplasmacytic lymphomas. MESAassociated B cell lymphomas generally follow an indolent course and tend to remain localized for prolonged periods of time. Radiation offers excellent local control for limited stage salivary gland lymphoma. Overall survival rates at 5 years approach 70-80 per cent, but there is a

continuing distant relapse risk, characteristic of the natural history of low-grade lymphoma. There is no role for chemotherapy in the management of low-grade tumors, although the chemotherapy and RT approach using an anthracycline-based chemotherapy is standard therapy for transformed intermediate/high-grade lesions. Thyroid Lymphomas of the thyroid gland comprise 2.5-3.0 per cent of all non-Hodgkin's lymphomas and 5 per cent of thyroid malignancies. Women are affected more commonly than men and the modal age of presentation is over 60 years. Patients usually present with a rapidly enlarging neck mass causing local obstructive and infiltrative symptomatology. Tumors are often bulky and neck adenopathy is common. Primary thyroid lymphomas occur most frequently in patients with Hashimoto's thyroiditis. MALT lymphomas are common and carry a better prognosis than non-MALT histology tumors.99 Surgery is a diagnostic procedure and is not a definitive intervention for clinically evident thyroid lymphoma. With locoregional, moderate dose RT (35-45 Gy), local control is achieved in over 75 per cent of patients. Overall, survival rates at 5 years range from 40 to 75 per cent with relapse-free rates of 38 to 64 per cent depending on the admixture of prognostic attributes.100,101 Given the high distant relapse rates, chemotherapy alone and, more commonly chemotherapy and RT have become the standard treatment approach. Systemic progression following RT is noted in the GI tract, liver and spleen. The linkage between the GI tract and Waldeyer's ring progression accords with the categorization of thyroid lymphoma within the MALT system. CNS involvement is rare. Localized thyroid lymphoma of intermediate-grade type is generally treated with combined modality therapy. RT alone may still be considered appropriate therapy for patients with limited, small bulk disease confined to the thyroid gland. With chemotherapy and RT, local control, overall survival and relapse-free proportions should exceed 70 per cent.101 Orbit Primary malignant lymphomas account for approximately 10 per cent of orbital tumors. Primary lymphomas of the orbit and eye account for about 4 per cent of all primary extranodal Stage I and II non-Hodgkin's lymphoma. The tumors are commonly seen in the elderly with a median age in the sixth decade. Topographically, these tumors arise in superficial tissues, including the conjunctiva and eyelids, or in deep tissues including the lacrimal gland and retrobulbar tissues. Typically the superficial conjunctival tumors present as salmon-pink-colored mass lesions in the fornices.

256 Localized non-Hodgkin's lymphoma

Symptoms include ptosis, blurred vision, chemosis and epiphora. Tumors of the retrobulbar region present with swelling and proptosis with disturbance of ocular movement. Vision is not usually impaired unless papilloedema or optic nerve dysfunction is apparent. Bilateral involvement occurs in approximately 10-15 per cent of cases. Involvement of the skin of the orbit is uncommon. Orbital presentations may be in the conjunctiva, one of the MALT lymphoma sites and commonly low grade, or in retro-orbital tissues, usually of intermediate-grade histology.102 Treatment is directed to cure, while preserving vision and the integrity of the orbit. Extensive surgery should therefore be avoided. Orbital lesions are typically easily controlled with low to moderate doses of RT. Conjunctival lesions may be treated with direct orthovoltage (250 kV) or 5-10MV photon beams. Treatment with an anterior orthovoltage X-ray or electron beam provides satisfactory therapy for anterior lesions limited to the eyelid of bulbar conjunctiva, with the advantage of sparing orbital structures compared to the use of a megavoltage photon beam. If an anterior orthovoltage field is used, a small lead eye shield suspended in the beam to shield the lens can result in a lens dose of less than 5-10 per cent.103,104 For unilateral retrobulbar tumors, a two-field technique using megavoltage photon beams (4-6 MV) is appropriate, with a corneal shield placed in the anterior field and the lateral field angled posteriorly to spare the lens in both eyes. An alternative arrangement employs an isocentric technique with two oblique (wedged) fields with a shield inserted in both fields, with the patient looking at the shield for each treatment field. Radiotherapy (20-30 Gy in 10-20 daily fractions) for low-grade lymphomas results in a local control rate in excess of 95 per cent.105,106 Higher doses are not required and their use results in higher acute and long-term morbidity. Fewer data are available for intermediate- and high-grade lymphomas. However, the dose-control data for lymphoma in general suggest that, for patients with small bulk tumors (<2.5 cm), a dose of 35 Gy in 1.75-2 Gy fractions provides excellent local control. For patients with larger intermediate- and high-grade tumors, short-duration doxorubicin-based chemotherapy followed by RT to a dose of 30-35 Gy in 1.5-1.75 Gy daily fractions is recommended. The complications of RT, commonly seen when doses of 40 Gy or more are used, include cataract formation, keratitis and sicca syndrome. The tolerance dose of the lacrimal gland is 40 Gy in 20 daily fractions. Damage to the optic nerve and retina should not be seen with an RT dose of 40 Gy or less. The overall actuarial 10-year survival rates reported in the literature are 75-80 per cent. These excellent survival rates are likely due to an excess of tumors with low-grade histology. After a complete response has been achieved, the risk of locoregional failure is extremely low. The common sites of relapse are the contralateral orbit and generalized disease. Distant failure rates vary from 20 to

50 per cent but, as in other cases of low-grade lymphoma, failures can be successfully managed and prolonged survival is common. In patients presenting with large cell lymphoma, particularly with bulky orbital lesions, the risk of distant failure is 30-60 per cent. Failures may not be salvaged with further RT, therefore chemotherapy plus RT is recommended for such patients. Occasionally, in patients with bulky tumors, where the cornea cannot be protected, the use of RT alone may result in severe radiation complications. In such cases, the use of chemotherapy alone or combined modality is preferable.

Testis Testicular lymphoma accounted for 2.3 per cent of highgrade (Kiel classification) non-Hodgkin's lymphomas registered with the BNLI. Most patients with primary testis lymphoma are over the age of 50 at presentation, while most germ cell tumors of the testis, except for spermatocytic seminoma, occur in patients under the age of 50. Lymphoma accounts for 25-50 per cent of primary testicular tumors in men over the age of 50; it is the most common testis tumor in patients over 60 years of age, and there is no racial predilection. There is no known association of testicular lymphoma with any previous testis pathology. A number of series have documented synchronous or metachronous involvement of the contralateral testis. The incidence of bilateral involvement has been reported to be as high as 18-20 per cent. This is in contrast to germ cell testis tumors where the incidence of bilateral involvement is 3-5 per cent. Most patients present with painless swelling of the testis. An antecedent history of orchitis and trauma has been described, but in contrast to germ cell tumors, a history of maldescent is rare. Diagnosis is most frequently obtained following pathologic assessment of the excised primary tumor. The staging assessment is focused on identification of regional lymph node spread in the paraaortic area and distant spread in Waldeyer's ring, lungs, bone, pleura, skin and CNS. A careful physical examination, imaging of the retroperitoneum and chest, and assessment of the bone marrow and cerebrospinal fluid (CSF) are required. Initial therapy invariably involves a radical inguinal orchidectomy.107 Indeed, some patients with truly localized disease have been cured with orchidectomy alone. Primary testicular lymphoma has been recognized as a potentially highly lethal disease, with historic overall 5year survival rates ranging from 16 to 50 per cent with a median survival of 12-24 months. Distant failures were commonly observed. The traditional postorchidectomy therapy for Stage I and II disease comprised RT (35 Gy) to the para-aortic and ipsilateral pelvic lymph nodes, and resulted in cure rates for Stage I of 40-50 per cent and for Stage II of 20-30 per cent. There is little evidence

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that regional RT impacts survival, although it does improve disease control in the retroperitoneal lymph nodes. Reports documenting long-term results of treatment including doxorubicin-based chemotherapy are infrequent. The best results to date have been obtained by Connors et al.y who reported 15 Stage I and II patients treated with a short course of CHOP chemotherapy and RT to the scrotum alone in Stage I patients or scrotum and pelvic and para-aortic lymph nodes in Stage II,108 and obtained a 93 per cent actuarial relapse-free survival at 4 years. Interestingly, no CNS prophylaxis was used and no CNS relapses were observed in this study. Other studies have, however, documented CNS relapse despite a treatment approach that included CHOP chemotherapy.109 The pattern of failure following locoregional therapy is well documented, with disease progression observed mainly in rare extranodal sites, such as skin, pleura, Waldeyer's ring, but also lung, liver, spleen, bone and bone marrow. CNS progression with both intracerebral and leptomeningeal involvement has been noted in up to 30 per cent of patients. Failures usually become manifest within 1-2 years following the initial therapy, but late relapse, especially isolated late CNS relapse, has been observed especially in patients treated without CNS prophylaxis.110 Failure in the contralateral testis is well documented and occurs in 5-35 per cent of patients. Doxorubicin-based chemotherapy improves the survival of patients with localized testicular lymphoma.108,111 The role of RT is less clear, especially if a full course of chemotherapy is used. Regional RT (para-aortic and ipsilateral pelvic - 35 Gy in 20 daily fractions) is used in Stage I and II disease, although excellent results have been obtained without RT of the regional lymph nodes in Stage I disease.108 Low-dose RT (25-30 Gy in 10-15 daily fractions) to the contralateral testis eliminates the risk of failure at this site, carries little morbidity in this elderly patient population and is recommended for all patients with primary testis lymphoma. The best protocol for CNS prophylaxis has not been determined. Although commonly used, intrathecal chemotherapy may be ineffective, since the pattern of failure includes parenchymal brain involvement and may not be required in well-staged patients treated with chemotherapy. Prophylaxis with intrathecal chemotherapy and cranial RT (20-24 Gy in 1.8-2.0 Gy daily fractions) is associated with a considerable toxicity and, in elderly patients, may be hazardous. However, a clear pattern of failure in the CNS warrants consideration of prophylaxis with, at least, intrathecal chemotherapy.110

Bladder Primary non-Hodgkin's lymphoma of the urinary bladder is extremely uncommon. It accounts for 0.15-0.2 per cent of primary lymphoma cases. The relative rarity of this condition has limited most

publications to individual case reports. Published reports indicate that primary lymphoma of the bladder occurs in the sixth and seventh decade of life, and is more common in women. Patients present with hematuria, frequency and dysuria. A history of cystitis is a preceding feature in many cases. The diagnosis is made on cystoscopic biopsy of the tumor. Cystoscopic appearances reveal a submucosal mass with an edematous and friable mucosa, and frequent displacement of the bladder wall. Frequently, the tumor mass is large and extends through the bladder wall into the perivesical tissues. Tumors are usually of small cell or lymphocytic type. Large cell lymphomas have been described, but are less common. Low-grade and MALT lymphomas have been described. The occurrence of MALT lymphoma is supported by reports of long-term survival following local therapy alone in patients with bulky primary bladder lymphoma. Treatment has traditionally involved partial cystectomy and/or RT to the pelvis. The prognosis is related to histologic type and extent of tumor.112 As in other extranodal lymphomas, low-grade lesions may be managed with radiation therapy alone but intermediate-grade lymphomas should probably be treated with doxorubicin-based chemotherapy followed by local RT. There are few data regarding the optimal dose and technique of RT, but there is no reason to suggest that the sensitivity of the tumor would be different from other extranodal lymphomas. Several reports suggest that primary lymphoma of the bladder is associated with a favorable prognosis.113,114 Long-term survival has been observed in about 40-50 per cent of patients.

Ovary Lymphoma of the ovary is rare as a primary presentation, although ovarian involvement in advanced, systemic lymphoma is not uncommon, particularly in those with high-grade disease.115 The usual modes of presentation are by mass lesion in the abdomen and pelvis, abdominopelvic pain or as an unexpected finding during the course of investigation of other gynecological complaints. The preoperative assessment of a solid ovarian lesion commonly leads to a surgical oophorectomy with or without surgical resection of disease extension to the Fallopian tubes, omentum, parametrium or lymph nodes. The disease is commonly bilateral and often of fairly bulky size. The disease is less frequently confined to the ovary and, for the majority, it is often unclear as to whether the ovary is the primary site or is involved secondarily to extensive systemic spread. In small series reported over long periods, various forms of treatment have been used singly or in combination. A 2-year and 5-year overall survival of 42 per cent and 24 per cent has been cited.116 As lymphomas of the ovary are most commonly of intermediate- or high-grade

258 Localized non-Hodgkin's lymphoma

type and clearly are most commonly associated with extensive dissemination, the initial treatment approach should comprise chemotherapy. RT may be appropriate in the circumstance of a localized presentation, with residual disease postsurgery or following definitive chemotherapy. Local control is, however, a lesser issue if the primary tumor at presentation is an unresected lesion, and the common pattern of failure is one of systemic disease progression. Uterus, cervix uteri and vagina Lymphomas of the uterine cervix are more common than endometrial or vaginal lesions, and may present as an asymptomatic, unexpected finding following hysterectomy for other reasons, or may present with bleeding, pain, dyspareunia and/or postcoital bleeding. Clinically apparent lesions are typically large (50 per cent exceeding 4 cm) and are usually endophytic with local invasion into paracervical tissues, giving rise to a barrelshaped lesion. Occasionally tumors arise from a cervical polyp. Vaginal lymphoma presents with vaginal bleeding. Diffuse large cell lymphoma comprises the majority of lesions of the cervix, endometrium and vagina (70 per cent). Low-grade and high-grade lesions also occur. The standard therapy for patients with Stage IE lesions has usually comprised RT with or without antecedent surgery. There is no evidence that radical gynecologic surgery is necessary and, indeed, there is no strong indication for more than a diagnostic biopsy with subsequent detailed staging evaluation. RT alone for localized low-grade tumors offers a very high probability of local control; chemotherapy and RT for intermediate or high grade tumors is appropriate and, given the impact of RT on ovarian function in those in the reproductive age range, the use of chemotherapy alone has been recommended with some clinical justification. A 5-year overall survival rate of 73 per cent is quoted by Harris and Scully117 comprising an 89 per cent 5-year survival for patients with Stage IE disease. Important prognostic factors include stage and histology. Local failure is very uncommon following surgery and RT for endometrial, cervical or vaginal lymphoma.118 Disease progression may be anticipated in approximately 20 per cent of patients with Stage IE lesions, particularly ..in those with intermediate- or high-grade lesions, and it is usually systemic in nature. Vaginal lesions have been characterized by progression in subcutaneous tissues of the abdominal wall, intra-abdominal nodes, lung and inguinal nodes.119

may affect very young and very old women as well. A bimodal pattern of presentation of primary breast lymphoma has been described. Breast lymphoma affecting young women tends to be associated with pregnancy and lactation, and is a high-grade lymphoma commonly presenting with bilateral disease diffusely involving both breasts. In contrast, the disease affecting older women tends to present with discrete masses and is commonly unilateral. Reports in the literature suggest synchronous bilateral involvement in up to 13 per cent of cases and metachronous contralateral involvement in 7 per cent of cases. The most commonly reported histologic type is diffuse large cell lymphoma. Low-grade lymphomas are less common, although cases of MALT lymphoma affecting the breast have been reported. Traditionally, patients with localized breast lymphoma have been treated with surgery, surgery followed by RT, or biopsy followed by RT. Most reports are based on patients treated without the systematic use of doxorubicin-based chemotherapy. It is important to note that the completeness of surgical excision does not appear to affect local control in RT-treated patients. Thus mastectomy is not recommended and breast preservation is possible in the majority of cases. Properly planned and delivered RT results in excellent local control, especially in patients presenting without bulky disease or those with low-grade histology. The RT volume should include the whole breast and the ipsilateral axillary lymph nodes. As in other lymphomas, a tumor dose of 35 Gy in 1.75-2.0 Gy fractions over 4 weeks achieves excellent local control. However, no reports include patients treated with modern chemotherapy alone. Distant failures are common when surgery and RT are the only modalities employed. The most common sites of failure include lungs, brain, liver, spleen and distant nodal sites. Isolated CNS relapses have been reported. Similarly, late failure in the contralateral breast may occur following therapy of unilateral primary breast lymphoma. The overall survival of patients treated with local treatment methods ranges from 40 to 66 per cent at 5-10 years.120,121 The local control rates in patients treated with RT range from 75 to 78 per cent.121,122 The risk of distant relapse is higher in patients with Stage II disease and their survival has been reported to be as low as 20 per cent. Current recommendations for treatment include the use of chemotherapy and RT in all patients with intermediateand high-grade lymphoma. Patients with low-grade lymphoma may be successfully treated with RT alone. CNS prophylaxis with intrathecal chemotherapy should be considered in all patients with high-grade histology, especially those with bulky or bilateral disease.

Breast Primary non-Hodgkin's lymphoma comprises only 2 per cent of localized extranodal presentations and only 0.04-0.5 per cent of all malignant breast tumors. The median age is in the sixth decade of life, but the disease

Bone Patients commonly present with local bone pain, soft tissue swelling and mass lesion or a pathological fracture.

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Long bones are the most common presentation site. MRI has contributed substantially to the evaluation of the primary lesion in terms of medullary, cortical and soft tissue extent. Nodal involvement is uncommon. Cure of lymphoma of bone by surgery alone has been recorded, although this would no longer be considered appropriate therapy. With RT alone, 5- and 10-year overall survival rates of 58 per cent and 53 per cent have been reported for solitary bone lesions. Outcome has also been influenced by the site of solitary presentation with 10-year overall survival rates of 78 per cent for femoral lesions, 59 per cent for mandible and maxillary lesions, 36 per cent for pelvis presentations and 24 per cent for lymphoma presenting in the vertebral body. Key issues relating to local control are the intramedullary and soft tissue extent of disease in relation to RT volume. MRI has been particularly important in revealing extension of disease not visualized before by routine X-rays or bone scan. Treatment approaches using RT have indicated high levels of local control (approximately 85 per cent), unacceptable rates of local or marginal failure (20 per cent) probably related to underestimation of tumor extent and bulk, and a systemic failure rate approaching 50 per cent. Therefore patients with localized lymphoma of bone should be treated with chemotherapy and RT, comprising initial anthracyline-based chemotherapy and subsequent RT to a minimum dose of 35 Gy. There is no indication for CNS prophylaxis. With chemotherapy and RT the overall survival and relapse-free rates should exceed 70 per cent at 5 years.123,124

high-grade lesions even when treated with chemotherapy, or chemotherapy and RT, with survival rates of 47 per cent at 5 years,126 and a median survival of 3 years. Systemic progression is common and relapse-free rates of approximately 40-50 per cent are expected. T cell lymphomas have a poor prognosis with a 50 per cent mortality at 2 years, even where chemotherapy and RT are applied. Central nervous system Non-Hodgkin's lymphomas arising in and limited to the CNS are called primary CNS lymphomas (PCNSL). The most common site of PCNSL is the brain.127,128 Primary leptomeningeal lymphoma, without parenchymal brain disease, accounts for only 7 per cent of PCNSL. Primary spinal cord lymphoma is even less common.129,130 The eye, a direct extension of the CNS, is another site of PCNSL. High-grade B cell lymphomas are most common; T cell lymphomas have been reported, but are exceedingly rare. PCNSL is one of the common acquired immunodeficiency syndrome (AIDS)-defining tumors. A significant increase in the incidence of PCNSL has been observed in the last two decades, both in human immunodeficiency virus (HlV)-infected and non-HIV-infected populations. PCNSL is also a common tumor following organ transplantation. Tonsillectomy and oral contraception use have also been implicated as possible factors.131 LYMPHOMA OF THE BRAIN

Lung Three broad categories of lymphoma of the lung require recognition: firstly, low-grade B cell tumor; secondly, a much less common intermediate- or high-grade tumor, usually of diffuse, large cell B cell type: and thirdly, a tumor usually occurring as part of a more widespread angiocentric and angiodestructive systemic process, such as lymphomatoid granulomatosis or peripheral T cell lymphoma. Patients are commonly over 50 years of age with an equal male:female ratio. Initial treatment has commonly been surgical resection; however, given current less invasive alternatives to achieve a secure diagnosis, there is no strong indication that resection contributes to outcome. Low-grade lymphoma has been treated by chemotherapy, usually a single alkylating agent. Lesions are commonly responsive to both chemotherapy and RT, although low tolerance of lung to RT limits its applicability to treatment of only part of the lung. There is no indication to what degree such treatments are curative, although prolonged survival is commonly observed - 94 per cent overall survival at 5 years with a median survival not reached at 10 years and no clear impact of type of therapy on outcome.125 The prognosis is clearly substantially worse for intermediate- and

Most patients present with symptoms of headache and raised intracranial pressure. Lesions are often multifocal or diffuse, and are periventricular with easy access to the CSE The incidence of meningeal seeding varies from 7.6 to 69 per cent when a vigorous search is conducted.129,130,132 Systemic lymphoma is apparent in only 7-8 per cent of autopsied patients. The diagnosis has to be confirmed histologically, but may be suspected based on characteristic CT/MRI appearances of the tumor. On precontrast CT, the tumor is usually isodense or hyperdense. A diffuse contrast enhancement of tumor on both CT and MRI is typical, but a small proportion of patients have non-enhancing lesions. Conventional treatment consists of whole-brain irradiation and corticosteroids.133'134 Primary brain lymphoma is extremely sensitive to initial treatment, producing a rapid symptomatic response. The recommended doses are 40-50 Gy to the whole brain in 1.8-2.0 Gy fractions. The Radiation Therapy Oncology Group (RTOG) addressed the issue of the role of a 20 Gy boost to the enhancing lesion plus a 2 cm margin.135 Analysis of the 41 eligible patients revealed the mean survival to be 12.2 months from diagnosis and 11.6 months from the start of therapy, with 48 per cent surviving 1 year and only 28 per cent 2 years. Karnofsky performance status and age were the most

260 Localized non-Hodgkin's lymphoma

important prognostic factors. Disease recurred in the brain in 61 per cent of the patients with 90 per cent of the brain recurrences occurring within the high-dose region and 85 per cent at the site of the original tumor. The median survival has been reported to be 12-18 months, with 2-year and 5-year survival rates of 28 per cent and 3-4 per cent, respectively.136-138 There is, therefore, no good evidence that high-dose treatment improves survival of this group of patients. It is, however, likely to increase the incidence of dementia in survivors. In recent years, several reports have suggested improved median survivals for patients receiving RT and chemotherapy.127,139-41 There are no randomized trials proving the benefit of combined modality therapy. Protocols using blood-brain barrier disruption (BBBD) strategies with intra-arterial mannitol and methotrexate, cyclophosphamide, procarbazine and dexamethasone have produced impressive results without RT and with little late neurologic toxicity.142 Neuwelt observed a median survival of 44.5 months in BBBD chemotherapytreated patients, but only 17.8 months in those treated with RT alone.141 Other blood-brain barrier penetrating chemotherapy (methotrexate and high-dose cytarabine) via intravenous and intrathecal (Omaya reservoir) routes was used by DeAngelis in a cohort of 31 patients with a median survival of 42.5 months, while in contemporary patients treated with RT alone the median survival was 21.7 months.139 An even more intensive and apparently efficacious approach (using high-dose methotrexate, intravenous thiotepa and vincristine, intrathecal methotrexate and cytarabine) has recently been reported.143 CHOP and CHOD regimens have been unsuccessful in PCNSL due to a lack of penetration of an intact blood-brain barrier by these agents, and increased neuro toxicity.127,144 However, combining such regimens with those containing drugs that cross the blood-brain barrier, such as BVAM - carmustine (BCNU), vincristine, cytarabine (araC), and methotrexate, with or without radiotherapy may be feasible;145 the North Central Cancer Treatment Group is undertaking a phase II study of CHOD/BVAM plus radiotherapy and a Medical Research Council randomized study is planned. These reports show that PCNSL is a chemosensitive disease but the optimal approach has not yet been defined. Long-term treatment-related neurologic toxicity has not been an issue, because of the short survival. However, with prolongation of survival using combined chemotherapy and radiation, delayed toxicity may become a problem.141,146 In a series from the Memorial Hospital, New York, 11.5 per cent of 1 year survivors developed dementia;147 in all, one-third of patients developed late treatment-related toxicity.140 Prognostic factors for survival include younger age (<60), a Karnofsky score >70, a tumor that is limited to the hemispheres, a RT dose of 40-50 Gy and the use of chemotherapy.127,148

Ocular lymphoma Two patterns of intraocular involvement occur: lymphoma involving the optic nerve, retina, and vitreous, which is commonly associated with CNS involvement; and lymphoma involving the uveal tract (choroid, ciliary body and iris), which is associated with visceral involvement.149 The diagnosis may be confused with an inflammatory syndrome of uveitis and vitritis or glaucoma.150 Bilateral involvement is common, although symptoms will usually affect one eye earlier than the other. Besides systemic evaluation, CSF cytology, and imaging of both eyes and brain with MRI or CT is required to delineate local disease extent. There is little information on the histologic type of these tumors. Most cases were classified as reticulum cell sarcoma, suggesting that diffuse large cell type is the most frequent histology. Both B and T cell phenotypes have been reported.150,151 Treatment results are poor, with long-term control being unusual and RT providing only temporary palliation. Reported survivals range from 6 to 18 months.148,152 There are reports of response with high-dose intravenous cytarabine alone.153 Although the optimal management has not been defined, with recognition of the pattern of failure, the presence of bilateral involvement, extension to the CNS and a significant risk of systemic disease, therapy should include RT to both orbits and the whole brain, together with systemic and intrathecal chemotherapy.

Extradural lymphoma Primary extradural lymphoma presents commonly with pain and progressive neurologic deficit due to spinal cord compression. The presence of spinal cord compression constitutes a medical emergency. Histologic diagnosis is imperative, and surgical biopsy and decompression are the first steps in management. Complete tumor removal is unnecessary, since further therapy is always required. The main objectives of surgery include adequate decompression of the spinal cord and removal of tissue appropriate for histologic diagnosis. Postoperative therapy has historically involved RT to the affected area of the spine. RT is delivered using megavoltage photon therapy with dose to the tumor limited to 35-40 Gy in 1.75-2.0 Gy fractions. Doses in excess of 40 Gy are discouraged to avoid the risk of radiation myelitis. The RT volume should take into account the presence of any paraspinal mass or regional lymph node involvement. RT alone results in excellent local disease control but, as with other localized intermediate-grade lymphomas, is associated with a 40-50 per cent distant failure rate at sites including mediastinum, pleura, bone, bone marrow and CNS. The use of doxorubicin-based chemotherapy following surgery and RT is associated with a reduced distant failure rate and an improved survival. In the

Management of primary extranodal lymphoma 261

Princess Margaret Hospital experience, the survival of patients treated with RT alone was 33 per cent compared with 86 per cent at 5 years for those treated with combined modality therapy.154 Although the traditional approach is to deliver RT before chemotherapy, this may not be the most optimal sequence. Eeles et al. documented that the use of chemotherapy followed by RT does not compromise neurologic function as compared to that achieved when RT is followed by chemotherapy.124,155 A controversial aspect of the management of primary extradural lymphoma relates to the issue of CNS prophylaxis. Although some have demonstrated extradural involvement as a risk factor for meningeal relapse,156 in the Princess Margaret Hospital experience, isolated CNS relapse in patients treated without CNS prophylaxis is uncommon. The routine use of intrathecal chemotherapy in patients with localized extradural lymphoma and no evidence of dural invasion may be questioned, but careful attention needs to be given to the extent of initial disease and the possibility of dural invasion.154

Skin (see also Chapter 26) Primary lymphomas of the skin may be divided into three categories:157,160 1 T cell lymphomas of low-grade, small lymphocytic type (mycosis fungoides/Sezary syndrome) constituting 65 per cent of all primary skin lymphomas; 2 T cell lymphoma of larger cells (pleomorphic, immunoblastic and anaplastic) - 10 per cent; 3 B cell lymphomas - 25 per cent. Cutaneous B cell lymphomas (CBCL) are a distinct group of malignant B cell lymphomas. Large cell lymphomas and, less commonly, small cell lymphomas occur. Patients present with violaceous nodules, tumors or plaques. Lesions commonly involve trunk, scalp and the lower legs in elderly patients. Histologically, tumors show diffuse infiltration of the dermis and subcutaneous fat. Skin-associated lymphoid tissue (SALT) does not contain a B cell population, therefore, the development of primary CBCL is regarded as dependent on the acquisition of B cell lymphoid tissue. Infection with Borrelia burgdorferi has been implicated among the stimuli known to induce cutaneous lymphoid hyperplasia with subsequent development of CBCL.161,162 This process appears analogous to Helicobacter pylori infection and development of MALT gastric lymphomas. The molecular basis of these lymphomas is not yet fully characterized but translocation is rare.163,164 Radiation therapy is a preferred treatment modality with very high local control rates (85-100 per cent) and favorable survival.157,165 Although over 25 per cent of patients eventually relapse, frequently with new skin lesions, death from CBCL is uncommon. Solitary lesions have a better

prognosis than multiple lesions, the latter possibly suggesting secondary skin involvement by a disseminated lymphoma, rather than the presence of primary skin lymphoma. Primary cutaneous large cell lymphomas of T cell phenotype (T-LCL) are uncommon, heterogeneous in histological appearance and clinical behavior, and commonly characterized as peripheral T cell lymphomas unspecified in the Revised European-American Lymphoma classification. A subset of these tumors have angioinvasive and angionecrotic features. Clinical presentation comprises solitary or localized nodules, multiple cutaneous lesions, and nodular and/or ulcerating tumors. Systemic disease is uncommon at presentation, but recurring skin tumors and systemic progression during the course of illness are usual. In a series of 18 patients with T-LCL, 16 died 1-56 months (median 23 months) after diagnosis. The immunoblastic variant of T-LCL appeared to have the worst prognosis.166 Localized tumors respond to external radiation in conventional dose; however, disease progression in skin sites beyond the radiation field and systemic dissemination are frequent. Initial chemotherapy, combined modality therapy and high-dose therapy as part of initial therapy or salvage have not provided a satisfactory management approach for the majority of patients with this disease. A distinct entity, CD 30-positive large cell lymphoma (anaplastic large cell lymphoma; ALCL) requires distinction within the entity of T-LCL. Although commonly of T cell phenotype, CD 30+ ALCL may also be of B cell or null-cell phenotype. Characteristically, CD 30+ ALCL presents as two clinical forms, which not readily distinguishable by histology alone. 1 A relatively benign, indolent cutaneous disease, demonstrating solitary or multiple, recurring, selfhealing, non-ulcerating lesions. Lesions are responsive to modest doses of radiation. This entity- lymphomatoid papulosis-like ALCL has a good prognosis, requires minimal therapeutic intervention and rarely demonstrates systemic disease progression.167,168 2 An aggressive disease, commonly nodal in presentation, but involving the skin as solitary or multiple lesions at presentation or subsequent disease progression - ALCL-like CD 30+ lymphoma. This entity has a rapid and aggressive natural history, but is highly responsive to multiagent chemotherapy, and demonstrates an appreciable cure rate with anthracycline-based induction regimens with or without high-dose intensification. It is readily apparent that the CD 30+ phenotype clearly distinguishes a much more favorable variant of T cell large cell lymphomas. CD 30-negative tumors, particularly of large cell/immunoblastic type are highly lethal with no clear indication yet of an effective therapeutic strategy. In addition, the t2:5 translocation also

262 Localized non-Hodgkin's lymphoma

appears to distinguish a less favorable group within the CD 30+ ALCL phenotype, being more commonly associated with the nodal form of ALCL or cutaneous large cell lymphoma secondary to systemic dissemination.169 A final distinct clinico-pathological entity are the T cell lymphomas of low-grade, small lymphocytic type (mycosis fungoides/Sezary syndrome), which constitute approximately 65 per cent of all primary skin lymphomas. These entities are discussed in Chapter 26.

MEDIASTINAL (THYMIC) LARGE CELL There has been controversy as to whether this lesion should be considered a separate entity, but the clinicopathological features have certain characteristics distinguishing this tumor from nodal lymphoma.170,171 Disease presents as a rapidly growing invasive tumor with contiguous spread within mediastinal tissues. Pleural and pericardial invasion with effusion and B symptoms are common, and 30-40 per cent of patients have superior vena caval obstruction at diagnosis. The lesion is frequently bulky (65 per cent being greater than 10 cm diameter) and involves the thymus. Sufficient tissue for phenotypic and genotypic studies is mandatory as the differential diagnosis includes Hodgkin's disease, lymphoblastic lymphoma, thymoma, germinoma/teratoma and Castleman's disease. Mediastinal large cell lymphoma is confined to the thorax in three-quarters of patients but is commonly extensive. Tumors typically have moderate to marked sclerosis with a large cell malignant infiltrate demonstrating some pleomorphism. Malignant cells are of B lineage, but clonal surface and cytoplasmic immunoglobulin expression are uncommon. Occasional T cell tumors are recognized. The outcome for patients with this tumor, treated by chemotherapy, or chemotherapy and RT, is equivalent to other large cell lesions of equivalent stage, i.e. complete remission rates of 70-80 per cent and overall 5-year survival of 50 per cent. Occasionally these tumors have demonstrated marked chemoresistance and radioresistance. Factors determining outcome include bulk (>10 cm), the use of chemotherapy and RT, and stage (extrathoracic versus localized).

SUMMARY The term localized non-Hodgkin's lymphoma encompasses an exceptionally heterogeneous group of diseases that may affect any organ or body part. It is unclear why some sites or organs are affected more than others. However, the role of antigenic stimulation, autoimmunity and immune dysregulation as an important component of the etiology and pathogenesis of non-Hodgkin's lymphoma is becoming increasingly recognized through

observations relating to congenital and acquired immunodeficiency states, Hashimoto's and Sjogren's syndrome, Crohn's disease, intestinal immunoproliferative disease and the role of Helicobacter pylori in MALT lymphoma. Knowledge arising from a more complete understanding of the biology and the genetic basis of lymphoma will undoubtedly lead to improved recognition of distinct clinical entities and refinements in patient management. The experience available to guide management of patients with localized nodal and primary extranodal lymphomas is limited. Large retrospective studies are available for nodal and commonly encountered lymphomas (GI tract, Waldeyer's ring, bone, orbital and thyroid lymphoma), while only infrequent case reports are available in uncommon presenting sites (adrenal, liver, spleen, etc.). Treatment results and the curability of some tumors may be obscured by the heterogeneity of presentations. Future studies of different treatment strategies recognizing distinct histopathologic entities may help to clarify the outcome. In summary, although their clinical behavior may differ, the principles of therapy of localized nodal and primary extranodal non-Hodgkin's lymphoma are similar. The choice of local versus systemic therapy is established by considering histologic type and tumor characteristics, including disease extent and bulk. In general, low-grade lymphomas are treated with RT alone, and intermediateand high-grade lymphomas are treated with chemotherapy followed by RT. The choice of brief chemotherapy followed by RT, a full curative course of chemotherapy followed by adjuvant RT, or chemotherapy alone is based chiefly on tumor bulk, the presence of adverse prognostic factors, such as B symptoms and high LDH, and the anatomic extent of disease. Special consideration has to be given to organs where curative doses of RT compromise function. CNS prophylaxis with intrathecal methotrexate or cytarabine may be necessary in patients with testis lymphoma and tumor involving parameningeal sites. These principles are most important in cases of primary extranodal lymphomas involving rare sites, where the available literature may not reflect the optimal approach. An attempt has been made to summarize the principles of management of lymphoma that allow an appropriate treatment strategy for lymphoma presenting in any organ or site. However, further refinements in the management of these diseases are required to maximize cure rates, and to reduce immediate and long-term morbidity of the disease and its treatment. Gains in our understanding of the genetic and molecular basis of non-Hodgkin's lymphoma have to be translated into medical practice to benefit patients with malignant lymphoma. Such improvements can only be achieved through prospective clinical trials, which, owing to the infrequent occurrence of each disease, will require international collaboration.

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References 267 126. Kennedy], Nathwani B, BurkeJ. Pulmonary lymphomas and their pulmonary lymphoid lesions: a clinics pathologic and immunologic study of 64 patients. Cancer 1985; 56: 539-52. 127. DeAngelis L. Current management of primary central nervous system lymphoma. Oncology 1995; 9: 63-71. 128. Dorreen MS, Ironside JW, BradshawJD, Jakubowski J, Timperley WR, Hancock BW. Primary intra-cerebral lymphoma: a clinico-pathological analysis of 14 patients presenting over a 10 year period in Sheffield. Quart J Med 1988; 67: 387-404. 129. Cappellani G, Giuffre F, Tropea R, et al. Primary spinal epidural lymphomas. Report of ten cases. J Neurosurg Sd 1986; 30:147-51. 130. Lachance D, Brizel D, Gockerman J, et al. Cydophosphamide, doxorubicin, vincristine, and prednisone for primary central nervous system lymphoma: short-duration response and multifocal intracerebral recurrence preceding radiotherapy. Neurology 1994; 44:1721-7. 131. Schiff D, Suman VJ, Yang P, Rocca WA, O'Neill BP. Risk factors for primary central nervous system lymphoma. A case-control study. Co/?cer1998; 82: 975-82. 132. DeAngelis L, Yahalom J, Heinemann M, Cirrincione C, Thaler H, Krol G. Primary CMS lymphoma: combined treatment with chemotherapy and radiotherapy. Neurology 1990; 40: 80-6. 133. Laperriere NJ, Cerezo L, Milosevic MF, Wong CS, Patterson B, Panzarella T. Primary lymphoma of brain: results of management of a modern cohort with radiation therapy. Radiother Oncol 1997; 43: 247-52. 134. Hough RE, Smith CML, Nakielny RA, etal. Primary intracerebral lymphoma: a clinico-pathological study of 28 patients Int J Oncol 1999; 14: 647-52. 135. Nelson D, Martz K, Bonner H, etal. Non-Hodgkin's lymphoma of the brain: can high dose, large volume radiation therapy improve survival? Report on a prospective trial by the Radiation Therapy Oncology Group (RTOG): RTOG 8315. Int J Radial Oncol Biol Phys 1992; 23: 9-17. 136. Miller DC, Hochberg FH, Harris NL, Gruber ML, Louis DN, Cohen H. Pathology with clinical correlations of primary central nervous system non-Hodgkin's lymphoma. Cancer 1994; 74:1383-97. 137. Krogh-Jensen M, d'Amore F, Jensen M, etal. Incidence, clinicopathological features and outcome of primary central nervous system lymphomas. Population-based data from a Danish lymphoma registry. Danish Lymphoma Study Group, LYFO. Ann Oncol 1994; 5: 349-54. 138. Berry M, Simpson W. Radiation therapy in the management of primary malignant lymphoma of the brain. IntJ Radial Oncol Biol Phys 1981; 7: 55-9. 139. DeAngelis L, Yahalom L, Thaler H, Kher U. Combined modality therapy for primary CNS lymphoma. J Clin Oncol 1992; 10: 635-43. 140. Socie G, Piprot-Chauffat C, Schlienger M, et al. Primary

lymphoma of the central nervous system. Cancer 1990; 65: 322-6. 141. Abrey LE, DeAngelis LM, Yahalom J. Long-term survival in primary CNS lymphoma. J Clin Oncol 1998; 16: 859-69. 142. Neuwelt E, Goldman D, Dahlborg S, et al. Primary CNS lymphoma treated with osmotic blood-brain barrier disruption: prolonged survival and preservation of cognitive function. J Clin Oncol 1991; 9:1580-90. 143. Sandor V, Stark-Vanes V, Pearson D, etal. Phase II trial of chemotherapy alone for primary CNS and intraocular lymphoma. J Clin Oncol 1998; 16: 3000-6. 144. Schultz C, Scott C, Wasseman T. Pre-irradiation chemotherapy (CTX) with Cytoxan, Adriamycin, vincristine, and Decadron (CHOD) for primary central nervous system lymphomas (PCNSL): Initial Report of Radiation Therapy Oncology Group (RTGG) protocol 88-06. ProcAm Soc Clin Oncol 1994; 13:174. 145. Bessell EM, Graus F, Punt JAG, etal. Primary nonHodgkin's lymphoma of the CNS treated with BVAM or CHOD/BVAM chemotherapy before radiotherapy. 7 Clin Oncol 1996; 14: 945-54. 146. BlayJ-Y, ConroyT, Chevreau C, etal. High-dose methotrexate for the treatment of primary cerebral lymphomas: analysis of survival and late neurologic toxicity in a retrospective series. 7 Clin Oncol 1998; 16:864-71. 147. DeAngelis L. Primary central nervous system lymphoma [Review]. Rec Results Cancer Res 1994; 135:155-69. 148. Pollack I, Lunsford L, Flickinger I, Dameshek H. Prognostic factors in the diagnosis and treatment of primary central nervous system lymphoma. Cancer 1989; 63: 939-47. 149. Qualman S, Mendelsohn G, Mann RB, Green WR. Intraocular lymphoma: natural history based on a clinicopathologic study of eight cases and review of the literature. Cancer 1983; 52: 878-86. 150. Corriveau C, Fasterbrook M, Payne D. Intraocular lymphoma and the masquerade syndrome. CanJ Opthalmol 1986; 21:144-49. 151. Michelson J, Michelson P, Borden G, Chisari F. Ocular reticulum cell sarcoma. Arch Ophthalmol 1981; 99: 1409-12. 152. Trudeau M, Shepherd F, Blackstein M, Gospodarowicz M, Fitzpatrick P, Moffat KP. Intraocular lymphoma: report of three cases and review of the literature. Am J Clin Oncol 1988; 11: 126-30. 153. Strauchen J, Dalton J, Friedman A. Chemotherapy in the management of intraocular lymphoma. Cancer 1989; 63:1918-21. 154. Rathmell AJ, Gospodarowicz MK, Sutcliffe SB, etal. Localized extradural lymphoma: survival, relapse pattern and functional outcome. The Princess Margaret Hospital Lymphoma Group. Radiother Oncol 1992; 24: 14-20. 155. Eeles R, O'Brien P, Horwich A, Brada M. Non-Hodgkin's lymphoma presenting with extradural spinal cord compression: functional outcome and survival. BrJ Cancer 1991; 63:126-9.

268 Localized non-Hodgkin's lymphoma 156. Mackintosh F, Colby T, Podolsky W, et al. Central nervous system involvement in non-Hodgkin's lymphoma: an analysis of 105 cases. Cancer 1982; 49: 586-95. 157. Rijlaarsdam J, Willemze R. Primary cutaneous B-Cell lymphomas [Review]. Leuk Lymphoma 1994; 14: 213-18. 158. Willemze R, Beljaards R, Rijlaarsdam U. Classification of primary cutaneous large cell lymphomas [Review]. Dermatol Clinics 1994; 12: 361-73. 159. Willemze R, Beljaards R, Rijlaarsdam U. Classification of primary cutaneous T-cell lymphomas [Review]. Histopathology 1994; 24: 405-15. 160. Jaffe ES, Burg G. Report of the symposium on Cutaneous Lymphomas: Sixth International Conference on Malignant Lymphoma. Ann Oncol 1997; 8(suppl 1): 83-4. 161. Slater D. MALT and SALT: the clue to cutaneous B-cell lymphoproliferative disease. BrJ Dermatol 1994; 131: 557-61. 162. Garbe C, Stein H, Dienemann D, Orfanos C. Borrelia bwrgdo//e/7-associated cutaneous B cell lymphoma: clinical and immunohistologic characterization of four cases. J Am Acad Dermatol 1991; 24: 584-90. 163. Harris N, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 164. Chow VT. Cancer and viruses. Ann Acad Med Singapore 1993; 22:163-9. 165. Kurtin P, DiCaudo D, Habermann T, Chen M, Su W. Primary cutaneous large cell lymphomas. Morphologic,

immunophenotypic, and clinical features of 20 cases. Am J Surg Pathol 1994; 18:1183-91. 166. Beljaards R, Meijer C, Putte SVD, et al. Primary cutaneous T-cell lymphoma: clinicopathological features and prognostic parameters of 35 cases other than mycosis fungoides and CD30-positive large cell lymphoma. J Pathol 1994; 172: 53-60. 167. Lindholm J, Barren D, Williams M. Ki-1 positive cutaneous large cell lymphoma of T-cell origin. Report of an indolent subtype. J Am Acad Dermatol 1989; 20: 342. 168. Beljaards R, Kaudewitz P, Berti E, etal. Primary cutaneous CD30-positive large cell lymphoma: definition of a new type of cutaneous lymphoma with a favorable prognosis. A European Multicenter Study of 47 patients. Cancer 1993; 71: 2097-104. 169. DeCoteauJF, ButmarcJR, Kinney MC, Kadin ME. The t(2;5) chromosomal translocation is not a common feature of primary cutaneous CD30+ lymphoproliferative disorders: comparison with anaplastic large-cell lymphoma of nodal origin. Blood 1996;87:3437-41. 170. Rodriguez L, Pugh WC, Romaguera JE, Luthra R, Hagemeister FB, McLauglin P. Primary mediastinal large cell lymphoma is characterised by an inverted pattern of large tumoral mass and low beta 2 microglobulin levels in serum and frequently elevated levels of serum lactate dehydrogenase. Ann Oncol 1994; 5: 847-9. 171. Lamarre L, Jacobson JO, Aisenberg AC, etal. Primary large cell lymphoma of the mediastinum. A histologic and immunophenotypic study of 29 cases. Am J Surg Pathol 1989; 13: 730-9.

19 Advanced Hodgkin's disease BW HANCOCK ANDPJSELBY

Introduction Stage IMA Hodgkin's disease Advanced Hodgkin's disease Use of maintenance chemotherapy Use of MOPP-like regimens Use of MOPP alternatives Use of alternating regimens Use of hybrid regimens

269 270 270 270 271 272 274 274

INTRODUCTION The dismal prognosis previously associated with the diagnosis of advanced Hodgkin's disease was irrevocably altered by the dramatic results first reported by De Vita and co-workers using the now famous cyclical four-drug MOPP combination (see Table 19.2).' With longer follow-up of this population, the possibility of cure was realized in over half of those treated.2 Nevertheless, a proportion of patients appear destined to fail treatment. Either complete remission is not achieved with first-line induction therapy or patients subsequently relapse after apparent successful eradication of disease. Many such patients ultimately die as a direct consequence of progressive Hodgkin's disease. As a result, work continues at major treatment centers (Table 19.1) to enhance the results of existing treatment programs, but also to develop new drug and radiotherapy combinations and to find new ways of delivering such therapy. This work has been conducted along two lines: through controlled randomized clinical trials; and through the retrospective analysis of patients who have completed treatment. This chapter is concerned chiefly with the findings of the former studies, although both have offered valuable guides to the design of subsequent studies, and reference will be made to retrospective analysis where appropriate. Comparing different trials is fraught with difficulty: patient numbers are often too small; the results from single-institution selective studies are generally better than those from co-operative groups;

Combined modality therapy Conclusions Salvage therapy Novel therapies New drugs Pregnancy References

275 276 277 278 279 279 279

different indices of response and survival are chosen in describing results; and lengths of follow-up (important Table 19.1 Lymphoma groups studying the treatment of advanced Hodgkin's disease Barts BNLI CALGB Christie CLG ECOG EORTC GATLA GELA GHSG Marsden MDA MSKCC NCI NCI NLG NLSG NTI SECSG Stanford SWOG WCOG WCSG Yale

St Bartholomew's Hospital, UK British National Lymphoma Investigation, UK Cancer and Leukemia Group B, USA Christie Hospital, UK Central Lymphoma Group, UK Eastern Co-operative Oncology Group, USA European Organisation for Research and Treatment of Cancer Grupo Argentine de Tratamiento de Leucemia Aguda, Argentina Group d'Etude Lymphome Adulte, France German Hodgkin's Study Group, Germany Royal Marsden Hospital, UK MD Anderson Cancer Center, USA Memorial Sloan Kettering Cancer Center, USA National Cancer Institute, Canada National Cancer Institute, USA Norwegian Lymphoma Group Nebraska Lymphoma Study Group National Tumor Institute, Italy South Eastern Cancer Study Group, USA Stanford University Medical Center, USA South West Oncology Group, USA West Coast Oncology Group, USA Western Cancer Study Group, USA Yale Cancer Center, USA

270 Advanced Hodgkin's disease

in a disease with a long natural history) are varied. Additionally, overall survival may or may not include death from other causes. Thus, only broad comparisons are possible.

STAGE MIA HODGKIN'S DISEASE The management of stage IIIA Hodgkin's disease has posed special problems, principally as a result of its watershed position between limited and advanced stages. In two respects it fulfills criteria of both stages: the Hodgkin's disease still being confined to lymph nodes, yet having spread to both sides of the diaphragm. Moreover, at one time the outlook for patients with Stage III Hodgkin's disease was as unfavorable as those with more advanced illness. Subsequently, the introduction of total nodal irradiation (TNI) provided the first means by which such patients could be cured of their disease.3'7 Nevertheless, initial enthusiasm was tempered by results that indicated that, in general, both survival and freedom of relapse were still less favorable than in early-stage disease.8,9 Attempts have been made to subdivide Stage III Hodgkin's disease according to the anatomical extent of disease. Disease limited to the spleen and/or upper abdominal nodes was designated substage III1; involvement of low abdominal nodes was designated substage III2 regardless of whether or not this was in addition to upper abdominal disease. In a partly randomized, partly retrospective analysis, Desser and his colleagues studied the outcome of patients in these subgroups and demonstrated better survival for patients at substage III, than III2, the respective 5-year figures being 93 per cent and 57 per cent.8 The concept of prognostically significant substages of IIIA was further followed-up in two subsequent studies: one a prospective clinical trial, the other a retrospective review of a large number of patients treated at several centers in the United States.10,11 Both confirmed the value of sub-staging. However, the Stanford group were unable to confirm this but identified a group of patients in whom prognostic distinctions could be made on the extent of splenic infiltration with .Hodgkin's disease found at laparotomy.12 Similar conclusions were reached by United Kingdom Lymphoma Investigation.13 On the other hand, Neeley et al. applied the Stanford criteria of splenic involvement to the distribution of substages, in patients treated in Chicago.12 Using these criteria, threequarters of substage II^A patients were found to have extensive splenic disease and over half of substage III2A patients had minimal involvement of the spleen, suggesting that the patient subgroups were biologically identical, although defined differently. Most of these early studies were complicated by the heterogeneity of investigation (particularly the role of pathological as

opposed to clinical staging) and treatment (varying from TNI to chemotherapy alone to combined modality therapy). With the advent of computed tomography (CT) scanning, the virtual demise of lymphangiography and diagnostic laparotomy and splenectomy, together with the apparent rarity of Stage III a'nd the feeling that radiotherapy alone is inadequate treatment to secure longterm remissions in the majority of instances, it is now generally felt that this stage should be treated primarily with chemotherapy as with other patients with 'advanced' Hodgkin's disease.

ADVANCED HODGKIN'S DISEASE Despite the conspicuous success of the MOPP regimen, two factors have led many groups of workers to devise other drug combinations (Table 19.2): • the considerable short-term morbidity of MOPP (particularly nausea, vomiting and phlebitis); • the realization that up to half the patients will ultimately fail this therapy. Many studies aimed at surmounting these problems have been reported; broadly they can be grouped into the following lines of approach: • the use of maintenance chemotherapy beyond complete remission; • the use of MOPP-like regimens in which the principal toxic drug mustine is substituted by an alternative alkylating agent; • the use of chemotherapy combinations comprising drugs of quite distinct pharmacological properties from those used in MOPP; • the addition of radiotherapy in a combined modality treatment plan; • the use of alternating 'non-cross-resistant' combination regimens; • the use of hybrid 'non-cross-resistant' combination regimens.

USE OF MAINTENANCE CHEMOTHERAPY In the early years of MOPP chemotherapy, the value of maintenance after induction and consolidation chemotherapy was assessed in randomised studies by the NCI, where patients were randomly allocated to receive either no further treatment, two cycles of MOPP every 3 months for 15 months, or BCNU (carmustine) given as a single drug every 3 months for 15 months. The study was stopped when it became apparent that no survival advantage was demonstrated to any of the groups.14 In the BNLI study15,16 where patients were randomized to maintenance with CVB every 3 months for 12 months, or to no further

Use of MOPP-like regimens 271

Table 19.2 Some chemotherapy acronyms in Hodgkin's disease

ABOD ABVD B-CAVe BAVS (ABOS) BCNU-VPP BCVPP BCVPP-Bleo BEACOPP BMOPP BOPP CABS

CAD CCNU-VP ChlVPP

CVB COPP CVPP CVPP

60 44 113 35 33 19 56 77 15 21 59 65 42 28 15 91 26 27

EVA

110,111

EVAP

61 40 109 4 1 18 36 84 147 62 125

LOPP MIME MOP-BAP MOPP MOPP-Bleo MVPP MVVPP NOVP PABIOE PACE/BOM

VAPEC-B

34,43 148

VBM

126

PAVe

Adriamycin (doxorubicin), bleomycin, Oncovin (vincristine), dacarbazine Adriamycin (doxorubicin), bleomycin, Velbe (vinblastine), dacarbazine Bleomycin, CCNU (lomustine), Adriamycin (doxorubicin), vinblastine Bleomycin, Adriamycin (doxorubicin), vincristine, streptozocin BCNU (carmustine), vinblastine, procarbazine, prednisolone BCNU (carmustine), cyclophosphamide, vinblastine, procarbazine, prednisolone BCVPP-bleomycin Bleomycin, etoposide, Adriamycin (doxorubicin)-COPP Bleomycin-MOPP BCNU (carmustine), Oncovin (vincristine), procarbazine, prednisolone CCNU (lomustine), Adriamycin (doxorubicin), bleomycin, streptozocin CCNU (lomustine), Alkeran (melphalan), desacetyl vinblastine amide sulfate (vindesine) CCNU (lomustine), vinblastine, prednisolone Chlorambucil, vinblastine, procarbazine, prednisolone CCNU (lomustine), vinblastine, bleomycin Cyclophosphamide, Oncovin (vincristine), procarbazine, prednisolone Cyclophosphamide, vinblastine, procarbazine, prednisolone CCNU (lomustine), vinblastine, procarbazine, prednisolone Etoposide, vinblastine, Adriamycin (doxorubicin) Etoposide, vinblastine, Adriamycin (doxorubicin), prednisolone Leukeran (chlorambucil), vinblastine, procarbazine, prednisolone Methyl GAG, ifosfamide, methotrexate, etoposide MOP-bleomycin, Adriamycin (doxorubicin), prednisolone Mechlorethamine (mustine), Oncovin (vincristine), procarbazine, prednisolone MOPP- bleomycin Mustine (mechlorethamine), vinblastine (Velbe), procarbazine, prednisolone Mechlorethamine (mustine), vincristine, vinblastine, procarbazine, prednisolone Novantrone (mitoxantrone), Oncovin (vincristine), Velbe (vinblastine), prednisolone Prednisolone, Adriamycin (doxorubicin), bleomycin, Oncovin (vincristine) Prednisolone, Adriamycin (doxorubicin), cyclophosphamide, etoposide, bleomycin, Oncovin (vincristine), methotrexate Procarbazine, Alkeran (melphalan), vinblastine Vincristine, Adriamycin (doxorubicin), prednisolone, etoposide, cyclophosphamide, bleomycin Vinblastine, bleomycin, methotrexate

treatment, again no survival advantage was seen. Certainly the overwhelming body of evidence does not support the theoretical advantage of maintenance chemotherapy beyond remission induction.17'22 As a result, the use of maintenance chemotherapy has been dropped by almost all treatment centers around the world. It is generally agreed that a minimum of six cycles of conventional chemotherapy are sufficient; attempts to shorten this are being evaluated23 but as yet benefits are unproven.

USE OF MOPP-LIKE REGIMENS The role of prednisolone in the MOPP combination had never been conclusively resolved. The original MOPP regimen used prednisolone only in the first and fourth cycles of treatment;1 however, many other centers have modified the regimen to include the steroid in every cycle of treatment. In the large retrospective Stanford

review24 there was no disadvantage demonstrated to those patients who had never received prednisolone during induction. The complete response rates were nearly identical. On the other hand, the BNLI in a prospective partially randomized study demonstrated a striking difference in complete response rates in those patients treated with steroids. Additionally, these patients had a survival advantage.15'16'25 The main way in which MOPP has been varied is by substitution of the putatively most toxic agent (mustine) by another alkylating agent. In various regimens (see Table 19.2), cyclophosphamide,26 CCNU (lomustine),27 chlorambucil,28-30 BCNU (carmustine)21'31-34 and melphalan (Alkeran)35 have been substituted. Often vincristine and vinblastine have been interchanged36 and the most commonly added cytotoxic has been bleomycin.15'18 Of the randomized studies, the CALGB substituted BCNU (carmustine) for mustine with identical complete remission (CR) and overall survival.21'35 This study also randomized to two three-drug regimens (in which either

272 Advanced Hodgkin's disease

procarbazine or the alkylating agent was removed); the three-drug schedules were significantly inferior on all response and survival parameters. The ECOG substituted vinblastine for vincristine and instead of mustine used both BCNU and cyclophosphamide.19'37 They found improved freedom from relapse for BCVPP but overall survivals were similar; BCVPP was, however, less toxic. The SWOG added bleomycin to MOPP and their initial favorable results, both in terms of the remission rate and overall survival, led them to conclude that the addition of low-dose bleomycin to MOPP (MOPP-Bleo) should be the basis for their future studies.4,18 Addition of doxorubicin (adriamycin) to this regimen (MOPP/BAP) improved the CR rate but no significant differences were seen in survival although MOPP/BAP proved superior in prognostically more favourable patients.4,38The BNLI also added bleomycin to MOPP; although the CR rates were better for BMOPP, overall survival data are similar after long-term follow-up.15,16 The BNLI followed this study by substituting mustine in MOPP with chlorambucil (Leukeran).39 This ensued from the finding of McElwain and his colleagues that substituting chlorambucil for

mustine in the MVPP regimen (i.e. ChlVPP) gave equally good results, yet was far less toxic for the patients.28 The BNLI randomized study confirmed these data, which still hold good with long-term follow-up.39-41 The WCSG, in a small study, found that substituting CCNU for mustine and procarbazine, improved remission and survival, but the results were not significantly different.42 Stanford substituted Alkeran for mustine in their PAVe/radiotherapy regimen and found this effective and well tolerated.34,43 From such studies we can conclude that substitution of mustine by other agents gives results as good as those for MOPP with less short-term toxicity. The addition of drugs such as bleomycin and/or doxorubicin may give marginal improvements. Prednisolone seems to be an essential component of the regimen.

USE OF MOPP ALTERNATIVES (Table 19.3) Doxorubicin-containing regimens (such as ABVD) were originally developed as second-line regimens for

Table 19.3 Advanced Hodgkin's disease: comparison between MOPP and other regimens

64

58 78

MOPP-Bleo became standard for subsequent studies

77 (P = 0.05)

61 (5 years) 66

60 68

MOP-BAP superior in prognostically more favorable patients

MOPP BOPP

63 67

1 Approx. 55 j(5 years)

Upprox. 50

No significant differences

91 IV

MOPP MOP

69 36

—

60 (5 years) 30 (P< 0.01)

Prednisolone essential

1976-1979 (15)

166 MB, III IV

MOPP B-MOPP

51 65

60 (10 years)

39

Similar survival data

70

42

1979-1983 (15,39-41)

299 III, IV

MOPP LOPP

63 57

60 (10 years)

52 54

LOPP less toxic

55

ECOG

1972-1976 (19,37)

293 III, IV

MOPP BCVPP

73 77

50 (5 years) 65 (P = 0.02)

61 65

Overall survival similar. BCVPP less toxic

NTI

1973-1974 (45, 46)

76IIB-IVB

MOPP ABVD

63 71

50 (10 years)

39 54

ABVD probably superior

63

1974-1982 (46, 47)

232 MB, III

3 MOPP/RT/ 3 MOPP 3 ABVD/RT/ 3 ABVD

81

76 (10 years)

64

Long term toxicity less with ABVD

92 p<002

87 (P = 0.03)

71

MOPP CCNU-VP

41 72

MOPP MOPP-Bleo

70 84

MOPP-Bleo MOP-BAP

207 IIIB-IVB

1970-1975 (15,16)

1965-1974 (4,18)

162 IIIB-IVB

1974-1978 (4, 38)

315MIB-IVB

CALGB

1969-1972 (21)

BNLI

SWOG

WSCG

1973-1978 (42)

Stanford 1974-1980 (34, 43)

47 II-IVB

115IIE, IMA/B

PAVe/RT MOPP/RT

67

53 (3 years)

45 (6 years)

82 (10 years)

81

60

No significant differences. CCNU-VP less toxic

75 78

PAVe as good and less toxic than MOPP

CR = complete response rate, FFR = freedom from relapse, OS = overall survival, RT = radiotherapy.

Use of MOPP alternatives 273

than reported by the NCI.50 Bonadonna, however, concluded that ABVD is less myelotoxic than MOPP and, therefore, it is easier to deliver full-dose chemotherapy with anthracycline-based rather than with alkylating agent-based regimens.46 However, ABVD does produce severe nausea and vomiting, hence multidrug regimens containing etoposide but not dacarbazine have been developed, usually as salvage regimens. Some of these may be as efficacious as ABVD in untreated patients but this has not been established in randomized studies.

MOPP failures44 but have also been used for initial therapy. The long-term efficacy for ABVD is at least that of MOPP, but it has a different spectrum of acute and chronic toxicity.45-47 ABVD contains no alkylating agent and, therefore, does not cause sterility, and is associated with an extremely low risk of secondary leukaemia. The CALGB showed that ABVD resulted in superior remission rates and failure-free survival rates compared with MOPP. As yet there is no improvement in overall survival.48,49 The study has been criticized in that MOPP was delivered at a lower dose intensity

Table 19.4 Alternating combination chemotherapy in advanced Hodgkin's disease

NTI

1974-1980 (46, 52-54)

88IVAand B

SECSG

1975-1981

212 1MB, IV 6BVCPP-Bleo 3 BVCPP-Bleo, 3 ABVD)

(56, 57)

CALGB

1975-1981 (35, 58)

1982-1987 (48, 49, 99)

12 MOPP 6 MOPP, 6 ABVD

74 89

Approx. 73

46 (10 years) 58 68 (P< 0.02) 69

Overall survival not now significantly different

68 (5 years) 77

62 64

No clear advantage to alternating regimen

113: all relapsed after prior RT

12CVPP 12 BAVS 6 CVPP + 6 BAVS

72 70 82

50 (5 years) 59 57

55 61 68

No significant differences seen

361 IIIA2, IIIB, IV

6 MOPP

66

6 MOPP, 6 ABVD 6AVBD

67 (P< 0.01) 50 (5 years) (P = 0.02) 83 65 82 61

75 73

Significantly inferior freedom from progression for MOPP compared with other regimens (P=0.01 at 8 years)

91 92

68 54

NCI, USA

1978-1988 (59)

125111,1V

6 MOPP 3 MOPP, 3 CABS

MSKCC

1979-1984 (64,65)

12811,111, IV

3 MOPP, 3 ABV, 3CAD + R T 5 MOPP, 4 ABVD + RT

65 (12 years) 72

7 A

p 8

p 3

6 r o ( 3

8 0 x . 90 years) 90

N o comparison with MOPP alone

EORTC

1981-1986 (55)

192 IIIB, IV 8 MOPP 2 MOPP x 2, 2AVBDx2

57 59

61 (6 years) 69

BNLI

1983-1989 (41,61)

594 IB, MB, 8 LOPP III,IV 4LOPP, 4EVAP

57 64ns

52 (5 years) 66 66 (P < 0.001 75 (P<0.05)

Alternating therapy superior as initial therapy

NLG

1985-1991 (60)

100 III, IV

6ChlVPP 3CMVPP/ 3ABOD

80 80

68 (5 years) 69

No significant differences

BNLI/CLG

1992-1996 (63)

682 IB, MB, 6 PABIOE III, IV (604 at 3ChlVPP/ interim 3 PABIOE analysis)

60 75

57 65

MOPP/CABS more toxic

81 80

Alternating therapy (2 monthly) improved progression-free survival

89 (2 years) Significantly inferior freedom from progression 93 at 2 years for PABIOE (52%) compared with alternating regimen (72%)

CR = complete response rate, FFR = freedom from relapse, OS = overall survival, ns = not significant, RT = radiotherapy.

274 Advanced Hodgkin's disease

USE OF ALTERNATING REGIMENS (Table 19.4) Theoretically the major problem with the regimens described above is the possibility of chemotherapy resistance. The Goldie-Coldman somatic mutation hypothesis51 predicts that the early introduction of multiple agents should reduce this problem, thereby increasing response rates and the durability of these responses. The Milan (NTI) group have led the field in such studies. Earlier results suggested that alternating MOPP and ABVD gave significantly improved survival data when compared with MOPP alone.52'53 Long-term follow-up, however, shows no significant differences in overall survival46'54 but it is worth commenting that a half of the MOPP patients ultimately received ABVD. The CALGB, who have compared MOPP, ABVD and MOPP alternating with ABVD, showed that ABVD is as good as alternating therapy, and that both are better than MOPP in CR and freedom from relapse data.48'49 The EORTC, who compared MOPP with MOPP/ABVD (using twomonthly alternations), showed improved progressionfree survival for the alternating regimen, although the data for overall survival were not significantly different.55 Other alternating regimens have been studied in randomized comparisons. BVCPP-Bleo alternating with ABVD was not superior to BVCPP-Bleo alone in the SECSG study56,57 and, in one of their earlier studies, CALGB confirmed that CVPP, BAVS and alternating CVPP/BAVS gave virtually identical survival figures.35,58 The NCI compared MOPP with MOPP/CABS and found MOPP/CABS more toxic with no improved efficacy.59 Alternating ABOD with ChlVPP gave identical results in the hands of the NLG.60 The only other study to show a significant advantage to alternating therapy was the BNLI LOPP/EVAP regimen. This proved superior to conventional (LOPP) chemotherapy in both relapse-free and overall survival.41,61 Analysis of the 680 evaluable patients on the BNLI/CLG ChlVPP/PABlOE62,63 versus PABlOE study shows significant differences in complete response and progression-free survival in favor of the alternating arm, and a strong suggestion that the overall survival in the alternating treatment arm will be better (P = 0.05). This finding seems to contrast with the CALGB data48,49 where the use of an anthracycline-containing regimen different to MOPP (in this case ABVD) seems to be the enhancing factor, rather than the philosophy of alternation. However, there are other differences between PABlOE and ABVD (in particular the use of oral etoposide instead of dacarbazine) and PABlOE alone cannot be recommended for first-line therapy in advanced disease.63 Multi-alternating regimens have also been tested. The MSKCC compared CAD/MOPP/ABV with MOPP/ ABVD (both arms with added 'bulk' radiotherapy) with nearly identical results.64,65 The GHSG have found no

difference in remission and survival rates in a comparison of a rapidly alternating 11-drug chemotherapeutic regimen with a standard alternating regimen.66

USE OF HYBRID REGIMENS (Table 19.5) A further extension of the multiagent approach has been the development of hybrid regimens in which seven or eight of the most active drugs are introduced into each cycle. Although initial results using MOPP/ABV(D) hybrid regimens were encouraging,67 longer term data from the NCI, Canada, and NTI, Italy, show no significant differences between hybrid and alternating therapy in their randomized studies, survival curves were virtually identical.46,68-71 However, a United States Intergroup study still shows improved failure-free and overall survival for hybrid chemotherapy compared with sequential MOPP/ABVD.72,73 The hybrid arm, although having more acute toxicity, was associated with a lower incidence of acute leukemia or myelodysplasia. The BNLI aborted its study of alternating (LOPP/EVAP) versus hybrid (LOPP/EVA) chemotherapy just 18 months into the study when it was found that the CR rate for the hybrid was significantly inferior, although 2-year survival data for this study showed no significant differences.74 The Christie/Barts (UK) group conducted a large study comparing ChlVPP/EVA hybrid with their standard MVPP regimen. Recently reported results show a significantly improved freedom from progression with the hybrid regimen.75 Also interim results from the GHSG trial comparing alternating COPP/ABVD with hybrid BEACOPP are showing significant superiority for the hybrid regimen in freedom from progression and also in freedom from treatment failure.76 In an analysis of these data presented at the Fourth International Symposium in Cologne, Diehl and co-workers77 reported complete remission rates of 83 per cent (COPP/ABVD), 88 per cent (BEACOPP) and 95 per cent (BEACOPP, with substantial dose escalation supported by granulocyte colony stimulating factor; G-CSF). These differences were associated with significantly lower earlier rates of disease progression in the escalated BEACOPP treatment arm and an early trend to better overall survival in that arm.77a These results for a hybrid regimen are comparable to those reported in the 12-week multidrug weekly regimen developed at Stanford,78 known as Stanford V, which is now being compared with ABVD in an Intergroup study.78a However, on a note of caution, the US Intergroup study of MOPP/ABV versus ABVD has been halted; the treatments were equivalent in efficacy but there was significantly more toxicity (including second cancers) in the hybrid arm.79 Also, seven secondary leukemia/ myelodysplasias were reported following escalated BEACOPP.77a

Combined modality therapy 275

Table 19.5 Hybrid chemotherapy in advanced Hodgkin's disease

NTI

NCI, Canada

Christie/ Barts,

1982-1990 415 IB, MB, 3 MOPP/ (46,52,70, III, IV 3ABVD 71) 6 MOPP ABVD hybrid

91

76 (10 years)

74

89

78

75

No differences (including freedom from progression rates)

1984-1989 (68, 69)

No differences

1984-1992 (75)

Intergroup, 1987-1989 USA

BNLI

GHSG

83

67 (5 years)

83

81

71

81

423 IB, MB, 6 MVPP III, IV 6 MVPP EVA

55 68

737 III, IV

(72,73)

71 (5 years) 80

Freedom from progression significantly better with hybrid All survival data better for hybrid

6MOPP/3ABVD 75 (sequential)

54 (8 years)

71

8 MOPP ABV

83 (P = 0.02)

64 (P = 0.001)

79 (P = 0.02)

CR significantly inferior with hybrid. Trial terminated prematurely

1990-1991

160 IB, MB, 3 LOPP/3 EVAP

65

85 (2 years)

88

(74)

III, IV

6LOPPEVA

40, P< 0.002

79

78

856 III, IV

8 MOPP ABV

71 73

65 (3 years) 67

87 85

Hybrid more toxic

8 ABVD

87 (3 years) 92

Recent analysis shows both BEACOPP variants significantly better for failure-free and overall survival

Intergroup, 1990-1995 USA

301 NIB, IV 4 MOPP/ 4 ABVD 8MOPPABV

(79) 1993-1997

1070 MB, III, 4 COPP, 4 ABVD 83

(76, 77a)

IV (505 in interim analysis)

8 BEACOPP (baseline or escalated)

92 (P < 0.002)

CR = complete response rate, FFR = freedom from relapse, OS = overall survival.

COMBINED MODALITY THERAPY (Table 19.6) The use of radiotherapy in advanced Hodgkin's disease is still controversial. Undoubtedly patients usually relapse, if they do so, at sites of previous disease and partial response can be converted to complete response by appropriate radiotherapy. For example, in the EORTC 20844 trial, 110 of 130 patients with partial response received involved field radiotherapy; 88 per cent of these were free of Hodgkin's disease at 4 years.80 Some authorities have suggested that both disease-free and overall survival are improved if radiotherapy is routinely added to initially involved (particularly bulky) nodal sites after obtaining remission with chemotherapy.81-85 However, such data are retrospective and others suggest that the advantages of routinely adding radiotherapy, in terms of marginally improved efficacy, are counterbalanced by increased short- and long-term toxicity.50 Despite this, many of the chemotherapy studies described in the previous sections have incorporated combined modality therapy, including the BEACOPP and Stanford V studies. Some randomized studies have been undertaken (particularly in Stage III disease), for example, SWOG,

comparing MOPP-Bleo with abbreviated MOPP-Bleo plus TNI could only show a possible freedom from relapse advantage for the nodular sclerosis subtype.86 The CALGB, in a four-way comparison, demonstrated significantly improved freedom from relapse for patients treated with TNI followed by BOPP. There were, however, no significant differences in overall survival.35'58 In the comparison of MVPP versus MVPP plus radiotherapy by the Christie Group87 and of TNI versus TNI plus LOPP by the BNLI in pathologically Stage IIIA disease,13'88 no longterm survival differences have been seen. However, in studies which have included IIIB and IV patients, some advantages have been reported. For example, in an earlier report of the CALGB study comparing CVPP alone (6 or 12 cycles) with CVPP followed by low dose radiotherapy and with radiotherapy sandwiched between courses of CVPP, there was a possible survival advantage to the sandwich arm.35 However, longer-term follow-up showed that augmented therapy (radiation to known disease or prolongation of induction chemotherapy) did not improve response or disease-free and overall survival.89 In the SWOG study of MOPP/BAP with or without RT there was a possible prolongation of remission duration in the nodular

276 Advanced Hodgkin's disease Table 19.6 Advanced Hodgkin's disease: role of combined modality therapy

BNLI

1975-1980 (13,88)

99 IMA

TNI TNI + LOPP

86 86

55 (15 years) 75 (P < 0.05))

CALGB

1974-1981

233 III

TNI TNI + 6 BOPP 6BOPP + TNI 6 BOPP

96-60 84-79 88-94 77-74

60 (3 years) 80 (P = 0.03) 55

247 1MB, IV

6or12CVPP 6CVPP + low-dose RT 3 CVPP/RT/ 3CVPP

68/59 57

60/55 (3 years) 55

65

65

137 III

lOMOPPBleo 3 MOPP Bleo + TNI

89 96

84 (5 years) 70

87 89

Possible FFR advantage for MOPP-Bleo in NS

278 III, IV (CR after CHT)

MOP-BAP MOP-BAP + RT

66 (5 years) 74

79 86

Possible FFR advantage for added RT in NS

56 IMA

MVPP MVPP + RT

i 80 (5 years)

.85

No differences

(19,92)

172 1MB, IV (PR/CR after CHT)

MOPP-Bleo + ABVD MOPP-Bleo + RT

168 (5 years) J66

92 Survival advantage to 83 (P < 0.01) ABVD consolidation

1977-1991

151 III, IV

6CVPP 6 CVPP + RT

(35)

1975-1981 (35, 89

SWOG

1975-1980 (86)

1978-1988 (90)

Christie 1975-1982 (87)

ECOG

GATLA

1976-1981

(94)

GELA

1989-1994 (93)

GHSG (91)

88 100

73 86

238 1MB, IV ABVPP or MOPP/ (PR/CR after ABV then further CHT) CHT or RT 105 1MB, IV 3 COPP 3 ABVD (CR after CHT) + RT 3 COPP 3 AVBD + COPP/ABVD

60

FFR better for TN I + BOPP. No significant differences in overall survival 58 (5 years)

23 (7 years) 51 (P< 0.02)

58 71

93 (26 months) 97

94 94

81 (21 months)

Short- and long-term morbidity a problem in both arms

No difference

Only IIIA entered after 1979 No differences yet

No differences yet

87

CR = complete response rate, FFR = freedom from relapse, OS = overall survival, PR = partial response, TNI = total nodal irradiation, CHT = chemotherapy, RT = radiotherapy, NS = nodular sclerosis.

sclerosis subgroup.90 Against this, studies from the ECOG, GHSG and GELA, where successful induction chemotherapy was followed either by further chemotherapy or by radiotherapy, no significant advantages have yet been seen for radiotherapy.19,91-93 Only the GATLA study, which compared CVPP and CVPP plus radiotherapy, has shown long-term differences in survival (particularly in freedom from relapse),94 but this study has been criticized on the basis that the CVPP regimen lacked optimal dose intensity;95 also, owing to poor results, the study was closed for patients with clinical Stage IIIB and IV after just 2 years. Although there are ongoing studies, for example, EORTC H34, still addressing this question, Loeffler et al. performed a meta-analysis of all randomized trials that compared chemotherapy alone versus combined modal-

ity treatment.96 Addition of radiotherapy to standard chemotherapy resulted in an 11 per cent improvement in tumor control rate but no significant difference in overall survival. Worryingly, however, when combined modality therapy was compared with chemotherapy alone in parallel-design studies, overall survival was significantly (8 per cent) inferior in the group that had radiotherapy.

CONCLUSIONS Against this background, what are the conclusions that can be reached about the initial therapy for Hodgkin's disease? There seems little doubt that the various

Salvage therapy 277

methods applied to improve the results of traditional MOPP chemotherapy have added somewhat in terms of increased efficacy, and short and long term complications may have been reduced. However, in the absence of an investigational program, ABVD, with its lack of secondary leukemia and permanent sterilization, and despite its potential for long-term pulmonary and cardiac toxicity, is acceptable first-line therapy. It would seem sensible to discourage the use of nitrosourea-containing regimens because of the high incidence of associated secondary leukemias. Regardless of the regimen chosen, therapy should be delivered as close to the intended dose and schedule as possible to achieve best results. Some authorities recommend avoiding artificial dose limitations; all dose reduction should be on the basis of actual toxicity observed. Vincristine is often quoted as an example of this philosophy. Six cycles of therapy are adequate for the majority of patients but up to a quarter of patients may require more. The proper duration of therapy may be determined by re-evaluating the patient's disease status at the half-way stage and at the end of the conventional number of courses. If there is continued improvement between these two assessments, two further cycles of treatment followed by a further reassessment of the status is the standard recommendation. Maintenance therapy does not prolong remission in Hodgkin's disease. The incremental value of adjuvant radiation therapy relative to optimal chemotherapy remains controversial and arguably may have become a question of historic rather than current interest.97 It seems logical to add radiotherapy in those patients who have had bulky presenting disease (particularly in the mediastinum) and also in those patients who have shown a slow response to treatment. There is no hard evidence that overall survival is improved but there is now a considerable body of evidence suggesting that it does reduce relapses in initially bulky lymph node sites. It does seem likely that doxorubicin-containing regimens are more efficacious and, in the long term, less toxic (than MOPP-like regimens), although even this has been disputed. The use of alternating or hybrid chemotherapy regimens, although theoretically of considerable promise, has shown differences in the order of 5-10 per cent in eventual survival, even with very large well-controlled clinical trials. Rosenberg suggests that the choice amongst these regimens should be made on the basis of acceptable acute and long-term toxicities rather than on small differences in cure and survival rates.98 Canellos recently concluded that the concept of 'standard' therapy is inappropriate since there is a moving edge to clinical research in Hodgkin's disease.99 If ABVD is seen as the 'standard' for most trials purposes, what are the appropriate areas to explore for the 'test' arms of future trials. Dose-escaled hybrids such as BEACOPP (escalated) and intensive weekly regimens such as Stanford V now have substantial supportive data and require further evaluation and comparison.

SALVAGE THERAPY

Relapse after initial radiotherapy The results with conventional chemotherapy given after initial therapy with radiation are on a par with those from studies in patients treated de novo with chemotherapy for advanced disease, with long-term survivals in over half of patients treated with MOPP-like or anthracyclinecontaining regimens.14,100-103 The NTI Milan Group, in particular, using ABVD in various guises, had over threequarters of their patients as long-term survivors.100 Several of the randomized studies referred to earlier in this chapter (with first-line regimens for advanced disease) include patients relapsing after radiation therapy; there was no major advantage to any particular regimen.

Relapse after initial chemotherapy Up to a half of patients with advanced Hodgkin's disease will relapse after initial conventional chemotherapy and the long-term prognosis for these patients is poor; however, the attrition rate is slow and a significant proportion of patients are alive at 5 years as a result of many different salvage strategies. Salvage therapy may take the form of: • radiotherapy to 'local', particularly nodal, relapse; • the 'same' chemotherapy for late generalized relapse; • alternative (non-cross-resistant) chemotherapy for initial non-response or early relapse; • high-dose chemotherapy with peripheral stem cell or bone marrow autograft. The role for radiotherapy in localized relapse is undisputed. More extensive large-field radiotherapy for systemic relapse has been tried104-108 but it is not now generally recommended, since those patients responding best are often those who will do well with conventional salvage chemotherapy. Most authorities agree that relapse after long (>1 year) chemotherapy-induced remissions are genuinely chemosensitive, and can be retreated with the same or alternative conventional regimens with high CR rates and worthwhile long-term disease-free remissions. Patients who show poor response to, or relapse early (< 1 year) after initial chemotherapy are mostly chemoresistant. Even in this group, however, CR can be obtained in over half with salvage chemotherapy and/or radiotherapy. Alternative 'non-cross-resistant' regimens have been developed largely in this scenario. ABVD gave CRs in up to two-thirds of patients previously treated with MOPP, but even here results were better for previous chemotherapy responders and where disease was nodal and without systemic symptoms. In the CALGB three-arm study, salvage data suggest that the likelihood of benefit is proportional to the duration of prior

278 Advanced Hodgkin's disease

response and that there may be less cross-resistance when ABVD is used as first-line therapy rather than MOPP." Examples of other regimens used in relapse are MIME,109 EVA110-112 and B-CAVe.113 In this situation, high-dose chemotherapy with autologous peripheral stem cell or bone marrow support is the most likely hope of prolonged remission, although there is a disappointing lack of randomized trials comparing 'high-dose' with 'conventional' salvage therapy. This subject is discussed fully in Chapter 24. About half of patients treated with high-dose chemotherapy achieve CR, with prolonged remissions in about one-third. Best results are seen in patients with low-volume and/or chemoresponding disease. Radiotherapy may be incorporated in the strategy but when given before transplant may be associated with a high post-transplant mortality rate.114

NOVEL THERAPIES Further improvements in overall cause-specific survival are unlikely to come from developments of conventional chemotherapy regimens. Current novel approaches include: • selection of poor risk categories for more intensive therapy from the outset; • use of hematopoietic growth factors to escalate chemotherapy doses and/or to ensure optimal intensity in established regimens; • use of less intensive combined modality therapy for good-risk patients; • experimental studies involving approaches alternative to chemotherapy and/or radiotherapy; • the introduction of new chemotherapeutic agents. It is now accepted that the classic prognostic features of histologic subtype and stage (and factors derived from these) are no longer relevant in cure and survival.98 Several groups have attempted to subgroup patients with advanced Hodgkin's disease according to other prognostic factors. For example, Proctor et al. constructed a numerical index based on disease stage, age, hemoglobin and absolute lymphocyte count,115 and the MSKCC identified adverse factors in a step-wise Cox regression analysis.64 However, such prognostic models sometimes conflict and have yet to be validated prospectively with current 'best' therapy. In fact, Rosenberg recently argued that prognostic groups as a whole are becoming less and less relevant to the management of Hodgkin's disease.116 The statistical overview of prognostic factors in over 5000 optimally treated patients from an international database of advanced Hodgkin's disease presented by Hasenclever at the Fourth International Symposium on Hodgkin's Lymphoma showed that any effects observed

from many prognostic indices are generally small and that no single study group has enough data to estimate these effects reliably.117 In this International Prognostic Factor Study, 5141 patients of less than 65 years were analysed. Seven factors (hemoglobin, albumin, age, white cell count, lymphocyte count, gender and stage) were shown to be significant on multivariate analysis and the addition of the effects of each factor could separate groups of different prognosis (with about a 7 per cent increase in the probability of tumor control per factor). However, in this project, no very high risk group could be defined, although just under 10 per cent of the patients had an expected chance of less than 50 per cent to be progression free at 5 years.118 This important contribution has set the standard for future prognostic factor analyses in advanced Hodgkin's disease. One school of thought is to offer high-dose chemotherapy with autologous stem cell or marrow support early in the treatment strategy, or after achieving remission with conventional therapy. This is discussed in Chapter 24 but the major problem with this concept, bearing in mind our inability to select out prognostic groups, is the risk of overtreatment of a substantial proportion of patients. At several centers, innovative therapeutic regimens are being developed and tested with the aim of reducing treatment duration, increasing dose intensity and using limited field radiotherapy as an adjuvant. It is the hope that such regimens will prove equally effective but with reduced long term toxicity compared with conventional treatments. Accrual to a recent UK four-center randomized study comparing weekly VAPEC-B with hybrid ChlVPP/EVA has been halted because of a significantly higher progression rate in those treated with the weekly schedule.119 The Stanford V schedule (using seven drugs (Adriamycin, vinblastine, mustine, etoposide, vincristine, bleomycin and prednisone) in a 12-week dose-intensive, latterly hematopoietic growth factorsupported regimen, followed by disciplined radiotherapy to initially bulky or residual disease) is proving highly effective.78,78a,120,121 In Milan, a pilot study has been undertaken with an intermediate-dose intensity chemotherapy (including epirubicin, cyclophosphamide and etoposide) program, followed by involved-field radiotherapy, as primary treatment.46,122 The GHSG study of a dose escalation study to assess the maximum tolerability of doxorubicin, cyclophosphamide and etoposide in a shortened and also growth factor-supported BEACOPP regimen is mentioned earlier.77,77a,123,124 In Southampton (UK), a 12-week alternating regimen (PACEBOM) has proved to be well tolerated and effective.125 In an effort to reduce particularly long-term morbidity and mortality, a more temperate approach may be taken in patients with favorable prognosis. For example, at Stanford, the VBM regimen uses drugs that are relatively well tolerated acutely, have minimal potential for long-term toxicity and seems to be effective as adjuvant

References 279

therapy to control occult disease, when combined with irradiation.126 The most innovative of the experimental approaches has been the use of radiolabeled antibodies. In one study 131 I-labeled antiferritin antisera induced partial remissions in 40 per cent of 38 patients with multitreated Hodgkin's disease.127 Extrapolation of immunoscintigraphic studies using specific anti-Hodgkin's disease monoclonal antibodies128 or immunotoxins129 may also be feasible to therapy. Some workers have focused on Epstein-Barr virus (EBV)-encoded antigens expressed on the Reed-Sternberg cell.130 However, specific immune responses against non-EBV-associated antigens in autologous tumor in patients with Hodgkin's disease have also been demonstrated, and could provide the basis for immunological and genetic therapeutic approaches.131 A range of immunotoxins using conventional and recombinant antibody technology now exists and are entering early clinical trials.132-136 Currently, there is considerable interest in oncology in the evaluation of enhanced cytotoxic T lymphocyte responses as therapeutic tools. Hodgkin's disease offers some targets for these by expressing some EBV T cell epitopes in some tumors. Preliminary evidence suggests that this approach should be pursued.137,138

NEW DRUGS The evaluation of new chemotherapeutic agents in Hodgkin's disease is made difficult by the heavy pretreatments most patients have received. However, useful activity has been suggested for vinorelbine, gemcitabine and idarubicin133'139'140 which may be evaluated further in future studies.

PREGNANCY (see also Chapter 15) Historically, Hodgkin's disease was thought to be exacerbated by pregnancy but more recent opinion is that this is not so;141-143 neither is the course of gestation and delivery affected by Hodgkin's disease.144 However, for obvious reasons, caution must be exercised in investigation and treatment. For example, magnetic resonance imaging is preferred to computed tomography because it does not expose the fetus to ionizing radiation. In the first trimester, both radiotherapy and chemotherapy pose significant teratogenic risks, and most authorities agree that therapeutic termination of pregnancy should be advised,143,145,146 to allow proper staging and treatment. If the patient does elect to continue the pregnancy, treatment should be deferred if at all possible until at least the second trimester. Truly localized supradiaphragmatic Hodgkin's disease can be treated appropriately with local radiotherapy. However, more

Table 19.7 Simplified scheme of clinical management of Hodgkin's disease in pregnancy

< 16 weeks

> 16 weeks

Consider termination or Small bulk (supradiaphragmatic) local radiotherapy All others

Advise termination or delay treatment or start chemotherapy (e.g. vinblastine) or consider modified radiotherapy

Small bulk (supradiaphragmatic)

Local radiotherapy (immediate or delayed) and consider early delivery

All others

Conventional chemotherapy and consider early delivery

advanced or symptomatic disease mandates chemotherapy, and treatment-related problems (e.g. neutropenic sepsis) may be compounded by the presence of pregnancy and vice versa.145 A possible scheme of management derived from a consensus of expert opinions142,143,146 is given in Table 19.7. Following successful treatment of Hodgkin's disease, it is customary to advise females in the reproductive age group to avoid pregnancy for up to 2 years after treatment, not because of any adverse interaction but mainly because recurrence within this time indicates poor prognosis.

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References 285 139. Hunerliturkoglu A, Kobbe G, Sohngen D, etal. High dose idarubicin added to CVB as an intensified high dose chemotherapy protocol for patients with primary refractory or relapsed malignant lymphoma. Proceedings of the Fourth International Symposium on Hodgkin's Lymphoma, Cologne. Leukaemia and Lymphoma, 1998: abstract P-153. 140. Reiser M, Schnell R, Wilhelm M, et al. A clinical phase II trial with dexamethasone, idarubicin and continuous infusion of ifosfamide and etoposide (DIZE) in patients with relapsed lymphoma. Proceedings of the Fourth International Symposium on Hodgkin's Lymphoma, Cologne. Leukaemia and Lymphoma, 1998: abstract P147. 141. Barry RM, Diamond HD, Craver LF. Influence of pregnancy on the course of Hodgkin's disease. AmJ Obstet Gynaecol 1962; 84: 445-54. 142. Ward F, Weiss R. Lymphoma and Pregnancy. Semin Oncol 1989; 16: 397-409.

143. Sadural E, Smith LJr. Haematologic malignancies during pregnancy. Clin Obstet Gynaecol 1995; 38: 535-46. 144. Sweet DLJr. Malignant lymphoma: implications during the reproductive years and pregnancy. J Reproduct Med 1976; 17:198-208. 145. Doll DC, Ringenberg QS, Yarbro YW. Management of cancer during pregnancy. Arch Intern Med 1988; 148: 2058-64. 146. Ward FT, Weiss RB. Managing lymphoma during pregnancy. Adv Oncol 1992; 8:18-22. 147. Hagemeister FB, Cabanillas F, Velasquez WS, et al. NOVP: A novel chemotherapeutic regimen with minimal toxicity for treatment of Hodkgin's disease. Semin Oncol 1990; 17(suppl 10): 34-^0. 148. Radford JA, Crowther D. Treatment of relapsed Hodgkin's disease using a weekly chemotherapy of short duration: results of a pilot study in 20 patients. Ann Oncol 1991; 2: 505-9.

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20 Aggressive non-Hodgkin's lymphoma ERGAYNORANDRI FISHER

Introduction Diffuse large cell lymphoma Diffuse immunoblastic lymphoma Diffuse small non-cleaved cell lymphoma Other diffuse aggressive lymphomas Summary

287 287 288 288 288 288

INTRODUCTION While the Revised European-American Lymphoma (REAL) pathology classification1 is likely to be excellent in interpreting prospective clinicopathological correlations, the Working Formulation provided clinicians with a conceptual framework in which the non-Hodgkin's lymphomas (NHLs) can be grouped as indolent or low grade, intermediate grade and high grade (Table 20.1).2 Table 20.1 Working Formulation I. Low grade A. Small lymphocytic B. Follicular, predominantly small cleaved cell C. Follicular mixed, small cleaved and large cell II. D. E. F. G.

Intermediate grade Follicular, predominantly large cell Diffuse small cleaved cell Diffuse mixed, small and large cell Diffuse large cell Cleaved cell Non-cleaved cell Sclerosis

III. High grade H. Large cell immunoblastic Plasmacytoid Clear cell Polymorphous Epithelioid component I. Lymphoblastic J. Small non-cleaved cell

Clinical features and staging Early stage disease Advanced stage disease (II bulky, III, IV) Summary Conclusion References

289 290 292 295 296 296

Several subtypes of diffuse large cell lymphoma fall in the intermediate category, while one subtype, immunoblastic lymphoma, is classified as a high-grade malignancy in the Working Formulation. The high-grade category also includes small non-cleaved cell lymphoma and lymphoblastic lymphoma. Lymphoblastic lymphoma is a relatively rare entity and is treated in a manner similar to the treatment of acute lymphoblastic leukemia. The treatment of this lymphoma is dealt with elsewhere in this book (see Chapter 21). Small noncleaved cell lymphoma is further subdivided into Burkitt's and non-Burkitt's variants. Diffuse large cell lymphoma, immunoblastic lymphoma and small noncleaved cell lymphoma, for convenience, can be considered as a group because they share similar clinical presentations and natural histories, and therapeutically they may be approached in a similar way.

DIFFUSE LARGE CELL LYMPHOMA These lymphomas account for approximately one-third of all NHLs. While they are biologically diverse with respect to their cell of origin, the vast majority are derived from lymphocytes. Seventy-five per cent are of B cell origin and the remainder are of T cell origin. T cell lymphomas may have a worse prognosis than B cell lymphomas. Approximately one-third of patients have early stage disease at presentation (Stage I or II), while the majority have clinically disseminated disease at the time of diagnosis. In addition to nodal sites of involvement, patients

288 Aggressive non-Hodgkin's lymphoma

will frequently present with extranodal sites of disease. The disease is aggressive with a median survival of less than 1 year in untreated patients.

DIFFUSE IMMUNOBLASTIC LYMPHOMA Prior to the availability of newer and more aggressive combination chemotherapy regimens, it appeared that this disease had a slightly worse prognosis than diffuse large cell lymphoma. In the Working Formulation, immunoblastic lymphoma is further subdivided into three types: plasmacytoid, clear cell and polymorphous. While these descriptive terms imply a particular cell of origin, T or B cell derivation cannot be accurately predicted based on morphology, and thus the subclassification of immunoblastic lymphoma has little clinical utility. Immunoblastic lymphomas that are of B cell origin may be associated with circulating monoclonal immunoglobulins. This subtype of diffuse large cell lymphoma is frequently found to involve the gastrointestinal tract and is the type of lymphoma that occurs in association with Sjogren's syndrome. Its natural history is the same as that of other types of diffuse large cell lymphoma and like them, it is curable with intensive combination chemotherapy.

DIFFUSE SMALL NON-CLEAVED CELL LYMPHOMA Lymphomas of the small non-cleaved cell (Burkitt's) type are endemic in certain parts of Africa. The disease in these areas appears to be etiologically related to the Epstein-Barr virus (EBV). The disease is also seen in the USA and its incidence is increasing particularly in human immunodeficiency virus (HIV)-infected patients. The relationship of EBV to the non-endemic Burkitt's is not as clear as the endemic variant. Burkitt's lymphoma is most often seen in the pediatric age group and is usually associated with bulky disease involving the jaw or abdomen, with frequent involvement of the bone marrow and meninges. Several protocols have been developed for the treatment of endemic Burkitt's. The best approach to treatment of the non-endemic variant remains to be defined. As noted above, many would treat this lymphoma in the same way as diffuse large cell and immunoblastic lymphomas. Because of its propensity to involve the meninges and because of its rapid rate of growth, several treatment programs have been developed that include intensive systemic therapy as well as prophylactic treatment of the central nervous system. None of these programs has been compared in a prospective manner with regimens commonly used to treat the other diffuse aggressive lymphomas, which are encountered more commonly in clinical practice.

However, the most promising of protocols is that piloted by the National Cancer Institute (Protocol 89-C-41) where nearly all patients achieved sustained complete remission.3 An international evaluation of this highintensity protocol co-ordinated by the United Kingdom Lymphoma Group is underway; preliminary results indicate that the protocol can be given to adults in a multicenter setting with an excellent chance of cure.4

OTHER DIFFUSE AGGRESSIVE LYMPHOMAS It is likely that no classification system of NHL will be permanent. Several new subgroups of aggressive lymphoma have already been identified that do not fall within the definitions of the Working Formulation. Examples of such lymphomas are anaplastic large cell lymphoma and adult T cell leukemia/lymphoma. Anaplastic large cell lymphoma is a recently recognized subtype of diffuse large cell lymphoma, which can be confused histologically with carcinoma because of the anaplastic appearance of the cells. The lymphoma is usually of T cell origin and the cells usually express the Ki-1 or Hodgkin's-associated antigen, CD 30. A characteristic chromosomal abnormality, t(2;5), is sometimes seen. This type of lymphoma occurs in adults but is more common in children, who frequently present with extranodal involvement of the skin. Currently treatment is the same as that used for other types of large cell lymphoma. Adult T cell leukemia/lymphoma is a rare disease that is associated with infection by the human T cell lymphotropic virus, HTLV-1. The disease shows a striking geographic variation, being particularly common in Japan and the Caribbean. Clinically it is associated frequently with involvement of the skin, lytic bone lesions and hypercalcemia. While it is responsive to chemotherapy, the patients usually do poorly and follow a rapid downhill course.

SUMMARY The diffuse aggressive lymphomas include a variety of subtypes of lymphoma. Several of these are relatively rare, e.g. lymphoblastic and Burkitt's lymphoma, and treatment approaches are unique to the subtype. Clinically the most commonly encountered subtypes are diffuse large cell and immunoblastic (REAL, diffuse large B cell lymphoma). In this chapter, we will discuss the prognostic factors, staging work-up and treatment of these subtypes of lymphoma. Because diffuse large cell and immunoblastic lymphoma share similar clinical features and natural histories, they may be considered together in terms of the approach to their treatment.

Clinical features and staging 289

CLINICAL FEATURES AND STAGING In general, these are lymphomas that occur in middleaged and older adults, although they can also be seen in younger patients. The staging system used for these lymphomas is the Ann Arbor system (Table 20.2), which was originally proposed as a staging system for Hodgkin's disease.5 While it is extensively utilized, this staging system has certain limitations when applied to the NHL. For example, the distinction between Stage III and IV in Hodgkin's disease is important because, in some instances, Stage III is curable with radiation therapy while cure of Stage IV disease requires the use of systemic chemotherapy. In contrast, Stage III and IV aggressive lymphomas are both treated with systemic chemotherapy and, with the use of aggressive chemotherapy, the prognostic differences between Stages III and IV may be less distinct. In addition, while the Ann Arbor system separates patients based on the extent of disease, it does not address the issue of bulky disease. Bulky disease, defined as any tumor mass >10cm or any mediastinal mass greater than one-third of the thoracic diameter, impacts both on prognosis and in some instances on the treatment of the aggressive NHL. In addition to bulk, several other pretreatment prognostic factors for NHL have been identified including age, serum lactate dehydrogenase (LDH), bulk of disease as defined above, the presence or absence of B symptoms, the number of extranodal sites of disease involvement and the stage of disease at diagnosis. Each of these clinical characteristics has been identified in one or more series of patients with aggressive lymphoma to be Table 20.2 Ann Arbor staging classification Stage I Involvement of a single lymph node region or of a single extranodal organ or site (IE). Stage II Involvement of two or more lymph node regions on the same side of the diaphragm, or localized involvement of an extranodal site or organ (IIE) and of one or more lymph node regions on the same side of the diaphragm. Stage III Involvement of lymph node regions on both sides of the diaphragm, which may also be accompanied by localized involvement of an extranodal organ or site (IIIE) or spleen (Ills) orboth(liy. Stage IV Diffuse or disseminated involvement of one or more distant extranodal organs with or without associated lymph node involvement. Fever > 38°C, night sweats, and/or weight loss > 10 per cent of body weight in the 6 months preceding admission are defined as systemic symptoms, and denoted by the suffix B. Asymptomatic patients are denoted by the suffix A.

of prognostic importance with respect to patient outcome. The International Non-Hodgkin's Lymphoma Prognostic Factors Project utilized pretreatment prognostic factors in a sample of several thousand patients with aggressive lymphomas to develop a predictive model of outcome for aggressive NHL.6 Five pretreatment characteristics were found to be independently statistically significant: age (<60 vs >60), tumor Stage I or II (localized) vs III or IV (advanced), the number of extranodal sites of involvement (< 1 vs > 1), patient performance status (0 or 1 vs >2) and serum LDH (normal vs raised). Patients were grouped according to the number of adverse factors - low risk (0-1), low intermediate risk (2), high intermediate risk (3), and high risk (4 or 5). When patients were analysed by risk factors, they were found to have very different outcomes with regard to complete response (CR) rate, relapse-free survival (RFS) and overall survival (OS). For example patients in the high-risk group had a CR rate of 44 per cent and a 5-year survival rate of only 26 per cent, compared to a CR rate of 87 per cent and a 5-year survival of 73 per cent in patients in the low-risk group. The value of any staging system is its ability to predict the likelihood of a response to a proposed treatment. Utilization of the predictive model detailed above may allow clinicians, prior to therapy, to predict a given patient's likelihood of responding adequately to the proposed treatment. Those whose outcome is predicted to be favorable with conventional therapy should be spared the added toxicity that is often associated with more aggressive experimental therapy. On the other hand, those in whom a CR is unlikely with conventional therapy would be identified as candidates for more aggressive treatment. Pretreatment evaluation should include, as a minimum, for all patients: 1 2 3 4

history and physical examination; complete blood count and chemistry survey; chest X-ray; computed tomography (CT) scan of the chest, abdomen and pelvis; 5 iliac crest bone marrow biopsies (ideally bilateral); 6 other investigations as indicated by the results of points 1-5 above.

Because bone marrow involvement increases the likelihood of lymphomatous involvement of the meninges, many would recommend that in these patients, a spinal tap be performed for cytologic and chemical analysis of the cerebral spinal fluid. Patients who present with lymphomatous involvement of the meninges should receive a course of intrathecal chemotherapy; many investigators would also give cranial irradiation in addition to intrathecal chemotherapy. In certain situations, additional studies may be indicated. For example, patients who have unexplained bone pain or an unexplained elevation of the alkaline phosphatase should be evaluated with a bone scan. Plain

290 Aggressive non-Hodgkin's lymphoma

X-rays of any abnormal area on the bone scan should be obtained to look for lymphomatous involvement of the skeleton. Another example requiring additional testing would pertain to patients presenting with Waldeyer's ring involvement. Because there is a high correlation between involvement of Waldeyer's ring and involvement of the gastrointestinal tract, the finding of disease in Waldeyer's ring necessitates studies of the gastrointestinal tract to document the presence or absence of disease. The diffuse aggressive lymphomas are usually systemic diseases at the time of diagnosis and therefore chemotherapy is the mainstay of treatment. A variety of chemotherapy regimens have been developed over the past 25 years. Those that are commonly used today which will be discussed in this chapter are shown in Table 20.3.

EARLY STAGE DISEASE

Phase II trials Once it had been established that the CHOP regimen was effective treatment for advanced stage disease, several studies utilized CHOP either alone or in combination with radiation therapy in patients with early stage disease. The number of courses of therapy required and the role of radiation therapy in combination with chemotherapy for early stage disease remain to be defined. Miller and Jones conducted a phase II trial employing the CHOP regimen in the treatment of localized disease.7 Forty-five patients were included in the study, 28 of whom received chemotherapy alone and 17 of whom received CHOP chemotherapy followed by involved field radiation therapy (IFRT). Fifteen patients had clinical stage (CS) I disease and 30 had CS II disease. Treatment assignment to chemotherapy alone or to combined modality therapy (CMT) was made on the basis of bone marrow reserve and the rate of tumor response to the initial cycle of chemotherapy. Those patients treated with chemotherapy alone received between 6 and 11 cycles of CHOP. Those treated with CMT received between two and eight cycles of CHOP prior to the initiation of IFRT. With a median follow-up time of 41 months at the time of reporting, 42 patients (92 per cent) were alive and 38 (84 per cent) were continually free of disease. There were no statistically significant differences in survival or relapse-free survival between patients receiving chemotherapy alone as compared to those receiving CMT. The stage at the time of diagnosis did not impact on OS or RFS. Eleven patients included in the study were over the age

of 65. In general, these patients received less intense therapy with CHOP being given at reduced dosage. They also tended to receive fewer cycles of chemotherapy. In spite of this, only one of the patients experienced disease relapse. The study results suggested that systemic chemotherapy with a doxorubicin (Adriamycin)-containing drug regimen is an effective treatment strategy for patients with clinically localized disease. In addition, the results seen in the elderly patients suggest that undetectable systemic disease may be eliminated with relatively few courses of chemotherapy. The minimum number of courses required to achieve disease control was not defined by this study. A prospective study using an abbreviated course of three cycles of CHOP followed by IFRT was conducted by Connors et al8 Seventy-eight patients ranging in age from 21 to 81 years were enrolled on the study. Eligibility requirements included CS I or II disease with favorable characteristics, which by definition meant no B symptoms and no bulky disease. Results were excellent with 77 (99 per cent) patients achieving a CR. With a median follow-up of 30 months off therapy, 66 (86 per cent) remained free of disease. The actuarial survival rate for the entire group was 84 per cent. The results of this study thus confirm that a brief chemotherapy program followed by IFRT is a very effective treatment approach to early stage disease. Because the study did include an elderly population, the results are more widely applicable as compared to those studies in which elderly were excluded or poorly represented. Employing a slightly longer chemotherapy program, Tondini et al. reported similar results.9 One hundred and eighty-three patients with Stage I or II disease and no more than three sites of disease were treated with 4-6 cycles of CHOP followed by extended field radiation therapy (EFRT). Patients who failed to achieve a CR after four cycles of CHOP were given an additional two cycles. At the end of therapy, 98 per cent had achieved a CR, one-third of whom had undergone diagnostic excision of all measurable disease prior to therapy. Of those with measurable disease, 87 per cent achieved a CR with chemotherapy alone and 11 per cent with the addition of radiation therapy (RT). RFS and OS were 83 per cent with a median follow-up of 5 years. There was a nonstatistically significant trend toward a higher relapse rate among patients achieving a CR after RT (31 per cent) as compared to those patients achieving a CR with chemotherapy (15 per cent) or initial surgery. While there were differences in patient selection, length and dose of chemotherapy, and RT dosage and ports, the results of these three series are very similar and support the efficacy of CHOP chemotherapy in this setting. It is probably not necessary to use more aggressive regimens in the management of patients with goodprognosis early stage disease.

Early stage disease 291

Table 20.3 Chemotherapeutic regimens

CHOP C = H = 0 = P =

cyclophosphamide Adriamycin Oncovin prednisone

750 mg/m2 iv 50 mg/m2 iv 1.4 mg/m2 iv (max 2.0 mg) 100 mg po

1 1 1 1-5

Repeat every 21 days

M-BACOD M = B = A = C = 0 = D =

methotrexatea bleomycin Adriamycin cyclophosphamide Oncovin Decadron

3000 mg/m2 iv 4 mg/m2 iv 45 mg/m2 iv 600 mg/m2 iv 1 mg/m2 iv 6 mg/m2 po

15 1 1 1 1 1-5

Repeat every 21 days

m-BACOO m = B = A = C = 0 = D =

methotrexatea bleomycin Adriamycin cyclophosphamide Oncovin Decadron

200 mg/m2 iv 4 mg/m2 iv 45 mg/m2 iv 600 mg/m2 iv 1.4 mg/m2 iv 6 mg/m2 po

8,15

Repeat every 21 days

ProMACE-MOPP Pro = prednisone 60 mg/m2 po a M = methotrexate 1500 mg/m2 iv A = Adriamycin 25 mg/m2 iv 650 mg/m2 C = cyclophosphamide E = etoposide 120 mg/m2 iv Followed by MOPP after maximal response 6 mg/m2 iv M = mechlorethamine 0 = Oncovin 1.4 mg/m2 iv P = Procarbazine 100 mg/m2 po P = prednisone 40 mg/m2 po ProMACE-CytaBOM Pro = prednisone A = Adriamycin C = cyclophosphamide E = etoposide Cyta = cytarabine B = bleomycin 0 = Oncovin M = methotrexatea

60 mg/m2 po 25 mg/m2 iv 650 mg/m2 iv 120 mg/m2iv 300 mg/m2 iv 5 mg/m2 iv 1 .4 mg/m2 iv 120 mg/m2 iv

MACOP-B M = A = C = 0 = P = B =

methotrexatea Adriamycin cyclophosphamide Oncovin Prednisone bleomycin

400 mg/m2 iv 50 mg/m2 iv 350 mg/m2 iv 1 .4 mg/m2 iv (max 2.0 mg) 75 mg/m2 po 10 mg/m2 iv

prednisolone

50 mg day 50 mg alternate days 35 mg/m2 iv 300 mg/m2 iv 1 50 mg/m2 iv 10 mg/m2 iv 1.4 mg/m2 iv 100 mg/m2 iv

1 1 1 1 1-5

1-14

1,8 1,8

A C E B 0 M a

= = = = = = =

Adriamycin (doxorubicin) cyclophosphamide etoposide bleomycin Oncovin (vincristine) methotrexate

Leucovorin rescue is given 24 hours after each methotrexate dose, iv = intravenous, po = oral.

Repeat every 28 days

1-14 1-14 1-14 1 1 1 8 8 8 8

8, 36, 64 1,15,29,43,57,71 1,15,29,43,57,71

8, 22, 36, 50, 64, 78 1-84 22, 50, 78

PACEBOM P

Repeat every 28 days

15 1,8 1,8 1,8

1-28 29-84 1,15,29,43,57,71 1,15,29,43,57,71 1,15,29,43,57,71

8, 22, 36, 50, 64, 78 8, 22, 36, 50, 64, 78 8, 22, 36, 50, 64, 78

Repeat every 21 days

292 Aggressive non-Hodgkin's lymphoma

Randomized trials Both the Eastern Co-operative Oncology Group (ECOG) and the Southwest Oncology Group (SWOG) have conducted randomized trials employing doxorubicin (Adriamycin)-based chemotherapy in patients with early stage disease. The ECOG trial addressed the question of the need for RT in addition to full-course chemotherapy.10 Three hundred and forty-five eligible patients with previously untreated bulky or extranodal Stage I and patients with Stage II intermediate-grade lymphomas were entered. Patients were randomly assigned to either eight cycles of CHOP or eight cycles of CHOP, followed by low-dose (30 Gy) consolidation RT to sites of pretreatment involvement if they had achieved a CR to induction chemotherapy. Patients on both arms who achieved only a PR with induction CHOP therapy were treated with high-dose (40 Gy) RT to sites of disease involvement. Of patients entered on study, 32 per cent had Stage I disease, 68 per cent had Stage II disease and 30 per cent had bulky disease. Overall, the CR rate was 61 per cent and the partial response (PR) rate was 28 per cent. Of those patients who achieved a PR, 28 per cent achieved a CR with high-dose RT. With a median follow-up of 6 years, the OS was 65 per cent with no differences noted in CR rate, disease-free survival (DFS) or OS between Stage I and II patients. Low-dose RT after achievement of CR with CHOP yielded a better DFS (73 vs 58 per cent). There was, however, no significant difference in survival between the two arms. The SWOG recently updated their study comparing full-course CHOP chemotherapy versus short-course CHOP (three cycles) followed by IFRT.11 The overall survival significantly favored short-course CHOP plus RT over full-course CHOP, with estimated 5-year survivals of 82 per cent and 72 per cent, respectively (P = 0.02). These data clearly suggest that the optimal management of patients with early stage disease should be shortcourse CHOP followed by local radiotherapy.

ADVANCED STAGE DISEASE (II BULKY, III, IV) Phase II trials The CHOP regimen was one of the first combination chemotherapy regimens to use the drug Adriamycin. The regimen was extensively studied by SWOG in a series of prospective randomized trials, which compared CHOP alone to CHOP in combination with bleomycin, bacille Calmette-Guerin, or levamisole.12 Patients with Stage III and IV disease had CR rates of 44-61 per cent. In the subset of patients with diffuse large cell lymphoma, CR rates ranged from 58 to 62 per cent.13 With greater than 14 years of follow-up, CHOP has been demonstrated to

cure 32 per cent of patients with advanced stage diffuse large cell lymphoma. Recognizing the need to improve on the results obtained with CHOP, new and more complex regimens were developed in the 1970s and 1980s. These regimens are frequently referred to as the second- and thirdgeneration regimens to distinguish them from earlier regimens such as CHOP. Many phase II studies of second- and third-generation regimens have been reported in the literature. The results from phase II trials of those regimens, which subsequently were studied in randomized phase III trials, are reviewed. ProMACE REGIMENS

These regimens were developed and piloted at the National Cancer Institute (NCI), USA. ProMACE/ MOPP flexitherapy was the first to be studied.14 In this regimen, two separate combination chemotherapy programs were used sequentially, with the timing of the use of each being based on an individual patient's rate of tumor response. When initially reported with a median follow-up of 31 months, the projected 4-year survival was 65 per cent. With longer follow-up, the actual survival is only 50 per cent. ProMACE/MOPP (day 1, day 8) is a modification of the flexitherapy regimen in which all eight of the chemotherapy drugs are given in each monthly cycle.15,16 While a phase II study of this regimen was not reported, it has been used as one arm in two different prospective trials (see later). The third ProMACE regimen, ProMACE-CytaBOM, uses several non-myelotoxic agents with antitumor activity on day 8 to allow recovery from the myelosuppressive effects of drugs given on day 1.15,16 Because each cycle is given every 3 weeks rather than every 4 as in the ProMACE/MOPP regimen, there is a 25 per cent increase in dose intensity using ProMACE-CytaBOM as compared to the ProMACE/MOPP regimen. A phase II trial was not reported by the NCI, but the regimen was used as one arm of a randomized trial conducted at the NCI. A phase II trial of ProMACE-CytaBOM was conducted by SWOG enrolling 78 patients with a median age of 54 years.17 Sixty per cent had diffuse large cell histology, 49 per cent had B symptoms, and 61 per cent had Stage III or IV disease. Fifty-one (65 per cent) patients achieved CR and, of these, 50 per cent remained alive and disease free at 3 years. The overall survival of the entire group at 3 years was 57 per cent. Overall and relapse-free survival were better in patients with Stage II disease compared to Stage III and IV patients. Eighteen patients experienced life-threatening toxicity and five (6 per cent) died as a result of therapy. m-BACOD

The original M-BACOD regimen developed at the Dana Farber Cancer Institute employed high-dose methotrexate.18

Advanced stage disease 293

While the regimen was effective, it was also very costly. In the m-BACOD regimen, moderate-dose methotrexate is substituted for the high-dose therapy.19 One hundred and thirtyfour patients were enrolled on a phase II study, all of whom had diffuse large cell or undifferentiated histology. Forty-six per cent of the patients had Stage III or IV disease; the median age was 49. Of the 61 per cent of patients who achieved a CR, 76 per cent remained in CR with a median follow-up of 3.6 years. The predicted survival at 5 years was 60 per cent and the predicted 5-year DPS was 74 per cent. Pulmonary toxicity was significant, leading to discontinuation of therapy in 18 per cent of patients. Mucositis was also common, occurring in 44 per cent of patients. SWOG conducted a confirmatory trial of the mBACOD regimen.20 One hundred and six patients enrolled and were stratified at registration as having either normal or impaired bone marrow reserve. Twenty-six patients with impaired bone marrow reserve were treated with reduced doses of cyclophosphamide and Adriamycin beginning with the first cycle of therapy. A total of 76 per cent of patients had diffuse large cell histology, 75 per cent had Stage III or IV disease and 46 per cent had B symptoms. The overall CR rate was 56 per cent with a median follow-up of 41 months; 64 per cent of patients with normal marrow reserve were free of disease. This contrasts with the finding that only 38 per cent (three of eight) with impaired marrow reserve remained free of disease. The estimated 3-year survival was 61 per cent for patients with normal marrow reserve versus 29 per cent for those with impaired reserve. Severe or greater toxicity was observed in 97 per cent of patients and fatal toxicity occurred in nine patients (8 per cent). Despite receiving lower doses of chemotherapy, the marrow-impaired group experienced toxicity similar to those who had received full-dose therapy. MACOP-B

This regimen, which is an intensive 12-week treatment program of continuous weekly therapy with Adriamycin and cyclophosphamide given during odd-numbered weeks and vincristine given during even-numbered weeks with either bleomycin or moderate dose methotrexate, was piloted by investigators at Vancouver.21 Oral prednisone is given daily throughout and all patients were given cimetidine or ranitidine prophylactically. One hundred and twenty-six patients with Stage I and II disease, if bulky and/or associated with B symptoms, and patients with Stage III and IV disease were eligible if they had diffuse aggressive lymphoma and had received no prior therapy. The median age of patients in the study was 55 years. With a median follow-up of 76 months, the authors reported an 84 per cent CR rate with a 3-year survival of 67 per cent. Actuarial 8-year survival is estimated to be 62 per cent and failure-free survival at this same time point is projected to be 52 per cent.22 Fifty per

cent of patients experienced severe mucositis, 11 per cent had major infectious complications and 6 per cent died as a result of treatment. A number of phase II studies of this regimen have been reported. In a single-institution confirmatory phase II trial conducted at Memorial Sloan Kettering, 71 patients with Stage II, III and IV intermediate- and highgrade lymphomas with no prior treatment were enrolled.23 CR rates were much lower than in the Vancouver experience, being 52 per cent for diffuse large cell and 58 per cent for all other histologies. Eight patients who were human immunodeficiency virus (HIV) positive had similar CR rates to the other patients but experienced a much higher mortality secondary to causes other than lymphoma. Excluding the HIV patients, 54 per cent of the patients remained in CR at 25 months. Mucositis occurred in 75 per cent, while 50 per cent of patients required hospitalization for treatmentrelated toxicity and five patients (7 per cent) died as a result of treatment. A confirmatory trial was also conducted by SWOG.24 A total of 109 patients with Stages II, III and IV intermediate- and high-grade histologies were studied. Seventy per cent had Stage III or IV disease, 63 per cent had diffuse large cell histology and the median age of treated patients was 53.5 years. A CR rate of 54 per cent, similar to that seen in the Memorial series, was reported by SWOG. With a median follow-up of 46 months, the 3-year survival was 51 per cent; 63 per cent of patients achieving CR were alive and disease free. Stage II patients did considerably better than their counterparts with more advanced disease. Severe mucositis occurred in 25 per cent and severe granulocytopenia in 51 per cent. The primary determinant of treatment tolerance was age with life-threatening toxicity, being seen in 47 per cent of patients over the age of 60 compared to 13 per cent of those under the age of 60. Fatal toxicity occurred in 5 per cent of patients. A total of 180 previously untreated patients with diffuse aggressive lymphoma were treated with MACOP-B in an Italian multicenter trial.25 Patients with poorprognosis Stage II and patients with Stage III and IV disease who had received no prior therapy were eligible. Of note, 43 per cent of patients had Stage II disease and patients over age 65 were excluded. Complete response was achieved in 71 per cent of the treated patients with a median follow-up of 28 months; the predicted 3-year survival and 3-year FFS were 60 per cent and 48 per cent, respectively. Among the patients who achieved a CR, the actuarial 3-year DPS was 67 per cent. As in other phase II trials, mucositis was common, being seen in 33 per cent of patients. Nine patients died as a result of therapy. As had been seen previously, age correlated with the likelihood of severe toxicity, being 11 per cent in those older than age 59 and 3 per cent in those less than age 59. Using the MACOP-B regimen, multiple investigators

294 Aggressive non-Hodgkin's lymphoma

have observed CR rates ranging from 50 to 84 per cent, DPS rates ranging from 54 to 76 per cent and OS rates ranging from 56 to 65 per cent. This variability in results may reflect many factors such as sample size, patient population and different incidences of adverse prognostic features. When assessing the value of any given regimen, obviously all of these variables must be considered, and such variables may have either a positive or negative impact on outcome.

Randomized trials As detailed above, the results of initial phase II studies were very encouraging and suggested that cure rates might be doubled with the newer regimens as compared to CHOP. Disappointingly, confirmatory phase II trials often failed to achieve the same excellent results as had been initially reported. Because of the selection bias inherent in single-institution studies and because of the variability noted above in the various phase II trials, it is important that randomized comparisons be done either to compare the new regimens to each other or, perhaps more appropriately, to compare the newer regimens to the standard first-generation regimen, CHOP. We will now review the results of several randomized studies that have been performed in the treatment of advanced stage diffuse aggressive lymphomas. ProMACE-MOPP VERSUS ProMACE-CytaBOM

One hundred and ninety-three patients with Stage II, III and IV intermediate- and high-grade lymphoma were entered on this trial conducted by the National Cancer Institute, USA.16 Ninety-nine patients were randomly assigned to ProMACE-MOPP and 94 to ProMACECytaBOM. Patients responding to therapy received at least six cycles of therapy or two cycles after a maximal clinical response. At the time of reporting, the median follow-up was 5 years. Seventy-four per cent of the ProMACE-MOPPtreated patients achieved a CR; 30 (41 per cent) have relapsed. Eighty-one (86 per cent) of the ProMACECytaBOM-treated patients achieved a CR and 22 (27 per cent) of the complete responders have relapsed. Thirtyone (33 per cent) of the patients died, six of whom developed fatal Pneumocystis carinii pneumonia. The CR rate was significantly higher on the ProMACE-CytaBOM arm than on the ProMACE-MOPP arm (P = 0.048). DFS plateaus at 55 per cent for ProMACE-MOPP as compared to 69 per cent for ProMACE-CytaBOM (P = 0.082). Survival curves plateau at 55 per cent for ProMACE-MOPP versus 69 per cent for ProMACECytaBOM (P = 0.046). Thus, in this single-institution trial, the ProMACECytaBOM regimen was found to be superior to ProMACE-MOPP both in terms of CR rate and survival. The authors note that the survival advantage of the

ProMACE-CytaBOM arm may have been blunted by deaths due to P. carinii, which occurred early in the study prior to the institution of prophylaxis for this infection. MACOP-B VERSUS ProMACE-MOPP

In this prospective randomized multicenter trial conducted by the Italian NHL Co-operative Group, 221 patients (197 evaluable) were randomized to therapy with either MACOP-B or ProMACE-MOPP.26 Patient eligibility criteria included Stage II bulky, Stage III and Stage IV disease, no prior therapy, and no acquired immunodeficiency syndrome (AIDS)-associated lymphoma. There were 104 evaluable patients on the ProMACE-MOPP arm and 93 on the MACOP-B arm; results were reported on an intention to treat 114 patients on the ProMACE-MOPP arm and 107 on the MACOP-B arm. The CR rate was 49.1 per cent on the ProMACEMOPP arm and 52.3 per cent on the MACOP-B arm. With a median follow-up of 41 months, the overall 3year survival rates were 45.2 per cent for ProMACEMOPP arm and 52.3 per cent for MACOP-B. Disease-free survival for responding patients was 52.3 per cent on the ProMACE-MOPP arm and 50.3 per cent on the MACOP-B arm. Progression-free survival for the entire group at 3 years was 36.4 per cent on ProMACEMOPP versus 36.1 per cent on the MACOP-B arm. None of these differences was statistically significant. Toxicities were similar with each of the regimens. The most important were leukopenia and granulocytopenia. Mucositis and infection occurred at higher rates on the MACOP-B arm. Fatal toxicity was 4.3 per cent on the ProMACE-MOPP arm and 9.3 per cent on the MACOPB arm (P - 0.1). Thus, in this study, no differences were seen comparing ProMACE-MOPP to MACOP-B in terms of CR, DFS or OS. It should also be noted that the results obtained with these two regimens were worse than those that were reported in the original single-institution trials of these regimens. m-BACOD VERSUS CHOP

A prospective trial was conducted by ECOG to compare the standard CHOP regimen to m-BACOD.27 A total of 392 patients were enrolled of whom 325 were eligible for the study. Patients with diffuse mixed cell and diffuse large cell with Stage III and IV disease were eligible if they had no prior therapy. CR was achieved in 88 of 174 (51 per cent) of the patients randomized to CHOP and 85 of 151 (56 per cent) of the m-BACOD-treated patients. Survival rates at 2 and 5 years were 62 per cent and 49 per cent for m-BACOD as compared to 59 per cent and 48 per cent, respectively for CHOP. There was no significant difference with respect to time to treatment failure, nor was there any difference in the duration of CR comparing the CHOP and m-BACOD arms.

Summary 295

m-BACOD was found to be significantly more toxic than CHOP. This was true with respect to hematologic, infectious and pulmonary toxicity. Most notable were the differences between treatments with respect to moderate, severe and life-threatening pulmonary toxicity (CHOP 3 per cent vs m-BACOD 23 per cent), infectious toxicity (CHOP 13 per cent vs m-BACOD 35 per cent) and stomatitis (CHOP 2 per cent vs m-BACOD 37 per cent). There were eight treatment-related deaths on the CHOP arm compared to nine on the m-BACOD arm. In this study, therefore, there was no advantage in terms of CR rate or outcome with the use of m-BACOD as compared to CHOP. There was, however, clearly more toxicity associated with the use of m-BACOD. Based on these results, CHOP would have to be considered the preferable treatment given a choice between these two regimens. MACOP-B VERSUS CHOP

This randomized trial, conducted by the New Zealand Lymphoma Study Group, compared MACOP-B to CHOP.28 A total of 236 eligible patients with bulky Stage I, II, III and IV disease were randomized to MACOP-B (125 patients) or CHOP (111 patients). The median age of patients was 54 years on the MACOP-B arm and 53 years on the CHOP arm. Complete remission was achieved in 64 (51 per cent) patients assigned to MACOP-B and 65 (59 per cent) of those assigned to CHOP (P = 0.3). FFS at 4 years was 44 per cent on the MACOP-B arm and 32 per cent on CHOP. The estimated 4-year survival was 56 per cent for MACOP-B and 51 per cent for CHOP (P = 0.69). There were no significant differences in CR rate, FFS or OS between the two arms. There were, however, differences in toxicities between the two arms. Patients on MACOPB experienced significantly more grade 3 and 4 hematologic toxicity (P = 0.04), stomatitis (P < 0.0001) and gastrointestinal ulceration (P = 0.03) compared to CHOP. Eighteen per cent of patients on MACOP-B were removed from protocol treatment due to toxicity as compared to 2 per cent on CHOP. Five deaths occurred on the CHOP arm due to toxicity and six on the MACOP-B arm. Thus, as was seen in the ECOG study, there was no advantage in terms of treatment outcome comparing the standard CHOP to a newer regimen. The newer regimen afforded no advantage over CHOP and, once again, CHOP would have to be considered the standard therapy.

CHOP chemotherapy.30 A total of 459 eligible patients were entered into the trial; overall there was no significant difference in outcome between the two arms of the trial. CR rates were 57 per cent for CHOP and 64 per cent for PACEBOM (P = 0.14), and actuarial overall survival at 5 years was 47 per cent for CHOP and 56 per cent for PACEBOM (P = 0.23). Hematological toxicity was significantly less with CHOP (P < 0.02). Thus CHOP remains the standard UK first-line therapy for histologically aggressive NHL. CHOP VERSUS m-BACOD VERSUS ProMACECytaBOM VERSUS MACOP-B

This intergroup study conducted by SWOG and ECOG enrolled 1138 patients with intermediate- or high-grade lymphoma with bulky Stage II, III and IV disease.31 Patients were randomly assigned to one of four treatment arms. Each regimen was administered exactly as had been described in prior phase II studies. Of the 899 eligible patients, 25 per cent were over the age of 64; the median age of treated patients was 54 years. There were no differences among the treatment arms with respect to CR or overall response rate. Complete response rates (in per cent) were: CHOP 44; m-BACOD 48; ProMACE-CytaBOM 56; and MACOP-B 51. Of all eligible patients, 36 per cent were estimated to be alive without disease at 5 years. By treatment arm, these percentages were: CHOP 35; m-BACOD 37; ProMACECytaBOM 36; and MACOP-B 33. The projected overall 5-year survival was 45 per cent with no significant differences among treatment arms. Observed toxicities were similar to those reported in the phase II trials of these regimens. Grade IV or lifethreatening toxicity occurred in 31 per cent of patients receiving CHOP, 54 per cent of those treated with mBACOD, 29 per cent of patients treated with ProMACECytaBOM and 43 per cent of patients treated with MACOP-B. The percentage fatal toxicity by treatment arm was: CHOP 1; ProMACE-CytaBOM 3; m-BACOD 5; and MACOP-B 6. The differences in fatal toxicity were not statistically significant (P = 0.09). However, when fatal and life-threatening toxicities were combined, significant differences were found between regimens, with CHOP and ProMACE-CytaBOM being less toxic than the other two regimens (P - 0.001). Thus, in this large prospective trial, once again CHOP was found to be equivalent to the newer regimens with respect to CR, FFS and OS rates. However, CHOP was less toxic and is, in fact, less expensive than the other regimens.

CHOP VERSUS PACEBOM

The PACEBOM regimen (which incorporates etoposide and reduced doses of methotrexate and steroids) was devised in an attempt to improve the efficacy and reduce the toxicity of MACOP-B.29 The British National Lymphoma Investigation compared this regimen with

SUMMARY Based on the available data as well as on the lower cost and less severe toxicity seen with the CHOP regimen, it

296 Aggressive non-Hodgkin's lymphoma

remains the best available standard treatment for patients with advanced stage intermediate- or highgrade NHL. This is not to imply that CHOP is adequate therapy and there is an obvious need for improvement in treatment for patients with these lymphomas. We strongly advocate participation in clinical trials and we believe that participation in such trials is, in fact, the best therapy for patients at this time. Outside of a clinical trial, CHOP is the standard therapy at this time. Several approaches may be taken to improve treatment outcome. These include: 1 the identification of new active drugs for the treatment of lymphoma: 2 the use of colony stimulating factors to allow dose escalation of the active but myelotoxic drugs; 3 the use of prognostic factors prior to therapy to identify patients who might be candidates for aggressive approaches, including intensive therapy with either bone marrow or peripheral stem cell support; 4 the use of strategies that may overcome the problem of resistance to chemotherapy, which is the ultimate cause of treatment failure in the majority of patients. Introducing new chemotherapy agents does not yet seem to be the answer; for example, SWOG showed only modest clinical efficacy for paclitaxel in a phase II study.32 However, one promising approach may be to add the chimeric anti-CD 20 monoclonal antibody rituximab to conventional CHOP therapy;33 randomized studies testing this combination are underway. The importance of dose, particularly with doxorubicin, as a determinant of outcome with conventional chemotherapy is well recognized. However, while using hematopoeitic growth factors may improve dose and schedule adherence, this has not so far improved survival.34,35 High-dose therapy (with autologous stem cell transplant: ASCT) is still being assessed in randomized studies as consolidation for disease responding completely or partially to conventional chemotherapy. Some of the earlier studies did not stratify for International Prognostic Index (IPI) poor-risk disease - overall there was no survival benefit for high-dose therapy36-38 - but subset analysis in the Groupe d'Etude Lymphome Adulte (GELA) study suggested a possible role for high-dose consolidation in patients with poor-risk disease.39 Randomized studies involving this group of patients are still underway; however, those so far reported by GELA40 and by the German and Italian NHL study groups41,42 have so far not shown an advantage to the high-dose arm. An alternative approach is the use of high-dose sequential (HDS) therapy (non-cross-resistant drugs given at high doses and supported by hematopoeitic growth factors and ASCT). ECOG have established that use of such a regimen is feasible in a multicenter context43 and early results from the Milan group's randomized study of HDS therapy versus conventional

(MACOP-B) chemotherapy suggest a significant advantage for the HDS group.44

CONCLUSION The diffuse aggressive lymphomas are among the most curable of all malignancies. While progress has been made in their treatment, cure is achieved only in the minority of patients with advanced disease. Clearly, better treatment strategies are needed for those whom we can identify prior to therapy as being at risk of treatment failure. The ability to identify such patients and to develop appropriate therapies for them is dependent upon continued basic science and clinical research to further our understanding of these diseases.

REFERENCES 1. Harris NJ, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms. A proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 2. The Non-Hodgkin's Lymphoma Pathologic Classification Project. National Cancer Institute Sponsored Study of Classifications of Non-Hodgkin's Lymphomas. Summary and description of a Working Formulation for clinical usage. Cancer 1982; 49: 2112-35. 3. Magrath IT, Adde M, Shad A, et al. Adults and children with small non-cleaved cell lymphoma have a similar excellent outcome when treated with the same chemotherapy regimen. 7 Clin Oncol 1996; 14: 925-34. 4. Mead G, Sydes M, on behalf of the United Kingdom Lymphoma Group. International evaluation of national cancer institute protocol 89-C-41 (with minor modifications) in adults with non-HIV-related Burkitt's lymphoma - a United Kingdom Lymphoma Group. Vllth International Conference on Malignant Lymphoma, Lugano, 1999. 5. Carbone PP, Kaplan HS, Musshoff K, Smithers DW, Tubiana M. Report of the Committee on Hodgkin's Disease Staging Classification. Cancer Res 1971; 31: 1860-1. 6. The International Non-Hodgkin's Lymphoma Prognostic Factors Project. A predictive model for aggressive nonHodgkin's lymphoma. N EnglJ Med 1993; 329: 987-94. 7. Miller TP, Jones SE. Initial chemotherapy for clinically localized lymphomas of unfavorable histology. Blood 1983; 62: 413-8. 8. Connors JM, Klimo P, Fairey RN, Voss N. Brief chemotherapy and involved field radiation therapy for limited-stage histologically aggressive lymphoma. Ann Intern Med 1987; 107: 25-30. 9. Tondini C, Zanini M, Lombard! F, et al. Combined modality treatment with primary CHOP chemotherapy

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followed by locoregional irradiation in Stage I or II histologically aggressive non-Hodgkin's lymphomas../ Clin Oncol 1993; 11: 720-5. Glick JH, Kim K, Earle J, O'Connell MJ. An ECOG randomized Phase III trial of CHOP versus CHOP plus radiotherapy for intermediate grade early stage nonHodgkin's lymphoma. ProcAm Soc Clin Oncol 1995; 14: 391 (abstract). Miller TP, DahlbergS, CassadyJR, et al. Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade nonHodgkin's lymphoma. New EnglJ Med 1998; 339: 21-6. Jones SE, Grozea PN, Metz EN, et al. Improved complete remission rates and survival for patients with large cell lymphoma treated with chemoimmunotherapy: a Southwest Oncology Group study. Cancer 1983; 51: 1083-90. Coltman CA, DahlbergS, Jones SE, et al. Southwest Oncology Group studies in diffuse large cell lymphoma: a subset analysis. In: Kimura, Ked. Cancer chemotherapy: challenges for the future. Tokyo: Excerpta Medica, 1988; 194-202. Fisher Rl, Devita VT, Hubbard SM, et al. Diffuse aggressive lymphomas: increased survival after alternating flexible sequences of ProMACE and MOPP chemotherapy. Ann Intern Med 1983; 98: 304-9. Fisher Rl, Devita VT, Hubbard SM, et al. Randomized trial of ProMACE-MOPP (day 1, day 8) vs ProMACE-CytaBOM in previously untreated, advanced stage, diffuse aggressive lymphomas. ProcAm Soc Clin Oncol 1984; 3: 242a. Longo DL, Devita VT, Duffey PL, et al. Superiority of ProMACE-CytaBOM over ProMACE-MOPP in the treatment of advanced diffuse aggressive lymphoma: results of a prospective randomized trial. 7 Clin Oncol 1991; 9: 25-38. Miller TP, DahlbergS, WeickJK, etal. Unfavorable histologies of non-Hodgkin's lymphoma treated with ProMACE-CytaBOM: a groupwide Southwest Oncology Group study.; Clin Oncol 1990; 8:1951-8. Skarin AT, Canellos GP, Rosenthal DS, etal. Improved prognosis of diffuse histiocytic and undifferentiated lymphoma by use of high dose methotrexate alternating with standard agents (M-BACOD). y Clin Oncol 1983; 1: 91-8. Shipp MA, Harrington DP, Klatt MM, et al. Identification of major prognostic subgroups of patients with large-cell lymphoma treated with m-BACOD or M-BACOD. Ann Intern Med 1986; 104: 757-65. Dana BW, Dahlberg S, Miller TP, et al. m-BACOD treatment for intermediate and high-grade malignant lymphomas: a Southwest Oncology Group phase II trial.7 Clin Oncol 1990; 8:1155-62. Klimo P, Connors JM. MACOP-B Chemotherapy for the treatment of diffuse large-cell lymphoma. Ann Intern Med 1985; 102: 596-602. Connors JM, Klimo P. MACOP-B chemotherapy for malignant lymphomas and related conditions: 1987

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update and additional observations. Semin Hematol 1988; 25: 41-6. Schneider AM, Straus DJ, Schluger AE, et al. Treatment results with an aggressive chemotherapeutic regimen (MACOP-B) for intermediate and some high grade nonHodgkin's lymphomas. y Clin Oncol 1990; 8: 94-102. Weick JK, Dahlberg S, Fisher Rl, et al. Combination chemotherapy of intermediate-grade and high-grade non-Hodgkin's lymphoma with MACOP-B: a Southwest Oncology Group study. J Clin Oncol 1991; 9: 748-53. Vitolo U, Bertini M, Brusamolino E, et al. MACOP-B treatment in diffuse large-cell lymphoma: identification of prognostic groups in an Italian multicenter study. J Clin Oncol 1992; 10: 219-27. Sertoli MR, Santini G, Chisesi T, et al. MACOP-B versus ProMACE-MOPP in the treatment of advanced diffuse non-Hodgkin's lymphoma: results of a prospective randomized trial by the non-Hodgkin's lymphoma cooperative study group. J Clin Oncol 1994; 12:1366-74. Gordon LI, Harrington D, Andersen J, et al. Comparison of a second-generation combination chemotherapeutic regimen (m-BACOD) with a standard regimen (CHOP) for advanced diffuse non-Hodgkin's lymphoma. N EnglJ Med 1992; 327:1342-9. Cooper IA, Wolf MM, Robertson Tl, et al. Randomized comparison of MACOP-B and CHOP in patients with intermediate grade non-Hodgkin's lymphoma. J Clin Oncol 1994; 12: 769-78. Sweetenham JW, Mead GM, Whitehouse JMA. Intensive weekly combination chemotherapy for patients with intermediate-grade and high-grade non-Hodgkin's lymphoma. J Clin Oncol 1991; 9: 2202-9. Linch DC, Vaughan HB, Hancock BW, et al. A randomised comparison of a third-generation regimen (PACEBOM) with a standard regimen (CHOP) in patients with histologically aggressive non-Hodgkin's lymphoma: a British Lymphoma Investigation report. BrJ Cancer 1996; 74:318-22. Fisher Rl, Gaynor ER, Dahlberg S, et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin's lymphoma. N EnglJ Med 1993; 328:1002-6. Press OW, LeBlanc M, O'Rourke TJ, et al. Phase II trial of paclitaxel by 24-hour continuous infusion for relapsed non-Hodgkin's lymphomas: Southwest Oncology Group Trial 9246. J Clin Oncol 1998; 16: 574-8. Coiffier B, Haioun C, Ketterer N, etal. Rituximab (antiCD20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: a multicenter phase II study. Blood 1998; 92:1927-32. Pettengell R, Gurney H, Radford JA, et al. Granulocyte colony-stimulating factor to prevent dose-limiting neutropenia in non-Hodgkin's lymphoma. A randomised controlled trial. Blood 1992; 80:1430-6. Gerhartz HH, Engelhard M, Meusers P, et al. Randomized, double-blind, placebo-controlled, phase III study of recombinant human-macrophage colony-stimulating

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factor as adjunct to induction treatment for high-grade malignant non-Hodgkin's lymphomas. Blood 1993; 82: 2329-39. Haioun C, Lepage E, Gisselbrecht C, et al. Comparison of autologous bone marrow transplantation with sequential chemotherapy for intermediate- and high-grade nonHodgkin's lymphoma in first complete remission. A study of 464 patients.; Clin Oncol 1994; 12: 2543-51. Verdonck LF, van Putten WL, Hagenbeek A, et al. Comparison of CHOP chemotherapy with autologous bone marrow transplantation for slowly responding patients with aggressive non-Hodgkin's lymphoma. N EnglJ Med 1995; 332:1045-51. Martelli M, Vignetti M, Zinzani PL, et al. High-dose chemotherapy followed by autologous bone marrow transplantation versus dexamethasone, cisplatin and cytarabine in aggressive non-Hodgkin's lymphoma with partial response to front-line chemotherapy: a prospective randomized Italian multicentre study. J Clin Oncol 1996; 14: 534-42. Haioun C, Lepage E, Gisselbrecht C, et al. Benefit of autologous bone marrow transplantation over sequential chemotherapy in poor-risk aggressive non-Hodgkin's lymphoma. Updated results of the prospective study LNH87-2J Clin Onco/1997; 15:1131-7.

40. Recess F, Lepage E, Morel P, et al. Failure of inductive high-dose chemotherapy (HDC) in poor-risk patients (PTS) with aggressive lymphoma. Updated results of the randomized LNH93-3 study. Blood 1997; 90: 594a. 41. Kaiser U, Uebelacker I, Havemann K. High dose chemotherapy with autologous stem cell transplantation in high grade NHL: first analysis of a randomized multicenter study. Bone Marrow Transpl 1998; 21: S177. 42. Santini G, Salvagno L, Leoni P, et al. VACOP-B versus VACOP-B plus autologous bone marrow transplantation for advanced diffuse non-Hodgkin's lymphoma. Results of a prospective randomized trial by the non-Hodgkin's lymphoma Cooperative Study group. J Clin Oncol 1998; 16:2796-802. 43. Schenkein DP, Miller KB, Sweet M, et al. A phase II trial of filgrastim (G-CSF) supported high dose sequential chemotherapy and peripheral blood stem cell (PBSC) transplantation as initial therapy for high-risk nonHodgkin's lymphoma (NHL). A multicenter pilot study. Blood 1995;86:964a. 44. Gianni AM, Bregni M, Siena S, et al. High-dose chemotherapy and autologous bone marrow transplantation compared with MACOP-B in aggressive Bcell lymphoma. N EnglJ Med 1997; 336:1290-7.

21 Lymphoblastic lymphoma in adults JWSWEETENHAM

Introduction Clinicopathological features Treatment High-dose therapy in first remission

299 299 300 302

INTRODUCTION Lymphoblastic lymphoma (LBL) is a rare disease, accounting for approximately 4 per cent of all adult non-Hodgkin's lymphomas (NHLs).1 The outlook for adult patients with this disease has improved considerably in the last two decades, although in most published series, the long-term disease-free survival is around only 40-60 per cent. Several problems still exist in the management of this disease. • In recent years, most therapeutic trials in LBL have focused on the role of early chemotherapy dose intensification. Several recent single-institution phase II studies of dose-intensive regimens show impressive long-term disease-free survival rates, but the influence of patient selection on these results is unclear. • The identification of 'good-risk' and 'poor-risk' patients with LBL is not consistent between different published reports, and reliable clinical or 'biological' prognostic factors are required. • The results of salvage therapy for patients who relapse after line therapy, or who relapse from an initial remission are very poor, with few long-term disease-free survivors. • The role of high-dose therapy and autologous stemcell transplantation requires further study. All of these problems have been addressed in recent studies, which are reviewed in the following text.

CLINICOPATHOLOGICAL FEATURES Lymphoblastic lymphoma is recognized as a distinct entity in all of the major lymphoma classifications. It is

Salvage therapy Summary References

304 305 306

included in the high-grade category of the Working Formulation2 and is recognized in the Revised European-American Lymphoma (REAL) classification.3 It is a malignant disease of precursor T or B cells, most commonly having a T cell immunophenotype in adults. Morphologically, T and B cell LBL are indistinguishable. LBL is morphologically and phenotypically identical to acute lymphoblastic leukemia (ALL), although the B cell phenotype is more common in 'typical' ALL. The clinical distinction between LBL and ALL varies in different centers, usually being based on the degree of bone marrow infiltration or peripheral blood involvement. However, these distinctions are arbitrary. The characteristic clinical features of LBL include male predominance, with the peak incidence in the second and third decades.4 Mediastinal involvement is common at presentation, owing to the thymic origin of the malignant cells, and may be associated with pleural or pericardial involvement (Fig. 21.1). In most recent series,5-8 approximately 60-70 per cent of patients have presented with mediastinal disease. Most of these cases show a T cell phenotype. Where immunophenotypic data are available, 70-80 per cent of adult patients have T cell markers. The disease shows a propensity for involvement of the bone marrow and central nervous system, and leukemic overspill is well recognized both at presentation, or more commonly as a terminal event. The incidence of bone marrow and peripheral blood involvement at diagnosis is difficult to determine, since it depends upon the criteria used for distinguishing LBL from ALL. These criteria are not consistent. For example, the series from Stanford University5 adopted the criteria originally described by Nathwani et a/.9 In this series, patients with more than 10 per cent circulating lymphoblasts or pancytopenia

300 Lymphoblastic lymphoma in adults

Stanford series.5 In this study, the Ann Arbor stage was more predictive of survival than Murphy stage, and the Ann Arbor system is used in most centers for staging this disease.

TREATMENT Early studies of the treatment of LBL included adults and children, and used first- and second-generation combination chemotherapy regimens originally designed for the treatment of intermediate-grade NHL.9-12 Results with these regimens were poor. Long-term disease-free survival (DPS) rates of only 10-15 per cent were reported. The introduction of intensive chemotherapy/radiotherapy protocols for children with LBL was associated with marked improvements in outcome. Long-term DPS rates of 60-80 per cent were reported for several protocols similar to those used in ALL, comprising intensive remission induction therapy, CNS prophylaxis, consolidation chemotherapy and prolonged maintenance chemotherapy.10,13,14 This led to the introduction of similar regimens for adult patients with LBL. Figure 21.1 Chest X-ray showing a large mediastinal mass, with radiographic evidence of pleura! and pericardial effusions in a 26-year-old man presenting with T cell lymphoblastic lymphoma.

secondary to bone marrow involvement were excluded from their LBL protocols and treated as ALL. By contrast, the studies from Memorial Sloan Kettering Cancer Center6 and Paris8 include patients with peripheral blood involvement, but separate these patients into 'leukemic' and 'non-leukemic' LBL, based on the proportion of lymphoblasts in the bone marrow (>25 per cent vs <25 per cent), and the circulating lymphoblast count (present versus absent). In most European centers, patients with 'leukemic LBL' according to the above criteria, are excluded from LBL treatment protocols, and treated as ALL. Peripheral lymph node involvement is also common (60-70 per cent of patients) at diagnosis. Although central nervous system (CNS) disease is unusual at presentation, occurring in 5-10 per cent of patients, it is a frequent site of relapse (see later).

Staging Some centers have adopted the Murphy staging system for patients with LBL.10 This system was originally proposed for children with high-grade NHL, in whom it provided more useful prognostic information than the Ann Arbor system.11 A formal comparison of the two staging systems in adult LBL was performed in the

Intensive chemotherapy/radiotherapy regimens Intensive combined modality regimens analogous to those used for ALL have produced much higher response and DPS rates in adult patients, compared with first- and second-line NHL regimens, although most series still report long-term DFS in only 40-60 per cent of patients, and refractory or relapsing disease remains a significant problem. The group from Stanford University has reported results of 44 adult patients who were treated with two consecutive novel protocols incorporating CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)-like induction chemotherapy, CNS prophylaxis (with intrathecal and high-dose systemic methotrexate in the first regimen, and intrathecal methotrexate and CNS irradiation in the second), followed by a consolidation chemotherapy treatment block, and oral maintenance chemotherapy for 1 year (Fig. 21.2).5 The response rate was 100 per cent (95 per cent complete remission, 5 per cent partial remission), and the 3-year actuarial freedom from relapse (FFR) was 56 per cent with a median follow-up of 26 months. In patients treated with the first regimen, CNS relapse occurred in 4 of 13 patients and the prophylaxis was, therefore, modified. With the second regimen, they reported a marked reduction in the incidence of CNS relapse, although there was no overall survival difference between the two protocols. Unfortunately, no update of this study has been published, but in Southampton, we were not able to reproduce these encouraging results.15 We treated 12

Treatment 301

Figure 21.2

Treatment schema for second protocol described by the Stanford University group. Adapted from reference 5.

adult patients with non-leukemic LBL according to the second regimen reported from Stanford. Four of these patients relapsed in the CNS, and only four patients are in continuing complete remission (CR). In a report from the Memorial Sloan Kettering Cancer Center,6 Slater et al. treated 51 adult LBL patients with five successive protocols originally developed for patients with ALL. This series included patients with leukemic and non-leukemic disease. The CR rate in this report was 78 per cent, with a 5-year actuarial overall survival (OS) of 45 per cent. Bernasconi et al. report a similar outcome in 31 patients treated with ALL-type regimens, with a CR rate of 77 per cent and 4-year actuarial OS of 35 per cent. Morel et al. reported results of 80 patients with LBL treated with CHOP plus maintenance chemotherapy (21) patients, the LNH-84 regimen (30 patients),16 the FRALLE protocol (22 patients)17 and the LALA protocol (seven patients).8 The CR rate was 82 per cent. With median follow-up of 55 months, the actuarial OS at 30 months was 51 per cent. There was a trend for a lower CR rate in patients treated with CHOP chemotherapy compared with the more intensive regimens, although this did not achieve statistical significance. Also in a single-center study from Marseille of 62 unselected patients, ALL-like induction was found to be more effective than a NHL-like regimen in achieving complete remission (89 per cent and 52 per cent, respectively); the overall survival of all patients (30 of whom were transplanted in remission) was 49 per cent at 5 years.18

We have treated 30 consecutive, unselected adult patients with leukemic and non-leukemic LBL according to four successive protocols. The CR rate in our patients is only 50 per cent, with 5-year actuarial overall survival of only 22 per cent (Fig. 21.3). The inferior outcome in our group may reflect differences in selection criteria compared with other reported series. For example, our series includes 8 (27 per cent) patients aged over 60 years at presentation. Very few patients over 60 years of age are included in the other published series. As these results demonstrate, despite considerable

Figure 21.3 Actuarial overall survival for 30 adult patients with LBL presenting to the CRC Wessex Medical Oncology Unit, University of Southampton. ....,95 per cent Cl.

302 Lymphoblastic lymphoma in adults

improvements in outcome since the introduction of dose-intensive regimens, the long-term DFS for adults with this disease is still unsatisfactory. Recent attempts to improve upon these results have focused on the early use of high-dose therapy with autologous or allogeneic stem-cell transplantation in groups considered to be at high risk from relapse or progression (see later).

Prognostic factors For patients with intermediate- and high-grade NHL, the recently conducted International Prognostic Factors Project has described risk groups, based on presenting clinical features, which are now used by most major treatment centers.19 Prospective clinical trials have been initiated, comparing different treatment approaches in the various risk categories. The most widely accepted prognostic factors in LBL are those described by the Stanford group. Patients with Ann Arbor stage < IV, or stage IV without bone marrow or CNS involvement, with a serum lactate dehyhdrogenase (LDH) level <300 IU/1 (normal = <200 IU/1) were defined as good risk. All other patients were defined as poor risk. The FFR for these two risk groups is shown in Fig. 21.4. Table 21.1 summarizes the adverse prognostic factors that have been identified by univariate and multivariate analysis in the series published to date. The factors identified are highly variable, and often directly conflicting between various reports. Interestingly, none of these series has identified immunophenotype or the presence of mediastinal disease as adverse prognostic factors. In our own patients, no adverse prognostic factors could be identified on univariate analysis. In a recent study, we have attempted to apply the International Index in a prospective fashion to a group of adult patients with LBL, being treated in the context

Figure 21.4

Actuarial freedom from relapse according to risk

group for adult patients with LBL treated at Stanford University. Reproduced from Coleman, Picozzi, Coxet al. Treatment of lymphoblastic lymphoma in adults. J Clin Oncol 7986; 4: 1626-37.

Table 21.1 Adverse clinical prognostic factors in adult lymphoblastic lymphoma

Advanced age Ann Arbor stage Bone marrow involvement Central nervous system involvement Leukemic involvement Serum lactate dehydrogenase B symptoms Time to attainment of complete remission

8 5,7 5 5 6 5, 8 5, 8 6

of a prospective randomized trial (the EBMT/UKLG LY01 trial, see later).20 A preliminary analysis of these data, shows that the International Index has predictive value in terms of OS - the actuarial OS at 12 months was 63 per cent for patients with zero or one risk factor, 60 per cent for those with two, 56 per cent for those with three factors, and only 36 per cent for those with four or five. These data are, however, very preliminary, and are based on a very small number of events. However, the results also show that the OS for patients within this study, analysed prospectively, is lower than that reported for most retrospective series, suggesting that previous series are likely to have included highly selected patient groups.

HIGH-DOSE THERAPY IN FIRST REMISSION Despite CR rates in excess of 80 per cent in most reports, only 40-60 per cent of patients achieve long-term disease-free survival. Thus, relapse rates in this disease are high, and the results of salvage therapy for relapsed or refractory patients are very poor. Several centers have therefore studied the use of high-dose therapy with autologous stem-cell transplantation (ASCT), or allogeneic bone marrow transplantation to consolidate first remission achieved with 'conventional' dose induction therapy. In most reports, the use of high-dose therapy has been restricted to patients thought to be at high risk of subsequent relapse on the basis of presenting prognostic factors. Since risk factors are variable from center to center, comparisons of the results of these studies must be made with caution. Overall, the early reports of first remission autografting in LBL have been encouraging, with long-term DFS rates superior to those reported with conventional dose therapy. The group from Genoa have reported 36 patients with LBL receiving induction therapy with a modified LSA2L2 regimen.21 These patients were considered to be at high risk from relapse, although no risk criteria were stated. Of the original 36 patients, 24 achieved a CR to induction therapy, and 18 of these proceeded to high-dose therapy and autologous bone

High-dose therapy in first remission 303

marrow transplantation (ABMT). With follow-up of 46 months, the 5-year actuarial DFS for the transplanted patients was 74 per cent. Although these results were encouraging in the group who were autografted, only 50 per cent of those who commenced the protocol received high-dose therapy. Based on an intention to treat analysis, the results are therefore disappointing. Milpied et al. reported 25 poor-risk patients treated in first remission with high-dose therapy and either autologous (13 patients) or allogeneic (12 patients) bone marrow transplantation.22 The adverse prognostic factors at presentation in this group included Murphy and Ann Arbor Stage IV disease (50 per cent) and malignant pleural effusions (35 per cent). The actuarial DPS was 69 per cent at 4 years, with no difference observed according to the source of bone marrow. Other reports from single institutions have been very small.23,24 Verdonck et al. have reported nine adult patients with 'poor-risk' disease as defined by the Stanford criteria, who received first remission high-dose therapy with ABMT.23 Six of these patients are in continuing CR at 12-113 months. Similar results have been observed for small numbers of patients included in two other reports.8,12 In a retrospective analysis, the European Group for Bone Marrow Transplantation (EBMT) reported 105 patients undergoing first remission ABMT for lymphoblastic lymphoma.25 In the most recent update of this study, 147 patients have been autografted in first CR,26 using either bone marrow or peripheral blood progenitor cells (PBPCs) or both. The selection criteria for first remission autografting are unclear, and are likely to have varied between the different contributing centers and over time, making interpretation of these results difficult. Sixty-three per cent of the patients had Stage IV disease at presentation, with bone marrow involvement in 33 per cent and CNS disease in 5 per cent. Serum LDH values at presentation were not available for all patients, but 67 per cent of those measured were elevated. The 5-year actuarial overall survival for this group was 64 per cent (Fig. 21.5). The median time to relapse was 6 months, with no relapses occurring after 38 months from the date of stem-cell reinfusion. Univariate analysis failed to identify any features at presentation, or at the time of autografting, which predicted for DPS or OS in this group. Although there was a trend for poorer outcome in patients with CNS disease or bone marrow involvement at presentation, this did not achieve statistical significance. No CNS relapses have been reported in patients undergoing first remission ASCT. Since the CNS is a frequent site of relapse in this disease, this observation suggests that early dose intensification of this type may prevent subsequent CNS relapse. Although these results for first remission ASCT are encouraging, at least two previous series have demonstrated that the attainment of a complete remission to conventional dose induction therapy is in itself an

Figure 21.5

Actuarial overall survival for adult patients with

LBL undergoing high-dose therapy and ASCT in first complete remission -from the EBMT lymphoma registry. Reproduced from Sweeten ham, Liberti, Pearce et al. High dose therapy and autologous stem cell transplantation (ASCT) for lymphoblastic lymphoma in adults: results from the European Group for Bone Marrow Transplantation, 1994.

important favorable prognostic factor.63 For patients achieving a CR, the subsequent long-term relapse-free survival was around 75 per cent in these two series. The selection of patients for first remission ASCT remains uncertain. The results of first remission ASCT are clearly superior to those reported by the Stanford group in 'poor-risk' patients, in whom the 5-year actuarial FFR was only 19 per cent. By contrast the corresponding 5-year FFR value for 'good-risk' patients was 94 per cent and there is no role for first remission ASCT in this group. Identification of poor-risk groups in whom first remission ASCT should be assessed prospectively requires further study. The influence of first remission ASCT on the outcome for patients with LBL is the subject of a prospective randomized study in the UK and Europe that has recently closed. Patients who achieved an initial remission to conventional dose induction therapy were randomized between first remission ASCT with bone marrow or peripheral blood progenitor cells, or continuation of conventional dose consolidation and maintenance chemotherapy (Fig. 21.6). All patients with LBL were eligible for the trial, irrespective of risk factors at presentation. The initial results show a trend towards improved relapse-free survival for patients receiving ASCT.27

Source of stem cells for rescue after highdose therapy in first CR There is little published literature on the role of allogeneic bone marrow transplantation in first remission for LBL. The study by Milpied et al. included 12 patients

304 Lymphoblastic lymphoma in adults Figure 21.6 Study design of the EBMT/UKLG study of first remission high-dose therapy for adult LBL Emergency chemotherapy given at presentation does not exclude patients from the trial. * Marrow must be negative at this stage; f if PBSCT is used, harvesting may be performed after randomization. LBL = lymphoblastic lymphoma, NR - non-response, PD - progressive disease, CR - complete response, PR = partial response, ABMT = autologous bone marrow transplantation, PBSCT = peripheral blood stem cell transplantation.

who underwent allogeneic bone marrow transplantation from HLA-identical siblings in first CR.22 In this small series, no difference in outcome was observed in this group compared with the 13 patients who received autologous bone marrow. In the report by Morel et a/.,8 eight patients received allogeneic marrow transplants but only one of these was in first CR. Although many centers regard allogeneic marrow as the preferred source of hemopoietic rescue, there are no comparative data at present that support this. Peripheral blood progenitor cells are now being used with increasing frequency in patients with lymphoma. The early multilineage hemopoietic recovery compared with autologous bone marrow is now well documented.28 In the EBMT series, a small number of patients have received PBPCs and the outcome in this group appears to be identical to that in patients undergoing ABMT. Although there is evidence to show that lymphoma cells can be mobilized into the

peripheral blood by progenitor cell mobilization regimens,29 this has not yet been demonstrated for LBL. It is likely that PBPCs will become the most frequent and preferred source of hemopoietic rescue for these patients.

SALVAGE THERAPY Despite improvements in outcome for patients treated with intensive initial therapy, the results of salvage therapy for refractory or relapsing patients with LBL are very poor. In the recently published series using intensive chemotherapy/radiotherapy induction regimens, less than 10 per cent of refractory/relapsing patients achieve long-term DPS. The median survival for these patients is around 9 months.5-8

Summary 305

High-dose therapy with ASCT has been used increasingly in this situation either as a component of the treatment used to induce a second remission or to consolidate a second CR attained with conventional dose salvage therapy. Most of the large studies of autografting for relapsed NHL have included patients with LBL, but the numbers have been too small to interpret reliably. In the study from Morel et al.8 of the 80 patients in the series, 37 eventually required salvage therapy. Fourteen of these patients achieved a second CR with conventional dose reinduction therapy. Of the seven patients treated with autologous transplants, three achieved long-term DPS. In the retrospective study from the EBMT, 41 patients underwent high-dose therapy and ASCT in second CR.26 The 3-year actuarial progression-free survival (PFS) and OS for this group were 30 per cent and 31 per cent, respectively. These results are difficult to interpret in view of the potential selection bias and registration bias of a registry-based study, but they are superior to the results of conventional dose salvage therapy. The EBMT series also included patients in whom high-dose therapy was used as salvage prior to the attainment of a second CR. As with other types of NHL,30,31 the responsiveness of the disease to conventional dose therapy given prior to the high-dose treatment was predictive of outcome. The 5-year actuarial OS for those with chemosensitive relapse was 31 per cent compared to 18 per cent for those with chemoresistant disease (Fig. 21.7). Since patients with chemosensitive relapse have a superior outcome to those with resistant relapse, all relapsing patients should receive conventional dose salvage therapy in an attempt to induce a second remission

prior to high-dose therapy and ASCT. Even for patients with resistant relapse, the results of high-dose therapy and ASCT from the EBMT are superior to those of conventional dose salvage. Direct comparisons of the 5year actuarial OS figure of 18 per cent with results from conventional dose salvage are not possible, but ASCT should be considered for this group, whose prognosis is otherwise very poor. As with other subtypes of NHL, the presence of active CNS disease at the time of high-dose therapy was a highly significant adverse factor32 and ASCT should not be considered for these patients.

SUMMARY Despite advances in the treatment of adult LBL in recent years, there are still several unresolved problems. Although intensive ALL-like induction regimens have undoubtedly improved long-term DFS and OS, these survival rates remain around 40-60 per cent, and it is not clear whether further dose intensification with high dose therapy and ASCT in the first remission will improve upon these results. Future protocols adapted to risk factors at presentation are desirable, although the clinical prognostic factors for adult LBL are not clearly defined, and require analysis of a large number of patients, preferably treated in the context of a clinical trial such as the UKLG/EBMT study. Investigations of 'biological' factors, which may identify risk groups, such as the use of cytogenetics, proliferation markers, etc. have not yet been formally conducted in LBL. Although there are uncertainties about the role of high-dose therapy in first remission, the results of salvage therapy with high-dose therapy are superior to those of conventional dose salvage but no comparative trials have been conducted. Patients who fail induction therapy should receive conventional dose therapy prior to transplantation in an attempt to induce a second remission. However, even in those patients with chemoresistant disease, high-dose therapy should still be considered. At present there is no evidence to support the use of allogeneic bone marrow instead of autologous marrow or PBPCs.

ACKNOWLEDGEMENTS

Figu re 21.7

Actuarial overall survival for adult patients with

LBL undergoing high-dose therapy and ASCT as salvage therapy outcome according to disease sensitivity. From the EBMT Lymphoma Registry. Reproduced from reference 26.

Dr Sweetenham is supported by a grant from the Leukaemia Research Fund. The author wishes to acknowledge the assistance of Rachel Pearce and Golnaz Taghipour from the EBMT Lymphoma Working Party office in London, in the analysis of EBMT data.

306 Lymphoblastic lymphoma in adults

REFERENCES 1. Simon R, Durrleman S, Hoppe RT, et al. The NonHodgkin's Lymphoma Classification Project. Long term follow-up of 1153 patients with non-Hodgkin's lymphoma. Ann Intern Med 1988; 109: 939-45. 2. Non-Hodgkin's Lymphoma Classification Project. National Cancer Institute sponsored study of classifications of non-Hodgkin's lymphoma: a summary and description of a working formulation for clinical usage. Cancer 1982; 49: 2112-35. 3. Harris ML, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 4. Rosen PJ, Feinstein Dl, Pettengale PK, et al. Convoluted lymphocytic lymphoma in adults: a clinicopathological entity. Ann Intern Med 1978; 89: 319-24. 5. Coleman CN, Picozzi VJ, Cox RS, et al. Treatment of lympoblastic lymphoma in adults. J Clin Oncol 1986; 4: 1626-37. 6. Slater DE, Mertelsmann R, Koriner B, et al. Lymphoblastic lymphoma in adults. J Clin Oncol 1986; 4: 57-67. 7. Bernasconi C, Brusamolino E, Lazzarino M, etal. Lymphoblastic lymphoma in adult patients; clinicopathological features and response to intensive multiagent chemotherapy analogous to that used in acute lymphoblastic leukaemia. Ann Oncol 1990; 1: 141-6. 8. Morel P, Lepage E, Brice P, et al. Prognosis and treatment of lymphoblastic lymphoma in adults: a report on 80 patientsj Clin Oncol 1992; 10:1078-85. 9. Nathwani BN, Diamond LW, Winberg CD, et al. Lymphoblastic lymphoma: a clinicopathological study of 95 patients. Cancer 1978; 48: 2347-57. 10. Murphy SB. Childhood non-Hodgkin's lymphoma. N Engl J Med 1977; 299:1446-8. 11. Carbone PP, Kaplan HS, Musshoff K, et al. Report of the committee on Hodgkin's disease staging classification. Cancer Res 1971; 31:1860-1. 12. Murphy SB. Management of childhood non-Hodgkin's lymphoma. Cancer Treat Rep 1978; 61:1161-73. 13. Aur RJ, Hustu HO, Simone JV, et al. Therapy of localised and regional lymphosarcoma of childhood. Cancer 1971; 27:1328-31. 14. Woolner N, Burchenal JH, Lieberman PH, etal. NonHodgkin's lymphoma in children. A progress report on the original patients treated with the LSSA2L2 protocol. Cancer 1979; 44:1990-9. 15. Sweetenham JW, Mead GM, Whitehouse, J MA. Adult lymphoblastic lymphoma: high incidence of central nervous system relapse in patients treated with the Stanford University protocol. Ann Oncol 1992; 3: 839-41. 16. Coiffier B, Gisselbrecht C, Herbrecht R, et al. A multicenter study of intensive chemotherapy in 737 patients with aggressive malignant lymphoma. J Clin Omro/1989; 7:1018-26.

17. Schaison G, Olive D, Bancillon A, etal. Intermediate risk children with acute lymphoblastic leukaemia: Amsacrine + Ara-C versus intermediate dose methotrexate for consolidation and 6MP-MTX vincristine versus monthly pulses for maintenance. ProcAm Soc Clin Oncol 1987; 6: 562 (abstract). 18. Bouabdallah R, Xerri L, Bardou V-J, et al. Role of induction chemotherapy and bone marrow transplantation in adult lymphoblastic lymphoma: a report on 62 patients from a single center. Ann Oncol 1998; 9: 619-25. 19. Shipp MA, Harrington DP, Anderson JR, et al. The International non-Hodgkin's Lymphoma Prognostic Factors Project. A predictive model for aggressive nonHodgkin's lymphoma. N EnglJ Med 1993; 329: 987-94. 20. Sweetenham JW, Santini G, Simnett SJ, et al. Conventional dose versus high dose post-remission therapy for adults with lymphoblastic lymphoma - a progress report on the EBMT/UKLG trial and a preliminary analysis of prognostic factors. Blood 1996; 88:124a (abstract). 21. Santini G, Coser P, Chisesi T, et al. Autologous bone marrow transplantation for advanced stage adult lymphoblastic lymphoma in first complete remission. Ann Oncol 1991; 2(suppl 2): 181-5. 22. Milpied N, Ifrah N, Kuentz, et al. Bone marrow transplantation for adult poor prognosis lymphoblastic lymphoma in first complete remission. BrJ Haematol 1989; 73: 82-7. 23. Verdonck LF, Dekker AW, de Gast GC, et al. Autologous bone marrow transplantation for adult poor risk lymphoblastic lymphoma in first remission.) Clin Oncol 1992; 10: 644-6. 24. Jackson GH, Lennard AL, Taylor PRA, et al. Autologous bone marrow transplantation in poor risk high grade non-Hodgkin's lymphoma in first complete remission. Br

JCancer1994;70:501-5. 25. Sweetenham JW, Libert! G, Pearce R, et al. High dose therapy and autologous bone marrow transplantation for adult patients with lymphoblastic lymphoma: results of the European group for Bone Marrow Transplantation. J Clin Oncol 1994; 12:1358-65. 26. Sweetenham JW, Liberti G, Pearce R, et al. High dose therapy and autologous stem cell transplantation (ASCT) for lymphoblastic lymphoma in adults: results from the European group for Bone Marrow Transplantation (EBMT). In: Dicke KA, Keating A eds, Autologous blood and marrow transplantation: Proc 7th Int Symp 1994; 357-63. 27. Sweetenham JW, Santini G, Simnett S, et al. Autologous stem cell transplantation (ASCT) in first remission improves relapse free survival (RFS) in adult patients (PTS) with lymphoblastic lymphoma (LBL): results from a randomised trial of the European group for Blood and Marrow Transplantation (EBMT) and the UK Lymphoma Group (UKLG). ProcAm Soc Clin Oncol 1998; 17:17a. 28. Gianni AM. Where do we stand with respect to the use of peripheral blood progenitor cells? Ann Onto/1994; 5: 781-4.

References 307

29. Sphall EJ, Jones RB. Release of tumor cells from bone marrow. Blood 1994; 83: 623-5. 30. Phillip T, Armitage JO, Spitzer G, et al. High-dose therapy and autologous bone marrow transplantation after

marrow transplantation for patients with non-Hodgkin's lymphoma who are still responsive to conventional-dose chemotherapy. 7 Clin Oncol 1989; 7:1621-9. 32. Williams CD, Pearce R, Taghipour G, et al. Autologous

failure of conventional chemotherapy in adults with

bone marrow transplantation for patients with non-

intermediate-grade or high-grade non-Hodgkin's lymphoma. N EnglJ Med 1987; 316:1493-7.

transplanted with active CNS disease have a poor

31. Gribben, JG, Goldstone AH, Linch DC, et al. Effectiveness of high-dose combination chemotherapy and autologous bone

Hodgkin's lymphoma and CNS involvement: those outcome - a report by the European Bone Marrow Transplant Registry. J Clin Oncol 1994; 12: 2415-22.

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22 Follicular lymphoma TA LISTER AN D AZS ROHATINER

311 316

Introduction 309 Pathology 309 Presentation features, natural history and clinical course 310

Management References

INTRODUCTION

may be indistinct and there is a range of 'follicularity'. Not infrequently, there is a partially diffuse pattern of infiltration.13-16 In addition, the proportion of smaller to larger cells is not necessarily the same from patient to patient, although in the majority, the ratio is usually more than 50:50. It is generally accepted that, when the proportion of large cells is very high, classification as low-grade lymphoma is inappropriate. Without dispute is the fact that transformation from follicular lymphoma, usually occurring over time, into a lymphoma of diffuse pattern and large cells is a grave event.17-23 The clinical significance of discordant lymphoma, usually with 'transformation' in at least one node but not in another, or transformation in a node but not in the bone marrow at the initial presentation is not so clear. It has now been demonstrated that, in addition to having a characteristic morphology and immune phenotype, follicular lymphoma also has a specific chromosomal abnormality, which is most likely, at least in part, to contribute to the development of the disease. The t(14;18) translocation is associated with up to 85 per cent cases of follicular lymphoma and a much lesser proportion of diffuse lymphomas, probably representing (if only by definition) de novo transformation of follicular lymphoma.24-28 The gene on chromosome 18, named bcl-2, which becomes juxtaposed to the immunoglobulin heavy-chain gene on chromosome 14,29-33 has now been identified and cloned. The rearrangement results in deregulation and hyperexpression of bcl-2, leading to an antiapoptotic effect, invoking a potential mechanism34 whereby the translocation might at least predispose to malignancy. It must be stressed that further events must be necessary, since patients who have previously had follicular lymphoma, but who have been clinically free of

Follicular lymphoma is the epitome of the low-grade non-Hodgkin's lymphomas in both of the major pathological classifications in use in the 1990s.1,2 Should the concept of 'grade' be withdrawn from the classification of lymphoma as proposed,3 the condition will doubtless retain its reputation for (perceived) 'indolence'. An uncommon, but not rare illness, occurring in approximately 4/100000 adults per year4 in the Western world, with unknown etiology, it presents a substantial challenge to the physician, and to the clinical and laboratory scientist. Current management will be described against a background of an historical perspective and the pathophysiology of the disease.

PATHOLOGY The criteria whereby follicular lymphoma may be diagnosed on lymph node biopsy and to a lesser extent in extranodal tissue have remained relatively undisputed5-7 since the disease first formally achieved 'malignant' status in 1938.8 These were reinforced 20 years later9 by a confirmation of the differences between it and follicular hyperplasia. Follicles of irregular size and shape, sometimes visible after staining to the naked eye, and best seen under low power, replace the normal architecture. They are composed of an admixture of smaller and larger follicle center cells (centrocytes and centroblasts), shown to be of B cell origin by expression of the B cell antigens CD 19, CD 20 and CD 10.10-12 The margins of the follicles

310 Follicular lymphoma

recurrence for many years, have been shown to have cells bearing the translocation in the bone marrow or peripheral blood.35-37 The latter have also been detected, albeit at very low levels,38 in hyperplastic tonsils of 'normal' individuals without lymphoma.39 These caveats notwithstanding, these discoveries have undoubtedly increased the understanding of lymphomagenesis and have already led to consideration of novel therapeutic strategies.

PRESENTATION FEATURES, NATURAL HISTORY AND CLINICAL COURSE The majority of patients with follicular lymphoma present with painless lymphadenopathy but no other symptoms. Examination often reveals multiple, peripheral lymph node enlargement, the spleen often also being palpable. Further investigations (see later) determined by the circumstances may confirm more widespread involvement, especially of the bone marrow40 and sometimes of the peripheral blood.23,41,42 The characteristics of 299 consecutive, newly diagnosed patients with follicular lymphoma at St Bartholomew's Hospital, London, over more than 20 years serve to illustrate this. Women and men were equally represented, 48 per cent:52 per cent. The age range was 20-90 years, with a median of 55. A quarter had 'B' symptoms. Only 15 per cent had disease confined to a single site (nodal 12 per cent, extranodal 3 per cent). The bone marrow was by far the commonest site at which disease was (sought and) detected (45 per cent by unilateral bone marrow biopsy). Liver, skin and lung (not including pleural effusions) were involved in 8.5 and 4 per cent, respectively. Multiple extranodal site involvement was quite common. The final clinical Ann Arbor stage was I (15 per cent), II (14 per cent), III (17 per cent) and IV (57 per cent). More extensive investigation would almost certainly have increased the proportion with advanced stage disease. Despite the relatively small proportion with constitutional symptoms, 82 per cent proceeded to treatment immediately, possibly reflecting an enthusiastic interventional therapeutic strategy in operation for much of the period. The natural history of the disease, happily, is rarely allowed to develop unimpeded nowadays because of the availability of at least partially effective therapy. There is no doubt, however, that the illness is usually slowly progressive. Long-term observations from Stanford University43 reveal that those who present with smallvolume, multiple-site disease, without either constitutional symptoms or evidence of vital organ impairment, will wait a median of 1-2 years before the illness has become extensive enough to 'warrant' therapy. They further confirm that the majority of patients do come to treatment sometime, a small proportion not for many

years. As yet, there are no data to indicate that early intervention in this group improves the prognosis.44 It has also been clearly recorded at Stanford, that spontaneous regressions occur,43 although they are rarely complete and usually transient. The best illustration of the influence of modest intervention on the natural history of the disease comes from Symmers in 1938.8 Reporting on his own series and assimilating previous case histories, he presented a picture of the disease easily recognized today, and highly worthy of the eponymous title 'Brill-Symmers disease'. Progressive, uncomfortable disease, particularly in lymph node or spleen was treated repeatedly, with symptomatic relief, by local irradiation. Four patterns of behavior were observed. First, and most common, was a progressing, partially remitting after irradiation, but recurring illness, in which the histological pattern of the involved tissue was persistently the same with each episode. Second, sarcomatous transformation with a poor subsequent prognosis followed. Third, leukemic spread was noted, and fourth, rarely, Hodgkin's disease was diagnosed. The median survival of this relatively small group of patients was about 5 years, similar to that reported by Gall and Mallory in 19416 and Rosenberg45 20 years later, for rather larger groups of patients in an almost completely prechemotherapy era. The median survival for patients treated in the 1970s and 1980s, predominantly with chemotherapy as the need arose, with various strategies sometimes directed at but failing to achieve cure, is reported to be nearer 10 years (Fig. 22.1); however, the same patterns of survival are seen 22,46-48 Transformation remains the greatest outstanding problem (Fig. 22.2),17-23 although some long survival has been achieved,49 even with conventional therapy. There is thus substantial room for improvement in the treatment of this disease. Its 'indolence' may be satisfactory for the elderly; it is manifestly not so for the younger.

Figure 22.1 Survival from diagnosis of patients with follicular lymphoma at St Bartholomew's Hospital.

Management 311

the treatment strategy warrants it. It should be possible to make a plan within a fortnight of presentation.

Treatment STRATEGY

Figure 22.2

Survival from transformation of follicular

lymphoma (without high-dose therapy) at St Bartholomew's Hospital.

MANAGEMENT Diagnosis Confirmation of the diagnosis at presentation, progression or recurrence is essential if the most appropriate management is to be effected. It is usually made on the basis of biopsy of an easily accessible lymph node. If any clinical suspicion of transformation exists, for example, rapid enlargement of a node at a different site from that originally biopsied or a large abdominal mass, repeat biopsy should be performed. Even in the latter case, this is a relatively minor procedure with computed tomography (CT) or ultrasound-guided Tru-cut needle biopsy (as opposed to aspiration).50 The necessity for any diagnostic assistance beyond morphology, for example, immune phenotyping or cytogenetics, will be determined by the therapeutic strategy.

Investigation It is customary to determine the distribution and approximate extent of disease prior to decisions being made about therapy. Clearly, the general circumstances of the patient will be the over-riding determinant of how far investigation is pursued. It is rare for the patient with lymphoma to be under investigated. History and clinical examination are usually accompanied by computed axial tomography and unilateral bone marrow biopsy. The peripheral blood film may be helpful, in addition to the blood count. Biochemical tests of liver and kidney function are undertaken, but are poor indicators of the disease. The lactate dehydrogenase and |32 microglobulin level may be surrogate markers and the uric acid must be known. In general, the same tests that were positive at the time of therapy are repeated afterwards, at the time of progression, if it occurs and if

The justification for therapy lies in the observations that relatively modest chemotherapy (or irradiation) usually makes people who feel ill with follicular lymphoma feel better, and that regression of lymphadenopathy, even if incomplete, correlates with survival.22 It may not be inferred from this, however, that immediate intervention is helpful. Most of those suffering from follicular lymphoma present well, with lumps, which gradually become larger. A randomized trial, comparing intensive therapy with a 'watch and wait' policy has shown no survival advantage for early intervention, supporting the 'Stanford philosophy' of expectant management unless treatment is perceived to be indicated.44 It is a sad reflection of our inability to cure this highly treatmentsensitive illness that this policy is almost universally accepted. The criteria for instituting therapy are generally accepted as being 'B symptoms', vital organ embarrassment, particularly of the bone marrow, and obvious progression. In practice, the decision to begin treatment is heavily influenced by the persuasion of both the patient and the physician, and whether or not a clinical trial is involved. Opinions vary about which treatment should be used and for how long it should be continued. There is, however, no compelling evidence that prolonging apparently successful therapy51 has any beneficial influence on survival. Interferon may be an exception to this.52 Prognostic factor analyses may assist in the selection of either a treatment approach or the precise treatment to be used. They are, however, of limited value because few of the factors in themselves have close enough correlation with outcome. Prognostic indices have therefore been generated (using factors correlating with survival) to break down the disease, apparently more meaningfully than by stage alone, with some success.53-55a Within the relatively small subgroup of patients with Stage I and II disease,56 three groups of patients have been identified on the basis of age, stage, the presence of 'B' symptoms and the size of the largest node. Younger, asymptomatic patients with small lymph nodes had a predicted 10-year survival of 75 per cent, those with Stage II and large nodes had a predicted 10-year survival of 58 per cent, whilst for the remainder it was less than 20 per cent. Much more data have been published about the prognosis of advanced disease. There is almost complete agreement that, as far as pathology is concerned, the small subset in which the follicles are almost entirely composed of large cells, has a poor prognosis if treated

312 Follicular lymphoma

'gently'. There is disagreement about the significance of the relative proportion of smaller to larger cells when both are present in reasonable numbers.16,57-62 Transformation carries a poor prognosis for most but not all patients, even if treated aggressively.17-23,49 The presence of proliferation markers63-68 or the t(14;18)69,70 have not been shown to be important prognostic factors for patients treated conventionally for follicular lymphoma. As might be expected, many studies have variously demonstrated that elderly patients, those who are debilitated and those with 'extensive disease', generally, but not always, fare worse than the rest.22,53,k71-75 Surrogate markers of high disease activity, such as lactate dehydrogenase (LDH) and (32 microglobulin, have also been cited as important prognostic factors.76 The best predictor of survival is response to therapy but, by definition, this cannot be considered as a prognostic factor at presentation. It is, however, perfectly valid to use it to help decide what to do on completion of a given treatment. The above discussion relates only to factors prognosticating for outcome from the time of initial therapy: there is much less information about the situation at the time of first treatment failure, manifest either by progression or recurrence. That which is available yields the expected data.77-79 The limitations imposed by the weakness of the individual prognostic factors on their value in stratifying therapy according to anticipated risk are clear. However, they at least provide a start and emphasize the need for recording potential factors prospectively, and possibly justify some degree of overinvestigation! SPECIFIC TREATMENT OPTIONS

Radiotherapy

Involved or extended field irradiation is the most widely used treatment for Stage I and II follicular lymphoma. Complete regression of lymphadenopathy almost always occurs unless the lymphadenopathy is very bulky.73,80-88 'Within field' recurrence is rare, provided that 45 Gy are delivered.88 Long follow-up confirms previous observations that radiotherapy is the best proven therapy for early-stage disease, with 44 per cent of patients predicted to be alive at 15 years and 35 per cent at 20 years.89 Adjuvant therapy has not been universally accepted to be appropriate, although some studies showed promising early results.85,86 It is normal practice to treat Stage I and often Stage II disease immediately, i.e. at the time of presentation, and not to manage expectantly because of the 'high chance of cure'. The 'watch and wait' policy is presently being tested in randomized trials. More extensive irradiation yields similar response rates to single agent chemotherapy in Stage III disease.90-95 Both total nodal and total lymphoid irradiation are relatively unfashionable at present, although there are provocative phase II data about combining total nodal irradiation with CHOP (see Table 20.3).96 High-dose total body irradiation combined with

cyclophosphamide is the most widely used myeloablative treatment for follicular lymphoma in an experimental setting. Targeted irradiation is presently the subject of phase II and III clinical trials, the preliminary results of which are exciting. Both are discussed later. Despite an overall decline in the use of external beam irradiation in the treatment of follicular lymphoma, it is nonetheless very important. It remains the treatment of choice for small-volume early-stage disease, is being tested in experimental settings and is an invaluable method of palliation. Chemotherapy

The vast majority of people with follicular lymphoma will receive chemotherapy during the course of the illness. Many will receive it repeatedly with increasing intensity and, towards the end, with declining benefit. Alkylating agents Chlorambucil or cyclophosphamide have not been bettered as first and often subsequent therapy of follicular lymphoma, if overall survival is the criterion of success and alternative therapy is used at the time of alkylating agent failure. The efficacy of chlorambucil was demonstrated 40 years ago when it was reported from the Royal Marsden Hospital and Winnipeg General Hospital that clinical remissions could be achieved with low doses.97,98 Evidence of response was seen within 6 weeks. Similar results have been reported (and with cyclophosphamide) repeatedly since, from both open and randomised trials.99-103 (Table 22.1). A continuous recurrence pattern is seen, the median duration of remission being between 1 and 4 years.22 The fact that nothing has yet been shown to be much better, coupled with the ease of administration of the drugs and their overall lack of subjective toxicity has established both drugs firmly as the treatment of first choice, either alone or as a component of combination therapy for advanced follicular lymphoma. Other single agents have been tested with some degree of success and have found their way into combination chemotherapy. None has yet achieved the popularity of chlorambucil. Reasonable numbers of patients entered trials of vincristine in the 1960s104-106 and early 1970s with the response rate in 'lymphosarcoma' being about 50 per cent. It is rarely used alone. The response rate to prednisolone107'108 is similar. The latter is occasionally used alone today, and to treat hemolytic anemia. Very little

Table 22.1 Response rate to individual components of 'CVP' in patients with advanced follicular lymphoma

Chlorambucil (or cyclophosphamide) Vincristine Prednisolone

9/12 (75) 36/42 (86) 99/115(86) 43/76 (57) 15/22(68)

Management 313

satisfactory phase II data are available about the anthracycline antibiotics109-111 or other DNA intercalating agents. Most may be found in papers concerning the therapy of refractory lymphosarcoma, which had already been extensively pretreated. Again they are not usually used alone, even palliatively, because of their toxicity. More than 20 years after the introduction of the anthracycline antibiotics, the purine analogs became available for clinical trials in lymphoma. It has become clear that their single-agent efficacy approaches that of the alkylating agents. Most information is available about fludarabine112-118 (Table 22.2). With doses that cause virtually no nausea, vomiting or alopecia, clinical remission is achieved in about half the patients with recurrent or refractory disease. The response rate is somewhat higher in patients who have received no prior therapy.119 Of possibly greater significance, the complete remission rate approaches 40 per cent.119 Treatment is given cyclically and responses, if they occur, are apparent after two or three cycles. Little meaningful data are available about freedom from progression. Less is known about chlorodeoxyadenosine (2-CDA, cladribine); those results that are published are similar to those reported with fludarabine120'121 and there is relatively little information about deoxycoformycin. It seems likely that this group of drugs will assume some role in the treatment of follicular lymphoma. Whether this will be palliative, as single agents (if so, the oral preparation becomes a necessity), or as part of a curative treatment strategy, remains to be seen. Exciting though this is, the disadvantages of this treatment must not be underestimated. There may be severe T cell dysfunction resulting in unexpected infection;122 hemolytic anemia may also occur. The taxane, docetaxel (Taxotere) is also currently being evaluated. Preliminary results in patients with recurrent or resistant disease, using 100 mg/m2 every 3 weeks, show it to have activity. The major toxicity is neutropenia.123 Combination chemotherapy Much less obvious success has attended the use of combination chemotherapy for follicular lymphoma than for Hodgkin's disease or the 'aggressive' non-Hodgkin's lymphomas. The most popular combination is that of cyclophosphamide, vincristine and prednisolone, given cyclically every 3-4 weeks.124-126 There are many varia-

Table 22.2 Response rate to fludarabine in patients with follicular lymphoma

Yes

19/167

No

24/49

55/167 18/49

CR = complete response, PR = partial response.

74/167(44) 32/49(65)

tions on the theme, probably the most popular is 'CVP'.125 Early clinical trials were encouraging, suggesting the complete remission rate (as defined at the time) to be higher than that seen with single alkylating agents alone. The duration of first remission was also found to be longer.102 However, the overall response rate (complete response plus partial response; CR + PR) was the same and no overall survival advantage for patients receiving CVP as initial therapy has been shown.91,100-102 However, it has become the treatment of first choice in the minds of many. Similarly disappointing have been the majority of the data about the further addition of doxorubicin to the combination (CHOP), with or without bleomycin.127-134 Early hopes of higher complete remission rates with prolonged freedom from progression have not been fulfilled, there being no evidence that it is any more likely to be curative than anything else.135 It has, nevertheless, been the treatment of first choice in some centers for patients with 'poor prognostic factors'. With the assumption that molecular evidence of the t(14;18) might be used as a surrogate marker for 'minimal residual disease', highly intensive chemotherapy combinations have been tested, 'polymerase chain reaction (PCR) negativity' being the end point. One such sequential combination (AT-T) has been reported to achieve this:136 clinical confirmation of the relevance of the result is awaited eagerly. An alternative combination comprising fludarabine, mitozantrone and dexamethasone (FMD) has also been reported to result in a very high response rate (94 per cent), with CR being achieved in 24/51 patients (47 per cent).137 The predominant toxicity has been myelosuppression and, as with fludarabine alone, opportunistic infections are a significant problem. While the original publication referred only to clinical efficacy, data subsequently presented show that treatment with FMD can also render a proportion of patients 'PCR negative'.138 The number of patients tested is still relatively small and the follow-up short, but these results are certainly provocative. Randomized studies of'FMD' against conventional therapy will be starting soon. High-dose therapy requiring stem cell rescue

There is now more than 10 years accumulated data about the use of high-dose chemotherapy or chemoradiotherapy with autologous bone marrow transplantation, as consolidation of second or subsequent remission of follicular lymphoma.139-143 Often the reinfused marrow has been treated in vitro to deplete it of potential residual lymphoma cells. Latterly, peripheral blood progenitor cells have been substituted for bone marrow144,145 and alternative methods of purifying the stem cell population have been explored.146 There is strong circumstantial evidence to suggest that this treatment prolongs duration of remission, although recurrences still occur and there is no proof of cure. The early mortality of the treatment is of the order of 5 per cent and there is a

314 Follicular lymphoma

disturbing incidence of myelodysplasia,140,147-148a the precise cause of which is unclear. It seems probable that successful in vitro depletion of the hematopoietic stem cell population of lymphoma cells is valuable1483,149,150 and 'PCR negativity' of the reinfused bone marrow at one center has confirmed a substantial advantage in freedom from recurrence.149 This lends considerable support to the concept that the achievement of 'molecular remission' may be a worthwhile goal. The improvement in the freedom from recurrence pattern (Fig. 22.3) must be weighed against the lack (to date) of a survival advantage and the overall cost of the therapy. In the future, if this is to become a regular therapy for follicular lymphoma, improvements will need to be made, because recurrences occur and the toxicity is appreciable. Perhaps the 'therapy' would be better and less toxic if targeted irradiation were substituted for total body irradiation (TBI). Peripheral blood support reduces hospital time. However, all the problems accepted, this maybe the best treatment for some patients at present. There is little enthusiasm for the use of high-dose therapy with autologous stem cell rescue for patients with refractory lymphoma, but allogeneic transplantation may have something to offer in this setting for selected younger patients. The preliminary results from MD Anderson Hospital, Houston, USA, in patients in whom every other approach had failed are encouraging, with 80 per cent disease-free survival being reported in small numbers of patients. Duration of remission considerably exceeded that of any previous remission.151 An alternative approach, also being evaluated in Houston is the use of a non-myeloablative preparative regimen (fludarabine + cyclophosphamide), the rationale being to reduce the morbidity and mortality of the treatment while harnessing the potential 'graft versus lymphoma' (GVL) effect. This strategy has been tried in patients with refractory disease; in the majority, it was

Figure 22.3 Duration of second remission of follicular lymphoma at St Bartholomew's Hospital: comparison between outcome following consolidation with Cyclophosphamide and total body irradiation (cyclo/TBI) supported by autologous bone marrow transplantation and observation (historical controls).

possible to establish complete engraftment or a mixed chimera. Patients have subsequently received donor lymphocyte infusions in an attempt to decrease the severity of graft versus host disease while retaining the GVL effect.152 Biological therapy

Quite appropriately, cytotoxic therapy has dominated the treatment of the malignant lymphomas and much has been achieved. It has long been held that 'biological' approaches might be best employed in circumstances of 'low tumour burden'. It is now becoming possible to achieve more complete remissions than hitherto and there are now biological treatments that are showing promise.152a Interferon Phase I trials of interferon began in the late 1970s on the basis of promising preclinical studies.153,154 Despite the fact that reduction of lymphadenopathy may be achieved, its role in lymphoma therapy has yet to be clarified. Although the remission rate in both previously treated and newly diagnosed patients is about 50 per cent, when given in doses the toxicity of which is 'reasonable',155-162 interferon is rarely given as a single agent for remission induction. This may be due to a combination of features, ranging from the low complete remission rate to the cost. Substantial effort has gone into exploration of the clinical relevance of the in vitro synergy observed between interferon and cytotoxic chemotherapy in murine models163-165 and its efficacy when given for a prolonged period, as in chronic myeloid leukemia. More than 1000 patients have been treated in randomized trials over 10 years. In most, chemotherapy, with or without interferon, has been followed by further randomization to 'continuation therapy' with chemotherapy, chemotherapy and interferon, or interferon alone for different lengths of time. The most cited study has yielded a statistically significant outcome in terms of response to initial treatment, freedom from recurrence and survival for patients treated throughout with a doxorubicin-containing regimen and interferon.52,166 Several but not all of the other studies167-172a have also shown improved freedom from recurrence; however, in none of them has this translated into a survival advantage. Whatever the interpretation, the survival advantage reported from France should not be ignored lightly. Many other strategies have resulted in prolongation of duration of remission. This is the first time that a survival advantage has been demonstrated for patients with advanced follicular lymphoma. Also a meta-analysis of randomized trials concluded that interferon prolonged survival in responding patients given more intensive initial therapy.172b Alternative, non-specific immunotherapy (if that is what interferon is) has been tested in the form of interleukin-2 (IL-2). Success has been limited.173-175

Management 315

Specific immunotherapy Antibody therapy Therapy with antibodies raised against the unique personal idiotypic determinants of the variable regions of the immunoglobulin molecule results in long remission of follicular lymphoma.176 Unfortunately, this treatment is impractical at present on a large scale. However, technology is now available for large-scale production of monoclonal antibodies to the normal differentiation antigen also present on the surface of follicular lymphoma cells. In the main, treatment with murine antibodies has been disappointing and restricted by the risk of development of antimouse antibodies.177-182 Thus, the introduction of the first 'humanized', chimeric pan-B cell antibody, CAMPATH-IH, was greeted with high expectations183,184 but the toxicity was unacceptable at the doses required to achieve remission. Early experience with an humanized anti-CD 20 antibody has been much more promising. Most of the studies to date have used the chimeric antibody, IDECC2B8 (rituximab) which comprises a human immunoglobulin Gl (IgGl) kappa constant region, with murine IgGl monoclonal heavy- and light-chain variable regions.57 It has been demonstrated that tumor cell lysis is mediated by both complement and antibodydependent cellular cytotoxicity. Phase I and phase II studies have established the treatment to be associated with only moderate clinical toxicity. The response rate in patients with recurrent low-grade lymphoma is of the order of 50 per cent and, once more, preliminary data suggest that in some patients known to have PCRdetectable lymphoma cells in peripheral blood or bone marrow, conversion to 'PCR negativity' has occurred. The treatment appears to be safe and can be administered on an ambulatory basis as four infusions given at weekly intervals.185-187 Phase III trials will give some indication about the possible role of this treatment either as an alternative to chemotherapy, in combination or tandem with chemotherapy, or as an adjunct. Targeted therapy Although labor intensive, this 'magic bullet' treatment is also generating exciting results, certainly using irradiation.188-195 Less success and more toxicity have been reported with immunotoxins.196"199 Both low-193,194 and high-dose iodine-131191,95 and Yltrium-90195a have been conjugated to anti-CD 20 and tested in phase I and phase II clinical trials, following demonstration of satisfactory biodistribution. Both strategies have resulted in high response rates (often with complete remission). There are obviously major differences in overall management of the patients: in the lowdose setting, hospital admission is only usually necessary while the patient is 'hot'; in the high-dose study, autologous hematopoietic stem cell rescue was necessary. Longer follow-up of more patients, with some phase III trials will clarify the potential role in palliation or cure of follicular lymphoma. 'Low-dose' treatment might complement or replace conventional chemotherapy and

'high-dose targeted irradiation' might provide an alternative to total body irradiation. Active immunotherapy Based on the observation that injection of idiotype with an immune adjuvant into mice led to an humoral response,200 clinical trials have been conducted in patients in remission of follicular lymphoma, following chemotherapy and sometimes myeloablative therapy.201 Patients mounting an immune response had longer remissions than those who did not.202 This is again exciting, particularly in the setting of using such treatment for patients with 'minimal residual disease'. As with idiotype therapy, the major drawback of this treatment is the practicality of producing the vaccine in large enough quantities at the right time for the right patient. DNA vaccination may be able to circumvent this.203,204 Preparation of the latter requires 106 cells as opposed to a 2 cm lymph node, and the techniques are relatively simple and amenable to scaling up. Phase I studies are currently in progress to evaluate the toxicity of intramuscular injection of DNA vaccine. It seems likely that the vaccine can also be substantially improved in terms of immunogenicity; it has been demonstrated that the cytokine GM-CSF enhances the response.205 Questions remain about the cellular response and the importance of co-stimulatory factors. Follicular lymphoma cells may, under certain conditions, be induced to express the co-stimulatory molecule B-7;206 preliminary data suggest that these cells can induce a blastogenic response in autologous T cells.207 A combined immunotherapy approach can be envisaged by the enthusiast. Obviously the host's ability to respond is crucial. Perhaps the dendritic cell holds the answer.208 Antisense therapy The ability to synthesize antisense oligonucleotides to the region of DNA spanned by the t(14;18) has opened up the possibility of testing antisense therapy.209-211 This has shown some promise in a murine model and a phase I clinical trial is in progress. Bcl-2 plays a major role in the regulation of apoptosis. Mutations have been demonstrated in the gene in patients with follicular lymphoma.212,213 It has been hypothesized that these mutations might influence heterodimerization with other regulatory proteins, and possibly predispose to transformation. The therapeutic implications are unclear as yet.

The decision In the preceding section, the spectrum of therapeutic options for the patient with follicular lymphoma has been presented, ranging from the well-tried, conventional and partially successful to the candidate, as yet unproven to be more successful. This year, four in 100 000 of the population of the Western world will develop follicular lymphoma, and there are many more alive with the disease at various stages needing advice.

316 Follicular lymphoma

What advice should they get? Needless to say it should be directed at ensuring that the illness has as little adverse effect on their lives as possible. Given the fact that the age range over which follicular lymphoma occurs is broad, advice cannot be entirely homogenous. Conventional (conservative) advice might be the following. Management should be expectant in the absence of well-recognized indications for intervention. First treatment should be as non-toxic as possible, for example, chlorambucil or CVP and, if clinical remission is achieved, should be followed by further observation. Failure to achieve clinical remission demands reevaluation: observation may be appropriate or alternative therapy (CHOP or fludarabine, for example) may be given if follicular lymphoma persists. Transformation then or at any time mandates management as for aggressive lymphoma. Remission needing second- or third-line therapy is usually short-lived. It is therefore reasonable to consider and advise high-dose therapy; some might consider interferon. Management of recurrence following a period of observation again demands re-evaluation. Immediate retreatment may well not be indicated. The decision will be influenced by whether an attempt is to be made to cure the patient, in which case early intervention when 'tumor burden' is low is appropriate. Conventionally, retreatment may be expected to be successful with the therapy that was used initially, or a similar alternative, two or three more times. Changes in tempo of the illness, even in the absence of transformation, justify changing to another class of compound, for example, fludarabine, or to a combination such as CHOP. It is becoming, possibly unjustifiably, 'conventional' to consider high-dose therapy as consolidation of second or subsequent remission in younger patients. As has been stated earlier, this has not yet been shown to influence survival. Patients with refractory disease must first be considered for a wholly palliative approach. For various reasons, this may be neither acceptable nor appropriate. Those wishing it, after being fully informed, may wish to participate in early clinical trials of experimental approaches. Variations on the theme of this advice will result in the survival pattern of follicular lymphoma remaining as it has done for the past two decades. The median survival will be about 10 years and will be punctuated by about three episodes of 'responsive' disease at about 3-year intervals. The perceived wisdom on which such conventional advice is founded must be based on the knowledge at the time and, to a certain extent, on the aspirations for the future. The opportunity now exists, should the will and enthusiasm be there, to find out whether therapy can be improved. In the appropriate groups of patients, novel strategies of therapy directed at cure can be explored. The concept of 'molecular' remission can be tested. How may the newest treatments be confirmed or not in their worth, without the risk of compromising the

outcome by denying patients the opportunity of conventional therapy? The following might be considered. 1 Humanized antibody could be tested, at presentation, with a view to at least postponing chemotherapy or, at best, avoiding it altogether. Open phase II or phase III trials would be ethically acceptable. 2 Patients recurring after conventional chemotherapy could be treated with targeted irradiation and, if this were successful, could be managed expectantly. 3 Patients entering subsequent remission could receive consolidation with myeloablative therapy, possibly incorporating high-dose targeted irradiation, if younger. This could be followed by active immunotherapy. Those for whom high-dose therapy was inappropriate could proceed directly to immunotherapy. The choice of 'conventional chemotherapy' could be determined by the expectations of the patients. Randomized trials, at specific points in the disease, could allow the testing of new ways of achieving 'molecular remission'. There is obviously room for debate about the sequence in which novel strategies may be tested. As yet, many of the options are interchangeable: to a considerable extent, policy will be influenced by anticipated toxicity, logistic factors and economic considerations. Even newer approaches, such as antisense therapy, will soon be in a position to be tested at the phase I level and may find their way into a therapeutic strategy. Resources will need to be pooled if the next edition of this book is to record a new 'conventional therapy'.

We are very grateful to Stephanie Thomas for typing this manuscript.

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References 323 182. Scheinberg DA, Straus DJ, Yeh SD, et al. A phase I toxicity, pharmacology, and dosimetry trial of monoclonal antibody OKB7 in patients with nonHodgkin's lymphoma: effects of tumor burden and antigen expression. J Clin Oncol 1990; 8: 792. 183. Hale G, Dyer MJS, Clark MR, et al. Remission induction in non-Hodgkin lymphoma with reshaped human monoclonal antibody CAMPATH-1H. Lancet 1988; 2: 1394. 184. Clendeninn NJ, Nethersell ABW, Scott JE, et al. Phase l/ll trials of CAMPATH-IH, a humanized anti-lymphocyte monoclonal antibody (MoAb), in non-Hodgkin's lymphoma (NHL) and chronic lymphocytic leukemia (CLL). Blood 1992; SO(suppl): 158a (abstract). 185. Maloney DG, Liles TM, Czerwinski CK, et al. Phase I clinical trial using escalating single dose infusion of chimeric anti-CD20 monoclonal anti-body (IDEC C2 B8) in patients with recurrent B-cell lymphoma. Blood 1994;84:8457. 186. Maloney DG, Bodkin D, Grillo-Lopez AJ, et al. Final report of a phase II trial in relapsed non-Hodgkin's lymphoma. Blood 1994; 84:169a (abstract). 187. Mclaughlin P, Grillo-Lopez AJ, Link BK, et al. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program, y Clin Oncol 1998; 16:2825-33. 188. Parker BA, Vassos AB, Halpern SE, et al. Radioimmunotherapy of human B-cell lymphoma with 90Yconjugated anti-idiotype monoclonal antibody. Cancer K«1990; SO(suppl): 1022s. 189. Kaminski MS, Fig LM, Zasadny KR, et al. Imaging, dosimetry, and radioimmunotherapy with iodine-131labeled anti-CD37 antibody in B-cell lymphoma. J Clin Oncol 1992; 10: 1696. 190. Goldenberg DM, Horowitz JA, Sharkey RM, et al. Targeting, dosimetry, and radioimmunotherapy of Bcell lymphomaswith iodine-131-labeled LL2 monoclonal antibody.J Clin Oncol 1991; 9: 548. 191. Press OW, Eary JF, Badger CC, et al. Treatment of refractory non-Hodgkin's lymphoma with radiolabeled MB-1 (anti-CD37) antibody. J Clin Oncol 1989; 7:1027. 192. DeNardo SJ, DeNardo GL, O'Grady LF, et al. Pilot study of radioimmunotherapy of B-cell lymphoma and leukemia using131 Lym-1 monoclonal antibody. Antibody Immunoconj Radiopharm 1988; 1:17. 193. Kaminski MS, Zasadny KR, Francis IR, et al. Radioimmunotherapy of B-cell lymphoma with 1311 anti-B1 (anti-CD20) antibody. N EnglJ Med 1993; 329: 459. 194. Kaminski MS, Zasadny KR, Francis IR, et al. lodine-131anti-B1 radioimmunotherapy for B-cell lymphoma. y Clin Oncol 1996; 14:1974. 195. Press OW, Eary JF, Frederick R, et al. Radiolabeledantibody therapy of B-cell lymphoma with autologous bone marrow support. N EnglJ Med 1993; 329:1219.

195a.WitzigTE, White CA, Wiseman GA, et al. Phase l/ll trial of IDEC-Y2B8 radioimmunotherapy for treatment of relapsed or refractory CD20+ B-cell non-Hodgkin's lymphoma. J Clin Oncol 1999; 17: 3793-803. 196. Amlot PL, Stone MJ, Cunningham D, et al. A Phase I study of an anti-CD22-deglycosylated ricin A chain immunotoxin in the treatment of B-cell lymphomas resistant to conventional therapy. Blood 1993; 82: 2624. 197. Vitetta ES, Stone M, Amlot P, et al. Phase I immunotoxin trial in patients with B-cell lymphoma. Cancer Res 1991; 51:4052. 198. Grossbard ML, Freedman AS, Ritz J, et al. Serotherapy of B-cell neoplasms with anti-B4 blocked ricin: a phase I trial of daily bolus infusion. Blood 1992; 79: 576. 199. Grossbard ML, Lambert JM, Goldmacher VS, et al. AntiB4 blocked ricin: a phase I trial of 7-day continuous infusion in patients with B-cell neoplasms. J Clin Oncol 1993; 11: 726. 200. Campbell MJ, Esserman L, Byers NE, et al. Idiotype vaccination against murine B cell lymphoma. Humoral and cellular requirements for the full expression of anti-tumor immunity.J Immunol 1990; 145:1029. 201. Kwak LW, Campbell MJ, Czerwinski BS, et al. Induction of immune responses in patients with B cell lymphoma against the surface-immunoglobulin idiotype expressed by their tumors. N EnglJ Med 1992; 327:1209. 202. HSU FJ, Caspar CB, Kwak LW, et al. Results of a trial of idiotype specific vaccine therapy for B-cell lymphoma. Blood 1986; 10: 273a (abstract). 203. Hawkins RE, Zhu D, Ovecka M, et al. Idiotype vaccination against human B-cell lymphoma. Rescue of variable region gene sequences from biopsy material for assembly as single-chain F, personal vaccines. Blood 1994; 83:3279. 204. Stevenson FK, Zhu D, King CA, et al. Idiotypic DNA vaccines against B-cell lymphoma. Immunol Rev 1995; 145:211. 205. Tao MH, Levy R. Idiotype/granulocyte colony stimulating factor fusion protein as a vaccine for B cell lymphoma. Nature 1993; 263: 755. 206. Shamash J, Davies DC, Salam A, et al. Induction of CD80 expression in low grade B cell lymphoma; a potential immunotherapeutic target. Leukaemia 1995; 9:1349. 207. Shamash J, Salam AH, Wallace DL, et al. Induction of CD80 in low grade B cell lymphoma leads to enhanced mixed lymphocyte responses with allogeneic or autologous lymphocytes. Blood 1995; 86(suppl): 536a (abstract). 208. Hsu FJ, Benika C, Fangoni F, et al. Vaccination of patients with B cell lymphoma using autologous pulsed dendritic cells. Nature Med 1996; 2: 52. 209. Reed J, Cuddy M, Maldars S, et al. bcl-2 mediated tumorigenicity of a human T-lymphoid cell line: synergy with Myc and inhibition by bcl-2 antisense. Proc NatlAcadSci USA 1990; 87: 3660.

324 Follicular lymphoma 210. Cotter F, Johnson P, Hall P, et al. Antisense oligonucleotides suppress B-cell lymphoma growth in a SCID-hn mouse model. Oncogene 1994; 9: 3049. 211. Cotter FE, Pocock CFE. In vitro modelling and antisense therapy in malignancy. In: Thomas NSB, ed.Apoptosis and cell cycle control in cancer. Bios Scientific Publishers, 1994:161.

212. Reed JC, Tanaka S. Somatic point mutations in the translocated bcl-2 genes of non-Hodgkin's lymphomas and lymphocytic implications for mechanisms of tumor progression. Leuk Lymphoma 1993; 10:1571. 213. Pappa V, Wilkes S, Rohatiner AZS, et al. Detection of somatic mutations of the bcl-2 oncogene in follicular non-Hodgkin's lymphoma. Blood 1994; 84: 444a.

23 Other low-grade non-Hodgkin's lymphomas JA RADFORD

Introduction B cell chronic lymphocytic leukemia Lymphoplasmacytoid lymphoma Mantle cell lymphoma Marginal zone B cell lymphoma Extranodal marginal zone B cell lymphoma of MALT type

325 325 325 325 326

Nodal marginal zone B cell lymphoma Splenic marginal zone lymphoma with or without villous lymphocytes AngioimmunoblasticTcell lymphoma Treatment of low-grade NHL of non-follicular type References

327 327 327 327 328

326

INTRODUCTION Low-grade non-Hodgkin's lymphomas exhibiting a diffuse histological pattern comprise approximately 50 per cent of all low-grade cases. The majority are of B lineage. A number of types are recognizable and some have distinctive clinical features that set them apart from the generality of low-grade lymphomas.

B CELL CHRONIC LYMPHOCYTIC LEUKEMIA; PRO LYMPHOCYTIC LEUKEMIA; SMALL LYMPHOCYTIC LYMPHOMA (REAL CLASSIFICATION)/B LYMPHOCYTIC LYMPHOMA. CLL (UPDATED KIEL CLASSIFICATION) B cell chronic lymphocytic leukemia comprises 90 per cent of chronic lymphoid leukemias in the USA and Europe. Most patients are older adults who usually present with generalized lymphadenopathy and bone marrow, liver, spleen and peripheral blood involvement (chronic lymphocytic leukemia) but in a minority the disease is confined to lymph nodes (small lymphocytic lymphoma). It is a slowly progressive disease, and many patients die of either unrelated causes or infection due to the associated impaired immunity. Death directly due to lymphoma usually follows transformation into a higher grade tumor, so-called Richter's syndrome.1 The incidence of this complication has been estimated at 3 per cent2 and, although the transformed

tumor is usually a large cell non-Hodgkin's lymphoma, Hodgkin's disease has also been reported.3 Prolymphocytic leukemia presents with a very high white cell count and splenomegaly, and runs a more aggressive clinical course than typical B chronic lymphocytic leukemias.4

LYMPHOPLASMACYTOID LYMPHOMA (REAL)/LYMPHOPLASMACYTIC (UPDATED KIEL) Although far less common than small lymphocytic lymphoma, lymphoplasmacytoid lymphoma occurs in the same age group (older adults) and also frequently presents with a chronic lymphocytic leukemia. The presence of isolated or generalized lymphadenopathy without leukemia is, however, more commonly seen than in small lymphocytic lymphoma. The majority of patients have an immunoglobulin M (IgM) monoclonal gammopathy (Waldenstrom's macroglobulinemia) and symptoms due to hypervicosity - confusion, visual disturbance and hemorrhage - may occur.5

MANTLE CELL LYMPHOMA (REALJ/CENTROCYTIC (UPDATED KIEL) This tumor occurs with approximately the same frequency as lymphoplasmacytoid lymphoma (about 5 per

326 Other low-grade non-Hodgkin's lymphomas

cent of all non-Hodgkin's lymphomas in Europe and the USA6) and is usually seen in older adults. Males are far more commonly affected than females.7 Generalized lymphadenopathy with, or more commonly without, a leukemic blood picture is the usual presenting feature, although it can present as a primary lymphoma of the gastrointestinal tract (lymphomatous polyposis).8 In these cases, polypoid tumors of lymphoma involve long segments of bowel and, unlike mucosa-associated lymphoid tissue (MALT) lymphomas of the gastrointestinal tract (see Chapter 8), which tend to remain localized for long periods,9 multiple lymphomatous polyposis is characterized by a high incidence of dissemination. Mantle cell lymphoma is commonly associated with a characteristic translocation [t(ll;14) (q13;q32)], which leads to juxtaposition of the promoter region of the bcl1 gene on chromosome 11 with the enhancer of the immunoglobulin heavy-chain gene on chromosome 14.10'11 This translocation results in overexpression of a gene known as PRAD-1, which encodes for cyclin Dl, a cell-cycle protein that is not normally expressed in lymphoid cells.12 Cyclin Dl is considered to affect the Gl-S transition of the cell cycle and is known to predispose cells to the development of lymphomas.13'14 This may account for the more aggressive course seen with mantle cell lymphoma where median survival is 3-5 years against 7-10 years for other types of low-grade lymphoma.7 Although characteristic of mantle cell lymphoma, t(ll;14) has also been reported in occasional cases of B prolymphocytic lymphoma15 and multiple myeloma/ plasma cell leukemia.16 Therefore, despite not being completely specific, the detection of cyclin D1 overexpression is valuable clinically because it identifies a group of patients whose prognosis is likely to be poor and for whom alternative treatments options maybe necessary.17

MARGINAL ZONE B CELL LYMPHOMA (REAL) In recent years, two tumors have been described that have sufficient morphological, immunophenotypic and clinical similarities to suggest that they are related. These are the low-grade B cell lymphomas of MALT18 and monocytoid B cell lymphoma.19,20 The nomenclature for these tumors has been confusing: some authorities have used the term monocytoid B cell lymphoma for both nodal and extranodal disease,19 others have restricted its use to nodal disease.20 In the REAL classification,21 tumors that show morphologic evidence of differentiation into cells of marginal zone type, and which appear to have the capacity to mature into both monocytoid B cells and plasma cells and appear to display tissuespecific homing patterns are included within the term marginal zone B cell lymphoma. Two subtypes, nodal and extranodal, are recognized.

EXTRANODAL MARGINAL ZONE B CELL LYMPHOMA OF MALT TYPE (REAL) These are tumors of adults with a slight female preponderance. Many patients have a history of autoimmune disease, such as Sjogren's syndrome22 or Hashimoto's thyroiditis, or Helicobacter gastritis. The majority present with localized extranodal disease involving the gastrointestinal tract, usually the stomach,23,24 lung,25 salivary gland26 or thyroid.27 Gastrointestinal involvement by this type of low-grade lymphoma is the best characterized. In the Western world, the stomach is the most commonly involved site, whereas in the Middle East, gastric and intestinal forms occur at a similar frequency. Although occurring predominantly in patients over the age of 50, an increasing number of cases are being reported in younger adults.28 Dyspepsia is the usual presenting symptom and patients are often first thought to have reflux oesophagitis, gastritis or peptic ulceration. Severe abdominal pain, vomiting, marked weight loss or the finding of a mass are unusual, and these features are far more likely to be associated with high-grade lymphoma, which accounts for the majority of primary gastrointestinal lymphomas, or carcinoma. Endoscopy usually reveals non-specific features and, in most cases, the disease is confined to the gastric wall. In these cases the prognosis is considered to be excellent29 and data from the Middle East suggest that the outlook for the small intestinal form of the disease is also good.30 Of particular interest, however, was the report that eradication of Helicobacter pylori infection, using ampicillin with either metronidazole and tripotassium dicitrobismuthate or omeprazole in patients with gastric MALTomas, led to resolution of symptoms, endoscopic abnormalities and regression of tumor in five out of six cases treated.31 Longer follow-up and further studies confirm this finding32 and these results are of considerable significance in terms of understanding the pathogenesis of low-grade B cell lymphomas of MALT. Immunoproliferative small intestinal disease (IPSID) is a specific form of gastrointestinal lymphoma that occurs almost exclusively in developing countries where it is a prevalent debilitating illness. Typically, the disease involves the proximal small intestine of young adults and is characterized by chronic diarrhea, leading to malabsorption (weight loss, anemia and edema). IPSID is distinguished from other MALT lymphomas by its epidemiological features, its almost complete restriction to the small bowel (although gastric and large bowel involvement have been reported33,34) and the extreme degree of plasma cell differentiation.35 These plasma cells synthesize an abnormal and heavy chain without a corresponding light chain, and this can often be detected (mainly in the early phase of the disease) as a circulating paraprotein36 - hence the alternative name of alpha chain disease. Cases of IPSID are associated with low

Treatment of low-grade NHL of non-follicular type 327

socioeconomic status, poor hygiene, and a high rate of parasitic infestation and infantile infectious enteritis,37 but to date no specific dietary agent or enteric pathogen has been clearly implicated in the pathogenesis.38 Despite this, several studies have shown that tetracycline is capable of inducing complete clinical, histological and immunological remissions in early stages of the disease36,39 and the analogy with gastric MALT lymphoma and eradication of H. pylori is obvious.

NODAL MARGINAL ZONE B CELL LYMPHOMA (REAL)/MONOCYTOID (UPDATED KIEL) The majority of these lymphomas occur in patients with either Sjogren's syndrome or other extranodal MALTtype lymphomas22 and are therefore likely to represent nodal spread of this form of lymphoma. Nodal involvement (either isolated or widespread) has occasionally been reported in the absence of extranodal disease19,20 but bone marrow peripheral blood involvement is rare.40

SPLENIC MARGINAL ZONE LYMPHOMA WITH OR WITHOUT VILLOUS LYMPHOCYTES (REAL) This entity appears to be morphologically and clinically distinct from extranodal (MALT type) and nodal marginal zone B cell lymphoma.41 There is, however, overlap with an uncommon type of adult chronic B lymphocytic lymphoma, often mistaken for hairy cell leukemia, called splenic lymphoma with villous lymphocytes.42 As in mantle cell lymphoma, t(ll:14), bcl-l rearrangement and overexpression of cyclin Dl are reported, but in splenic marginal zone lymphoma these abnormalities are found in over 15-18 per cent of patients.43 Typically, patients have bone marrow and peripheral blood involvement with a moderate lymphocytosis and marked splenomegaly, but usually no lymphadenopathy. The disease is considered indolent and splenectomy may be followed by prolonged remission.

ANGIOIMMUNOBLASTIC T CELL LYMPHOMA (REAL) The condition angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) was first described in 1975.44 It was first thought to be a non-neoplastic disease that either resolved spontaneously, caused death due to the associated immunodeficiency or was complicated by the evolution of lymphoma. However, more recent studies have shown that most if not all cases are T cell lymphoma.45 Patients usually present acutely with generalized

lymphadenopathy, skin rash, hepatosplenomegaly and severe constitutional symptoms (fever, weight loss, malaise). Typically, hyperglobulinemia and associated autoimmune phenomena also occur.

TREATMENT OF LOW-GRADE NONHODGKIN'S LYMPHOMA OF NONFOLLICULAR TYPE With the possible exception of localized MALT lymphomas, which may be cured by surgery or local radiotherapy, low-grade non-Hodgkin's lymphomas of diffuse type should currently be regarded as incurable. Studies from Stanford in the 1970s showed that there was no difference in freedom from progression or survival between four very different approaches to treatment, namely, single alkylating agent therapy, whole body irradiation, CVP (cyclophosphamide, vincristine, prednisolone) chemotherapy and CVP plus total lymphoid irradiation.46,47 Thus, intensive therapies causing appreciable toxicity appear to have no long-term advantages over simple relatively non-toxic treatment in the management of low-grade non-Hodgkin's lymphoma. The Stanford group also showed that patients with low-grade non-Hodgkin's lymphoma do not necessarily require to start treatment as soon as the diagnosis is made, and a 'watch and wait' policy in selected groups of patient does not lead to an inferior outcome for these individuals.48 A reasonable approach therefore is to avoid treatment unless patients have B symptoms, bulky disease causing local symptoms, such as pain or lymphedema, paraproteinemia with hyperviscosity syndrome, or peripheral blood cytopenias due to bone marrow involvement. When treatment does become necessary, single alkylating agent therapy (oral chlorambucil or cyclophosphamide) is an appropriate first step, although the CVP combination is an alternative and may be preferable in circumstances (such as in patients with very extensive disease) where a more rapid response is required. As previously discussed, peripheral lymphocytosis is a feature of non-Hodgkin's lymphoma of diffuse type but, unless the lymphoma count reaches levels of 50 x 109/1 or greater and/or is associated with other indications for treatment, our policy is to continue a 'watch and wait' policy. This conservative approach is particularly applicable to older patients (the majority) who, in general, are less tolerant of drug toxicity. At relapse, remission can often be achieved using further courses of chlorambucil or CVP, and doxorubicincontaining therapies such as CHOP can also be utilized. Eventually, however, low-grade non-Hodgkin's lymphomas become resistant to alkylating agent therapy and, in such circumstances, the purine analogs of adenosine arabinoside may be useful. These drugs - fludarabine phosphate, cladribine (2-chlorodeoxyadenosine) -

328 Other low-grade non-Hodgkin's lymphomas

interfere with DNA synthesis by inhibiting DNA polymerase and ribonucleotide reductase. Fludarabine has also been shown to be associated with a greater than 50 per cent response rate in previously treated patients with chronic lyrnphocytic leukemia.49 Other low-grade lymphomas of diffuse type treated with fludarabine or cladribine in relapse after previous chemotherapy appear to be less responsive50,51 but a number of trials to determine the role of these agents in first line treatment are currently in progress. The deferred treatment policy outlined above is appropriate for the majority of patients with low-grade non-Hodgkin's lymphoma of non-follicular type (small lyrnphocytic, lymphoplasmacytoid and marginal zone types), where the median survival from diagnosis is in the order of 7-10 years. Mantle cell lymphoma, however, is a more aggressive disease and immediate treatment is probably indicated. Unfortunately, complete remissions are rarely achieved and, even when they are, they are slower to occur and their duration is short.52 Because of this poor outcome, patients with mantle cell lymphoma are now receiving high-dose chemotherapy supported by autologous hemopoietic rescue.53 Preliminary results are encouraging and it is likely that randomized trials comparing this approach with conventional treatment such as CHOP will follow. Meanwhile, opinion is divided as to whether high-dose therapy should be recommended to suitable patients.54,55 Splenectomy should be considered for patients with splenomegaly where this either constitutes the main bulk of disease (splenic lymphoma with or without villous lymphocytes) or is associated with a hypersplenic blood picture or pain. Preoperative pneumococcal vaccination should always be given in these circumstances as fulminating septicemia is a well-recognized complication in asplenic patients. Radiotherapy has only a limited role in low-grade lymphomas of diffuse histological type. It is, however, useful in the treatment of extranodal marginal zone B cell lymphomas presenting as localized disease affecting the thyroid gland or salivary tissue. Similarly, in circumstances of disseminated lymphoma, where a 'watch and wait' policy is being pursued, radiotherapy may be used to treat local areas of symptomatic disease and so allow the need for chemotherapy to be deferred. Finally, radiotherapy can be used after chemotherapy to regions of previous bulk in order to reduce the risk of relapse at sites likely to cause specific problems (such as ureteric obstruction from a pelvic mass). The role of interferon-cc in the induction and maintenance treatment of diffuse indolent non-Hodgkin's lymphomas is still unclear. In the French study, which demonstrated a survival advantage to interferon, only follicular lymphomas were included;56 in other studies, where other low-grade lymphomas have been included, overall survival was not improved.57,60 The anti-CD 20 antibody, rituximab, also requires

further evaluation particularly as an adjunct to other therapies.54 Responses are seen in up to half of patients with relapsed indolent lymphomas of all types.61'62,63

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30. Cammoun M, Jarfoura H, Tabbare F, Halphen M. Immunoproliferative small intestinal disease with alpha chain disease: a pathological study. Gastroenterology 1989;96:750-63. 31. Wotherspoon AC, Doglioni C, Diss TC, et al. Regression of primary low-grade B-cell gastric lymphoma of mucosaassociated lymphoid tissue type after eradication of Helicobacter pylori. Lancet 1993; 342: 575-7. 32. Zucca E, Roggero E, Delchier J, et al. Interim evaluation of gastric malt lymphoma response to antibiotics in the ongoing LY03 randomized cooperative trial of observation vs chlorambucil after anti-helicobacter therapy. Pro Am Soc Clin Oncol 2000; 19: 5a (abstract 12). 33. Guardia J, Mirada H, Moragas A, Armengol JR, MartinezVazquez JM. Alpha chain disease of the stomach. HepatoGastroenterology 27: 238-9. 34. Rhodes JM, Jewell DP, Janossy G. Alpha-chain disease diagnosed by rectal biopsy. BrMedJ 1980; 280:1043-4. 35. Isaacson PG, Dogan A, Price SK, Spencer J. Immunoproliferative small intestinal disease: an immunohistochemical study. Am J Surg Pathol W89; 13: 1023-33. 36. Doe JF, Alpha chain disease: clinicopathological features and relationship to so called Mediterranean lymphoma. BrJ Cancer 1975; 31(suppl 2): 350-5. 37. Alpha-chain disease and related small intestinal lymphoma: a memorandum. Bull World Health Organisation 1976; 54: 615-24. 38. Khojasteh A, Hagshenass M, Haghighi P. Immunoproliferative small intestinal disease. A 'third world lesion'. N EnglJ Med 1983; 308:1401-5. 39. Rappaport H, Ramot B, Hulu N, Park JR. The pathology of so-called Mediterranean abdominal lymphoma with malabsorption. Cancer 1972; 29:1502-11. 40. Carbone A, Gloghini A, Pinto A, Atachia V, Zagorel V, Volpe R. Monocytoid B-cell lymphoma with bone marrow and peripheral blood involvement at presentation. Am J Clin Pathol 1989; 92: 228-36. 41. Schmid C, Kirkham N, DissT, Isaacson PG. Splenic marginal zone cell lymphoma. Amj Surg Pathol 1992; 16:455-66. 42. Melo JV, Hegde U, Parreira A, Thompson I, Lampert IA, Catovsky D. Splenic B cell lymphoma with circulating villous lymphocytes: differential diagnosis of B cell leukaemias with large spleens. J Clin Pathol 1987; 40: 642-51. 43. Jadayel D, Matutes E, Dyer MJ, et al. Splenic lymphoma with villous lymphocytes: analysis of bcl-1 rearrangements and expression of the cyclin D1 gene. Blood 1994; 83: 3664-71. 44. Frizzera G, Moran EM, Rappaport H. Angioimmunoblastic lymphadenopathy with dysproteinaemia. Lancet 1974; 1:1070-3. 45. Feller AC, Griesser H, Schillung CV, et al. Clonal gene rearrangement patterns correlate with immunophenotypeand clinical parameters in patients with angioimmunoblastic lymphadenopathy. Am J Pathol 1988; 133: 549-56.

330 Other low-grade non-Hodgkin's lymphomas 46. Portlock CS, Rosenberg SA, Glatstein E, Kaplan HS. Treatment of advanced non-Hodgkin's lymphomas with favourable histologies: preliminary results of a prospective trial. Blood 1976; 47: 747-56. 47. Hoppe RT, Kushlan P, Kaplan HS, Rosenberg SA, Brown BW. The treatment of advanced stage favourable histology non-Hodgkin's lymphoma: a preliminary report of a randomized trial comparing single agent chemotherapy, combination chemotherapy, and whole body irradiation. Blood 1981; 58: 592-8. 48. Horning SJ and Rosenberg SA. The natural history of initially untreated low-grade non-Hodgkin's lymphomas. N EnglJ Med 1984; 311:1471-5. 49. Keating MJ, Kantarjian H, Talpaz M, et al. Fludarabine: a new agent with major activity against chronic lymphocytic leukaemia. Blood 1989; 74:19-25. 50. Whelan JS, Davis CL, Rule S, et al. Fludarabine phosphate for the treatment of low grade lymphoid malignancy. Br 7 Concur 1991; 64:120-3. 51. Tulpule A, Schiller G, Harvey-Buchanan LA, et al. Cladribine in the treatment of advanced relapsed or refractory low and intermediate grade non-Hodgkin's lymphoma. Cancer 1998; 83: 2370-6. 52. Hiddeman W, Unterhalt M, Herrmann R, et al. Mantlecell lymphomas have more widespread disease and a slower response to chemotherapy compared with folliclecenter lymphomas: results of a prospective comparative analysis of the German low-grade Lymphoma Study Group. J Clin Oncol 1998; 16:1922-30. 53. Vose JM, Weisenburger DD, Anderson JR, et al. Mantle cell lymphoma (MCL) has a poorer prognosis than follicular non-Hodgkin's lymphoma (F-NHL); however, high dose therapy (HOC) and autologous stem cell transplantation (ASCT) may overcome treatment resistance in MCL. Blood 1993; 82:135a (abstract). 54. Freedman AS, Neuberg D, Gribben JG, et al. High-dose chemoradiotherapyand anti-B-cell monoclonal antibody-purged autologous bone marrow transplantation in mantle-cell lymphoma: no evidence for long-term remission.; Clin Oncol 1998; 16:13-18. 55. Goldman JM, Schmitz N, Niethammer D, Gratwohl A, for the Accreditation Sub-Committee of the European Group for Blood and Marrow Transplantation. Allogeneic and autologous transplantation for haematological diseases,

56.

57.

58.

59.

60.

61.

62.

63.

solid tumours and immune disorders: current practice in Europe in 1998. Bone Marrow Transplant 1998; 21:1-7. Solal-Celigny P, Lepage E, Brousse N, et al. Doxorubicincontaining regimen with or without interferon alfa-2b for advanced follicular lymphomas: final analysis of survival and toxicity in the Groupe d'Etude des Lymphomes Folliculaires 86 trial.J Clin Oncol 1998; 16: 2332-8. Smalley RV, Andersen JW, Hawkins MJ, et al. Interferonalfa combined with cytotoxic chemotherapy for patients with non-Hodgkin's lymphoma. N Engl J Med 1992; 327: 1336-41. Hagenbeek A, Carde P, Meerwaldt JH, et al., for the European Organization for Research and Treatment of Cancer Lymphoma Cooperative Group. Maintenance of remission with human recombinant interferon alfa-2a in patients with stages III and IV low-grade malignant nonHodgkin's lymphoma. J Clin Oncol 1998; 16: 41-7. Arranz R, Garcia-Alfonso P, Sobrino P, et al. Role of interferon alfa-2b in the induction and maintenance treatment of low-grade non-Hodgkin's lymphoma: results from a prospective, multicenter trial with double randomization.) Clin Oncol 1998; 16:1538-46. Fisher Rl, Dana BW, LeBlanc M, et al. Interferon alfa consolidation after intensive chemotherapy does not prolong the progression-free survival of patients with low-grade non-Hodgkin's lymphoma: results of the Southwest Oncology Group randomized phase III study 8809.7 Clin Oncol 2000; 18: 2010-16. Coiffier B, Haioun C, Ketterer N, et al. Rituximab (antiCD20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: a multicenter phase II study. Blood 1998; 92:1927-32. McLauglin P, Grillo-Lopez AJ, Link BK, et al. Rituximab chimeric anti-CD20 monoclonal antibody therapy for relapsed indolent lymphoma: half of patients respond to a four-dose treatment program. 7 Clin Oncol 1998; 16: 2825-33. Foran JM, Rohatiner AZS, Cunningham D, et al. European phase II study of rituximab (Chimeric anti-CD20 monoclonal antibody) for patients with newly diagnosed mantle-cell lymphoma and previously treated mantlecell lymphoma, immunocytoma, and small B-cell lymphocytic lymphoma. J Clin Oncol 2000; 18: 317-24.

24 High-dose therapy PJ BIERMAN, JM VOSE AND JO ARMITAGE

Introduction

331

Transplantation results Comparison with conventional salvage chemotherapy

332

results

Comparison of rescue sources Purging Current status

335

Future directions

Early transplantation

337

References

Preparative regimens

339

INTRODUCTION The poor results of conventional-dose salvage chemotherapy for Hodgkin's disease and non-Hodgkin's lymphoma have led to the increasing use of high-dose therapy followed by autologous bone marrow and peripheral blood stem cell transplantation for patients with relapsed and refractory disease.1-5 The rationale for this approach is based upon the steep dose-response curves exhibited by a number of chemotherapeutic agents that have activity against lymphoma,6 and the fact that transplantation allows chemotherapy or radiation doses to be escalated several-fold over what would otherwise lead to fatal myelosuppression. Early reports of autologous bone marrow transplantation to abrogate chemotherapy or radiation-induced myelosuppression for lymphoma date back nearly 40 years, although techniques at that time lacked refinement.7-9 In 1978 investigators at the National Cancer Institute reported results of high-dose BACT chemotherapy (carmustine, cytarabine, cyclophosphamide and 6-thioguanine) followed by reinfusion of cryopreserved autologous bone marrow in a group of patients with refractory non-Hodgkin's lymphoma.10,11 The BACT regimen was not marrow ablative, since control patients who did not receive marrow infusions experienced hematopoietic recovery. However, hematopoietic recovery was significantly faster in patients who received autologous marrow and, more importantly, some of these patients were cured. Since then, the use of autologous bone marrow and peripheral blood stem cell transplantation has been used

340 343 344 344 344

with increasing frequency for patients with relapsed and refractory lymphoma. Approximately 7000 autologous transplants for Hodgkin's disease and non-Hodgkin's lymphoma have been reported to the International Bone Marrow Transplant Registry. Lymphoma is the second most common indication for autologous transplantation, after breast cancer, in North America. Approximately 850 transplants for non-Hodgkin's lymphoma and approximately 300 transplants for Hodgkin's disease are being reported to the registry each year. It is estimated that this represents approximately 50 per cent of transplants being performed for these diseases. Improvements in patient selection, transplant team experience and supportive care, such as hematopoietic growth factors, have made transplantation safer and less expensive.12 Peripheral blood stem cell transplantation has largely replaced autologous bone marrow transplantation at many institutions. Transplantation for lymphoma has extended into community hospitals and the outpatient setting, and can be safely performed in elderly patients.13 Phase III trials are now helping to determine the value of high-dose therapy in comparison with conventional salvage therapy, and other trials are evaluating the role of transplantation as part of initial therapy for lymphoma. Still other trials are evaluating the role of high-dose therapy for low-grade lymphoma. Long-term follow-up studies have identified late complications, such as solid tumors and leukemia,14,15 and safer preparative regimens are being developed. Finally, phase III trials are now evaluating the role of immunotherapy following transplantation to decrease relapse rates.

332 High-dose therapy PROGNOSTIC FACTORS

TRANSPLANTATION RESULTS

Non-Hodgkin's lymphoma Results of selected phase II trials of high-dose therapy with autologous bone marrow and peripheral blood stem cell transplantation for intermediate-grade and high-grade non-Hodgkin's lymphoma are displayed in Table 24.1. These results demonstrate that long-term disease-free survival is possible with rates that range between 11 and 60 per cent. Transplant-related mortality rates vary between 3 and 36 per cent. It is difficult to compare the results from different institutions owing to differences in patient selection criteria, preparative regimens, prognostic factors and length of follow-up. In addition, some series include low-grade lymphomas or other histologic subtypes that may differ in behavior.

The most important prognostic factor with respect to transplantation for non-Hodgkin's lymphoma relates to disease chemotherapy sensitivity at the time of transplant. This concept was validated in one of the first large trials of autologous bone marrow transplantation for patients with relapsed and refractory non-Hodgkin's lymphoma (Fig. 24.1).16 Patients who had failed to enter a complete remission with primary therapy (primary refractory disease) had an extremely poor prognosis, and none were projected to be alive and free of disease 1 year after transplantation. The remaining patients had relapsed after achieving a complete remission and could be divided into two groups based upon their response to conventional-dose salvage chemotherapy prior to transplantation. Those who achieved at least a partial remission with conventional salvage chemotherapy (sensitive relapse) had an actuarial disease-free survival of 36 per

Table 24.1 Results of autologous transplantation for intermediate-grade and high-grade non-Hodgkin's lymphoma

16

100

Various

40 months

21

19% 3-year DPS

17

46

TACC, BEAM or Cy + TBI

32 months

9

60% 3-year DPS

Includes patients in first CR. Includes low-grade lymphomas

18

68

Cy + TBI

5.3 years

21

16% DFS

Includes patients with mycosis fungoidesand malignant histiocytosis

19

101

Various

26 months

21

11% 5-year EFS

Includes patients in first CR. Includes low-grade lymphomas and Hodgkin's disease

20

70

Cy + TBI or Cy + Ara-C+BCNU

2.3 years

13

32% FFS

Includes patients in first CR. Includes low-grade lymphomas

21

44

BEP

13 months

24(55%) CCR (12-57 months)

Includes low-grade lymphomas

22

44

Cy + VP-16 + TBI

42 months

36

57% DFS

Includes low-grade lymphomas

23

158

Various

21 months

36

29% 3-year FFS

24

53

Various

19 months

8

40% 3-year EFS

Includes low-grade lymphomas

25

78

CBV

ns

7

43% 3-year FFS

Includes patients in first CR

26

53

Cy + VP-16 + TBI

643 days

17

45% 2-year EFS

Includes patients in first CR. Includes low-grade lymphomas and Hodgkin's disease

27

72

Cy + Vp-16 + TBI

2.5 years

10

53% 3-year EFS

Includes patients in first CR. Includes low-grade lymphomas

28

48

BEAC

906 days

23

30% 3-year FFS

Includes patients in first CR

29

107

BEAM

29 months

7

35% 5-year PFS

DPS = disease-free survival, EPS = event-free survival, FFS = failure-free survival, CCR = continuous complete remission, PFS = progression-free survival, ns = not stated, CR = complete remission, TACC = lomustine, cytarabine, cyclophosphamide, 6-thioguanine, BEAM = carmustine, etoposide, cytarabine, melphalan, Cy = cyclophosphamide, TBI = total body irradiation, Ara-C = cytarabine, BCNU = carmustine, BEP = carmustine, etoposide, cisplatin, VP-16 = etoposide, CBV = cyclophosphamide, carmustine, etoposide, BEAC = carmustine, etoposide, cytarabine, cyclophosphamide.

Transplantation results 333

Figure 24.1 Actuarial 3-year disease-free survival for 100 patients with intermediate-grade or high-grade non-Hodgkin's lymphoma following autologous bone marrow transplantation for sensitive relapse (solid line), resistant relapse (dashed line) and after failing to attain a complete remission (broken line).'6

cent compared with 14 per cent for relapsed patients who failed to respond to conventional-dose salvage chemotherapy (resistant relapse). Subsequent trials have confirmed the importance of chemotherapy sensitivity as a prognostic factor for transplantation.17,20,21,23,25,27,29 The extent of conventional therapy prior to transplantation has also been associated with prognosis. Vose et al. demonstrated that patients who had received more than two chemotherapy regimens prior to transplantation had inferior outcomes,23 and others have similarly demonstrated that transplant results are more favorable if patients are transplanted earlier in the course of disease before they receive multiple cycles of conventional salvage chemotherapy.19,26,28 Other prognostic factors reported to be associated with adverse outcome include high lactic dehydrogenase (LDH) levels at the time of transplant,23,28 poor performance status,18,19 and highgrade histology.17,19,25,26 The International Prognostic Index uses age, stage, LDH, performance status and the number of extranodal sites of disease to determine the prognosis for patients with newly diagnosed nonHodgkin's lymphoma.30 This index may also be useful for patients undergoing autologous bone marrow transplantation for non-Hodgkin's lymphoma.31 Other prognostic markers include histologic features and disease localization. For example, good prognosis patients with follicular large cell histology have improved survival compared with similar patients with diffuse large cell histology.32 Also patients with primary mediastinal B cell large cell lymphoma may do better with high-dose chemotherapy than those with other types of diffuse large B cell lymphoma.33 The presence of bulky disease prior to transplantation may be a surrogate for disease sensitivity and has been associated with a poor outcome.23 It is common practice to administer conventional-dose salvage chemotherapy or involved-field radiation therapy prior to transplantation to reduce tumor bulk. Rapoport et al. demonstrated

that event-free survival was 48 per cent for patients with minimal disease at the time of transplantation, as compared with 25 per cent for patients who had at least one area of disease measuring more than 2 cm (P = 0.04).24 Pretransplant involved-field radiation therapy is frequently performed, although this may be associated with increased pulmonary toxicity.21,22,28 Occasionally surgery has been used prior to transplantation to remove bulky masses. The results of allogeneic transplantation for acute myelogenous leukemia are similar whether patients are transplanted in early first relapse or in second remission.34 Mills et al. noted a progression-free survival of approximately 59 per cent in patients who proceeded to transplant in untested relapse.29 Although these patients were carefully selected, these results suggest that not all patients require conventional salvage chemotherapy prior to transplantation.

Transplantation for low-grade nonHodgkin's lymphoma There has been relatively little experience with transplantation for low-grade lymphoma in comparison with more aggressive histologic subtypes. Results of high-dose therapy for low-grade lymphoma are displayed in Table 24.2. These series contain patients with a wide range of prognostic variables who were treated at various stages of disease. Interpretation of results is also complicated by the fact that some trials include patients with follicular large cell histology, which may have a different clinical behavior from other follicular lymphomas.44 This heterogeneity makes it difficult to identify important prognostic variables relating to autologous transplantation for low-grade lymphoma. As was seen in aggressive non-Hodgkin's lymphoma, the presence of chemotherapy-sensitive disease may be associated with increased survival following transplantation.35,37,38,40 It is also evident that patients who are transplanted after receiving multiple courses of conventional therapy have inferior outcomes.39,41,43 The presence of histologic transformation has been associated with a shorter survival in some series,38,41,45 although this has not been seen in others.25,35 The results of phase II trials of autologous transplantation for low-grade lymphoma demonstrate that transplantation can be performed with low mortality and that high response rates are seen. Nevertheless, survival curves from most series show a continuous pattern of relapse and it is not clear whether patients are cured or whether the natural history of disease is changed (Fig. 24.2). Rohatiner et al. noted that freedom from recurrence in 41 follicular lymphoma patients autografted in second remission was significantly better than historical controls, although no significant differences in overall survival were observed.39 The natural history of lowgrade lymphomas mandates prolonged follow-up to

334 High-dose therapy Table 24.2 Results of autologous transplantation for low-grade lymphoma

35

51

Cy + TBI

Purged marrow

2

47% 4-year DPS

Includes patients with small lymphocytic and diffuse intermediate histology

36

10

TACCorBEAM

Purged or unpurged marrow

0

8 (80%) CCR (15-43 months)

Includes patients in first CR

37

42

Various

Peripheral blood stem cells or purged or unpurged marrow

7

58% EPS

Includes patients with follicular large cell histology

38

92

Various

Purged or unpurged marrow

ns

52% PFS

39

64

Cy + TBI

Purged marrow

5

35 (55%) CCR (1-8 years)

Includes patients with follicular large cell histology

40

34

Cy + TBIorBAC

Peripheral blood stem cells or purged or marrow

12

18% 2-year DFS

Includes patients with small lymphocytic histology

41

60

Various

Peripheral blood stem cells

8

53%2-yearFFS

Includes patients with follicular large cell histology

42

48

Cy +TBI or BEAM

Peripheral blood stem cells

4

76% 2-year DFS

Includes patients in first CR

43

100

Various

Peripheral blood stem cells or unpurged marrow

8

44%4-yearFFS

DPS = disease-free survival, CCR = continuous complete remission, EPS = event-free survival, PFS = progression-free survival, FFS = failure-free survival, ns = not stated, CR = compilete remission, Cy = cyclophosphamide, TBI = total body irradiation, TACC = lomustine, cytarabine, cyclophosphamide, 6-thioguanine, BEAM = carmustine, etoposide, cytarabine, melphalan, BAC = carmustine, cytarabine, cyclophosphamide.

evaluate the role of transplantation. For example, the St Bartholomew's Hospital, UK group have indicated a possible role for high-dose therapy in patients with transformed follicular lymphoma but comment that there is a late risk of myelodysplastic syndrome.46,46a At the University of Nebraska, a relapse 74 months after

transplantation has been observed43 and relapses as late as 9 years after transplantation have been reported.36,37 Ongoing trials are evaluating the role of autologous transplantation for patients with low-grade lymphoma in first remission.

Hodgkin's disease Results of selected phase II trials of autologous bone marrow and peripheral blood stem cell transplantation for Hodgkin's disease are displayed in Table 24.3. Disease-free survival ranges from 25 to 64 per cent, and mortality rates vary from 0 to 23 per cent. As has been seen for non-Hodgkin's lymphoma, the heterogeneity of patient characteristics and treatments make it difficult to compare the results of different series. PROGNOSTIC FACTORS Figure 24.2 Overall survival (solid line) and failure-free survival (dashed line) for 100 patients with relapsed and refractory follicular low-grade non-Hodgkin's lymphoma following high-dose therapy and autologous hematopoietic rescue. University of Nebraska, unpublished.

The most consistently identified prognostic factor relating to autologous transplantation for Hodgkin's disease is the number of chemotherapy regimens patients have received prior to transplantation. This concept was first noted by investigators at MD Anderson Cancer Center

Comparison with salvage therapy results 335

Table 24.3 Results of autologous transplantation for Hodgkin's disease

47 48 49 21 50 51 52 24 53 54 55 27 56 57

50 26 56 35 73 25 47 47 58 155 128 24 85 62

CBV Cy + TBI CBV BEP VP-16 + Mel Cy + TBI + MTX + VP-16+Mel Cy + VP-16 + TLI BEAC CBV ± Plat BEAM CBV Cy + VP-16 + TBI Cy + VP-16 + TBIorCBV

ns 3.8 years 3.5 years 13 months 30 months 67 months 40 months 2 years 2.3 years

CBV

ns

ns 77 months 2.5 years 28 months

4 23

21 3 4 ns 17 17 5 10 9 4 8 0

1 2(24%) CCR (9-32 months) 27% PFS 47% 5-year EFS 16(46%) CCR (10-52 months) 39% 4-year DFS 48% PFS 50% DFS

49% 3-year EFS 64% PFS 50% 5-year DFS 25%4-yearFFS 47% 3-year EFS 58% 2-year EFS 38% 3-year DFS

CCR = continuous complete remission, PFS = progression-free survival, EPS = event-free survival, DFS = disease-free survival, FFS = failure-free survival, ns = not stated, CBV = cyclophosphamide, carmustine, etoposide, Cy = cyclophosphamide, TBI = total body irradiation, BEP = carmustine, etoposide, cisplatin, VP-16 = etoposide, Mel = melphalan, MIX = methotrexate, TLI = total lymphoid irradiation, BEAC = carmustine, etoposide, cytarabine, cyclophosphamide, Plat = cisplatin, BEAM = carmustine, etoposide, cytarabine, melphalan.

and University of Nebraska who reported that median progression-free survival was 5.1 months in patients who had failed at least two conventional chemotherapy regimens, compared with 26.9 months for less heavily pretreated patients.58 These findings have subsequently been validated in larger series from these institutions55'59 as well as others.54,56 These results have been used to support the early use of transplantation for patients with relapsed Hodgkin's disease before the development of chemotherapy resistance and other complications related to prolonged use of chemotherapy. Reece et al. developed a prognostic model based upon the presence of systemic symptoms at relapse, length of initial remission and the presence of extranodal disease at relapse.53 Progression-free survival at 3 years was (in per cent) 100, 81, 40 and 0 for patients with 0, 1, 2 or 3 risk factors, respectively. The presence of systemic symptoms at the time of transplant was also associated with an inferior outcome in the Minnesota experience57 and the presence of extranodal disease at the time of transplant was associated with shorter survival in the City of Hope experience.56 Similarly, patients with longer initial remissions have had better outcomes in other series.54,60 Other prognostic factors associated with improved survival following autologous transplantation for Hodgkin's disease include higher performance status48,49,55,61 disease sensitivity54 and absence of bulky disease at the time of transplant.50,54,57 As with non-Hodgkin's lymphoma it is common practice to reduce tumor bulk with conventional salvage chemotherapy or involved-field radiation prior to transplantation for Hodgkin's disease. Crump et al. demonstrated a disease-free survival of 68 per cent for patients transplanted with no evidence of disease, as compared with 26 per cent for patients with persistent non-bulky

disease, and 0 per cent for those with bulky disease.50 Selected patients, particularly those with minimal disease at relapse, may benefit by proceeding directly to transplantation without receiving conventional salvage therapy. At the University of Nebraska, 5-year failurefree survival was 90 per cent for patients transplanted in untested first relapse, as compared with 33 per cent for patients who received conventional salvage chemotherapy prior to transplantation.60 Chopra et al. noted that 5year progression-free survival was 78 per cent for patients transplanted in untested relapse.54 It has also become common practice to administer radiation therapy following transplantation to areas of prior disease. Although many patients cannot receive this treatment because of previous radiation therapy, this approach may be able to convert some partial remissions after transplantation into complete and durable responses.55,62 Post-transplant consolidation radiation therapy has been used routinely at some institutions to improve results, although the benefits of this approach are difficult to prove outside of a randomized trial.50,54 The results in Table 24.3 demonstrate that long-term disease-free survival can be accomplished with minimal mortality, although prolonged follow-up is necessary. Relapses beyond 3 years and as late as 6 years following transplantation have been described.48,49,54,56

COMPARISON WITH CONVENTIONAL SALVAGE CHEMOTHERAPY RESULTS The results displayed in Tables 24.1 and 24.3 are better than the majority of reports of conventional-dose salvage chemotherapy for Hodgkin's disease and non-Hodgkin's

336 High-dose therapy

lymphoma. Nevertheless, patients who proceed to transplant may be highly selected and these results do not provide conclusive proof of the superiority of transplantation.63 Recent studies are refining the role of transplantation for lymphoma. Non-Hodgkin's lymphoma Evidence to support the superiority of transplantation for patients with relapsed and refractory non-Hodgkin's lymphoma comes from a retrospective analysis of 244 patients reported by the Groupe d'Etude des Lymphomes de 1'Adulte (GELA).64 All patients had progressed after receiving the identical LNH-84 regimen. Overall survival at 4 years was projected to be 14 per cent among 200 patients who received conventional salvage chemotherapy, as compared with 33 per cent for 44 patients who received bone marrow transplantation (40 autologous, 4 allogeneic; P < 0.001). A similar analysis of patients with relapsed childhood lymphoma showed that no patients were cured with conventional salvage chemotherapy, although 27 per cent of patients who were transplanted (14 autologous, 1 allogeneic) were alive and in remission 4 years later.65 The randomized PARMA trial has now provided convincing evidence of the superiority of transplantation as compared with conventional salvage chemotherapy for patients with relapsed non-Hodgkin's lymphoma.66 In this trial, 215 patients with relapsed intermediate- and high-grade lymphoma were treated with two cycles of DHAP (dexamethasone, cytarabine, cisplatin) conventional salvage chemotherapy. Responders were then randomized to receive two additional cycles of DHAP plus involved-field radiotherapy or to receive autologous transplantation with involvedfield radiotherapy. At 5 years, event-free survival was 46 per cent following transplantation and 12 per cent in the conventional salvage treatment group (P = 0.001). Overall survival was projected to be 53 per cent following transplantation, as compared with 32 per cent in patients treated with DHAP (P = 0.038) (Fig. 24.3). These results suggest that high-dose therapy followed by autologous bone marrow or peripheral blood stem cell transplantation is the treatment of choice for patients with relapsed aggressive non-Hodgkin's lymphoma. HodgkirTs disease Retrospective evidence from Stanford University supports the superiority of autologous bone marrow transplantation over conventional salvage chemotherapy for relapsed and refractory Hodgkin's disease.67 Failure-free survival among 60 patients with refractory Hodgkin's disease or first relapse was 60 per cent following transplantation, as compared with 30 per cent for a matched cohort who received conventional salvage therapy.

Months after randomization

Figure 243

Overall survival for 109 patients with

chemotherapy-sensitive relapsed non-Hodgkin's lymphoma randomized to conventional treatment or autologous bone marrow transplantation.611

Despite this difference, there were no significant differences in overall survival. The only prospective trial comparing transplantation and conventional salvage chemotherapy for Hodgkin's disease has been performed by the British National Lymphoma Investigation.68 The design of this trial offered the opportunity to validate the concept of dose intensity for patients with relapsed and refractory Hodgkin's disease because patients were randomized to treatment with BEAM (carmustine, etoposide, cytarabine, melphalan), followed by autologous bone marrow transplantation, or to conventional salvage chemotherapy with the same drugs administered at doses that do not require hematopoietic rescue (mini-BEAM). The 3-year eventfree survival was 53 per cent in the BEAM group and 10 per cent in the mini-BEAM group (P = 0.025) (Fig. 24.4). There was also a significant difference in progression-free survival and a trend in favor of overall survival, although this difference was not significant (Fig. 24.4). The trial was closed after accrual of only 40 patients because of patient preference for transplantation. The relative merits of autologous transplantation and conventional salvage chemotherapy for Hodgkin's disease can also be compared by observing results of transplantation in patients in first relapse, since this is the situation in which the best results of conventional salvage chemotherapy have been observed, especially in patients whose initial remission duration exceeds 1 year.3^5 The best results in this situation have been reported by the Vancouver group who noted an actuarial progression-free survival of 64 per cent in patients who were transplanted after their first relapse.53 Patients with an initial remission duration of at least 1 year had a progression-free survival estimated at 85 per cent and those with shorter initial remissions had a progression-free survival estimated at 48 per cent (Fig. 24.5). These results are better than the best results reported for conventional salvage chemotherapy and are supported by similar results from other institutions that have evaluated the results of transplantation in first relapse.51,54,56,60

Early transplantation 337

Figure 24.5 Progression-free survival for 58 Hodgkin's disease patients with initial complete remissions of 12 months or longer (solid line) or less than 12 months (dashed line) following autologous bone marrow or peripheral blood stem cell transplantation.53

conventional salvage chemotherapy.5,69 Reece et al. reported a progression-free survival of 42 per cent in a group of 30 patients who were transplanted with persistent or progressive Hodgkin's disease after primary chemotherapy.70 The Milan group reported a 31 per cent event-free survival in patients who were transplanted after induction failure for Hodgkin's disease51 and similar results have been noted by others.52,54,56 These results have led most investigators to recommend transplantation for Hodgkin's disease patients who fail to achieve remission with initial chemotherapy and for those who relapse after initial remissions that are less than 12 months in duration. Failure-free survival rates following transplantation for patients who have initial remissions exceeding 1 year in length appear to be better than the best results of conventional salvage chemotherapy, although improvements in overall survival have not been demonstrated. The increasing ease and safety of transplantation have led many investigators to recommend transplantation also for these patients. Figure 24.4 Overall survival (top), event-free survival (middle) and progression rate (bottom) in 40 patients with relapsed and refractory Hodgkin's disease randomized to conventional salvage chemotherapy or autologous bone marrow transplantation. Reproduced with permission from Linch DC, Winfield D, GoldstoneAH et al. Dose intensification with autologous bonemarrow transplantation in relapsed and resistant Hodgkin's disease: results of a BNLI trial. Lancet 341: 1051-4. © The Lancet Ltd, 1993.

Results of autologous transplantation for patients with primary refractory Hodgkin's disease also suggest the superiority over conventional salvage chemotherapy.683 Few patients who fail to enter complete remission achieve long-term disease-free survival with

EARLY TRANSPLANTATION Despite the success of modern chemotherapy regimens for advanced Hodgkin's disease and non-Hodgkin's lymphoma, a substantial percentage of patients will relapse or fail to achieve initial remission. Patients at high risk for relapse are candidates for innovative treatment strategies. One such strategy is the use of early transplantation for poor-prognosis patients. This strategy requires the ability to identify these patients and the ability to perform transplants with low morbidity and mortality, since some patients might have otherwise been cured without transplantation. Various prognostic factors have been identified that can help to identify

338 High-dose therapy

poor-prognosis non-Hodgkin's lymphoma patients at the time of diagnosis.30 These factors can be used to identify patients with adverse risk factors who might be candidates for transplantation earlier in the course of disease. One of the earliest attempts at using early autologous bone marrow transplantation for poor-prognosis nonHodgkin's lymphoma was reported from the Memorial Sloan Kettering Cancer Center.71 Fourteen patients with aggressive non-Hodgkin's lymphoma and poor-prognostic features were started on combination chemotherapy and were transplanted in first complete or partial remission. Thirteen additional patients were treated with the full course of conventional chemotherapy and considered for transplantation if they relapsed or failed to enter complete remission with standard therapy. Overall survival was significantly better in the patients who had early transplants as compared with those who received conventional therapy. Since then several other phase II trials of early transplantation have been performed for patients with poorprognosis non-Hodgkin's lymphoma (Table 24.4). These trials demonstrate that the use of transplantation as a means of delivering high-dose consolidation therapy can generally be accomplished with low mortality. Furthermore, outcomes appear to be better than for

historical controls. Nevertheless, patients in these series may be subject to selection bias. Survival curves in these studies generally are calculated from the time of transplant rather than the time of diagnosis. These trials have often failed to report the number of high-risk patients at the time of initial diagnosis that might have been eligible for early transplantation. Some studies indicate that only a fraction of patients that are identified as high risk at the time of diagnosis may actually ever proceed to transplantation.73,80 Randomized trials have been performed to address this issue of selection bias. A GELA trial randomized 464 patients with intermediate- and high-grade lymphoma in first complete remission to treatment with sequential conventional chemotherapy consolidation or to receive high-dose chemotherapy consolidation followed by autologous bone marrow transplantation.83 The 3-year disease-free survival rate was 59 per cent in transplanted patients compared with 52 per cent for patients who continued with conventional chemotherapy (P = 0.46). However, among patients with high-intermediate risk and high-risk groups,30 3-year disease-free survival was estimated at 60 per cent following transplantation, as compared with 41 per cent in patients who continued consolidation therapy (P = 0.07) (Fig. 24.6). Follow-up data from this study has shown a projected 5-year

Table 24.4 Non-randomized trials of results of autologous transplantation in first remission for poor-prognosis non-Hodgkin's lymphoma

71

14

0

11 (79%) CCR (31-71 months)

72

13

0

70% 4-year DFS

73

21

5

66% DFS

40 patients initially entered on trial

74

12

17

8 (67%) CCR (8-52 months)

Survival significantly better than historical controls treated with chemotherapy alone

75

9

0

6 (67%) CCR (12-113 months)

76

0

0

84% 13-month DFS

77

26

0

85% 28-month DFS

16 patients in CR at transplant 10 patients in minimal disease state at transplant

78

28

0

83% EFS

Outcome includes 2 patients who relapsed prior to transplant

79

102

70% 5-year PFS

80

17

48% 3-year EFS

26 patients initially entered on trial

81

16

100% DFS

12 patients in CR at transplant 4 patients in PR at transplant

82

33

61% 2-year EFS

Survival significantly better than historical controls treated with chemotherapy alone

6 patients in CR at transplant 8 patients in PR at transplant. Survival significantly better than concurrent controls treated with chemotherapy alone

CR = complete remission, PR = partial remission, CCR = continuous complete remission, DPS = disease-free survival, EFS= event-free survival, PFS = progression-free survival.

Preparative regimens 339

Figure 24.6

Disease-free survival for 203 patients with poor-

prognosis non-Hodgkin's lymphoma randomized to sequential conventional chemotherapy (solid line) or high-dose chemotherapy with autologous bone marrow transplantation (dashed line) following induction chemotherapy.83

disease-free survival rate of 59 per cent following transplantation, compared with 39 per cent for patients in the high-intermediate and high-risk groups who underwent transplantation or sequential chemotherapy, respectively (P = 0.01).84 Overall survival rates were 65 and 52 per cent, respectively (P = 0.06). Randomized studies stratifying for poor-risk disease are still underway; however, those so far reported by GELA and by the German and Italian NHL Study Groups85,87 have so far shown no advantage to the highdose arm. In fact, in the GELA study (LNH-93), where ACVB (doxorubicin, cyclophosphamide, vinblastine, bleomycin) as conventional therapy was compared with an intensified induction regimen followed by high-dose therapy, overall survival at 3 years was better for the conventional compared with the high-dose arm (63 per cent vs 47 per cent; P = 0.0003). The Milan Cancer Institute has conducted a prospective trial comparing MACOP-B chemotherapy (see Table 20.3)88 with a 60-day high-dose sequential regimen of debulking chemotherapy followed by high-dose chemotherapy with autologous peripheral blood stem cell transplantation for patients with high-risk diffuse large cell lymphoma.89 Progression-free survival was 88 per cent after intensive chemotherapy followed by transplantation and 41 per cent with MACOP-B alone (P = 0.0001). Follow-up reports indicate that overall survival is improved with this approach90 and the Eastern Cooperative Oncology Group (ECOG) have established that the use of such a regimen is feasible in a multicenter context.91 Another factor associated with poor prognosis for non-Hodgkin's lymphoma is slow response to initial chemotherapy.92 Two prospective randomized trials have investigated the use of transplantation in patients who are in partial remission midway through their initial chemotherapy regimen. A Dutch trial randomized patients in partial remission after three cycles of CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) to receive five additional cycles of CHOP, or to

one additional cycle of CHOP followed by high-dose chemotherapy and autologous bone marrow transplantation.93 No significant difference in outcome was observed between the groups. An Italian trial randomized patients in partial remission after completion of two-thirds of primary therapy to treatment with conventional salvage chemotherapy, or to receive transplantation.94 Progression-free survival at 55 months was projected at 73 per cent following transplantation and 52 per cent in patients who received conventional chemotherapy (P = 0.3). Although early studies demonstrated the poor prognosis of patients with primary refractory disease,16 it is now recognized that these patients can be divided into two groups. One group has lymphoma that fails to respond during initial chemotherapy and the other group consists of patients who attain a partial response with initial therapy. Patients in this latter group have sensitive disease and may respond well to transplantation. Philip et al. demonstrated a 75 per cent 2-year overall survival rate in a group of 17 patients who were transplanted after achieving a partial remission on completion of primary therapy.95 Mills et al. reported that progression-free survival was 69 per cent in patients transplanted in first partial remission29 and GELA, in a retrospective comparative study noted that 5-year eventfree survival was 62 per cent in patients transplanted in first partial remission, as compared with 30 per cent for conventionally treated patients; overall survival was also better (65 per cent compared to 40 per cent).96 There is less experience with early transplantation for Hodgkin's disease, as compared with non-Hodgkin's lymphoma. Carella et al. reported an 87 per cent eventfree survival rate among 15 poor-prognosis Hodgkin's disease patients transplanted in first complete remission, as compared with 33 per cent for 24 concurrent patients who achieved a complete remission but refused transplantation.97 Moreau et al. reported that all 16 Hodgkin's disease patients transplanted in partial remission midway through primary therapy were alive and in remission between 8 and 52 months following transplantation.98

PREPARATIVE REGIMENS A wide variety of high-dose therapy regimens have been used prior to autologous transplantation for lymphoma. Examples of some of the commonly used regimens are displayed in Table 24.5. There are significant differences in drug dosing and scheduling, even within regimens that contain the same drugs. No prospective trials have been completed in which individual lymphoma transplant regimens have been compared. Such a trial would require approximately 200 patients in each arm to detect a 10-15 per cent difference with 80 per cent power. One convenient way to separate regimens is to divide

340 High-dose therapy Table 24.5 Commonly used high-dose therapy regimens for Hodgkin's disease and non-Hodgkin's lymphoma

CBV

Cydophosphamide, 4.8-7.2 g/m2 Carmustine, 300-600 mg/m2 Etoposide, 750-2400 mg/m2

BEAC/BAVC

Carmustine, 200-300 mg/m2 Etoposide, 600-1200 mg/m2 Cytarabine, 800-1200 mg/m2 Cydophosphamide, 140-180 mg/kgor 6 mg/m2

BEAM

Carmustine, 300 mg/m2 Etoposide, 400-800 mg/m2 Cytarabine, 800-1600 mg/m2 Melphalan, 140 mg/m2

Cy-TBI

Cydophosphamide, 120-200 mg/kg Total body irradiation, 800-1320 cGy

VP-16, Cy, TBI

Etoposide, 60 mg/kg or 750 mg/m2 Cydophosphamide, 100-120 mg/kg Total body irradiation, 1200-1375 cGy

them into those that contain total body irradiation (TBI) and those that contain only drugs. Retrospective analyses of several large series have failed to demonstrate a significant survival advantage for TBI-containing regimens used in non-Hodgkin's lymphoma16,19,20,23,38,41,43 or for Hodgkin's disease.56,99 The use of TBI has been associated with increased toxicity in several series. Investigators from Seattle noted that five out of 19 patients who had received prior chest irradiation died of pulmonary complications after receiving TBI, as compared with 0 of 12 patients who received non-TBI-containing regimens (P = 0.052).19 Similarly, Phillips et al. reported three cases of fatal interstitial pneumonitis following TBI in 11 Hodgkin's disease patients who had received mediastinal irradiation as compared with 0 of 15 patients who had not received prior radiation (P = 0.06).48 Gulati et al. reported that the addition of etoposide to a regimen containing cyclophosphamide and TBI improved results over previously treated patients with Cydophosphamide and TBI alone, although a 30 per cent rate of fatal pulmonary complications was observed.22 The use of TBI has also been associated with an increase risk of secondary leukemia and myelodysplastic syndromes.14 At present, there is no conclusive evidence that adding TBI to chemotherapy gives superior results.100 No prospective trials have compared the efficacy of high-dose regimens that consist only of drugs. A European Bone Marrow Transplant Registry survey reported that non-Hodgkin's lymphoma patients who received the CBV regimen (Table 24.5) had a longer progression-free survival than those receiving BEAM (Table 24.5).101 Hodgkin's disease patients had superior outcomes with

BEAM as compared with CBV, however. Rapoport et al. reported that use of the BEAC regimen (Table 24.5) compared with other regimens was associated with improved event-free survival for Hodgkin's disease patients.24 These results must be interpreted with caution in the light of the retrospective nature of the studies and the presence of confounding variables. Increasing the doses of drugs within regimens has been used in an attempt to improve outcome. Mills et al. escalated the total dose of etoposide in the BEAM regimen from 800 mg/m2 per day to 1600 mg/m2 per day and 2400 mg/m2 per day.102 Although follow-up was limited, there was no evidence of improved outcome with larger doses of etoposide, although the highest dose level was associated with increased procedure-related mortality and gastrointestinal complications. Dose escalation trials of the CBV regimen (Table 24.5) have shown increased rates of pulmonary toxicity when doses of carmustine are escalated from 300-450 mg/m2 to 600 mg/m2.103,104 Also the Southwest Oncology Group has reported on the value of augmented preparative regimens in patients with relapsed or refractory diffuse aggressive nonHodgkin's lymphoma.105 Phase I/II trials have demonstrated that radiolabeled antibodies have significant response rates in patients with relapsed lymphoma. In comparison with TBI, these agents may allow higher doses of radiation to be administered to tumor-bearing areas while sparing normal tissues.106 Preliminary trials combining radiolabeled antibodies with high-dose chemotherapy and autologous transplantation for Hodgkin's disease have been performed107 and trials in non-Hodgkin's lymphoma are ongoing.

COMPARISON OF RESCUE SOURCES The use of autologous peripheral blood stem cells has increased in recent years in comparison with autologous bone marrow and many institutions are performing transplants exclusively with peripheral blood stem cells. The main advantage of this source of rescue is that it allows the collection of hematopoietic progenitors in patients with hypocellular marrow and in those with known marrow metastases. In addition, peripheral stem cells can be collected without the need for general anesthesia. Investigators have reported that peripheral blood stem cell collections may contain fewer malignant cells than autologous bone marrow harvests.108 Finally, most series have reported more rapid hematopoietic reconstitution with autologous peripheral blood stem cells, which has led to decreased need for blood product support, fewer complications and shorter hospital stays (Table 24.6). It must be remembered that most of these trials are not prospective and that engraftment following autologous bone marrow transplantation has been compared to that of stem cell collections mobilized with

Comparison of rescue sources 341

chemotherapy or hematopoietic growth factors. Limited evidence suggests that engraftment following bone marrow collected after growth factor use may be similar to that of mobilized stem cells.115 It is unclear whether survival rates following transplantation are influenced by the rescue source. Vose et al. noted in a retrospective analysis that a good prognostic group of patients defined by chemosensitivity, disease bulk, LDH and extent of prior therapy had a 3-year failure-free survival of 70 per cent following autologous peripheral stem cell transplantation compared with 32 per cent following autologous bone marrow transplantation (Fig. 24.7).23 An ongoing trial is currently reevaluating these results in a randomized fashion. Other trials (Table 24.6) show no definite evidence of a survival difference between patients transplanted with autologous bone marrow or stem cells. However, one multicenter randomized study concluded that peripheral stem cell transplantation is as safe and more cost effective in the short term than autologous bone marrow transplantation.116 Allogeneic bone marrow transplantation has also been used for patients with lymphoma. The use of allogeneic bone marrow eliminates the possibility of infusing tumor cells and offers the possibility of a 'graft versus lymphoma effect' similar to the graft versus leukemia effect seen following allogeneic transplantation for

Figu re 24.7

Failure-free survival for good-prognosis non-

Hodgkin's lymphoma patients following autologous bone marrow transplantation (solid line) or peripheral blood stem cell transplantation (dashed line).23

Table 24.6 Comparative results of autologous bone marrow transplantation with peripheral blood stem cell transplantation for lymphoma - outcome

Reference Prospective Disease

ABMT

PSCT

P

Comments

> 0.7

PSCT patients had more rapid engraftment and shorter hospital stays

109

Yes

HD and NHL

28

34% RFS

53% RFS

110

No

HD and NHL

142

44% Rel/Prog

45% Rel/Prog

23

No

NHL

158

23% 3-year FFS

40% 3-year FFS

0.014

111

No

HD

242

28% 4-year FFS

25% 4-year FFS

0.9

112

No (casecontrolled analysis)

HD and NHL

166

36% PFS

39% PFS

0.8

113

No

HD and NHL

41

11/19CCR 18/22CCR (12-40 months) (2-17 months)

24

No

HD NHL

47 53

50% 3-year EFS 41% 3-year EFS

HD and NHL

58

No differences in survival

114

Yes

33% 3-year EFS 36% 3-year EFS

PSCT patients had more rapid engraftment Difference only significant in good prognosis patients

PSCT patients had more rapid engraftment and less toxicity

PSCT patients had more rapid engraftment, shorter hospital stays, less blood product use and lower costs)

0.63 0.99 PSCT patients had more rapid engraftment, shorter hospital stays, less blood product use

ABMT = autologous bone marrow transplantation, PSCT = peripheral blood stem cell transplantation, HD = Hodgkin's disease, NHL = nonHodgkin's lymphoma, RFS = relapse-free survival, Rel/Prog = relapse or progression, FFS = failure-free survival, PFS = progression-free survival, CCR = continuous complete remission, EFS = event-free survival.

342 High-dose therapy

leukemia.117 Disadvantages of allogeneic transplantation include the increased mortality associated with graft versus host disease and the lack of a suitably matched sibling donor in most circumstances. Several institutions have reported comparative results of autologous and allogeneic bone marrow transplantation for lymphoma. Jones et al. noted that the actuarial relapse probability was 46 per cent following autologous bone marrow transplantation in a cohort of Hodgkin's and nonHodgkin's lymphoma patients, as compared with 18 per cent following allogeneic transplantation (P - 0.02).118 However, event-free survival was 47 per cent following allogeneic transplantation and 41 per cent following autologous transplantation (P - 0.8), owing to the higher transplant-related mortality associated with allogeneic transplantation (42 per cent vs 13 per cent; P = 0.01). A similar trial from Wayne State compared autologous and allogeneic bone marrow transplantation in 66 patients with relapsed or refractory non-Hodgkin's lymphoma of all histologic grades.119 Relapse probability was significantly higher in patients who received autologous bone marrow; however, death due to infectious complications and graft versus host disease were more frequent in allogeneic marrow recipients and progression-free survival rates were not statistically different (Fig. 24.8). A matched-pair analysis of 202 patients from the European Bone Marrow Transplant Group noted that progressionfree survival was 49 per cent following allogeneic transplantation and 46 per cent following autologous transplantation for non-Hodgkin's lymphoma.120 Progression-free survival in patients with lymphoblastic lymphoma was 48 per cent following allogeneic transplantation compared with 24 per cent following autologous transplantation (P = 0.035). Procedure-related mortality in patients with intermediate- and high-grade lymphoma was 28 per cent compared with 14 per cent following autologous transplantation (P = 0.008). There was a significantly lower relapse rate in patients with

Figure 24.8

chronic graft versus host disease compared with patients who had no chronic graft versus host disease. These results suggest that a graft versus lymphoma effect exists, although they can also be used to support ' the theory that relapse rates are lower following allogeneic transplantation due to lack of tumor contamination. A trial incorporating significant numbers of syngeneic transplants would be required to answer this question. There is increasing enthusiasm for employing allogeneic transplantation for low-grade lymphoma. Investigators from the MD Anderson Cancer Center reported a 2-year disease-free survival of 59 per cent in 15 patients undergoing allogeneic transplantation for low-grade lymphoma.121 An International Bone Marrow Transplant Registry survey reported that 3-year diseasefree survival was 43 per cent in 81 patients undergoing allogeneic bone marrow transplantation for low-grade non-Hodgkin's lymphoma.122 Comparative trials of autologous and allogeneic transplantation in Hodgkin's disease also suggest the presence of a graft versus lymphoma effect. Investigators from Seattle reported a relapse rate of 45 per cent following matched allogeneic transplantation for Hodgkin's disease compared with 76 per cent for patients undergoing autologous bone marrow transplantation.123 Event-free survival rates were not statistically different, however. An analysis of 100 HLA-identical sibling allogeneic transplants for Hodgkin's disease reported to the International Bone Marrow Transplant Registry noted a 14 per cent 3year disease-free survival rate.124 Treatment-related mortality was 61 per cent. A European Bone Marrow Transplant Registry study matched 45 HLA-identical allogeneic Hodgkin's disease transplant recipients to 45 autologous bone marrow transplant recipients.125 Overall survival at 4 years was 25 per cent following allogeneic transplantation and 37 per cent following autologous bone marrow transplantation. The actuarial 4-year rate

Probability of (a) disease progression, and (b) progression-free survival in 66 patients with relapsed and refractory non-

Hodgkin's lymphoma randomized to autologous or allogeneic bone marrow transplantation.™

Purging 343

of procedure-related mortality was 48 per cent following allogeneic transplantation and 27 per cent following autologous transplantation (P = 0.04). The procedure-related mortality of allogeneic transplantation makes it difficult to recommend this approach routinely. However, allogeneic transplantation may be considered for younger patients and those with bone marrow involvement, high-grade histology and poor prognostic features. The results of allogeneic transplantation for low-grade lymphoma make this approach a reasonable consideration for younger patients, although long-term follow-up studies are needed. The high mortality associated with allogeneic transplantation for Hodgkin's disease suggest that this approach should only be considered for carefully selected patients.

PURGING The greatest concern associated with autologous transplantation for lymphoma involves the risk of infusing malignant cells with the graft. This risk is eliminated with allogeneic transplantation, but procedure-related mortality and lack of donor availability limits use of this approach. Another approach involves the removal of malignant cells (purging) from the autograft, which can be accomplished in a variety of ways.126 While the removal of malignant cells from the autograft makes theoretical sense, there is relatively little information on the clonogenicity of contaminating cells. Even if these cells are clonogenic, there is little information on the effects of cryopreservation, the number of reinfused cells that might be necessary to cause relapse and the effects of high-dose therapy on the microenvironment. Relapse occurs after allogeneic transplantation and so not all relapses can be attributed to infusion of malignant cells. Most relapses after autologous transplantation occur at sites of prior disease, suggesting that relapse most commonly results from deficiencies in the preparative regimen rather than reinfusion of malignant cells. Furthermore, retrospective analyses,19,20,22 as well as a matched-pair analysis from the European Bone Marrow Transplant Registry,127 have failed to identify significant benefits from purging autologous transplants for lymphoma. There is a significant amount of evidence that does suggest a benefit from purging, however. Studies in which autologous bone marrow cells have been marked with the neomycin-resistance gene have demonstrated that contaminated grafts may contribute to relapse in some cases of acute and chronic myelogenous leukemia.128,129 Similar studies in patients with non-Hodgkin's lymphoma and a variety of solid tumors are ongoing. Early disseminated relapse in some patients undergoing autologous bone marrow transplantation for non-Hodgkin's lymphoma

also suggests that some relapses may be secondary to contaminated marrow.130,131 Additional indirect evidence of the importance of contaminating cells is demonstrated by studies from Sharp et al. who investigated the outcome of autologous transplantation in relation to the presence of contaminating tumor cells.132 Five-year relapse-free survival was 64 per cent in non-Hodgkin's lymphoma patients who received peripheral stem cell transplants with collections that did not contain detectable tumor cells compared with 57 per cent for autologous bone marrow transplant patients whose marrow contained no detectable tumor cells and 17 per cent for autologous bone marrow transplant patients whose harvests contained tumor cells. Gribben et al. performed purged autologous bone marrow transplants in 114 patients with non-Hodgkin's lymphoma in whom lymphoma cells were detectable prior to transplantation by means of the polymerase chain reaction for bcl-2 translocations.133 Following purging, with monoclonal antibodies and complement, 57 patients had detectable lymphoma cells in the marrow and 57 patients had no detectable cells. Diseasefree survival was significantly higher in patients with no detectable lymphoma cells after purging (Fig. 24.9). Also, in a retrospectively analysed French study of 120 autografted patients, improved outcome was noted for marrow purging in vitro with mafosfamide.134 These results suggest that purging may be useful, although the presence of tumor cells in the marrow product and the ability to purge successfully may simply be markers for disease sensitivity or a measure of disease aggressiveness. These controversies may only be settled in the context of a prospective trial.

Figu re 24.9 Disease-free survival following purged autologous bone marrow transplantation in 114 patients with B cell nonHodgkin's lymphoma. 'Negative' denotes patients without detectable lymphoma cells in the bone marrow following purging, and 'Positive' denotes patients who had residual detectable lymphoma cells.™

344 High-dose therapy

CURRENT STATUS There now seems to be a world-wide consensus of opinion as to the role of high-dose chemotherapy and transplantation.135,137 For chemotherapy-sensitive relapsed Hodgkin's disease and aggressive non-Hodgkin's lymphoma this is now the gold standard for patients judged appropriate for such therapy; there may also be a role in patients with partially responsive but progressively improving disease. For patients in first remission, those with aggressive non-Hodgkin's lymphoma with poor-risk disease should be encouraged to enter ongoing trials; if not, the option of high-dose treatment should be discussed. For refractory Hodgkin's disease but not aggressive non-Hodgkin's lymphoma, this is also a reasonable treatment option. For low-grade non-Hodgkin's lymphoma, the procedure should be studied in clinical trials. This is also the case for mantle cell lymphoma, although high-dose chemotherapy is commonly offered following conventional cytoreductive chemotherapy. The value of allogeneic stem cell transplant is still unproven, but this may be considered in relapsed aggressive non-Hodgkin's lymphoma and in Hodgkin's disease, where there is a HLA-identical sibling donor, for relapse following autologous stem cell transplant.

FUTURE DIRECTIONS The increasing use and safety of autologous transplantation for lymphoma has led to the recognition that relapse is now the major complication of transplantation rather than procedure-related mortality. Future efforts will focus on improving the results of transplantation. This goal can be accomplished in four ways. 1 Decrease transplant-related mortality. Mortality following autologous transplantation for lymphoma has fallen to levels below 5 per cent at most institutions and further reductions are unlikely to substantially improve overall survival. Nevertheless, continued efforts at decreasing morbidity and mortality will allow the use of transplantation to be increased, and will allow use in poor-prognosis patients who might not otherwise be transplant candidates. 2 Improvements in preparative regimens. Doses of available chemotherapy agents are unlikely to be escalated much further without incurring doselimiting non-hematopoietic toxicity. Studies investigating the use of radioactive antibodies as a means of more selective radiation delivery are under way. Unless new drugs are developed or agents are developed to protect non-hematopoietic organs, it is unlikely that substantial improvements in preparative regimens will be forthcoming.

3 Purging. The role of purging is unclear. If infused marrow cells do contribute to relapse, then development and incorporation of successful purging techniques or the use of positive selection techniques may lead to improved transplant results. 4 Post-transplant therapy. Relapse is the major cause of transplant failure. Ongoing trials are investigating the use of post-transplant consolidation radiation, as well as immunotherapy with interferon, conjugated antibodies and interleukin-2. The graft versus lymphoma effect following allogeneic transplantation suggests that this form of transplantation will gain increasing use if mortality can be decreased. It should also be possible to achieve this effect using immune modulation and non-myeloablative allogeneic transplantation.

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25 AIDS-related lymphoma AM LEVINE

Epidemiology Etiology and pathogenesis Pathologic aspects Clinicopathologic correlations Clinkal features Prognostic factors for survival

351 351 352 353 353 353

EPIDEMIOLOGY Lymphoma became an acquired immunodeficiency syndrome (AIDS)-defining condition in 1985 and its incidence has continued to increase, coincident with the progressive prolongation of survival in patients with human immunodeficiency virus (HIV) infection. While lymphoma currently comprises approximately 3 per cent of all initial AIDS-defining conditions, it accounts for as many as 12-16 per cent of all AIDS-related deaths, as reported from one large teaching hospital in the UK.1 In one particular study of antiretroviral therapy (primarily zidovudine) in patients with AIDS, conducted at the National Cancer Institute, USA, the incidence of lymphoma was approximately 19 per cent at 36 months of follow-up.2 Although the use of zidovudine has been questioned as potentially etiologic in the pathogenesis of these lymphomas, recent population-based studies have not confirmed this hypothesis.3 While the relative risk of lymphoma in the setting of HIV is approximately 100-fold greater than expected in the general population, the relative risk increases substantially among patients who have already been diagnosed with full-blown AIDS. Thus, the risk of immunoblastic lymphoma is approximately 627-fold over expected, Burkitt's lymphoma is increased approximately 220-fold, and the relative risk of diffuse large cell lymphoma is increased 145-fold in patients with AIDS, when compared with the population in general.4 While highly active antiretroviral therapy (HAART) has been associated with a significant decline in the incidence of various opportunistic infections and Kaposi's

Treatment options in newly diagnosed AIDS lymphoma Therapy for patients who have failed or relapsed after initial chemotherapy Primary CMS lymphoma References

353 356 356 356

sarcoma,5'6 such a decrease has only recently been described in terms of AIDS-related lymphoma, which now appears to have decreased by approximately 50 per cent, when the years 1997-1999 are compared to earlier time frames.7 It is in this latter period that widespread use of HAART therapy has been documented. Lymphoma occurs with approximately equal frequency in all population groups at risk for HIV infection, including injection drug users, homosexual or bisexual men, transfusion recipients, and patients with hemophilia.8 Thus, in a group of 1295 HIV-infected men with hemophilia, 5.5 per cent eventually developed lymphoma, with a mean latency period between initial HIV infection and lymphoma diagnosis of 59 months.9 AIDSrelated lymphoma is seen more frequently in men than in women, which is also the case in de novo lymphoma, unrelated to underlying HIV infection. While Kaposi's sarcoma may be diagnosed in persons with relatively high CD 4 cells, patients with AIDSrelated lymphoma tend to present with more advanced HIV disease. Thus, the median CD 4 cell count for patients with systemic AIDS lymphoma has ranged from 100 to 200/dl, while CD 4 cells less than 50/dl have been found in the majority of patients with AIDS-related primary central nervous system (CNS) lymphoma.2,10

ETIOLOGY AND PATHOGENESIS The AIDS-related lymphomas arise as a consequence of long-term stimulation and proliferation of B lymphocytes, due to several factors, including HIV itself,11 as well

352 AIDS-related lymphoma

as to Epstein-Barr virus (EBV).12 Aside from its direct ability to stimulate B cells, HIV may also be operative indirectly, by inducing the expression of a number of cytokines, which in turn serve to increase B cell activation and proliferation. Thus, interleukin-6 (IL-6) and IL-10, each induced by HIV, have been associated with both autocrine and paracrine growth of lymphoma cells in vitro,13,14 while elevated serum levels of IL-6 have been shown to correlate with increased likelihood of developing lymphoma over time.2 In the setting of chronic B cell proliferation, ongoing for a decade or more, the chance of an acquired genetic error may be increased, leading to aberrent expression of certain oncogenes and/or tumor suppressor genes, often by means of the chromosomal translocations that have been described in AIDS-related lymphoma - t(8;14); t(8;22); t(8;2).15 For example, with juxtaposition of the c-myc oncogene on chromosome 8 next to the transcriptionally active immunoglobulin heavy- or light-chain genes on chromosome 14 and 22 or 2, c-myc activation may occur, leading to a selective growth advantage, and the eventual development of a monoclonal B cell lymphoma, arising from a polyclonal B cell response.16,17This specific pathogenic mechanism may be operative in the small non-cleaved variants of AIDS lymphoma, in which other molecular biologic abnormalities have also been described, including abnormal expression of the p53 tumor suppressor gene18 and the ras oncogene, among others. The molecular pathogenesis of AIDS-related immunoblastic lymphoma appears to be distinct from that of small non-cleaved lymphoma.19 Thus, the immunoblastic lymphomas are more likely to be driven by EBV, with absence of c-myc dysregulation. Clonal integration of EBV has been demonstrated within tumor cells, with expression of various latent EBV proteins in essentially all cases of AIDS-related primary CNS lymphoma20 and in as many as two-thirds of systemic lymphomas.21 Defective EBV immunity maybe important.22 The specific molecular aberrations described in patients with AIDS-related diffuse large cell lymphoma appear distinct as well, with abnormal bcl-6 expression described in approximately 40 per cent of such cases.23 Of interest is the fact that bcl-6 expression has also been found in HIV-negative cases of diffuse large cell lymphoma.

PATHOLOGIC ASPECTS Well over 95 per cent of all AIDS lymphomas thus far reported have been of B lymphoid origin. The B cell nature of this malignancy has been demonstrated by immunophenotypic study, revealing evidence of B cell lineage, with frequent expression of CD 19, CD 20 and CD 22 antigens, usually with monoclonal surface immunoglobulin, and a lack of T cell antigens.24

The full spectrum of B cell neoplasia has been reported in HIV-infected patients, including B cell acute lymphoblastic leukemia, B cell chronic lymphocytic leukemia, plasmacytoma, multiple myeloma, and low-, intermediate- and high-grade lymphomas.25 Despite this wide spectrum of reported disease, the vast majority of AIDS lymphomas have been of high-grade type, including either the immunoblastic or small non-cleaved types, the latter of which may further be subclassified into Burkitt's or non-Burkitt's subtype. These tumors comprise as many as 70-90 per cent of all cases,26 representing a significant departure from the usual setting in de novo lymphoma, in which these high-grade types comprise approximately 10 per cent of all cases. Aside from the high-grade lymphomas, intermediate-grade, diffuse large cell lymphoma is also commonly diagnosed in the setting of HIV infection. The specific proportions of small non-cleaved, immunoblastic and diffuse large cell lymphomas diagnosed in various series have differed, perhaps because of the known complexity and lack of reproducibility of lymphoma classification in general.27 However, 113 cases of AIDS-related lymphoma were recently reviewed by a pathology study group in France, with consensus review required for all cases. Small non-cleaved lymphoma comprised 36 per cent of the group, while large cell immunoblastic accounted for 29 per cent and diffuse large cell lymphoma was diagnosed in 31 per cent. The remainder were not classifiable.28 The vast majority of AIDS lymphomas have been monoclonal B cell tumors, as demonstrated by immunoglobulin gene rearrangement after Southern blot analysis.19,26 Of interest, however, is that multiple monoclonal B cell expansions (oligoclonal lymphomas) have also been described, with the presence of one or more faint rearrangement bands in addition to the predominant clone.29 Recently, genotypically polyclonal B cell lymphomas have been reported, which lack evidence of EBV infection.30 While encountered only rarely in other series, these polyclonal lymphomas comprised 40 per cent of the systemic lymphomas reported by the group in San Francisco, and were defined by lack of IH rearrangement, while light-chain expression or gene rearrangement were not evaluated. Although clear 'clones' of B cells were described within these polyclonal tumors, the authors chose to term these tumors 'polyclonal' rather than oligoclonal. It is possible, then, that these polyclonal, EBV-negative lymphomas are similar to the oligoclonal tumors described by others. Further clarification is awaited. Of interest, is the fact that patients with 'polyclonal' lymphomas were found to survive significantly longer than those with 'monoclonal' disease. Although not considered as part of the AIDS epidemic, T cell lymphomas have also been described in HIV-infected patients. The incidence of T cell lymphoma has not increased since the onset of AIDS and these cases are currently considered to represent chance

Treatment options in newly diagnosed AIDS lymphoma 353

occurrence.26 However, rather unusual T cell lymphomas have been described, including cases of Ki-1 -positive, large cell anaplastic lymphoma. The clinical and pathologic characteristics of this disease appear similar to those seen in de novo Ki-1-positive lymphoma and the significance of these cases remains undefined.31,32 Interestingly, CD 30-positive anaplastic lymphoma, presenting as disease localized to body cavities, has been associated with the presence of a newly described human herpes virus, also detected within Kaposi's sarcoma tissues in HIV-infected individuals.33

C LIN I CO PATHOLOGIC CORRELATIONS The vast majority of primary CNS lymphomas are of the immunoblastic or large cell type. Furthermore, these tumors are uniformly associated with EBV.20 In a series of 113 patients with AIDS lymphoma, in which consensus pathology review was accomplished on all cases, the large cell or immunoblastic lymphomas were also more likely to involve the gastrointestinal tract and oral cavity, when compared to patients with small non-cleaved lymphoma. In the latter individuals, lymphoma was more likely to involve the bone marrow, lymph nodes and/or muscles.28 The majority of large-scale, prospective, multiinstitutional studies have found no differences in response or survival among patients with the various pathologic types of systemic AIDS lymphoma.26,34,36 It should be noted, however, that patients with primary CNS lymphoma do particularly poorly, with median survival in the range of only 2-3 months.37 These patients are usually diagnosed with immunoblastic lymphoma. Whether the poor survival is related to the specific site of disease within the CNS or to the pathologic type of disease per se remains to be clarified. Nonetheless, patients with systemic immunoblastic lymphomas seem to fare the same as those with the other pathologic types.2636

CLINICAL FEATURES Systemic 'B' symptoms are expected in approximately 80 per cent of patients with systemic AIDS lymphoma and in 90 per cent of those with disease primary to the CNS.26 It is mandatory to exclude the presence of an occult opportunistic infection before ascribing these symptoms to the lymphoma itself. An advanced stage of disease is expected in the majority of patients with extranodal involvement reported in 60-90 per cent of all large series.26,34,36 The likelihood of disseminated involvement is so great that, for all practical purposes, such patients must be assumed to have extensive disease and treated with systemic chemotherapy, even if dissemination is not confirmed on

routine staging evaluation. Common sites of extranodal involvement include the CNS in approximately 30 per cent at diagnosis, the gastrointestinal tract in 25 per cent and bone marrow in approximately 25 per cent. Essentially, any other site in the body may also be involved, including the heart, rectum, soft tissues, oral cavity and others.

PROGNOSTIC FACTORS FOR SURVIVAL In various prospective and retrospective studies, four factors have been shown to predict survival in patients with AIDS related lymphoma. These include history of AIDS prior to the lymphoma, CD 4 cells <200/dl, Karnofsky performance status <70 per cent and Stage IV disease, especially if due to bone marrow involvement.10,35 In patients who lack all such factors, median survival has been in the range of 11-12 months, while median survival has been approximately 4 months in patients with one or more of these characteristics at diagnosis. Recently, older age (over 30) and elevated lactic dehydrogenase (LDH) levels have also been associated with shorter survival,38 as has history of injection drug use. The group in San Francisco has demonstrated an improved response and survival in patients with polyclonal lymphomas,30 although this has not yet been confirmed by others. Patients with primary CNS lymphoma have an extremely poor prognosis, with median survival in the range of only 2-3 months, despite therapy.26,37 These individuals have evidence of profound HIV-related immunodeficiency, with a history of AIDS prior to the lymphoma in 73 per cent and median CD 4 cells of less than 50/dl.2,10

TREATMENT OPTIONS IN NEWLY DIAGNOSED AIDS LYMPHOMA At the outset of the AIDS epidemic, various standard, 'dose-intensive' regimens of multiagent chemotherapy were employed in patients with HIV-related lymphoma. However, results were disappointing, with low rates of complete remission and high rates of complicating opportunistic infections.39,40 In an attempt to ascertain if 'less might be better', the AIDS Clinical Trials Group (ACTG) embarked upon a study of a low-dose modification of the m-BACOD regimen (see Table 20.3), with early use of intrathecal cytosine arabinoside to prevent CNS relapse and a total treatment period consisting of 4-6 cycles, given monthly.36 With 35 evaluable patients, a complete remission rate of approximately 50 per cent was achieved; these responses were rapid in onset and durable in approximately 80 per cent. Median survival of complete

354 AIDS-related lymphoma

responders was 18 months. With the use of intrathecal cytosine arabinoside, isolated CNS relapse was not observed. Opportunistic infections were seen in approximately 20 per cent of patients during the course of therapy. It became apparent from this trial that patients with AIDS lymphoma could be treated effectively and could experience long-term, lymphoma-free survival.36

Addition of hematopoietic growth factors Use of the CHOP regimen (see Table 20.3), either with or without granulocyte-macrophage colony stimulating factor (GM-CSF) was studied by the group in San Francisco, resulting in a clear benefit for the GM-CSFtreated patients in terms of nadir granulocyte counts, development of fever and number of days hospitalized for fever.41 A complete remission rate of 70 per cent was reported in 11 patients receiving GM-CSF from days 4-13 of each chemotherapy cycle. Although serum p24 antigen levels rose to 243 per cent of baseline during the third week of therapy in these patients, the clinical significance of this finding could not be determined. The ACTG also explored the use of GM-CSF with escalating doses of m-BACOD, noting that full dose m-BACOD could be given safely, without clinical progression of HIV disease.42 In an attempt to ascertain the role of dose intensity in the setting of AIDS-related systemic lymphoma, the ACTG has conducted a large prospective trial in which 188 patients were stratified by prognostic factors and then randomized to receive either low-dose m-BACOD or fulldose m-BACOD with GM-CSF support.43 Interestingly, the only significant difference between the two treatment groups was increased toxicity in the patients treated with standard-dose m-BACOD, while complete remission rate, duration of remission and duration of survival were equivalent. With low-dose m-BACOD plus GM-CSF 27 per cent of patients survived more than a year; with standard dose m-BACOD, the figure was 24 per cent.44 Anecdotal reports have described the use of granulocyte-CSF (G-CSF) with multiagent chemotherapy in patients with AIDS lymphoma, noting an amelioration of chemotherapy-induced myelosuppression with no upregulation of HIV. Relatively low doses of G-CSF (1-3 JJ-g/kg per day) may be effective in this setting.

Addition of antiretroviral agents to chemotherapy Several studies have now demonstrated that zidovudine is difficult to administer together with combination chemotherapy owing to serious marrow compromise.45 However, the low-dose m-BACOD regimen has been administered with concomitant zalcitibine (ddC), at a dose of 0.75 mg orally, three times per day.46 Although both ddC and vincristine may cause peripheral neuropathy, significant toxicity in this regard was not

encountered, and the combination was found to be safe and effective with a complete remission rate of 56 per cent that was durable in the majority. Notably, the HIV viral burden, as measured by acid-dissociated p24 antigen, was found to decrease significantly or return to non-detectable levels in approximately 53 per cent of treated patients. Further, use of concomitant ddC was associated with equivalent complete response rates, and overall survival in patients with good or poor prognostic indicators of lymphomatous disease.46 Also Tosi et al. have reported that a combination of AZT (zidovudine) and methotrexate, with hematopoietic growth factor support when needed, is effective and well tolerated.47 In an attempt to ascertain if HAART therapy could be used safely in conjunction with multi-agent chemotherapy for AIDS-lymphoma,48 the National Cancer Institute (NCI) sponsored AIDS Malignancy Consortium embarked upon a trial of CHOP, along with stavudine (d4T, Zerit; 40 mg orally every 12 hours), lamivudine (3TC, Epivir; 150 mg orally every 12 hours), and indinavir (Crixivan, at 800 mg orally every 8 hours). The first cohort received half-dose CHOP (cyclophosphamide, 375 mg/m2; doxorubicin, 25 mg/m2), while the second cohort received full-dose CHOP (cyclophosphamide, 750 mg/m2; doxorubicin, 50 mg/m2). In both groups, patients received the same doses of vincristine (1.4 mg/m2 on day 1), and prednisone (100 mg orally on days 1-5). Pharmacokinetic studies were performed for doxorubicin, cyclophosphamide and indinavir. Clearance rates for doxorubicin and indinavir varied by only minor amounts in the half-dose and full-dose CHOP groups when compared with that reported in the literature. However, the clearance rate for cyclophosphamide was found to be 39 ml/min/m2 in both the half-dose and full-dose CHOP groups, compared with 70 ml/min/m2 in prior studies. Nonetheless, no clinically adverse effect was seen, and the toxicity profile of treated patients was similar to that reported for CHOP without concomitant HAART.48 It is apparent from this work that combination chemotherapy can be used safely in conjunction with HAART.

Infusional chemotherapy: CDE Several studies have been published using the platform regiment CDE (cyclophosphamide, doxorubicin, etoposide) in newly-diagnosed patients with AIDS-related lymphoma.49 The regimen consists of a 4-day infusion, given every 28 days, as follows: Cyclophosphamide 200 mg/m2/day x 4 days Doxorubicin 12.5 mg/m2/day x 4 days Etoposide 60 mg/m2/day x 4 days Intrathecal prophylaxis in patients with marrow involvement or small non-cleaved (Burkitt or Burkitt-like) histology • Prophylaxis against opportunistic infections (cotrimoxazole, fluconazole). • • • •

Treatment options in newly diagnosed AIDS lymphoma 355

The regimen was initially used between September 1990 and May 1993 in 21 patients from Albert Einstein, and was then tested from June 1993 to February 1995 in 25 patients who also received didanosine.50 Finally, a larger multi-institutional trial was accomplished in 107 patients between January 1995 and July 1999, as part of the Eastern Cooperative Oncology Group (ECOG).49 In general, addition of didanosine was associated with decreased likelihood of neutropenia (< 500 neutrophils/ dl), while addition of saquinavir was associated with a statistically increased likelihood of grade III or IV mucositis. CD 4+ cell counts fell by approximately 50 per cent, despite the addition of antiretroviral agents. No significant change in HIV RNA levels was found, although a 2-fold increased risk of opportunistic infections occurred while on CDE, consisting primarily of herpes simplex and CMV infections. Patients with low CD 4+ counts and/or bone marrow involvement were more likely to experience neutropenia, thrombocytopenia and leukopenia. Multivariate analysis of prognostic factors indicated that female gender, involvement of three or more sites of disease (all nodal involvement counted as 1 site), and CD 4+ counts < 50 cells/mm3 were independently associated with complete remission (CR), while three or more sites of disease and CD 4+ counts < 50 cells/mm3 were independently associated with increased hazard of death. The phase II ECOG trial included routine use of didanosine in the 48 patients accrued between January 1995 and December 1996, while the 59 patients accrued between January 1997 and July 1999 received HAART regimens. Results are summarized in Table 25.1. For the 107 patients as a whole, the CR rate was 44 per cent and the PR rate was 11 per cent, with additional patients yet to be analyzed in terms of response. Median overall survival was 14.8 months. A total of 57 per cent have died, with death secondary to lymphoma in 36 per cent and treatment-related death in 4.6 per cent. On multivariate analysis, only CD 4+ count < 50 cells/mm3 was associated with increased risk of death.

Table 25.1 Baseline characteristics and outcomes in ECOG study of CDE plus antiretroviral therapy

Number Median CD4+ count at entry Elevated LDH History of IDU Complete remission Alive at 1 year Median survival

48 78 81% 65% 46% 48% 8.2 months

59 227 61% 60% 42% 55% 17.8 months

CDE = cyclophosphamide, doxorubicin, etoposide, HAART = highly active antiretroviral therapy, LDH = lactic hydrogenase, IDU = intravenous drug use.

Infusional chemotherapy: risk-adjusted EPOCH The infusional EPOCH (regimen has been piloted at the National Cancer Institute in the US. In this regimen, doses of cyclophosphamide are adjusted based upon the CD 4+ count at baseline and the neutrophil nadir in the preceding cycle.51 The specific EPOCH regimen is as follows: Etoposide 50 mg/m2/day x 4 days Vincristine 0.4 mg/m2/day x 4 days Doxorubicin 10 mg/m2/day x 4 days Cyclophosphamide 187 mg/m2 IV on day 5 for CD 4+ < 100 cells/mm3 or 375 mg/m2 IV on day 5 for CD 4+ > 100 cells/mm3 • Prednisone 60 mg/m2 orally, days 1-5 • G-CSF: start on day 6 • Repeat on day 22. • • • •

All antiretroviral agents were discontinued at the time that EPOCH was begun, and we were reinstituted on day 6 of cycle 6. A total of 33 patients have been treated, of whom 94 per cent are males. Pathology included diffuse large cell in 70 per cent, Burkitt-like in 15 primary effusion lymphoma (PEL) in 3 per cent, and indeterminate histology in 12 per cent. Elevated LDH was present in 73 per cent. High/intermediate poor prognostic score (International Prognostic Index, IPI) was present in 31 per cent, with 21 per cent presenting with high-risk features by the IPI. The median CD 4+ count was 198 cells/mm3 (range, 6-1182), and 36 per cent presented with a CD 4+ count below 100 cells/mm3. The median HIV RNA was 3.69log10 copies/ml (approximately 5,000 copies/ml). The results are summarized in Table 25.2. Of great importance, there have been no relapses among patients with complete response i.e. there is 100 per cent disease-free survival, with the longest patient now followed for over 5 years. In terms of toxicity, 25 per cent of cycles were associated with grade IV neutropenia (absolute neutrophil count <500/dl), 18 per cent of cycles were associated with platelet counts <50,000/dl, and 10 per cent of cycles were associated with neutropenic fever. A major question concerns the effect of EPOCH chemotherapy on parameters of HIV disease if concomitant antiretroviral therapy is not given. In this study, the HIV viral load rose by 1000-fold by cycle 4, but fell to pre-treatment levels within three months of restarting antiretroviral therapy; likewise, although CD 4+ cell counts fell during chemotherapy, they returned to baseline values by 12-24 months post-EPOCH. These data are extremely interesting, and represent the highest response rates yet reported in this patient population. Furthermore, the lack of relapse in any complete responder is extremely promising. Nonetheless, the issue of patient selection is a real question in this series, as in all such small, single-institution trials. Further evaluation

356 AIDS-related lymphoma

Table 25.2 Outcomes among 33 newly-diagnosed patients treated with infusional, risk-adjusted EPOCH

CD4+ count < 100 cells/mm3 CD4+ count > 100 cells/mm3

67 86

75 90

8 5

50 86

79

85

6

73

of this dose-adjusted, infusional EPOCH regimen in the multi-institutional setting is clearly warranted, and represents an area of high priority for future study.

THERAPY FOR PATIENTS WHO HAVE FAILED OR RELAPSED AFTER INITIAL CHEMOTHERAPY No standard of therapy currently exists for patients who are resistant to front-line therapy or who have relapsed after an initial response. Several new modalities may offer help for such patients. Mitoguazone (MGBG) interferes with polyamine biosynthesis and, as such, represents a new mechanism of known antitumor activity. Preliminary use of MGBG, given at a dose of 600 mg/m2 by vein on day 1, day 8 and every 2 weeks thereafter, has shown promise in patients with relapsed or refractory AIDS lymphoma.52 Response rates of approximately 30 per cent have been reported in patients with faradvanced disease and significant immunocompromise. The drug crosses the blood-brain barrier and has no significant myelotoxicity.52 The use of an anti-B4 (CD 20) monoclonal antibody, conjugated to the potent toxin, ricin, has also shown some efficacy in patients with relapsed/refractory AIDS lymphoma.53 Use of this agent, given as a 28-day continuous infusion, is currently being evaluated when administered with CHOP chemotherapy or as a 7-day infusion together with the low-dose m-BACOD regimen in patients with newly diagnosed systemic lymphoma. Other monoclonal antibodies directed against various surface determinants on the lymphoma cells are also in clinical trial at this time. Results are awaited with great interest.

majority of lymphomas are of the large cell or immunoblastic subtype, and uniform presence of EBV, with expression of EBV-related latent proteins has been demonstrated,20 with markers of EBV infection present in spinal fluid as well.56 The optimal therapy for patients with AIDS-related primary CNS lymphoma is currently unknown. The usual standard of treatment has been whole-brain radiation, which results in complete remission rates between 20 and 50 per cent, after delivery of approximately 4000 rad to a helmet field, with an additional 1000 rad to the specific site(s) of tumor.37,57,58 However, despite achievement of complete remission, the median survival of these patients has only been in the range of approximately 2-4 months, with death often due to complicating opportunistic infections. Survival is not substantially changed by withholding therapy altogether, although radiation has been associated with an improvement in the quality of survival in approximately 75 per cent of treated patients.37 Ongoing trials are evaluating the use of short courses of multiagent chemotherapy or use of less myelosuppressive single agents, followed by whole-brain radiation. While such approaches appear efficacious in non-HIV-infected patients with primary CNS lymphoma,59'60 no data are currently available with regard to AIDS-related disease.

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PRIMARY CNS LYMPHOMA Patients with AIDS-related primary CNS lymphoma are extremely fragile with far advanced HIV-induced immunodeficiency.26'37 These patients may present with focal neurologic deficits, seizures and/or altered mental status.3754 Any site in the brain may be involved, and 1-4 space occupying lesions are usually seen on magnetic resonance imaging or computed tomography.55 The

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References 357 5. Ledergerber B, Telenti A, Effer M. Risk of HIV related Kapsois's sarcoma and non-Hodgkin's lymphoma with potent antiretroviral therapy. Prospective cohort study, fir Medy 1999; 319: 23-4. 6. Palella FJ, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N EnglJ Med 1998; 338: 853-60. 7. Beral V, Newton R, Reeves G. International collaboration on HIV and cancer. Abstracts of the 4th International AIDS Malignancy Conference; May 16-18, 2000. Bethesda: M D. J Acquir Immune Defic Syndr Hum Retmvirol 2000; 23: A8 (abstract S2). 8. Biggar RJ, Rabkin CS. The epidemiology of acquired immunodeficiency syndrome-related lymphomas. Curr Opin Oncol 1992; 4: 883-93. 9. Ragni MV, Belle SH, Jaffe FA, et al. Acquired immunodeficiency syndrome-associated non-Hodgkin's lymphomas and other malignancies in patients with hemophilia. Blood 1993; 81:1889-97. 10. Levine AM, Sullivan-HalleyJ, Pike MC, et al. HIV-related lymphoma: prognostic factors predictive of survival. Cancer 1991; 68: 2466-72. 11. Schnittman SM, Lane HC, HigginsSE, et al. Direct polyclonal activation of human B lymphocytes by the AIDS virus. Science 1986; 233:1084-6. 12. Neri A, Barriga F, Inghirami G, et al. Epstein Barr virus infection precedes clonal expansion in Burkitt's and AIDS-associated lymphoma. Blood 1991; 77:1092-5. 13. Nakajima K, Martinez-Maza 0, HiranoT, et al. Induction of IL-6 production by human immunodeficiency virus.7 /Awm/m>/1989;142:531-6. 14. Masood R, Zhang Y, Bond MW, et al. lnterleukin-10 in an autocrine growth factor for acquired immunodeficiency syndrome-related B cell lymphoma. Blood 1995; 85: 3423-30. 15. Bernheim A, Berger R. Cytogenetic studies of Burkitt lymphoma: leukemia in patients with acquired immunodeficiency syndrome. Cancer Genet 1988; 32: 67-74. 16. Subar M, Neri A, Inghirami G, et al. Frequent c-myc oncogene activation and infrequent presence of EpsteinBarr virus genome in AIDS-associated lymphomas. Blood 1988; 72: 667-71. 17. Bhatia K, Spangler G, Gaidano G, et al. Mutations in the coding region of c-myc occur frequently in acquired immunodeficiency syndrome-associated lymphomas. Blood 1994; 84: 883-8. 18. Nakamura H, Said JW, Miller CW, Koeffler HP. Mutation and protein expression of p53 in acquired immunodeficiency syndrome related lymphomas. Blood 1993; 82: 731-5. 19. Ballerini P, Gaidano G, GongZ, et al. Molecular pathogenesis of HIV associated lymphomas. AIDS Res Hum Retroviruses 1992; 8: 731-5. 20. MacMahon EME, GlassJD, Hayward SD, et al. Epstein Barr virus in AIDS-related primary central nervous system lymphoma. Lancet 1991; 338: 969-74.

21. Shibata D, Weiss LM, Hernandez AM, et al. Epstein Barr virus associated non-Hodgkin's lymphoma in patients infected with the human immunodeficiency virus. Blood 1993; 91: 2102-9. 22. Kersten MJ, Van Gorp J, Pals ST, Boon F, van Oers MH. Expression of Epstein-Barr virus latent genes and adhesion molecules in AIDS-related non-Hodgkin's lymphomas: correlation with histology and CD4-cell number. Leuk Lymphoma 1998; 30: 515-24. 23. Gaidano G, Lo Coco F, Ye BH, et al. Rearrangements of the bcl-6 gene in acquired immunodeficiency syndromeassociated non-Hodgkin's lymphoma: association with diffuse large cell subtype. Blood 1994; 84: 397-402. 24. Hamilton-Dutoit SJ, Pallesen G, Granzmann MB, et al. AIDS-related lymphoma: histopathology, immunophenotype and association with Epstein Barr virus as demonstrated by in situ nucleic acid hybridization. Am] Pathol 1991; 138:149-63. 25. loachim HL, Dorsett B, Cronin W, et al. Acquired immunodeficiency syndrome associated lymphomas: clinical, pathological, immunologic and viral characteristics of 111 cases. Human Pathol 1991; 22: 659-73. 26. Levine AM. Acquired immunodeficiency syndromerelated lymphoma (Review). Blood 1992; 80: 8-20. 27. NCI Non-Hodgkin's Lymphoma Classification Project Writing Committee. Classification of non-Hodgkin's lymphomas: reproducibility of major classification systems. Cancer 1985; 55: 91-5. 28. Raphael M, Gentilhomme 0, Tulliez M, et al. Histopathologic features of high-grade non-Hodgkin's lymphomas in acquired immunodefiency syndrome. The French Study Group of Pathology for Human Immunodeficiency Virus-associated tumors. Arch Pathol Lab Med 1991; 115:15-20. 29. Pelicci PG, Knowles DM II, Arlin ZA, et al. Multiple monoclonal B cell expansions and c-myc oncogene rearrangements in acquired immune deficiency syndromerelated lymphoproliferative disorders: implications for lymphomagenesis..J Exp Med 1986; 164: 2049-76. 30. Shiramizu B, Herndier B, Meeker T, et al. Molecular and immunophenotypic characterization of AIDS-associated EBV negative polyclonal lymphoma. J Clin Oncol 1992; 10: 383-9. 31. Chadburn A, Cesarman E, Jagirdar J, et al. CD30 (Ki-1) positive anaplastic large cell lymphomas in individuals infected with the HIV. Cancer 1993; 72: 3078-90. 32. Tirelli U, Vaccher E, Zagonel V, et al. CD30 (Ki-1) positive anaplastic large cell lymphomas in 13 patients with and 27 patients without HIV infection: the first comparative clinicopathologic study from a single institution that also includes 80 patients with other HIV related systemic lymphomas. J Clin Oncol 1995; 13: 373-80. 33. Cesarman E, Chang Y, Moore PS, et al. Kaposi's sarcomaassociated herpesvirus-like DNA sequences in AIDSrelated body cavity-based lymphomas. N EnglJ Med 1995; 332:1186-91.

358 AIDS-related lymphoma 34. Ziegler JL, Beckstead JA, Volberding PA, et al. NonHodgkin's lymphoma in 90 homosexual men: relation to generalized lymphadenopathy and the acquired immunodeficiency syndrome. N EnglJ Med 1984; 311: 565-70. 35. Kaplan LD, Abrams Dl, Feigal E, et al. AIDS-associated non-Hodgkin's lymphoma in San Francisco. JAMA 1989; 261:719-24. 36. Levine AM, Wernz JC, Kaplan L, et al. Low dose chemotherapy with central nervous system prophylaxis and azidothymidine maintenance in AIDS-related lymphoma: a prospective multi-institutional trial. JAMA 1991; 266: 84-8. 37. Baumgartner JE, Rachlin JR, Beckstead JH, et al. Primary central nervous system lymphomas: natural history and response to radiation therapy in 55 patients with acquired immunodeficiency syndrome. J Neurosurg 1990; 73: 206-11. 38. Vaccher E, Tirelli U, Spina M, et al. Age and serum lactate dehydrogenase level are independent prognostic factors in HIV related non-Hodgkin's lymphomas: a single institution study of 96 patients. J Clin Oncol 1996; 14:2217-23. 39. Gill PS, Levine AM, Krailo M, et al. AIDS-related malignant lymphoma: results of prospective treatment trials. J Clin Oncol 1987; 5:1322-8. 40. Dugan M, Subar M, Odajnyk C, et al. Intensive multiagent chemotherapy for AIDS related diffuse large cell lymphoma. Blood 1986; 68:124a. 41. Kaplan LD, Kahn JO, Crowe S, et al. Clinical and virologic effects of recombinant human granulocyte-macrophage colony-stimulating factor in patients receiving chemotherapy for human immunodeficiency virus associated non-Hodgkin's lymphoma: results of a randomized trial.J Clin Oncol 1991; 9: 929. 42. Walsh C, Wernz J, Levine AM, et al. Phase I study of m-BACOD and granulocyte-macrophage colony stimulating factor (GM-CSF) in HIV associated nonHodgkin's lymphoma. J AIDS 1993; 6: 265-71. 43. Kaplan L, Straus D, Testa M, Levine AM. Randomized trial of standard dose mBACOD with GM-CSF versus reduced dose mBACOD for systemic HIV-associated lymphoma: ACTG #142. ProcAm Soc Clin Oncol 1995; 14: 288. 44. Kaplan LD, Straus DJ, Testa MA, et al. Low-dose compared with standard-dose m-BACOD chemotherapy for non-Hodgkin's lymphoma associated with human immunodeficiency virus infection. N EnglJ Med 1997; 336: 1641-8. 45. Tirelli U, Errante D, Okssenhendler E, et al. Prospective study with combined low-dose chemotherapy and zidovudine in 37 patients with poor prognosis AIDS-related non-Hodgkin's lymphoma. Ann Oncol 1992; 3: 843-7. 46. Levine AM, Tulpule A, Espina B, et al. Low dose m-BACOD with zalcitabine (ddC) in patients with AIDS lymphoma: correlations between serum IL-6, systemic 'B' symptoms, viral burden and response to therapy. Blood 1994; 84: 519a. 47. Tosi P, Gherlinzoni F, Visani G, et al. AZT plus

48.

49.

50.

51.

52.

53.

54. 55.

56.

57.

58.

59.

60.

methotrexate in HIV-related non-Hodgkin's lymphomas. Leak Lymphoma 1998; 30:175-9. Ratner L, Redden D, Hamzeh F, et al. Chemotherapy for HIV associated non-Hodgkin's lymphoma in combination with highly active antiretroviral therapy (HAART) is not associated with excessive toxicity. Third National AIDS Malignancy Conference. Bethesda: MD J AIDS 1999; 21: A32,1000 (abstract 92). Sparano JA, Lee S, Henry DH, et al. Infusional cyclophosphamide, doxorubicin and etoposide in HIV associated non-Hodgkin's lymphoma: a review of the Einstein, Aviano, and ECOG experience in 182 patients. Abstracts of the 4th International AIDS Malignancy Conference; May 16-18, 2000. Bethesda, MDJAcquir Immune Defic Syndr Hum Retrovirol 2000; 23: A11 (abstract S15). Sparano JA, Wiernik PH, Hu X, et al. Pilot trial of infusional cyclophosphamide, doxorubicin, and etoposide plus didanosine and filgrastim in patients with human immunodeficiency virus-associated nonHodgkin's lymphoma. J Clin Oncol 1996; 14: 3026-35. Little RF, Pearson D, Gutierrez M, et al. Dose adjusted chemotherapy with suspension of antiretroviral therapy for HIV associated non-Hodgkin's lymphoma. Abstracts of the 4th International AIDS Malignancy Conference; May 16-18,2000. Bethesda; MDJ Acquir Immune Defic Syndr Hum Retrovirol 2000; 23: A11 (abstract S16). Levine AM, Weiss GR, Tulpule A, et al. Multicenter Phase II study of mitoguazone (MGBG) in relapsed or refractory AIDS-lymphoma. ProcAm Soc Clin Oncol 1985; 14: 288. Scadden DT, Doweiko J, Schenkein D, et al. A phase I/I I trial of combined immunoconjugate and chemotherapy for AIDS-related lymphoma. Blood 1993; 82: 386a. Fine HA, Mayer RJ. Primary central nervous system lymphoma [Review]. Ann Intern Med 1993; 119:1093-104. Gill PS, Graham RA, Boswell W, et .al. A comparison of imaging, clinical and pathologic aspects of space occupying lesions within the brain in patients with acquired immunodeficiency syndrome. AmJPhysiol Imaging 1986; 1:134-41. Cinque P, Brytting M, Vago L, et al. Epstein Barr virus DNA in cerebrospinal fluid from patients with AIDSrelated primary lymphoma of the central nervous system. Lancet 1993; 342: 398-401. Formenti SC, Gill PS, Lean E, et al. Primary central nervous system lymphoma in AIDS: results of radiation therapy. Cancer 1989; 63:1101-7. Goldstein JD, Dickson DW, Moser FG, et al. Primary central nervous system lymphoma in acquired immunodeficiency syndrome: a clinical and pathologic study with results of treatment with radiation. Cancer 1991; 67: 2756-65. DeAngelis LM, Yahalom J, Heinemann MH, et al. Primary CMS lymphoma: combined treatment with chemotherapy and radiotherapy. Neurology 1990; 40: 80-6. DeAngelis LM, Yahalom J, Rosenblum M, et al. Primary CNS lymphoma: managing patients with spontaneous and AIDS-related disease. Oncology 1987; 1: 52.

26 Cutaneous lymphomas RTHOPPEANDYH KIM

Introduction

359

Other cutaneous lymphomas

Mycosis fungoides and the Sezary syndrome

359

References

INTRODUCTION The cutaneous lymphomas are not very common, but include an interesting group of diseases that have a different natural history, management and prognosis than the majority of other nodal, extranodal or systemic lymphomas. They are difficult to classify according to existing classification systems, and it is most helpful to categorize them according to T cell or B cell lineage and then further subclassify them according to critical clinical or histopathological criteria. The T cell lymphomas include mycosis fungoides/Sezary syndrome, peripheral T cell lymphomas, lymphoblastic lymphoma, angiocentric lymphoma, human T cell lymphomotrophic virus type 1 (HTLV-1) lymphoma, the majority of CD 30 (Ki-1) positive (anaplastic large cell) cutaneous lymphomas and pleomorphic small/large cell lymphomas. There is also a lymphoma-like cutaneous T cell lymphoproliferative disease called lymphomatoid papulosis. The Revised European-American Lymphoma (REAL) classification1 allows identification of distinct cutaneous disease entities. In this classification, mycosis fungoides, Sezary syndrome and CD 30-positive lymphoproliferative disease of the skin (primary cutaneous anaplastic large-cell lymphoma) are confirmed as the major specific cutaneous peripheral T cell malignancies. The B cell lymphomas include both follicular and diffuse lymphomas derived from follicular center cells and are often classified according to the criteria of the Working Formulation. Primary B cell lymphomas (defined as malignant B cell proliferations presenting with cutaneous involvement alone and no evidence of extracutaneous manifestations over a period of at least 6 months from presentation) may also be subtyped according to a European Organisation for Research and

367 368

Treatment of Cancer classification.2 The major subtypes are follVe center cell lymphoma of the head and trunk, and immunocytoma (subtypes with indolent behavior) and B cell lymphoma of the leg (with intermediate behavior). It will be interesting to see how these entities fare when studied prospectively. Virtually any type of lymphoma may have cutaneous manifestations. Quite often, the skin involvement is only incidental and will not influence management programs. Examples include angiocentric T cell lymphoma, HTLV1-related lymphoma, lymphoblastic lymphoma, and systemic (Stage IV) B cell or peripheral T cell lymphomas. This chapter will deal only with lymphomas that are manifest primarily in the skin. These include mycosis fungoides/Sezary syndrome, primary cutaneous (Stage IE or HE) B cell lymphoma and Ki-1-positive cutaneous lymphomas. These account for about 65, 25 and 10 per cent of primary cutaneous lymphomas, respectively.

MYCOSIS FUNGOIDES AND THE SEZARY SYNDROME Etiology and epidemiology

Mycosis fungoides (ME) is the most common cutaneous lymphoma. However, it accounts for only 0.5 per cent of the new cases of non-Hodgkin's lymphoma diagnosed in the USA each year.3 The peak age at presentation is 55-60 years and there is a 2:1 male preponderance. The incidence in African-Americans is about twice that of whites. It is uncommon in Asians. The etiology of ME is unknown. Environmental and occupational exposures have been implicated in its etiology but a large case-controlled study fails to support this

360 Cutaneous lymphomas

hypothesis.4 A viral etiology was proposed based on the isolation of HTLV-1 from a patient with cutaneous lymphoma resembling MR However, this proved not to be MF but rather HTLV-1-related adult T cell lymphoma. Some studies have demonstrated a higher risk for MF in the presence of certain histocompatibility antigens and others have identified specific chromosomal abnormalities in patients with MF. However, the significance of these observations is unknown.

Pathology Skin biopsies in cases of MF demonstrate characteristic abnormal cells infiltrating the epidermis (epidermotropism) as single cells or in clusters (Pautrier microabscesses). The neoplastic cells are mononuclear and contain hyperconvoluted nuclei with a cerebriform appearance.5 Typically, the biopsy will show an upper dermal infiltrate, which also includes histiocytes, eosinophils and plasma cells. Based upon the severity of the epidermal and dermal involvement, categories 'diagnostic of, 'consistent with' and 'suggestive of MF are defined.6 Immunohistochemical staining evaluating the expression of specific T cell antigens on the surface of the infiltrating lymphocytes has become an important tool in the diagnosis of MF. When the routine histology is equivocal, the immunophenotypic results may help in confirming or refuting the diagnosis, which may be important for clinical management. These studies indicate that the majority of cases of MF exhibit a helper/inducer T cell phenotype (CD 4+).7 The pan-T cell antigens CD 2, CD 3 and CD 5 are usually expressed. In many instances, the neoplastic cells lose other mature T cell antigens, such as Leu-8 or CD 7. This finding may help in the differential diagnosis of MF from benign dermatoses.7 CD 25 (TAC)and Ki-67 are variably expressed. CD 30 (Ki-1) expression is associated with a poor prognosis. Rare cases of MF have been demonstrated to be CD 8+ (cytotoxic/suppressor T cell phenotype). Evaluation of skin biopsies to detect T cell receptor (TCR) gene rearrangements, or 'genotyping', may also be helpful in the differential diagnosis of early MF. TCR gene rearrangements can be detected by Southern blot analysis or methods utilizing polymerase chain reaction amplification.8 Genotyping is not a common or essential diagnostic procedure, but is usually reserved for situations where both the routine histology and immunophenotyping results are only equivocal despite a clinical presentation strongly suggestive of MF. In general, multiple lesions in a single patient biopsied at the same time or different lesions biopsied sequentially in the same patient will demonstrate consistent rearrangements. The pathology of extracutaneous disease poses special problems. Enlarged lymph nodes may only demonstrate dermatopathic lymphadenitis, with sinus histiocytosis,

an abundance of pigment-laden macrophages and a variable number of atypical lymphocytes with cerebriform nuclei. The degree of lymph node abnormality is quantified in a 'lymph node classification system'. Lymph nodes are classified as LNO to LN4, corresponding to involvement ranging from 'no atypical lymphocytes' (LNO) to 'partial or complete replacement of nodal architecture by atypical lymphocytes or frankly neoplastic cells' (LN4). Classical lymph node involvement correlates with LN4. This descriptive system for grading lymph node involvement has prognostic relevance.9 Clonal TCR p-gene rearrangements have been identified in lymph nodes of patients with MF. Rearrangements are generally absent in histologically uninvolved lymph nodes (LNO-2), present in half of lymph nodes with dermatopathic changes (LN3), and in most of lymph nodes effaced with lymphoma (LN4).10 The presence of gene rearrangements is associated with a worse prognosis and probably explains the observation in earlier studies that palpable adenopathy, even when showing only dermatopathic change on biopsy, is associated with a worse outcome.11 Studies of the peripheral blood mononuclear cells of MF patients using Southern blot analysis reveal that clonal TCR b-gene rearrangements are uncommon in patients with patch, plaque or tumorous disease (Tl, T2, T3), but prevalent in erythrodermic MF (T4), and present in most cases of Sezary syndrome.12 Approximately one-third of patients with histologically proved lymph node involvement show clonal rearrangement in the peripheral blood and this is associated with a worse prognosis.

Clinical presentation and natural history Mycosis fungoides often has a long natural history. The diagnosis may be preceded by a prediagnostic (premycotic) phase lasting 5-10 years or longer, marked by scaly or pruritic patches similar to those seen in patients with benign skin conditions, such as psoriasis, parapsoriasis, eczematous dermatitis, photodermatitis or drug reactions. These lesions may respond to treatment with topical corticosteroids. Biopsies during this phase are non-specific. In its earliest diagnostic phase, well-defined patches or plaques of variable size and shape are generally present. The disease is often confined to the bathing trunk distribution, although any body surfaces may be affected. Occasionally, there may be prominent poikiloderma (skin atrophy, dyspigmentation and telangiectasia), alopecia or follicular mucinosis. Pruritus is generally a prominent symptom. As the disease progresses, patches may evolve into infiltrated plaques with a more generalized distribution. With generalized disease, the palms and soles are frequently involved. Infiltration of the hair follicles may result in alopecia. Patients with a history of plaque

Mycosis fungoides and the Sezary syndrome 361

disease may develop ulcerated or exophytic tumors. Occasional patients present de novo with tumors, socalled tumor cTemblee. Extensive involvement of the face may result in the appearance of'leonine fades'. Another phase of skin involvement is generalized erythroderma (I'homme rouge or the 'red man syndrome'). The erythema may be accompanied by either very atrophic or lichenified skin, and plaques or tumors may also be present. These patients are almost always intensely symptomatic secondary to pruritus and scaling. If peripheral blood involvement is present (atypical 'Sezary' cells >5 per cent of circulating lymphocytes), these patients are considered to have the Sezary syndrome (SS).13 Lymphadenopathy and splenomegaly are often present, as well. About 15-20 per cent of patients will develop manifestations of extracutaneous disease.6 This is often manifest initially by regional lymphadenopathy in regions draining extensive skin involvement. Visceral involvement may develop subsequently, with the lungs, spleen, liver, upper aerodigestive and gastrointestinal tracts most frequently affected. Autopsy studies have shown that involvement of any organ may occur in the final stages of disease. The likelihood of developing extracutaneous disease is correlated with the extent of skin involvement, ranging from less than 10 per cent for patch/plaque disease to greater than 30 per cent for patients with cutaneous tumors or erythroderma. In large cohorts of patients with long-term follow-up, the median survival of patients who are diagnosed with MF is nearly 10 years. Among patients who present with limited patch or plaque disease, the majority (80 per cent) will die from unrelated causes, such as cardiopulmonary disease or other cancers. Patients who are treated at the time that disease is in the limited plaque phase of skin involvement enjoy a long-term survival equivalently to an age-, gender- and race-matched population.14 The risk for these patients to develop progressive disease is less than 10 per cent. However, for patients who present with tumorous involvement or the Sezary syndrome, or who develop extracutaneous spread, the prognosis is poor. The majority of these patients (76-95 per cent) will die from MF or complications related to the disease, such as infection and sepsis, and their median survival is less than 3 years.6 An analysis of

Table 26.1 TNMB classification for mycosis fungoides

T1 T2 T3 T4

Limited patch/plaque (< 10% of skin surface) Generalized patch/plaque (> 10% of skin surface) Tumors Generalized erythroderma

NO N1 N2 N3

Lymph nodes clinically uninvolved Lymph nodes enlarged, histologically uninvolved Lymph nodes clinically uninvolved, histologically involved Lymph nodes enlarged and histologically involved

MO M1

No visceral disease Visceral disease present

BO B1

No circulating atypical cells (< 5% of lymphocytes) Circulating atypical cells (> 5% of lymphocytes)

patients with erythrodermic MF or SS managed at Stanford demonstrates that patient age, stage of disease and peripheral blood involvement are independent prognostic factors, and patient survival varies widely, from only 1.5 to more than 10 years, depending upon these variables.15

Staging The TNMB staging classification system for MF is summarized in Table 26.1.16 Approximately 20-25 per cent of patients will present with limited plaque (Tl), 35-40 per cent with generalized plaque (T2), 20-25 per cent with tumorous (T3) and 15-20 per cent with erythroderma (T4). The extent of skin involvement is a very important prognostic factor. Actuarial survivals for patients with MF, based on the extent of skin involvement, are shown in Fig. 26.1. The 10-year survivals are 87, 57, 25 and 29 per cent for patients with Tl, T2, T3 and T4 disease, respectively. The current status of patients is displayed in Table 26.2. • Stage groupings can be defined by the TNMB criteria (Table 26.3). Clinical groupings based on this staging system define patients with a good, intermediate or poor prognosis. Patients with limited or generalized plaque disease and no evidence of extracutaneous spread (Stage I-IIA) have a median survival of nearly 18 years; patients

Table 26.2 Current status of 555 patients with mycosis fungoides (MF) managed at Stanford University

Alive, NED Alive, with disease Dead, NED Dead from MF NED = no evidence of disease.

67 (55) 35 (29) 17(14) 2(2)

45(22) 58 (28) 67 (33) 35(17)

12(9) 19(15) 26 (20) 71 (55)

7(7) 9(9) 33 (33) 52 (51)

362 Cutaneous lymphomas Figure 26.1

Actuarial

survival of 556 patients treated at Stanford University categorized by the extent of skin involvement Patients with cutaneous tumors (T3) or erythroderma (T4) have a similar prognosis. 1 = T1(n = 122);

2 = T2(n = 205); 3 = T3(n = 128); 4 = T4(n = 101).

Table 26.3 Stage classification of mycosis fungoides

IA IB MA IIB MIA NIB IVA IVB

T1 T2 T1-2 T3 T4 T4 T1-4 T1-4

NO MO N1 N0-1 NO N1 N2-3 NO-3

MO MO MO MO MO MO MO M1

with cutaneous tumors or erythroderma (Stage IIB-III) have a median survival of about 3.5 years; and patients with extracutaneous disease (Stage IV) have a median survival of only 1.5 years. Figure 26.2 displays the survival of patients according to these stage groupings.

Routine staging studies include a careful examination of the skin (especially the scalp, palms, soles and perineum), a complete blood count, analysis of peripheral blood for Sezary cells, screening chemistries and chest Xray. Lymph node biopsies are obtained if lymphadenopathy is present. Patients with lymph node biopsies showing only reactive or dermatopathic changes with just a small number of atypical cells (LN1 or LN2) have a 5-year survival of 80 per cent, those with large clusters of paracortical atypical cells (LN3) have a 5-year survival of 30 per cent, and those with effaced nodes (LN4) have a 5-year survival of only 15 per cent.9 Biopsy documentation of suspected visceral disease is indicated since other disease processes may mimic the clinical appearance of ME Imaging studies such as computed tomography (CT) scans should only be completed

Figure 26.2

Actuarial

survival of 556 patients treated at Standford University categorized by overall clinical stage. 1 = Stage IA/IB/IIA

(n = 326);

2 = StagellB/lll(n = 175); 3 = Stage IV (n = 55).

Mycosis fungoides and the Sezary syndrome 363

if there is suspicion of extracutaneous disease. Routine imaging studies are otherwise unproductive.

Topical and regional therapy The successful management of MF requires effective skin treatment. Non-specific topical therapy, such as emollients, antipruritics, anti-inflammatories and hydrocortisone, may provide some relief of symptoms, especially in patients with minimal disease. Definitive management includes topical therapies, such as photochemotherapy, nitrogen mustard and irradiation. With these therapies, patients may experience an initial apparent exacerbation of disease, related to the inflammatory reaction that may develop in areas of minimal disease. With continuation of therapy, however, a response will become evident. Supportive treatments, such as emolliation, topical steroids and oral antipruritics, are often used in conjunction with definitive therapy. PHOTOTHERAPY

Phototherapy involves the use of ultraviolet (UV) radiation in the UVA or UVB wavelength region. Long-wave UVA has an advantage over UVB owing to the greater depth of penetration of its photons into the dermal infiltrates of MF. For limited disease, UVB alone or home UV phototherapy (UVA + UVB) may be an effective modality. More commonly, the UV is used with psoralen, a photosensitizing agent, as psoralen plus UVA (or PUVA). Topical photochemotherapy (PUVA) consists of oral 8-methoxypsoralen (0.4-0.6 mg/kg) followed 1.5-2 hours later by exposure to UVA light. The psoralen intercalates between pyrimidine base pairs within DNA and on exposure to ultraviolet light in the 360 nm range forms monofunctional and bifunctional adducts that inhibit DNA replication. The UVA penetrates the epidermis and upper dermis. Patients receive a timed exposure to UVA light in a phototherapy unit (PUVA box). The initial dose and dose increment is a function of skin type and type of skin involvement by MF. Patients with erythroderma tolerate only very low starting doses and dose increments. Only the eyes are shielded routinely. All other body surfaces may be treated; however, certain areas, such as the perineum, axillae and other skin fold areas, may not receive adequate exposure. In the initial clearing phase, patients are treated 2-3 times per week with at least 48 hours between treatments in order to monitor for delayed erythema. After skin clearance, a maintenance program with decreasing treatment frequency is initiated. The average time to clearance is 2-6 months and the likelihood of clearance is related to the extent of skin involvement. Patients with minimal patch disease achieve complete response rates as high as 90 per cent. For patients with more infiltrated plaques, the complete response rate is 60-80 per cent.17 If maintenance therapy is discontinued, the majority of patients

will relapse. However, another response may follow resumption of treatment. Acute complications of PUVA treatment include erythema, other phototoxic reactions, pruritus, skin dryness and nausea. Potential long-term complications include increased risk of cataracts (requiring the use of UVAopaque goggles during therapy). Photoprotection must be continued for 24 hours following psoralen ingestion. Some patients who undergo long-term continuous treatment with PUVA are at risk for developing secondary cutaneous squamoproliferative lesions, including basal cell and squamous carcinomas. Among patients treated for MF, this risk is greatest for patients who have undergone long-term treatment with multiple topical therapies.18 Indications for PUVA treatment include the primary therapy of patients with limited or generalized plaque phase of skin involvement or as a secondary therapy following the failure of other topical modalities. PUVA may also be effective in patients with erythroderma, provided that very low daily exposures are utilized to avoid phototoxicity reactions.19 In patients with the Sezary syndrome, PUVA may be supplemented by systemic therapies, such as interferon-a, or chlorambucil and prednisone. TOPICAL CHEMOTHERAPY

A common therapy for MF is topical nitrogen mustard (mustine; mechlorethamine; HN2). This maybe applied as an aqueous solution prepared by the patient or in an ointment base, such as aquaphor, prepared by the pharmacist. Its mechanism of action of is uncertain. It is not likely to act as a direct alkylating agent and it is more likely that one of the degradation products is the active agent. Nitrogen mustard is applied daily. For the aqueous preparation, it is applied to the skin with a cloth or brush at a concentration of 10-20 mg per 100 ml of water. Nitrogen mustard ointment is prepared at a concentration of 10-20 mg per 100 g of aquaphor. The skin may be treated in its entirety, although the face, scalp, intertriginous and genital areas are not usually included in the initial treatment unless there is evidence of active disease. The aqueous and aquaphor preparations appear to have similar clinical efficacy.20 The choice is often dependent on convenience or patient preference. For patients with disease limited to a single skin region, treatment may be restricted to that region. Complete response (CR) rates range from 30 to 70 per cent, with the likelihood of response dependent on initial extent of skin involvement: about 50 per cent for limited plaque and 25 per cent for generalized plaque disease.14'20'21 The median time to skin clearance is about 8 months. Maintenance treatment is generally continued for 1-2 years after skin clearance. When treatment is discontinued, more than half of patients will relapse, almost

364 Cutaneous lymphomas

always in the skin, but most will respond to a resumption of therapy. The proportion of patients treated with topical nitrogen mustard who have a durable complete response is about 20 per cent but it may be as high as 45 per cent in patients with limited plaque disease.14 The primary complication of topical nitrogen mustard therapy is an acute or delayed hypersensitivity reaction, which develops in about 30 per cent of people treated with the aqueous preparation and in less than 5 per cent of patients treated with the ointment preparation.20 Desensitization may be accomplished with a variety of topical or systemic desensitization programs. There is no systemic absorption of topically applied nitrogen mustard, thus systemic complications, such as hematologic depression or sterility, are not potential toxicities. Occasional patients treated with topical nitrogen mustard develop secondary squamoproliferative lesions of the skin.21 This has been a problem primarily for patients treated with multiple sequential topical therapies.18 Topical nitrogen mustard is indicated as initial primary therapy for patients with limited patch or plaque disease or those with less-infiltrated generalized plaque disease. Another chemotherapeutic agent that has been used topically is carmustine (BCNU).22 Carmustine powder is dissolved in water to achieve a concentration of 10-20 mg per cent. It is applied to individual lesions daily until a response is achieved. Maintenance therapy is not employed. The efficacy of carmustine is similar to topical nitrogen mustard; however, because of the systemic absorption of carmustine, the potential hematologic complications are greater and the maximum duration of treatment is limited. In addition, patients treated with carmustine tend to develop telangiectasias in areas where the drug is applied. However, the frequency of hypersensitivity reactions to carmustine is reportedly quite low. Topical phosphocholines have also been used in a small group of patients with MR Phosphocholines inhibit tumor cell growth directly by inhibition of protein kinase C and induction of cellular differentiation.23 They may also have immunoregulatory effects by stimulation of cytokines, activation of monocytes and enhancement of peptide binding to class II major histocompatibility complex (MHC). In a recent study of 12 patients with MF, topical application of hexadecylphosphocholine resulted in responses in 50 per cent of patients and a 17 per cent CR rate.23 RADIATION THERAPY

Mycosis fungoides is an extremely radiosensitive neoplasm and modest doses are capable of achieving longterm local control. Spot (local) treatment with orthovoltage X-rays (150-250 kV) or low-energy electrons (6-9 MeV) may be used in the management of individual plaques or tumors. Fractionated doses of

15-25 Gy generally suffice for local control. Spot therapy may be used in conjunction with PUVA or topical nitrogen mustard. For treating large surfaces of skin, techniques of total skin electron beam therapy (EBT) have been developed. Patients are treated in the standing position, 3-4 m distant from a linear accelerator. Treatment at this distance provides for an ability to treat large surfaces. A rotating platform or multiple patient positions during treatment allows treatment of the entire circumference.24 The 80 per cent depth dose with 6-9 MeV electrons is 3.7-7 mm, a depth ideally suited for treating MF, yet sparing deeper tissues. At Stanford, the weekly dose is 3-4 Gy in four fractions. Most patients will tolerate 4 Gy per week, but lower doses may be used for patients with erythroderma, atrophic skin or a previous history of EBT. The total dose is generally 36 Gy administered over a 10-week period, with a 1 week break after the first 18-20 Gy in order to provide for some relief from the generalized skin erythema that often accompanies EBT. In the standard course of treatment, only the eyes are shielded. Additional individualized shielding is utilized as clinical circumstances indicate. Certain portions of the body surface (top of the scalp, the perineum and the soles of the feet) are 'shadowed' and receive relatively lower electron doses. Supplemental treatment to these areas must be provided. The most common acute complication of total skin EBT is erythema and desquamation. This is generally only a minor problem if a 1-week split is incorporated midway through treatment. Intermediate-term complications include alopecia, which is incomplete and usually only temporary if the scalp dose can be limited to 24 Gy. Most patients experience temporary fingernail and toenail loss 2-4 months following completion of treatment. Most report an inability to sweat properly for the first 6-12 months following therapy and thereafter note chronically dry skin that requires regular emolliation. In long-term follow-up, occasional patients display scattered telangiectasias, rarely evident on casual examination. Long-term effects are very dependent on details of treatment technique. Although secondary malignancies, such as squamous cell and basal cell cancers of the skin, are probably increased after the use of total skin EBT, the patients in whom these have become problematic are those who have received repeated treatment with multiple therapies including irradiation, topical nitrogen mustard and PUVA.18 Radiation may also provide a very important palliative benefit for patients with localized extracutaneous disease. Megavoltage photons (4 MeV or greater) may be used to treat symptomatic adenopathy or visceral sites of disease, with techniques similar to those used for other lymphomas. The dose should be titrated to the response, but typically may be limited to 24-36 Gy. In large series, the complete response rates for patients

Mycosis fungoides and the Sezary syndrome 365

with patch or plaque disease average 80 per cent.6,25 The complete response rate for patients who present with tumorous involvement is 60-70 per cent. As many as 55 per cent of patients with limited plaque disease and 25 per cent of patients with generalized plaque disease who achieve a complete response will enjoy long-term freedom from relapse after the completion of therapy. When patients experience a relapse, it is generally in the skin. Total skin EBT is indicated as primary therapy for patients with generalized plaque (T2) or tumor-stage (T3) diseases. In tumorous disease, thicker lesions require supplemental small-field radiation therapy. Despite the high likelihood of relapse, a significant palliative benefit is achieved by the use of total skin EBT. Furthermore, relapse of disease after treatment is often limited in extent and may be managed readily by the use of small-field orthovoltage or electron irradiation, topical nitrogen mustard, etc. The risk of relapse may be reduced by the routine use of adjuvant therapies, such as topical nitrogen mustard or PUVA, but the utility of this approach has not been proved.26 Second complete courses of total skin treatment may be given to selected patients with the expectation of excellent palliative responses.27 Systemic treatment CHEMOTHERAPY

Systemic chemotherapy, so effective in the management of other lymphomas, has contributed little to the management of patients with MR6,28 The most commonly utilized single agents are methotrexate and chlorambucil. Most effective combinations include cyclophosphamide, vincristine and prednisone, with or without Adriamycin.2930 Complete response rates are about 25 per cent (range 11-57 per cent) with response durations of 3-20 months.6,28 Few patients achieve durable complete responses and cure of advanced disease is uncommon. Systemic management is often employed for patients with the Sezary syndrome.6,13,29 A common treatment combines chlorambucil and prednisone.31 The chlorambucil dose is initially 2 mg/day, titrated according to response and toxicity (leukopenia and thrombocytopenia). Prednisone is started at 20 mg/day, decreasing as palliation is achieved. If a systemic response is achieved but cutaneous symptoms present, topical therapy such as low-potency corticosteroids, low-dose PUVA or low concentration nitrogen mustard may be added.6 Some newer drugs show promise in early clinical trials. Fludarabine, a purine antimetabolite, has demonstrated clinical activity against MF (overall response rate 19 per cent, CR rate 3 per cent).32 Another drug that may be useful is 2'-deoxycoformycin (pentostatin), which inhibits adenosine deaminase, an enzyme with a high level of activity in T cells and required for DNA synthesis. This drug has demonstrated activity in MF and a variety of other non-Hodgkin's lymphomas. The

response rate in MF may be as high as 50 per cent.33 A small trial has reported a 33 per cent response rate to 2chlorodeoxyadenosine (2-CDA; cladribine).34 Because of the inefficacy of systemic chemotherapy and its significant potential complications, chemotherapy treatment generally is limited to patients with refractory, progressive disease and for palliative therapy of extracutaneous disease. It is often used in conjunction with other forms of topical therapy, such as palliative radiation therapy. BIOLOGICAL AGENTS

The interferons, which have antiproliferative, cytotoxic and immunoregulatory functions, have shown some utility in the management of MF. Interferon-a (IFN-a) is the interferon with the most profound antitumor activity.35,36 Response rates are reported to be about 50 per cent, with a duration of about 6 months. The likelihood of response correlates with stage of disease, intensity of prior therapy and dose of interferon. The greatest likelihood of response is in patients with limited disease, little prior therapy and interferon doses as high as 50 x 106 u/day for 5 days, every 3 weeks. Other schedules call for administration of the drug thrice weekly on alternate days at a dose of 3-5 million units with an escalating dose until response is achieved or toxicity intervenes. It is indicated primarily for palliative management of refractory or advanced disease, and is often used in combination with other topical or systemic therapies. Patients experience mild to moderate systemic reactions, including fatigue, anorexia, decreased performance status and leukopenia. Another biological therapy that has been utilized in MF is anti-T cell monoclonal antibodies. Trials have been reported with a pan-T cell murine monoclonal antibody (anti-Leu 1), an 131T-radiolabeled version (T101), and a pan-T cell anti-CD 5 antibody linked to ricin. Treatment is often limited by the development of human antimouse antibodies (HAMA). In order to avoid the development of HAMA, a chimeric (mouse-human) antihelper T cell (anti-CD 4) antibody has been used to provide a more specific treatment against the MF subset of T cells.37 The responses to antibody therapy are generally brief. However, given even minimal responses, this modality deserves further evaluation. Toxicities may include lowgrade fever, malaise, pruritus, urticaria and occasional dyspnea. Radiolabeled antibodies also may cause myelosuppression. Another approach in the treatment of MF is the use of recombinant fusion toxins - growth factor-cytotoxin fusion proteins designed specifically to kill defined cell populations. One example of this approach is the interleukin-2 (IL-2)-diphtheria toxin fusion protein. This fusion protein is cytotoxic only for cells expressing high-affinity IL-2 receptors. Once bound to such cells, the fusion protein is internalized by endocytosis, followed by

366 Cutaneous lymphomas

inhibition of protein synthesis and eventual cell death. A phase I clinical trial using the IL-2-diphtheria toxin fusion protein has demonstrated significant clinical response with minimal toxicity in a group of patients with refractory disease.38 The retinoids are natural or synthetic analogs of vitamin A, which promotes differentiation and inhibits proliferation of epithelial tissues. Treatment with retinoids, such as isotretinoin, achieves reported response rates of 45 per cent (20 per cent complete) in patients with MR39 Newer retinoids with potentially higher potency without increased toxicity are in clinical trials. Retinoids are indicated primarily for palliative therapy for refractory or advanced disease, usually as an adjuvant to other topical or systemic therapy. Potential toxicities include photosensitivity and dryness of the skin, and the mucous membranes, myalgias, arthralgias and fatigue. The teratogenic effects of retinoids must be considered in women of childbearing age. Because of their potential hepatotoxic and hyperlipidemic effects, liver function and lipid panel (triglycerides/cholesterol) must be monitored during treatment. PHOTOPHERESIS

Extracorporeal photopheresis (ECPP) is a form of extracorporeal PUVA.40 Psoralens are administered orally, followed by UV irradiation of the lymphocyte-enriched peripheral blood through an extracorporeal circuit. The blood is then reinfused into the patient. The treatment is administered on two consecutive days monthly, with the frequency titrated to response. Treatment may be tapered prior to discontinuation, but maintenance therapy is often required. In one report on this treatment, the majority of patients (73 per cent) responded to therapy.40 The likelihood of response was greatest among patients with erythroderma who had only a small number of Sezary cells, who had an overall response rate of 83 per cent.41 The mechanism of action of ECPP remains unclear. It is hypothesized that there may be a dual effect: a direct cytotoxic or antiproliferative effect on the neoplastic cells and an 'immune-enhancing' effect on the competent lymphocytes against the neoplastic cells. Compared with other systemic therapies, ECPP has minimal toxicity. Some patients may experience nausea, mostly due to the ingested psoralen, and some experience a transient low-grade fever or slight malaise after treatment. As with conventional PUVA, photoprotection must be employed for up to 24 hours after administration of psoralens.

Combined modality therapy Combined modality therapy includes combined topical therapies, and combined topical and systemic treatment. Because of the reliably high complete response rate to

total skin EBT and the high risk for relapse after completion of that treatment, topical adjuvant therapy is often utilized after completion of EBT. Adjuvant therapies have included topical nitrogen mustard and PUVA. Either of these adjuvants may prolong the duration of the disease-free interval but it is not clear that the longterm likelihood of relapse is altered.26 Topical and systemic therapies have also been combined. Anecdotal reports of successful treatment with combined EBT and systemic chemotherapy led to the initiation of a randomized trial at the National Cancer Institute.42 Patients with all stages of disease were randomized to conservative therapy (sequential treatment with topical nitrogen mustard PUVA, total skin EBT, oral methotrexate and systemic combination chemotherapy) or combined therapy (total skin EBT combined with cyclophosphamide, doxorubicin, etoposide and vincristine chemotherapy) at the outset. The overall response rate was significantly higher in the combined therapy group (90 vs 65 per cent; P = 0.003). However, actuarial disease-free and overall survival were similar for either management approach. The median survival after combined therapy was 91 months, compared to > 76 months (median not yet reached) after conservative therapy. Clearly, more effective systemic management programs are needed in order to improve the efficacy of combined modality therapy. Another innovative approach is the combination of PUVA with IFN-a.43 Reports indicate an overall response rate of nearly 90 per cent and a complete response rate greater than 60 per cent. Currently, a national trial is being designed to test the value of adjuvant interferon administered after successful topical therapy, nitrogen mustard (PUVA or EBT). IFN-oc has also been combined with etretinate, ECPP and pentostatin. These series are small, but in each there appears to be an enhanced efficacy with the addition of IFN-a.

Guidelines for treatment Patients with limited plaque disease (Tl) can be treated effectively with either topical nitrogen mustard or PUVA. When nitrogen mustard is employed, treatment is initiated to the entire skin, since other areas of disease activity may become evident secondary to the inflammatory reaction provoked by the nitrogen mustard. After a period of several weeks, treatment may then be limited to the affected region, if the initial disease was limited to one body region. Treatment is continued daily until complete skin clearance and for as long as a year thereafter. There is no evidence that more prolonged maintenance therapy is beneficial. If response is particularly slow, the concentration of the nitrogen mustard may be increased to 30-50 mg per cent, especially to small areas, or the frequency of application may be increased to twice a day.

Other cutaneous lymphomas 367

PUVA may also be employed for limited plaque disease. Treatment is initiated thrice weekly until skin clearance is achieved, after which the frequency of treatment is gradually decreased to as infrequently as once every 2 weeks. Maintenance therapy should be discontinued within 1 year in order to minimize the risks of cutaneous carcinogenesis. Our usual choice is to initiate treatment with topical nitrogen mustard, since it is easier for the patient, requires only occasional visits to the clinic for surveillance, results in excellent long-term outcome14 and it is less expensive than PUVA. Unilesional MF may be treated with local irradiation followed by observation. Patients with generalized plaque disease may be treated with either nitrogen mustard, PUVA or total skin EBT. Irradiation should be considered for patients with very thickened plaques, owing to the greater depth of penetration of EBT. It should also be considered for patients with a recent history of rapid progression of disease. Patients treated with either nitrogen mustard or PUVA should be followed closely, with EBT initiated if there is disease progression. Generally, following completion of EBT, adjuvant treatment with topical nitrogen mustard is appropriate and may be continued for a year or longer. Patients with limited or generalized plaque disease who fail to respond to one therapy, or who begin to progress after an initial response, may be treated with an alternative topical therapy. There is no evidence that the development of resistance to one modality affects subsequent response to an alternative modality.14 The majority of patients with tumorous involvement have generalized disease and the greatest likelihood of a response is with EBT. Individual tumor lesions may be given boost doses of radiation. In view of the high risk for relapse after irradiation, even among those patients who achieve a complete response, adjuvant therapy (e.g. nitrogen mustard) should be used. Adjuvant topical nitrogen mustard (in an aquaphor base) provides the dual role of treatment for residual disease and emolliation of the skin, often chronically dry after completion of EBT. Patients with a discrete number of tumors sometimes may be treated with localized irradiation to individual tumors combined with topical nitrogen mustard or PUVA. Rare patients may present with isolated tumors, e.g. pagetoid reticulosis or WoringerKolopp disease, a hyperkeratotic, verrucous form of MF that presents with limited involvement of a single site, often an extremity. These patients are candidates for treatment with localized irradiation alone. Patients with erythroderma are the most challenging to manage. They usually have very atrophic skin and are exquisitely sensitive to cutaneous therapies. If there is no peripheral blood involvement, treatment may be initiated with photopheresis. Low-dose PUVA (care must be taken to avoid phototoxic reactions) also may be effective treatment for this stage of disease. In the presence of

peripheral blood involvement (Sezary syndrome), systemic management with chlorambucil and prednisone or photopheresis may be beneficial. If a systemic response is achieved but cutaneous symptoms persist, topical therapy, such as low-potency corticosteroids, low-dose PUVA or low concentrations of nitrogen mustard, may be added. Combined modality programs employing IFN-oc are also often useful in these patients. Patients with extracutaneous disease, especially that involving lymph nodes, may be treated with megavoltage photon irradiation to local symptomatic sites for palliation. Systemic chemotherapy or biological therapies are appropriate to consider in these patients, as well. Owing to the inadequacy of standard therapy, all patients with extracutaneous disease or the Sezary syndrome should be considered candidates for investigational therapies. It may, for example, be possible to select out patients with Sezary syndrome on the basis of a prognostic risk index;44 in this prospective study of 62 patients, survival in the low-risk group was 58 per cent at 5 years compared with 5 per cent in the high-risk group.

OTHER CUTANEOUS LYMPHOMAS Other cutaneous lymphomas have a male preponderance and the median age of onset is about 60 years. Microscopically, the infiltrate in the non-MF cutaneous lymphomas is usually limited to the dermis, sparing the epidermis and dermal-epidermal junction (Grenz zone) until rather late in the course of disease, when secondary ulceration may occur. Immunoperoxidase studies indicate that 50-75 per cent are of B cell origin. Prognosis is related to age, histology and stage.45,46 The most common histologic subtypes of B cell lymphoma are diffuse large cell and immunoblastic, which account for one-half to two-thirds of cases.47 The lowgrade cutaneous lymphomas, such as small lymphocytic, must be distinguished from benign lymphocytic infiltrates, such as lymphocytoma cutis. This is best done by genotyping (gene rearrangement studies), which reveals a polyclonal nature of lymphocytoma cutis, in contrast to the monoclonality of the cutaneous lymphomas. Primary cutaneous B cell lymphomas Cutaneous B cell lymphomas often present as nodules. The predominant site is the head and neck area. Regional lymph nodes are uncommonly affected. The staging evaluation should include studies generally employed for other patients with non-Hodgkin's lymphoma, including physical examination, complete blood counts, screening chemistries, a chest X-ray, CT scan of the chest, abdomen and pelvis, and a bone marrow biopsy. Following an incisional biopsy, patients with localized involvement of the skin (Stage IE), may be treated with

368 Cutaneous lymphomas

local irradiation. The primary lesion with 1-2 cm margins is included in the field. A dose of 36-40 Gy for low-grade and 40-44 Gy for intermediate- or highgrade lymphomas will generally suffice. Depending on the depth of the lesion, 6-12 MeV electrons may be required. If an excisional biopsy was performed, the role for local irradiation is not as well established, but quite often used. At least half of these patients will be cured.45,47 Systemic treatment may be reserved for those patients who have a relapse of disease after localized radiation treatment. The most common site of failure is in distant skin sites. The 10-year survival of patients who present with Stage IE disease is 60-70 per cent.45,47,48 Patients with Stage HE disease (regional lymph nodes involved) are best treated with combined modality therapy, including a primary doxorubicin-containing chemotherapy and involved field irradiation. For patients with Stage III or IV disease, the cutaneous involvement is considered incidental unless it is particularly bulky and poses a problem for local control with chemotherapy, in which case adjuvant irradiation may be added.

extracutaneous sites (either concurrently or subsequently) is the most important prognostic factor for these patients.49 Patients with extracutaneous disease should be treated systemically. For patients with disease limited to the skin, the prognosis may vary somewhat if the disease is primary or secondary (prior T cell lymphoproliferative disease, such as MF or lymphomatoid papulosis), but this issue has not been clearly resolved.54'55 If localized, the primary lesion(s) of CD 30-positive lymphoma may be treated either by excision, with or without postexcision radiation, or primary radiation therapy. There is no evidence that systemic management is indicated for patients with a localized disease process. Even where there are multiple skin lesions, an expectant policy may be warranted before initiating any chemotherapy, since the skin nodules may show spontaneous regression.

REFERENCES 1. Harris NL, Jaffe ES, Stein H, et a I. A revised European-American classification of lymphoid

CD BO/Ki-1-positive cutaneous lymphoproliferative diseases A group of cutaneous lymphoproliferative diseases expresses the CD 30 (Ki-1 or BerH-2) antigen. This includes frank lymphomas and borderline lesions, such as lymphomatoid papulosis. The CD 30 antigen is expressed by highly activated B and T cells, and is characteristic of Reed-Sternberg cells in Hodgkin's disease. CD 30-positive lymphomas include anaplastic largecell and non-anaplastic non-Hodgkin's lymphomas.49 Nearly all (80 per cent) of the anaplastic large-cell lymphomas are of the T cell type. The non-anaplastic variety may be of the T or B cell type, and often are classified as diffuse large cell in the Working Formulation. Lymphomatoid papulosis is a disease marked by waxing and waning nodular skin lesions. Treatment is generally symptomatic, since the lesions regress spontaneously. Studies of TCR gene rearrangements indicate that it is a monoclonal T cell proliferation.50 Lymphomatoid papulosis may arise independently, or it may precede or follow a diagnosis of mycosis fungoides or Hodgkin's disease. The relationship between these diseases is not clearly understood.51 However, the REAL classification acknowledges that primary cutaneous anaplastic largecell lymphoma appears to represent a histologic and clinical continuum with lymphamatoid papulosis.52 CD 30-positive anaplastic large-cell lymphoma of the skin is not associated with the same poor prognosis as systemic anaplastic large-cell lymphoma.53 Patients who present with this lymphoma should undergo staging similar to that of other patients with newly diagnosed non-Hodgkin's lymphoma. The. discovery of disease in

neoplasms: a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 2. Kerl H, Cerroni L Primary B-cell lymphomas of the skin. Ann Oncol 1997; 8(suppl 2): S29-S32. 3. Weinstock MA, Norm JW. Mycosis fungoides in the United States. Increasing incidence and descriptive epidemiology. JAMA 1988; 260: 42-6. 4. Whittemore AS, Holly EA, Lee IM, et al. Mycosis fungoides in relation to environmental exposures and immune response: a case-control study. J Invest Dermatol 1989; 93: 626-9. 5. Lutzner M, Edelson R, Schein P, et al. Cutaneous T-cell lymphomas: the Sezary syndrome, mycosis fungoides, and related disorders. Ann Intern Med 1975; 83: 534-52. 6. Hoppe RT, Wood GS, Abel EA. Mycosis fungoides and the Sezary syndrome: pathology, staging, and treatment. Curr Problems Cancer 1990; 14: 295-361. 7. Wood GS, Weiss LM, Warnke RA, et al. The immunopathology of cutaneous lymphomas: immunophenotypic and immunogenotypic characteristics. Semin Dermatol 1986; 5: 334. 8. Weinberg J, Rook A, Lessin S. Molecular diagnosis of lymphocytic infiltrates of the skin. Arch Dermatol 1993; 129: 1490-500. 9. Sausville EA, EddyJL, Makuch RW, et al. Histopathologic staging at initial diagnosis of mycosis fungoides and the Sezary syndrome: definition of three distinctive prognostic groups. Ann Intern Med 1988; 109: 372-82. 10. Lynch J, Linoilla I, Sausville E, et al. Prognostic implications of evaluation for lymph node involvement by T-cell antigen receptor gene rearrangement in mycosis fungoides. Blood 1992; 79: 3293-9.

References 369 11. Hoppe R, Fuks Z, Bagshaw M. Radiation therapy in the management of cutaneous T-cell lymphomas. Cancer Treatment Rep 1979; 63: 625. 12. Bakels V, Van Oostveen J, Gordijn R, Walboomers J, Meijer C, Willemze R. Diagnostic value of T-cell receptor beta gene rearrangement analysis on peripheral blood lymphocytes of patients with erythroderma.y Invest Dermatol 1991; 97: 782-6. 13. Wieselthier JS, Koh HK. Sezary syndrome: diagnosis, prognosis, and critical review of treatment options. J Am Acad Dermatol 1990; 22: 381. 14. Kim YH, Jensen RA, Watanabe GL, Varghese A, Hoppe RT. Clinical stage IA (limited patch and plaque) mycosis fungoides: a long-term outcome analysis. Arch Dermatol 1996; 132: 1309-13. 15. Kim YH, Bishop K, Varghese A, Hoppe RT. Prognostic factors in erythrodermic mycosis fungoides and Sezary syndrome. Arch Dermatol 1995; 131:1003-8. 16. Bunn PA, Lamberg SI. Report of the committee on staging and classification of cutaneous T-cell lymphomas. Cancer Treatment Rep 1979; 63: 725. 17. Rosenbaum MM, Roenigk HJ, Caro WA, et al. Photochemotherapy in cutaneous T cell lymphoma and parapsoriasis en plaques. Long-term follow-up in fortythree patients. J Am Acad Dermatol 1985; 13: 604-12. 18. Abel EA, Sendagorta E, Hoppe RT. Cutaneous malignancies and metastaticsquamouscell carcinoma following topical therapies for mycosis fungoides. JAm Acad Dermatol 1986; 14:1029-38. 19. Abel E, Sendagrta E, Hoppe R, Hu C-H. PUVA treatment of erythrodermic and plaque-type mycosis fungoides: ten-year follow-up study. Arch Dermatol 1987; 123: 897. 20. Hoppe RT, Abel EA, Deneau DG, et al. Mycosis fungoides: management with topical nitrogen mustard, J din Oncol 1987; 5:1796-803. 21. Vonderheid EC, Tan ET, Kantor AF, et al. Long-term efficacy, curative potential, and carcinogenicity of topical mechlorethamine chemotherapy in cutaneous T cell lymphoma. J Am Acad Dermatol 1989; 20: 416. 22. Zackheim HS, Epstein EH, Crain WR. Topical carmustine (BCNU) for cutaneous T cell lymphoma: a 15-year experience in 143 patients. J Am Acad Dermatol 1990; 22: 802. 23. Dummer R, Krasovec M, Roger J, Snidermann H, Burg G. Topical administration of hexadecylphosphocholine in patients with cutaneous lymphomas: results of a phase I/I I study. JAm Acad Dermatol mi; 29: 963-70. 24. Hoppe RT, Cox RS, Fuks Z, et al. Electron-beam therapy for mycosis fungoides: the Stanford University experience. Cancer Treatment Rep 1979; 63: 691-700. 25. Jones GW, Tadros A, Hodson Dl, et al. Prognosis with newly diagnosed mycosis fungoides after total skin electron radiation of 30 or 35 GY. Int J Radial Oncol Biol Phys 1994; 28: 839-45. 26. Price NM, Hoppe RT, Constantine VS, et al. The treatment of mycosis fungoides: adjuvant topical mechlorethamine after electron beam therapy. Cancer 1977; 40: 2851-3.

27. Becker M, Hoppe RT, Knox Sj. Multiple courses of highdose total skin electron beam therapy in the management of mycosis fungoides. Int J Radial Oncol Biol Phys 1995; 32:1445-9. 28. Broder S, Bunn PA. Cutaneous T-cell lymphomas. Semin Onco/1980;7:310. 29. Molin L, Thomsen K, Volden G, et al. Combination chemotherapy in the tumour stage of mycosis fungoides with cyclophosphamide, vincristine, VP-16, adriamycin and prednisolone (COP, CHOP, CAVOP): a report from the Scandinavian Mycosis Fungoides Study Group. Ada Derm Venereol (Slockholm) 1980; 60: 542. 30. Tirelli U, Carbone A, Veronesi A, et al. Combination chemotherapy with cyclophosphamide, vincristine, and prednisone (CVP) in TNM-dassified stage IV mycosis fungoides. Cancer Treatment Rep 1982; 66:167. 31. Winkelmann RK, Diaz-Perez JL, BuechnerSA. The treatment of Sezary syndrome. JAm Acad Dermatol 1984; 10:1000. 32. Von Hoff DD, Dahlberg S, Hartstock RJ, et al. Activity of fludarabine monophosphate in patients with advanced mycosis fungoides: a Southwest Oncology Group study. Postgrad MedJ 1990; 66: 773-5. 33. Mercieca J, Matutes E, Dearden C, et al. The role of pentostatin in the treatment of T-cell malignancies: analysis of response rate in 145 patients according to disease subtype. 7 C/m Oncol 1994; 12: 2588-93. 34. Kuzel T, Samuelson E, Roenick H, et al. Phase II trial of 2chlorodeoxyadenosine (2-CDA) for the treatment of mycosis fungoides or the Sezary syndrome. ProcAm Soc Cl'in Oncol 1992; 11:1089. 35. Kohn EC, Steis RG, Sausville EA, et al. Phase II trial of intermittent high-dose recombinant interferon alfa-2a in mycosis fungoides and the Sezary syndrome. Dermatol Clin 1990; 8:169-71. 36. Olsen EA, Rosen ST, Vollmer RT, et al. Interferon alfa-2a in the treatment of cutaneous T cell lymphoma. J Am Acad Dermatol 1989; 20: 395. 37. Knox SJ, Levy R, Hodgkinson S, et al. Observations on the effect of chimeric anti-CD4 monoclonal antibody in patients with mycosis fungoides. J Am Acad Dermatol 1991; 216-20. 38. Hesketh P, Caguioa P, Koh H, et al. Clinical activity of a cytotoxic fusion protein in the treatment of cutaneous Tcell lymphoma. J Clin Oncol 1993; 11:1682-90. 39. Molin L, Thomsen K, Volden G, et al. Oral retinoids in mycosis fungoides and Sezary syndrome: a comparison of isotretinoin and etretinate. A study from the Scandinavian Mycosis Fungoides Group. Ada Derm Venereol (Stockh) 1987; 67:179-82. 40. Edelson R, Berger C, Gasparro F, et al. Treatment of cutaneous T-cell lymphoma by extracorporeal photochemotherapy: preliminary results. N EnglJ Med 1987; 316: 297. 41. Heald P, Rook A, Perez M, et al. Treatment of erythodermic cutaneous T-cell lymphoma with extracorporeal photochemotherapy. J Am Acad Dermatol 1992; 27: 427-33.

370 Cutaneous lymphomas 42. Kaye FJ, Bunn PA, Steinberg SM, et al. A randomized trial comparing combination electron-beam radiation and chemotherapy with topical therapy in the initial treatment of mycosis fungoides. N EnglJ Med 1989; 321: 1784. 43. Kuzel T, Gilyon K, Springer E, et al. Interferon alfa-2a combined with phototherapy in the treatment of cutaneous T-cell lymphoma../ Natl Cancer I nst 1990; 82: 203-7. 44. Bernengo MG, Quaglino P, Novell! M, et al. Prognostic factors in Sezary syndrome: a multivariate analysis of clinical, haematological and immunological features. Ann Oncol 1998; 9: 857-63. 45. Burke JS, Hoppe RT, Cibull ML, et al. Cutaneous malignant lymphoma: a pathologic study of 50 cases with clinical analysis of 37. Canter 1981; 47: 300-10. 46. Webb A, McCarthy K, Cunningham D, et al. Multicentre retrospective review of primary cutaneous lymphoma excluding mycosis fungoides. Ann Oncol 1996; 7(suppl 3): 131. 47. Esche BA, Fitzpatrick PJ. Cutaneous malignant lymphoma. IntJ Radiation Oncol Biol 1986; 12: 2111-5. 48. Joly P, Charlotte F, Leibowitch M, et al. Cutaneous lymphomas other than mycosis fungoides: follow-up study of 52 patients. J Clin Oncol 1991; 9:1994-2001. 49. Paulli M, Berti E, Rosso R, et al. CD30/KM-positive lymphoproliferative disorders of the skin dinicopathologic correlation and statistical analysis of 86

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54.

55.

cases: a multicentric study from the European Organization for Research and Treatment of Cutaneous Lymphoma Project Group. 7 Clin Oncol 1995; 13: 1343-54. Weiss LM, Wood GS, Trela M. Clonal T-cell populations in lymphomatoid papulosis: evidence for a lymphoproliferative etiology in a clinically benign disease. N Engl J Med 1986; 315: 475-9. DavisTH, Morton CC, Miller CR, et al. Hodgkin's disease, lymphomatoid papulosis, and cutaneous T-cell lymphoma derived from a common T-cell clone. N EnglJ Med 1992; 326:1115-22. Jaffe ES, Krenacs L, Raffeld M. Classification of T-cell and NK-cell neoplasms based on the REAL classification. Ann Oncol 1997; 8(suppl 2): S17-S24. DeBruin PC, Beljaards RC, VanHeerde P, et al. Differences in clinical behaviors and immunophenotype between primary cutaneous and primary nodal anaplastic large cell lymphoma of T-cell or null cell phenotype. Histopathology 1993; 23:127-35. Kaudewitz P, Stein H, Dallenbach F. Primary and secondary cutaneous Ki-1+(CD30+) anaplastic large cell lymphomas. Am J Pathol 1989; 135: 359-67. Beljaards R, Kaukdewitz P, Berti E, et al. Primary cutaneous large cell lymphomas: definition of a new type of cutaneous lymphoma with a favorable prognosis: a European multicenter study on 47 patients. Cancer 1993; 71: 2097-104.

27 Pediatric lymphomas JS MALPAS''

Introduction

371

Hodgkin's disease

376

Epidemiology

Long-term effects of therapy Future developments

379

Biology

371 372

Non-Hodgkin's lymphoma

372

References

381

INTRODUCTION Lymphomas account for 11.5 per cent of cancers in children aged 0-14 years.1 The incidence of Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) is approximately equal. There has been an increase in some childhood cancer recorded by the surveillance, epidemiology, end results (SEER) programme, but this has been slight in the lymphomas1 and the effect on mortality is countered by a dramatic recent improvement in survival, particularly in the case of childhood NHL.2 The frequency with which lymphomas occur, and their curability, merit special consideration, but other features of special interest in children are the almost universal occurrence of high-grade lymphomas, the high frequency of extranodal presentation of NHL, and the importance of considering the effects of treatment on all aspects of development and organ function. The occurrence of long-term toxicity in children and adolescents is of the greatest importance and is now influencing new treatment programs.

EPIDEMIOLOGY The incidence of lymphoma varies with geographical site. In NHL, Burkitt's lymphoma, for example, is very common in the sub-Saharal region of Africa, while the sporadic version is relatively rare in Western countries.

* With a contribution from Professor C.R. Pinkerton, Royal Marsden NHS Trust, Downs Road, Sutton, Surrey SM2 5PT, UK.

380

In HD, the highest rates for children are seen in Costa Rica and among Hispanics in Los Angeles, and the lowest in Japan.3 The incidence of NHL rises in children with the greatest frequency in the 9-11 year age group. HD is rare in children under the age of 5, but increases steadily, falling again in early adulthood to give a bimodal peak. In NHL and HD the incidence in boys is two to three times that in girls. As adolescence approaches this ratio becomes less so that incidence is approximately equal by the time adulthood is reached. The incidence of the various subtypes of HD is variable, with nodular sclerosing histology most frequent in the USA, UK and Australia, while mixed cellularity is more common in Turkey, the Middle East and other areas of poor socioeconomic conditions. Middle Eastern countries also show the highest incidence of lymphocytedepleted pathology.4 It has recently been suggested that HD is a heterogenous entity, composed of two different diseases - nodular sclerosing disease and mixed cellularity disease. The former is dramatically increased in adolescence5 and is commoner in more affluent societies.6 The definitive cause of lymphoma is at present unknown. A number of factors which predispose to NHL or HD have been identified.7

Non-Hodgkin's lymphoma Human T cell lymphoma virus type 1 (HTLV-1) causes adult T cell lymphoma/leukemia but is not associated with childhood disease. Infection, particularly with the acquired immunodeficiency syndrome (AIDS) viruses, is now giving rise to an increased incidence of NHL, presumably as a result of the acquired immunodeficiency

372 Pediatric lymphomas

state. This is unlikely to account for the occurrence of NHL in children and, indeed, for the long-term steady increase seen in its occurrence in adults. The Epstein-Barr virus (EBV) is thought to be a necessary cause of Burkitt's lymphoma in Africa and many lymphomas that are due to immunodeficiency. However, EBV is not associated with other forms of childhood NHL as far as can be determined. Rare genetic syndromes associated with immunodeficiency, such as Wiskott-Aldrich syndrome, ataxia telangectasia and the X-linked lymphoproliferative syndrome are most frequently complicated by NHL.

c-myc from chromosome 8 to the immunoglobulin (Ig) heavy-chain region on chromosome 141(8;14), bringing the c-myc gene into apposition with the Ig heavy-chain gene promoter.11 In T cell malignancies, rearrangements of the T cell receptor genes are seen but these are variable. Features of the cytogenetics of childhood lymphoma are given in more detail when the individual entities are considered later. There are no constant changes in HD, although a number of chromosomes, including 1, 2, 7, 11, 14, 15 and 21, have shown changes which may be non-random.

Hodgkin's disease NON-HODGKIN'S LYMPHOMA The early peak of HD incidence and the clustering of HD cases both suggest a virus of low infectivity.7 EBV remains a prime candidate and studies of HD material from children support this.8,9 It is now thought that about three-quarters of childhood HD, and a relatively higher proportion of the mixed cellularity subtype may be a rare response to EBV infection, together with an as yet unidentified cofactor related to affluence.6

BIOLOGY Immunophenotyping The realization that all lymphomas were related to lymphoid cells of the T and B lineage has been of great importance in the understanding of the biology of these neoplasms, and has helped with their classification. Identification of the lymphoid cell surface antibodies, and their grouping into 'cluster of differentiation' (CD) types, have helped to divide lymphomas into B cell and T cell proliferations, and the very immature pre-B cell lineage. These groups have their counterpart in the lymphoblastic leukemias. There is correlation with the clinical presentation and the natural history, and in consequence the phenotype is of great importance to the clinician. A more detailed presentation of the patterns seen in childhood NHL is given later. In HD, CD determinants have not been of clinical relevance, although at this stage it has been shown that Reed-Sternberg cells consistently express high levels of CD 3010 and this has enabled study of their origin.

Classification A daunting feature of NHL is the number of classifications of histology that have been produced, and this also applies to the childhood disease. Recently the Kiel system was largely used in Europe and the Working Formulation (WF) in the USA. In an attempt to facilitate international studies of lymphoma, the revised European-American (REAL) classification has been devised.12 (see also Chapter 1.) Virtually all childhood NHL is in the category known as 'aggressive'. It is probably most helpful to summarize the histology, immunophenotype and cytogenetic features of the lymphoid malignancies seen in children. B CELL NEOPLASMS

Precursor B lymphoblastic lymphoma This entity has previously been described as lymphoblastic (under the Rappaport classification), lymphoblastic B cell type (Kiel classification), lymphoblastic (WF classification) and is called 'precursor B lymphoblastic lymphoma' in the REAL classification. The morphology of the cells is that of lymphoblasts, which are larger than the small lymphocytes and have frequent mitoses. Immunophenotypically they show terminal deoxynucleotidyl transferase (tdt), CD 19, CD 79a and CD 10 (the latter occurring in over 50 per cent of cases). Genetic features are Ig heavy-chain gene rearrangements. The majority of precursor B lymphoblastic disease presents as leukemia but about 20 per cent will be lymphomatous in children.

Cytogenetics

Diffuse large B cell lymphoma

Non-random cytogenetic abnormalities have been described in childhood NHL but not, so far, in HD. The outstanding cytogenetic abnormality is that seen in Burkitt's lymphoma, where an 8; 14 translocation is a common feature. Most cases show a translocation of

This has been known under the Rappaport classification as diffuse histiocytic lymphoma, under Kiel as centroblastic or B immunoblastic, and as diffuse large B cell (REAL). The cells are large with nuclei at least twice the size of a small lymphocyte. Some cells are large and cleaved, and

Non-Hodgkin's lymphoma 373

may be multilobulated. Rarely, they show appearances identical with those of anaplastic large-cell lymphoma. The immunophenotype shows positive surface immunoglobulin in more than 50 per cent of cases, CD 19, CD 20, CD 22 and CD 79a are positive, bcl-2 gene rearrangements occur in about a third. Burkitt's lymphoma

In the Rappaport classification this was known as undifferentiated lymphoma (Burkitt type); Kiel classified it as Burkitt's lymphoma; WF defined it as 'small non-cleaved cell Burkitt type'; it is also known as high-grade B cell lymphoma (Burkitt type) or Burkitt's lymphoma (REAL). The morphology is highly characteristic, with large monomorphic cells with cytoplasmic lipid vacuoles. The immunophenotype is characteristic, with immunoglobulin on the surface (SIg M), CD 19, CD 20, CD 22, CD 79a and CD 10 being positive, and CD 5 negative. Genetic changes of a non-random type are translocations t(8;14), or t(2;8) or t(8;22). T CELL NEOPLASMS Precursor T lymphoblastic lymphoma

In the Rappaport classification, this was known as 'poorly differentiated lymphocytic diffuse', Kiel classified it as'T lymphoblastic', and WF as 'lymphoblastic convoluted or non-convoluted'. It is known as 'precursor T-lymphoblastic in the REAL classification. Its morphology is identical to that of the precursor B lymphoblastic cells described above. The immunophenotype of the majority is CD 7+ or CD 3+. About 50 per cent of tumors are tdt+, CD la+. B cell-associated antigens are all negative. The cells can express gd, y8 or no T cell receptor molecules. Among the genetic features, rearrangements of T cell receptor gene and IgH gene have been noted, but are variable. About 40 per cent of childhood lymphomas belong in this category. Anaplastic large-cell (CD 30) lymphoma

This was known as 'diffuse histiocytic' under Rappaport classification, as 'large cell anaplastic' under Kiel, and was not listed under WF. Various other names have been applied, including 'malignant histiocytosis' and 'histiocytic medullary reticulosis'. The tumor has recently been recognized in children by the use of the Ki-1 (CD 30) antibody. The morphology is of large blastic cells with pleomorphic horseshoe-shaped or multiple nuclei, mimicking the Reed-Sternberg cell, and has been defined as anaplastic large-cell lymphoma (ALCL). The immunophenotype shows CD 30, CD 45 and CD 25 positivity in about 50 per cent of cases, and epithelial membrane antigen (EMA) positivity in about 50 per cent of systemic tumors. The majority show a translocation t(2;5) or the ALK-NPM transcript.13 This tumor is being increasingly frequently recog-

nized in children. A number were previously misdiagnosed as HD and the incidence is now thought to be possibly as high as 15 per cent. Clinical features of NHL in children Extranodal presentation is a feature of childhood NHL.14 There is a high frequency of abdominal presentation, with just under half (45 per cent) of children presenting in this way, while mediastinal presentations (30 per cent) are the next most common. Head and neck presentations (Fig. 27.1) comprise the remaining 25 per cent, together with a variety of relatively uncommon primary presentations, such as bone, kidney and skin. In a review of the use of radiology in childhood NHL, the radiological features of a series of 80 children15 confirmed the abdomen as the most frequent primary site, and computed tomography (CT) scanning showed the highest frequency of involvement in the gastrointestinal tract and mesenteric retroperitoneal lymph nodes. Renal, liver and splenic involvement also occurred (Table 27.1). Presentation is usually with a rapidly increasing abdominal mass. Occasionally pain may mimic various abdominal conditions, including acute appendicitis, or there may be features of acute intestinal obstruction. A laparotomy may be undertaken but, if a tumor is disclosed, minimal surgical intervention with a biopsy should be encouraged, and on no account should major resection be undertaken. With the increasing availability of CT or ultrasound-guided needle biopsy, the use of laparotomy is declining. In the mediastinum, the tumors are also rapidly growing, and may present with superior mediastinal obstruction, giving rise to marked respiratory distress or dysphagia. These tumors may be complicated by pleural or pericardial effusions. They present a diagnostic dilemma, because the children may be so ill that an anesthetic for a biopsy cannot be given. Pleural fluid aspiration or a fine-needle biopsy under local anesthetic are probably safest. Patients with this form of the disease usually have involvement of the bone marrow, testis and (very rarely) the central nervous system at presentation, so that examination of these areas is mandatory. In the head and neck, the region of Waldeyer's ring and the superficial lymph nodes in the neck are the third most common site (Fig. 27.1). Features of nasal obstruction, such as snoring or a persistent nasal discharge, or difficulty in breathing or swallowing, are often seen at presentation. Other rare sites of presentation are the orbit, the thyroid gland, kidney, bones, epidural spaces and skin. Diagnosis and staging The diagnosis must always be made on histological or cytological examination of tissue, of either nodes,

374 Pediatric lymphomas Table 27.1 Distribution of disease by primary site in 80 children presenting with non-Hodgkin's lymphoma (after reference 15)

Abdomen Gastrointestinal Mesenteric retroperitoneal lymph nodes Renal Liver and spleen

21 (26) 15 3 2 1

Extranodal head and neck Tonsil Nasopharynx Mandible Maxilla Palate Parotid Orbit

18(23) 7 5 2 1 1 1 1

Mediastinum

16(20)

Peripheral lymph nodes Cervical Axillary Pelvic Submandibular Cervical, axillary and inguinal

15(19) 9 2 2 1 1

Other Testes Penis Ovary Skin Bone

10(13) 2 1 1 4 2

Total

80 (100)

effusions or bone marrow smears, and all should be subject to histology, immunochemistry, phenotyping and cytogenetic assessment, which underlines the necessity for early referral to a center specializing in pediatric oncology. Diagnosis and staging must be expedited - a prolonged staging procedure is not acceptable. A suggested list of practical investigations is given in Table 27.2. Since treatment will depend on the stage of the disease, it is important to use these investigations to determine the anatomical spread of the disease as soon as possible. It is generally accepted that the Ann Arbor staging scheme is not appropriate for childhood nonHodgkin's lymphoma. A number of other schemes have been advanced, but the classification introduced by Murphy16 at St Jude's Children's Research Hospital has been widely adopted. This staging system is shown in Table 27.3. In addition to staging and assessment, the child's general condition must be assessed, with particular reference to dehydration, infection, poor nutrition, anemia and thrombocytopenia. The correction of dehydration and the reduction of uric acid level with allopurinol or uric oxidase are of particular importance, as a preliminary to the introduction of chemotherapy. Cytotoxics may induce a tumor lysis syndrome, causing a major metabolic disturbance with, amongst other features, 'phosphate shower', uric acid nephropathy and cardiac dysfunction. Many protocols now use a relatively low dose of antitumor agents at the beginning of induction which may reduce tumor lysis, but more importantly, avoids the additional early complications of myelosuppression and mucosilis in the event of severe lysis syndrome.

Figure 27.1 This shows the almost complete occlusion of the airway of a boy with non-Hodgkin's lymphoma, with massive infiltration of Waldeyer's ring.

Non-Hodgkin's lymphoma 375 Table 27.2 Non-Hodgkin's lymphoma diagnostic and staging procedures 1. Surgical biopsy with review by lymphoma pathologist 2. Cytology of pleural, pericardia! or cerebrospinal fluids 3. History detailing sweating, fever, weight loss 4. Physical examination of all lymph node sites, Waldeyer's ring, liver, spleen and testes 5. Full blood count, bone marrow examination, cerebrospinal fluid examination if not done already 6. Evaluation of liver function, kidney function, estimation of serum uric acid, serum electrolytes and lactic dehydrogenase 7. Computed tomography scanning or ultrasound of abdomen; chest X-ray; postnasal films if indicated

Treatment The dramatic improvement seen in the outlook for childhood NHL over the past two decades has been the result of a succession of steps in improving management. The first was the realization that NHL was a disseminated disease at presentation and that local measures, such as surgery or radiotherapy, had only a very limited role to play. Recognition of the value of combinations of active drugs given in a manner similar to that used in acute leukemia was the next major step, and results were very much improved by closer attention to supportive care and by the proper management of infections, Table 27.3 Stjude staging for childhood non-Hodgkin's lymphoma Stage I A single tumor (extranodal) or single anatomic area (nodal) with the exclusion of mediastinum or abdomen. Stage II A single tumor (extranodal) with regional node involvement. Two or more nodal areas on the same side of the diaphragm. Two single (extranodal) tumors with or without regional node involvement on the same side of the diaphragm. A primary gastrointestinal tract tumor usually in the ileocecal area with or without involvement of associated mesenteric nodes only. Stage III Two single tumors (extranodal) on opposite sites of the diaphragm. Two or more nodal areas above and below the diaphragm. All the primary intrathoracic tumors (mediastinal, pelvic, thymic). All extensive primary intra-abdominal disease. Stage IV Any of the above with initial central nervous system and/or bone marrow involvement.

biochemical and hematological problems, and appreciation of the tumor lysis syndrome. It was recognized that all children had high-grade lymphomas, but that some were of the lymphoblastic type, mostly T cell, requiring not only intensive initial therapy, but long-term continuation or maintenance therapy. They could thus be distinguished from other high-grade B cell lymphomas, where short intensive courses were more appropriate and highly successful. The development of protocols has produced a greater than 80 per cent cure rate in children treated in a number of countries.13,17,18 The question of how much treatment is necessary to ensure a cure but nevertheless avoid serious long-term toxicity is now of prime importance. Where possible, the total dose of chemotherapy is being reduced and, in particular, the quantity of alkylating agents and anthracyclines. In this way, second malignancy may be avoided and fertility may be preserved. The avoidance of anthracyclines, which produce cardiac dysfunction, is also being explored. The necessity for including children with NHL in national protocols to enable these questions to be addressed cannot be overemphasized. SURGERY

The role of surgery is limited and extensive resection of lymphoma, particularly in the abdomen, is to be deprecated. There is no good evidence that in high-grade lymphoma 'debulking' improves prognosis and, indeed, by delaying the start of chemotherapy, it may increase initial mortality. When surgery is unavoidable, such as with intussusception, obstruction or perforation, supportive care with blood products, antibiotics and careful fluid replacement is essential. RADIOTHERAPY

Lymphoma is very sensitive to radiotherapy but its indication in childhood NHL is increasingly limited. Even in localized disease it has no place and a number of randomised studies have confirmed this.19 Where there is overt lymphomatous involvement of the central nervous system, craniospinal irradiation together with chemotherapy is the treatment of choice. Otherwise it should not be used in disseminated NHL but it can occasionally be helpful in the relief of symptoms, such as localized bone pain or the rapid onset of spinal cord compression. CHEMOTHERAPY

Cure rates have improved dramatically to around 80 per cent and chemotherapy has become the mainstay of treatment, adapted to the different subtypes of NHL, particularly Burkitt's and the lymphoblastic lymphomas.20 Since all tumors are high grade, therapy is indicated as soon as the diagnosis and staging is complete. Histology is helpful in deciding the appropriate program, with

376 Pediatric lymphomas

patients with T cell lymphoma responding to a 'leukemia-type' protocol with induction, consolidation and maintenance, while B cell lymphomas can be successfully managed with intensive short-term therapy. This was confirmed in a classical study21 in which the ISA L2 protocol was compared with COMP. Other protocols developed in the USA, Europe and Great Britain are given in Table 27.4. Many programmes contain a cytoreductive phase, with lower doses of active agents given initially, followed by a more intensive induction. A consolidation phase follows during which central nervous system chemotherapy prophylaxis is introduced. Patients with lymphoblastic disease then progress to a maintenance or continuation phase. As can be seen from the pivotal studies from the 1980's shown in Table 27.4, response rate and event-free survival was high. These protocols, however, are constantly being revised, so that entry into current study protocols is advisable. Escalating the doses of drugs, such as cyclophosphamide, methotrexate and cytarabine, with minimum delay and shorter duration schedules is improving survivals further for advanced disease.22,25 However, for children presenting with localized disease, more moderate approaches may be appropriate26 and the current collaborative venture between the French Societe Francaise d'Oncologie Pediatrique (SFOP), the United Kingdom Childrens Cancer Study Group (UKCCSG) and the United States Childrens Cancer Group (USCCG) should resolve this and other unanswered questions.27

extranodal sites, for example, head and neck and gastrointestinal tract, and involvement of other organs, particularly the bone marrow and central nervous system, is common. In young adults these lymphomas were shown to be potentially curable with standard NHL regimens28 but the prognosis remained poor, particularly in those patients with bad prognosis disease. Intensive regimens have achieved excellent results, with over two-thirds of patients surviving.29,31 Recently, it has become evident, based on the experience with childhood Burkitt's lymphoma, that excellent results can be achieved with short but very intensive chemotherapy; the disease is frequently cured despite involvement of the bone marrow or central nervous system. One approach has been to consolidate remission with autologous bone marrow transplant;32 however, short-duration high-dose chemotherapy has been highly successful in both children and adults.22,32,35 A major lead has come from the National Cancer Institute (NCI), which has been involved in studies for many years. They have developed various protocols for adults, the most successful of which has been cyclophosphamide, vincristine, doxorubicin, methotrexate (CODOX-M),36 where the dose of cyclophosphamide and methotrexate has been escalated. For poor-prognosis disease, a non-cross-resistant protocol incorporating ifosfamide, etoposide and cytarabine (IVAC) was added. For the small number who relapse, high-dose therapy with autologous or allogeneic stem cell transplant may be of value.37

Burkitt's lymphoma Burkitt's lymphoma (and Burkitt-like lymphoma) merit special mention as they are models for successful chemotherapy. These are rare, fast-growing and aggressive B cell neoplasms, which most commonly occur in children and young adults. While the African form of the disease is commonly localized to the jaw and is cured by relatively simple chemotherapy, the Western form commonly presents with bulky, widespread disease and has a worse prognosis. These tumors commonly arise at

HODGKIN'S DISEASE Clinical presentation In developed countries, children with HD are relatively well at presentation, only some 20-30 per cent having fever, sweats or a 10 per cent loss of weight.38,39 Massive disease such as that seen in Fig. 27.2 is uncommon in Western countries, but seen frequently in the Middle

Table 27.4 Studies in childhood non-Hodgkin's lymphoma that form the basis of current practice

Lymphoblastic III

24

III III IV

38

German BFM StJ Judes French 1MB 84

III and IV III and IV mostly

LSA2-L2

76 at 2 years

21

57 at 2 years

21 24

Non-lymphoblastic COMP

75 15 29 216

75

at21 months 53j 81 at 2 years 78 at median 41 months

18 17

LSA2-L2 = 10 drug leukemia-type regimen, COMP = cyclophosphamide, oncovin, methotrexate, prednisone, BFM = Berlin, Frankfurt, Munster, 1MB = lymphoma maligne Burkitt.

Hodgkin's disease 377

Table 27.5 Hodgkin's disease: diagnostic and staging procedures 1. Surgical biopsy reviewed by lymphoma pathologist 2. Clinical history noting fever, sweating and weight loss of > 10 per cent, ie. 'B' symptoms 3. Physical examination noting Waldeyer's ring, and liver and spleen enlargement 4. Complete blood count and erythrocyte sedimentation rate 5. Postnasal space X-rays 6. Chest X-ray 7. Computed tomography scan of chest and abdomen 8. Abdominal ultrasound as baseline for follow-up 9. Bone marrow trephine if indicated by extensive disease or B symptoms 10. Additional procedures being assessed: gallium-67 scanning and magnetic resonance imaging

Radiology

Figure 27.2

Massive cervical lymphadenopathy in a young

boy from the Middle East.

East. Lymphadenopathy is commonly seen in the cervical and supraclavicular region.39 Other presentations include mediastinal obstruction with breathlessness, dysphagia and early morning facial edema. Subdiaphragmatic presentations are on the whole uncommon.

Diagnosis and staging Diagnosis must be based on the histology of a lymph node biopsy, or (where this is not possible or there is adequate experience) guided needle biopsy may be appropriate. A suggested programme for staging is given in Table 27.5. General assessment should include an estimate of the hemoglobin, white blood cell count and platelets, and an erythrocyte sedimentation rate. Except in children with extensive disease or 'B' symptoms, bone marrow trephine biopsy is unlikely to show involvement, and aspirations are nearly always unhelpful.39 Biochemistry and, in particular, liver function tests, should be available, but interpretation of the alkaline phosphatase in the young child needs to be done with caution. Normal values for alkaline phosphatase in children are available.40

Ultrasound and CT scanning have now replaced lymphangiography as appropriate radiology for HD. A chest X-ray and views of the postnasal space should be routinely performed. Care may be necessary to differentiate an enlarged thymus from a mediastinal mass. Staging laparotomy Surgical procedures to examine and biopsy the abdominal contents, and proceed to either partial or complete splenectomy are no longer used. The reasons for this are the undoubted morbidity from recurrent intestinal obstruction and the vulnerability of the splenectomized child to life-threatening or fatal infection. More recently, an increase in the second malignancy rate has been noted in splenectomized children.41,42 The frequency with which combined modality therapy, with chemotherapy and in-field radiotherapy, is now being used has also rendered this procedure unnecessary. When treatment procedures are dependent on accurate staging, laparotomy was the only way to ensure that radiotherapy, when used alone, includes all areas of disease. The spleen had to be removed in its entirety, because partial splenectomy results in a false-negative rate. Staging The Ann Arbor staging system, or its more recent modification, the Cots wold classification, is in use (Table 27.6). The propensity to relapse caused by large mediastinal masses where the tumor is greater than a third of

378 Pediatric lymphomas

Table 27.6 Staging of Hodgkin's disease: Ann Arbor and Cotswold modification Stage I Involvement of a single lymph node (I) or a single extralymphatic organ (IE) Stage II Involvement of two or more lymph node regions on the same side of the diaphragm (II) or localized involvement of an extralymphatic organ or site and of one or more lymph node regions on the same side of the diaphragm (ME) Stage III Involvement of lymph node regions on both sides of the diaphragm (III), which may also be accompanied by localized involvement of extralymphatic organs or sites (HIE) or by involvement of the spleen (IMS) or both (IIISE) Stage IV Diffuse or disseminated involvement of one or more extralymphatic organs or tissue with or without associated lymph node enlargement Each stage is divided into A and B categories: A No systemic symptoms B Unexplained weight loss of > 10% of body weight within last 6 months or unexplained fever (about 38°C) and/or night sweats X Mediastinal masses greater than one-third thoracic diameter or > 10 cm in diameter

the chest diameter and by other masses > 10 cm is recognized in the Cotswold classification.43

Treatment The two modalities available for treatment of HD are radiotherapy and chemotherapy. With the introduction of linear accelerators and the definition of a curative dose, extended field radiotherapy in pathologically staged patients was highly effective as a primary treatment in adults, and it subsequently was used in children. Serious effects on growth and development were soon evident (Fig. 27.3). The use of mantle irradiation in the

Figure 27.3

The late results of mantle irradiation given 5

years previously, with clavicular shortening and failure of development of the upper thorax.

young child prevented proper development of the upper half of the trunk, and there was marked loss of neck tissue. Involved field irradiation alone44'45 produced disappointing relapse-free survivals (Table 27.7). Multidrug combinations of chemotherapy, such as MOPP, having been shown to be effective in adult HD, were demonstrated to be equally so in children. Because of the nausea and vomiting induced by these therapies, they were not well tolerated in the child, however, and alternative therapies were introduced, such as chlorambucil, vincristine, procarbazine, prednisolone (ChlVPP) and ABVD (Table 27.8). Giving MOPP alone produced relapse-free survival of between 80 and 90 per cent.38 The use of alkylating agents in large doses has produced a definite increase in second malignancies and this, together with the almost universal sterility caused in boys and the serious effects on fertility in girls, has made this approach less acceptable. Combined modality therapy reported from Stanford, London and France has produced excellent disease-free survival (Table 27.7). Randomized trials comparing the use of pathological staging, plus extended or in-field radiotherapy and

Table 27.7 Treatment of Hodgkin's disease in children

Radiotherapy only Radiotherapy IF Radiotherapy EF

51 54

PS IA IIA PS l-ll

72 28

95 96

Jereb et al. (44) Sullivan et al. (45)

Radiotherapy + chemotherapy MOPP x 6 ChlVPP x 3-6 4 ABVD or 4-6 MOPP/ABVD

75 84 157

PS I-IV CS I-IV CS I-IV

89 82 88

90 94 95

Russell et al. (46) Robinson et al. (39) Dionet et al. (47)

Chemotherapy only MOPP or ChlVPP

53

CS I-IV

92

94

Ekert et al. (48)

PS = pathological stage, CS = clinical stage, RFS = relapse-free survival, EF = extended field, IF = involved field.

Long-term effects of therapy 379

Table 27.8 MOPP-alternative chemotherapeutic regimens

ChlVPP49 Chlorambucil 6 mg/m2 per day po Procarbazine 100 mg/m2 per day po Prednisolone 40 mg/day po Vinblastine 6 mg/m2 iv 14-day cycles with a 14-day rest period.

1-14 1-14 1-14a 1 and 8

50

ABVD

Adriamycin 25 mg/m2 iv Bleomycin 10 mg/m 2 iv Vinblastine 6 mg/m2 iv Dacarbazine 1 50 mg/m2 iv 14-day cycles with 14-day rest periods.

1 and 14 1 and 14 1 and 14

1-5

a

Reduced appropriately in children, iv = intravenous, po = oral.

chemotherapy, with clinical staging and combined modality therapy will never now be done. However, a useful comparison of the two approaches to treatment has been reported.51 In 171 children treated at Stanford and at St Bartholomew's and Great Ormond Street Hospitals in London, the Stanford children were pathologically staged, while the London children were clinically staged. The two groups were remarkably similar. At 10 years the survival of both groups was 91 per cent. There was a trend for the relapse-free interval to be lower in the London children (83 per cent compared to 90 per cent at Stanford), but this was not significant. Other groups have also reported similar results, with long-term survival rates consistently around 80 per cent.52-55 Many children who are survivors of earlier studies and were subjected to laparotomy and splenectomy are now on long-term follow-up, and the problem of preventing fatal infections from encapsulated organisms is frequently encountered. The current recommendation is for the use of a polyvalent vaccine such as Pneumovax (which should be renewed every 5 years) and the administration of Haemophilus B immunization at the same time, together with long-term oral prophylactic penicillin. Results in HD are now so good with combined modality therapy that the question of how far can either of these modalities be reduced can be asked. How far can anthracyclines, such as doxorubicin, be eliminated or should alkylating agents no longer be given? The problems of what to do about resistant and relapsing disease, and the role of intensive chemotherapy supported by either autologous bone marrow transplantation or peripheral blood stem cells remain to be investigated.

LONG-TERM EFFECTS OF THERAPY Because of the earlier success in producing a high rate of durable remissions in HD, there is more information

about the incidence of long-term side effects than is available for childhood NHL. Nevertheless, a number of excellent studies in leukemia and lymphoma are applicable, and have been included.

Cardiotoxicity The cardiotoxicity of anthracyclines is well known in adults and has been demonstrated in children treated with these drugs in combinations for acute leukemia.56,57 It has been shown that girls are more susceptible than boys58 and that, the older the child at the time of therapy, the less toxicity ensues. Removal of anthracyclines from both NHL and HD treatment protocols could possibly prejudice the response and survival of children. Treatment programs have therefore been devised in which an attempt is made to reduce the amount of anthracycline and alkylating agent by alternating standard regimens containing these with other regimens that do not. In this way the total cumulative dose of each agent can be reduced. A review of the long-term outcome of an ABVD/MOPP combination in childhood HD59 reported no deleterious effect on cardiac function in children given a total cumulative dose of 150 mg/m2 in 29 patients studied 22-132 months after completion of therapy. However, in those children treated on trials at St Jude from 1968-90, as well as excess mortality from second cancers and infections, there was a significantly increased mortality from cardiac disease. All patients were male and had had extended field radiotherapy and no anthracycline-containing chemotherapy.60 In a study of 103 young survivors of NHL treated on National Cancer Institute protocols, a predominate late effect was cardiotoxicity related to doxorubicin therapy in doses exceeding 200 mg/m2.61

Pulmonary function Bleomycin has produced lung fibrosis with consequent deterioration in pulmonary function, and is a constituent of the ABVD program. In 40 children who were long-term survivors of HD and had received ABVD as part of their treatment, 27 had normal pulmonary function, ten had mild and three moderate impairment of gas transfer, obstructive or restrictive patterns, 6-121 months after completion of therapy.59 This study emphasizes the need for studies of both heart and lung function during the course of therapy, and assessment at the end of treatment programmes, with long-term subsequent follow-up.

Endocrine function Dysfunction occurs primarily in the thyroid and gonads after radiation to fields including the sites of these

380 Pediatric lymphomas

organs, or after chemotherapy, particularly with alkylating agents. Biochemical evidence of thyroid dysfunction is seen after mantle radiotherapy, although overt hypothyroidism is uncommon. Elevated levels of thyroid stimulating hormone (TSH) and low levels of thyroid have been seen.62 Biochemical evidence shows that hypothyroidism can recover spontaneously.63 Long-term followup of children with raised TSH has indicated a liability to thyroid carcinoma as a second malignancy in those children who had thyroid irradiation.64 There is a mandatory requirement for regular examination of the thyroid, both clinically and by ultrasound, in these children. Gonadal dysfunction

Until recently it has not been possible to say with certainty whether survivors of NHL will have progeny with a propensity to develop cancer. Considerable reassurance comes from a study of 382 offspring of parents surviving acute leukemia or NHL.75 A total of 2776 person-years of follow-up were accrued by these children, with a mean and median follow-up of 7.3 and 5.8 years, respectively. No malignant neoplasms occurred in the whole population, and the authors conclude that there is no added risk of developing malignancy in this cohort. Psychosocial aspects There has been concern that a higher incidence of psychological disturbance is seen in the long-term survivors of childhood lymphomas.75 Marital difficulties and problems at work seem to be more frequent, although educational achievement is normal or even enhanced.76 Major concerns are the discrimination of employers and difficulty in obtaining insurance.

Gonadal dysfunction has been described in adult females65 and males,66 and the effect of MOPP chemotherapy on adolescent Ugandan boys67 was one of the earliest accounts of the problem of infertility in these children. Studies of testicular function in the long term68'69 have shown a high proportion of infertility in boys treated with alkylating agents. In these boys, estimations of follicle stimulating hormone (FSH) and luteinizing hormone (LH) have shown gradual elevation over time. A disturbing feature of these postpubertal patients was a fall in testosterone levels in some, despite a high level of LH. This would suggest that premature Leydig cell dysfunction is a real possibility. In reviewing the Stanford experience,70 similar findings of infertility in boys were seen. In girls, however, the findings were more hopeful, for 87 per cent had normal menstrual function at a median follow-up of 9 years.

It is very probable that more sophisticated means of discriminating between the various subvarieties of lymphoma will define new entities. This has already happened with the recent recognition of childhood anaplastic large-cell lymphoma, with a Ki-1 (CD 30) phenotype which is certainly more frequent in children than was originally thought.

Second malignancy

Prospects for therapy

Acute myeloid leukemia and a variety of solid tumors occur following treatment for HD. A follow-up of 979 children under the age of 16 at diagnosis71 showed that leukemia and lymphoma occurred with increasing frequency up to 5 years after treatment, and then plateaued. The incidence of solid tumors (usually occurring within an irradiated site) was progressive and still rising after 30 years of follow-up. The risk of second leukemia was greater in those children who had undergone splenectomy. It has been suggested that survivors of pediatric HD require lifelong evaluation and cancer screening.72 In 883 children with NHL treated between 1974 and 1985,10 deaths (2 per cent) out of the 476 children who died in the series were due to second primary tumors.73 Six had acute myeloid leukemia, two had osteosarcoma and two had astrocytomas as second tumors. The majority occurred in the first 10 years of follow-up. While the deaths from second tumors appear to decline over time, deaths from late effects of therapy appear to increase.74

Population based data on childhood NHL and HD show very good results at 5 years2 of 73 and 93 per cent, respectively. The priorities for new studies do, however, differ. In NHL there is still some way to go to achieve better survival rates either by intensifying conventional therapy, by the use of high-dose therapy supported by bone marrow transplantation or peripheral blood stem cells, or by the possible use of some form of targeted therapy using, for example, interleukin-2 or other cytokines. In HD the priority is the development of treatment programs with minimal effects on fertility, heart and lung function. In both NHL and HD, programs to reduce the incidence of late second primary tumors need to be developed. In NHL the prospects for improvement in firstgeneration protocols (e.g. CHOP) by the multidrug second- and third-generation programs did not appear too good, given the results of a randomized study in adults comparing CHOP with more intensive regimens.77

FUTURE DEVELOPMENTS New entities

References 381

However, with more recently introduced intensive regimens with dose escalation of agents, such as cyclophosphamide, methotrexate and cytarabine, even Burkitt's lymphoma presenting with central nervous system involvement is curable in the majority of cases.20 While high-dose therapy with or without total body irradiation is technically feasible, it only rescues about 15 per cent of children treated.78 Attention needs to be focused on the high incidence of drug resistance in relapsed lymphoma. In HD the aim has been to reduce long-term side effects by avoiding alkylating agents or anthracyclines with cardiotoxic properties. Thus, regimens such as ABVD have been preferred or used in combination with MOPP.58 Epirubicin and etoposide were used in the vincristine, etoposide, epirubicin, prednisolone (VEEP) combination79 but a disturbing early relapse rate led to the abandonment of this regimen. A study of the features of relapsed and resistant childhood HD80 showed that most relapses occurred within 2 years, and that the overall survival of these relapsed children was only 45 per cent at 10 years. Those who relapsed in the first year, or at multiple sites, had the worst prognosis. In children who have disease that remains chemosensitive, highdose therapy with support is probably currently the best option as conventional relapse protocols are disappointing. The prospects for survival of children with lymphoma have improved beyond all expectation in the last three decades. With the introduction of new chemotherapeutic agents and the exploitation of the latest discoveries in molecular biology, it is to be hoped that future progress is still possible.

ACKNOWLEDGEMENTS I am very grateful to Mrs Io Barton for her expert typing of this manuscript.

REFERENCES 1. Miller RW. Childhood cancer. Cancer 1994; 75: 395-405. 2. Stiller CA. Population-based survival rates for childhood cancer in Britain. BrMedJ 1994; 309:1612-6. 3. Parkin DM, Stiller CA, Draper GJ, et al. The international incidence of childhood cancer. Int J Cancer 1988; 42: 511-20. 4. Padmalatha C, Ganick DJ, Hafez GR, et al. Hodgkin's disease and non-Hodgkin's lymphoma in children and young adults - a clinical pathological study of 127 cases. Med Pediat Oncol 1982; 10:175-84. 5. Medeiros LJ, Greiner TC. Hodgkin's disease. Cancer 1995; 75: 357-69. 6. Stiller CA. What causes Hodgkin's disease in children? Review. EurJ Cancer 1998; 34: 523-8.

7. Hartge P, Devesa S, Fraumeni J. Hodgkin's and nonHodgkin's lymphoma. In: Cancer Surveys 19/20: Trends in Cancer Incidence and Mortality. London: Imperial Cancer Research Fund, 1994; 423-53. 8. Coates PJ, Mak WP, Slavin G, et al. Detection of simple copies of Epstein-Barr virus in paraffin wax sections by non-radioactive in situ hybridisation. J Clin Pathol 1991; 44:487-91. 9. Khan G, Gupta RK, Coates PJ, et al. Epstein-Barr virus infection and bcl-2 proto-oncogene expression. Am J Pathol 1993; 143:1270-4. 10. Stein H, Gerdes J, Schwab U, et al. Identification of Hodgkin and Sternberg-Reed cells as a unique cell type derived from a newly-detected small cell population. Int J Cancer 1982; 30: 445-59. 11. Gupta RK, WhelanJS, Lister TA, et al. Direct sequence analysis of the t(14;18) chromosomal translocation in Hodgkin' disease. Blood 1992; 79: 2084-8. 12. Harris NL, Jaffe ES, Stein H, et al. A revised European-American classification of lymphoid neoplasms-a proposal from the International Lymphoma Study Group. Blood 1994; 84:1361-92. 13. Brugieres L, Caillaud JM, PatteC, et al. Malignant histiocytosis: therapeutic results in 27 children treated with a single polychemotherapy regimen. Med Pediat Oncol 1989; 17:193-6. 14. Murphy SB, Fairclough DL, Hutchison RE, et al. NonHodgkin's lymphomas of childhood: an analysis of the histology, staging and response to treatment of 338 cases at a single institution. J Clin Oncol 1989; 7: 186-93. 15. NgYY, HealyJC, Vincent \M,et al. The radiology of nonHodgkin's lymphoma in childhood - a review of 80 cases. Clin Radiol 1994; 49: 594-600. 16. Murphy SB. Classification, staging and end results of treatment of childhood non-Hodgkin's lymphoma: dissimilarities from lymphomas in adults. Semin Oncol 1980; 7: 332-9. 17. Patte C, Philip T, Rodary C, et al. High survival rate in advanced B-cell lymphomas and leukaemias without CMS involvement with a short intensive polychemotherapy. Results from a French Pediatric Oncology Society randomised trial of 216 children. J Clin Oncol 1991; 9: 123-32. 18. Murphy SB, Bowman WP, Abromowitch M, et al. Results of treatment of advanced-stage Burkitt's lymphoma and B cell (Sig+) acute lymphoblastic leukaemia with highdose fractionated cyclophosphamide and co-ordinated high-dose methotrexate and cytarabine. J Clin Oncol 1986; 4:1732-9. 19. Link MP, Donaldson SS, Berard CW, et al. Results of treatment of childhood localised non-Hodgkin lymphoma with combination chemotherapy with and without radiotherapy. N EnglJ Med 1990; 322: 1769-74. 20. Patte C. Non-Hodgkin's lymphoma. Paediatric update. EurJ Cancer 1998; 34: 359-63.

382 Pediatric lymphomas 21. Anderson JR, Wilson JJ, Jenkin RT, et al. The results of a randomised therapeutic trial comparing a 4-drug regimen (COMP) with a 10-drug regimen (LSA2-L2). N Eng J Med 1983; 308: 559-65. 22. Patte C, Philip T, Rodary C, et al. High survival rate in advanced stage B-cell lymphomas and leukaemias without CMS involvement with a short intensive polychemotherapy. Results of a randomized trial from the French Pediatric Oncology Society (SFOP) on 216 children. J Clin Oncol 1991; 9:123-32. 23. Magrath IT, Adde M, Shad A, et al. Adults and children with small non cleaved cell lymphoma have a similar excellent out-come when treated with the same chemotherapy regimen. J Clin Oncol 1996; 14: 925-34. 24. Reiter A, Schrappe M, Parwaresch R, et al. Non-Hodgkin's lymphomas of childhood and adolescence: results of a treatment stratified for biologic subtypes and stage. A report of the Berlin-Frankfurt-Munster Group.7 Clin Oncol 1995; 13: 359-72. 25. Atra A, Gerrard M, Hobson R, Imeson JD, Ashley S, Pinkerton CR, on behalf of the UKCCSG. Improved cure rate in children with B-cell acute lymphoblastic leukaemia (B-ALL) and stage IV B-cell non-Hodgkin's lymphoma (B-NHL) - results of the UKCCSG 9003 protocol. BrJ Cancer 1998; 77: 2281-5. 26. Link MP, Shuster JJ, Donaldson SS, Berard CW, Murphy SB. Treatment of children and young adults with early-stage non-Hodgkin's lymphoma. N EnglJ Med 1997; 337: 1259-66. 27. Pinkerton CR. Commentary. EurJ Cancer 1998; 34: 362-3. 28. Anderson JR, Wilson JF, Jenkin TDR, et al. Childhood nonHodgkin's lymphoma. The results of a randomised therapeutic trial comparing a 4-drug regimen (COMP) with a 10-drug regimen (LSA2-LJ. N EnglJ Med 1983; 308: 559-65. 29. Bernstein Jl, Coleman NC, Strickler JG, et al. Combined modality therapy for adults with small non-cleaved cell lymphoma (Burkitt's and non-Burkitt's types). J Clin Oncol 1986; 4: 847-58. 30. LopezTM, Hagemeister FB, McLaughlin P, et al. Small non-cleaved cell lymphoma in adults: superior results for stages l-lll disease.) Clin Oncol 1990; 8: 615-22. 31. Longo DL, Duffey PL, Jaffe ES, et al. Diffuse small noncleaved cell, Burkitt's lymphoma in adults: a high-grade lymphoma responsive to ProMACE-based combination chemotherapy. J Clin Oncol 1994; 12: 2153-59. 32. McMaster ML, Greer JP, Greco A, et al. Effective treatment of small-non cleaved-cell lymphoma with high-intensity, brief-duration chemotherapy. J Clin Oncol 1991; 9: 941-6. 33. Schwenn MR, Blattner SR, Lynch E, Weinstein JJ: HiCCOM: a 2-month intensive chemotherapy regimen for children with stage III and IV Burkitt's lymphoma and Bcell acute lymphoblastic leukaemia. J Clin Oncol 1991; 9: 133-8.

34. Philip T, Meckenstock R, Deconnick E, et al. Treatment of poor prognostic Burkitt's lymphoma in adults with the Societe Francaise d'Oncologie Pediatrique LMB protocol - a study of the Federation Nationale des Centres de Lutte Centre le Cancer (FNLCC). EurJ Cancer 1992; 28A: 1954-9. 35. Gasparini M, Rottoli L, Massimino M, et al. Curability of advanced Burkitt's lymphoma in children by intensive short-term chemotherapy. EurJ Cancer 1993; 29A: 692-8. 36. Magrath IT, Janus C, Edwards BK, et al. An effective therapy for both undifferentiated (including Burkitt's) lymphomas and lymphoblastic lymphomas in children and young adults. Blood 1984; 63: 1102-11. 37. Philip T, Pinkerton R, Hartmann 0, et al. The role of massive therapy with autologous bone marrow transplantation in Burkitt's lymphoma. Clin Hematol 1986; 15: 205-18. 38. Donaldson SS. Hodgkin's disease in children. Semin Oncol 1990; 17: 736-48. 39. Robinson R, Kingston JE, Noguera Costa R, et al. Chemotherapy and irradiation in Hodgkin's disease. Arch Dis Childhood 1984; 59:1162-9. 40. Nelson WE. Table in: Behrman RE, Vaughan VC, Nelson WE, eds Textbook of Pediatrics. Philadelphia: WB Saunders, 1987:1582. 41. Rosenberg SA. Exploratory laparotomy and splenectomy for Hodgkin's disease - a commentary [editorial]. J Clin Oncol 1988; 6: 574-5. 42. Meadows AT, Obringer AC, Monero 0, et al. Second malignant neoplasms following childhood Hodgkin's disease: treatment and splenectomy risk factors. Med Pediat Oncol 1989; 17: 477-84. 43. Lister TA, Crowther D. Staging for Hodgkin's disease. Semin Oncol 1990; 17: 696-703. 44. Jereb B, Tan C, Bretsky S, et al. Involved field (IF) irradiation with or without chemotherapy in the management of children with Hodgkin's disease. Med Pediat Oncol 1984; 12: 325-32. 45. Sullivan MP, Fuller LM, Chen T, et al. Intergroup Hodgkin's disease study in children of Stage I and II - a preliminary report. Cancer Treatment Rep 1982; 66: 937-47. 46. Russell KJ, Donaldson SS, Cox RS, et al. Childhood Hodgkin's disease: patterns of relapse. J Clin Oncol 1984; 2: 80-7. 47. DionetC, Oberlin 0, HalrandJL, et al. Initial chemotherapy and low-dose irradiation in limited fields in childhood Hodgkin's disease - results of a joint cooperative study by the French Society of Paediatric Oncology (SFOP) and Hopital St Louis, Paris. Int J Radial Oncol Biol Phys 1988; 15: 341 -6. 48. Ekert H, Waters KD, Smith PJ, et al. Treatment with MOPP and ChlVPP chemotherapy only for all stages of childhood Hodgkin's disease. J Clin Oncol 1988; 6: 1845-50.

References 383 49. Dady PJ, McElwain TJ, Austin DE, et al. Five year experience with ChlVPP. Effective low toxicity combination chemotherapy for treatment of Hodgkin's disease. BrJ Cancer 1982; 45: 851-9. 50. Bonnadonna G, Zucali R, Monfardini S, et al. Combination chemotherapy of Hodgkin's disease with adriamycin, bleomycin, vinblastine and imidazole carboxamide versus MOPP. Cancer 1975; 36: 252-9. 51. Donaldson SS, Whitaker SJ, Plowman PN, et al. Stage l-ll pediatric Hodgkin's disease: long term follow-up demonstrates equivalent survival following different management schemes..J Clin Oncol 1990; 8:1128-37. 52. Jenkin DR, Chan H, Freedman M, et al. Hodgkin's disease in children: treatment results with MOPP and low-dose, extended-field irradiation. Cancer Treatment Rep 1982; 66: 949-59. 53. Oberlin 0, Leverger G, Pacquement H, et al. Low-dose radiation therapy and reduced chemotherapy in childhood Hodgkin's disease: the experience of the French Society of Pediatric Oncology. J Clin Oncol 1992; 10:1602-8. 54. Schellong G, Bramswig JH, Hornig-Franz I. Treatment of children with Hodgkin's disease: results of the German Pediatric Oncology Group. Ann Oncol 1992; (suppl 4): 73-6. 55. Maity A, Goldwein JW, Lange B, et al. Comparison of highdose and low-dose radiation with and without chemotherapy for children with Hodgkin's disease: an analysis of the experience at the Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania. J Clin Oncol 1992; 10: 929-36. 56. Lipschultz SE, Colon SD, Gelber RD, et al. Late cardiac effects of doxorubicin therapy of acute lymphoblastic leukaemia in childhood. N Engl J Med 1991; 324: 808-15. 57. Steinherz LJ, Steinherz PG, Tan CT, et al. Cardiac toxicity 4 to 20 years after completing anthracycline therapyJ/W/l 1991; 266:1672-7. 58. Silber JH, Jakacki Rl, Larsen RL, et al. Forecasting cardiac function after anthracyclines in childhood - role of dose, age and gender. In: Bricker JT, Green DM, D'Angio GJ, eds Cardiac toxicity after treatment for childhood cancer. New York: Wiley-Liss Inc., 1992: 95-102. 59. Hunger SP, Link MP, Donaldson SS. ABVD/MOPP and lowdose involved-field radiotherapy in pediatric Hodgkin's disease - the Stanford experience. J Clin Oncol 1994; 12: 2160-6. 60. Hudson MM, Poquette CA, Lee J, et al. Increased mortality after successful treatment for Hodgkin's disease.; Clin Oncol 1998; 16: 3592-600. 61. Haddy TB, Adde MA, McCalla J, et al. Late effects in longterm survivors of high-grade non-Hodgkin's lymphomas. J Clin Oncol 1998; 16: 2070-9. 62. Shalet SM, Rosenstock JD, Beardwell CG, et al. Thyroid dysfunction following external irradiation to the neck for Hodgkin's disease in childhood. Clin Radiol 1977; 8: 511-5.

63. Donaldson SS, Kaplan HS. Complications of treatment of Hodgkin's disease in children. Cancer Treatment Rep 1982; 66: 977-89. 64. Shafford EA. Personal communication. 65. Chapman RM, Sutcliffe SB, Malpas JS. Cytotoxic induced ovarian failure in women with Hodgkin's disease. JAMA 1979; 242:1877-1. 66. Waxman JH, Terry YA, Wrigley PFM, et al. Gonadal function in Hodgkin's disease: long term follow up of chemotherapy. BrMedJ 1982; 285:1612-3. 67. Sherins RJ, Olweny CLM, Ziegler JL Gynaecomastia and gonadal dysfunction in adolescent boys treated with combination chemotherapy for Hodgkin's disease. N Engl y Med 1978;299:12-16. 68. Shafford EA, Kingston JE, Malpas JS, et al. Testicular function following the treatment of Hodgkin's disease in childhood. BrJ Cancer 1993; 68:1199-204. 69. Aubier F, Flamont F, Brauner R, et al. Male gonadal function after chemotherapy for solid tumours in childhood.; Clin Oncol 1984; 7: 304-9. 70. Ortin TTS, Shostak CA, Donaldson SS. Gonadal status and reproductive function following treatment for Hodgkin's disease in childhood - the Stanford experience. Int J Radial Oncol Biol Phys 1990; 19: 873-80. 71. Robertson CM, Stiller CA, Kingston JE. Causes of death in children diagnosed with non-Hodgkin lymphoma between 1974 and 1985. Arch Dis Childhood 1992; 67: 1378-83. 72. Wolden SL, Lamborn KR, Cleary SF, Tate DJ, Donaldson SS. Second cancers following pediatric Hodgkin's disease. J Clin Oncol 1998; 16: 536-44. 73. Robertson CM, Hawkins MM, Kingston JE. Late deaths and survival after childhood cancer - implications for care. Br MedJ 1994; 309:162-6. 74. Hawkins MM, Draper GJ, Winter DL. Cancer in the offspring of survivors of childhood leukaemia and non-Hodgkin's lymphoma. BrMedJ 1995; 71: 1335-9. 75. Wasserman AL, Thompson El, Wiliams JA, et al. The psychological status of survivors of childhood/adolescent Hodgkin's disease. AmJ Dis Childhood 1987; 141: 626-31. 76. Allen A, Malpas JS, Kingston JE. The educational achievements of survivors of childhood cancer. Pediat Hematol Oncol 1990; 7: 339-45. 77. Fisher Rl, Gaynor ER, Dahlberg S, et al. A Phase III comparison of CHOP vs. m-BACOD vs. ProMACE-CytaBOM vs. MACOP-B in patients with intermediate or high-grade non-Hodgkin's lymphoma. Results of SWOG 8576 (Intergroup 0067) the National High Priority Lymphoma study. Ann Oncol 1994; 5: 591-5. 78. Philip T, Hartmann 0, Pinkerton CR, et al. Curability of relapsed childhood B-cell non-Hodgkin's lymphoma after intensive first line therapy. A report from the Societe Francaise d'Oncologie Pediatrique. Blood 1993; 81: 2003-6.

384 Pediatric lymphomas 79. O'Brien MER, Pinkerton CR, Kingston JE, et al. 'VEEP' in

80. James ND, Kingston JE, Plowman PN, et al. Outcome of

children with Hodgkin's disease - a regimen to decrease

children with resistant and relapsed Hodgkin's disease,

late sequelae. BrJ Cancer 1992; 65: 756-60.

BrJ Cancer 1992; 66:1155-8.

28 Lymphoma in the elderly PWM JOHNSON

Introduction - the scale of the problem Is lymphoma in the elderly a different disease? Is advanced age perse a prognostic factor? Age-specific considerations in lymphoma treatment

385 386 386 388

INTRODUCTION - THE SCALE OF THE PROBLEM The increasing longevity of the population and the escalating incidence of neoplasia with age (1000-fold between the ages of 40 and 801) have combined to produce a rising number of elderly patients with all types of malignancy. Lymphoma, particularly of non-Hodgkin's types (NHL) is no exception to this.2 In populationbased registries the median age at presentation of NHL is 65, with up to 40 per cent over the age of 70.3'4 In addition, the age-adjusted annual incidence of NHL has more than doubled in the last 40 years, and data from the North American surveillance, epidemiology and endresults (SEER) program shows a nearly 60 per cent increase between 1973 and 1989, much of this in the elderly.5 The largest rise has been seen among Caucasian males aged 75 or older, where a 300-400 per cent increase occurred in the same interval6 (Fig. 28.1). Hodgkin's disease has not shown the same degree of rise and the age-adjusted incidence remains stable. The bimodal age distribution with one peak in the third decade and a rising incidence from the fifth decade onwards persists, although a proportion of cases in the older population have now been recognized as low-grade NHL. The relative proportion of elderly patients in different series varies considerably according to patterns of referral. A population-based survey from Stockholm in the 1970s had 43 per cent of patients over the age of 507 and a national study in the USA had 20 per cent of cases presenting at over 60 years.8 However, the International Database in Hodgkin's Disease (IDHD), which collated data on over 14 000 patients from 20

Treatment strategies Conclusions References

390 393 393

groups world-wide, had only 8 per cent over the age of 60 and a report from a single center (Stanford) had only 4 per cent in this age group.9 Despite their numerical importance, lymphomas in the elderly have been relatively little studied. In reported trials of treatment, the usual median age of patients with NHL is around 50 and for Hodgkin's disease 35. Most protocols exclude patients older than 65 or 70. In a registration study of seven centers in the South-West Oncology Group, among 76 elderly patients with aggressive lymphomas, only 21 (28 per cent) entered trials, principally due to exclusion from protocol criteria (39 cases) or elective choice of different therapy (16 cases).10 As a consequence, it is difficult to know whether the strategies for treatment established in younger populations may be

Figure 28.1 Overall incidence of non-Hodgkin's lymphoma in Yorkshire showing a rising trend over time. Data from Yorkshire Cancer Registry.

386 Lymphoma in the elderly

extrapolated to the elderly. The difficulties of selection bias are well documented in lymphoma trials and may just as well apply to age as any other criterion. These problems have led to the organization of some trials specifically designed to optimize lymphoma cure rates in the elderly. Previous reluctance to employ intensive chemotherapy in older patients is being overcome by the realization that life expectancy at the age of 85 is 7 years in women and 51/2 years in men,11 so that treatment having a significant impact upon 5-year survival is of considerable importance. Similarly, the finding that intensive treatment may result in improved quality of life if the response rate is increased, has demonstrated that an impact on duration of life is not necessarily at the expense of its quality.

IS LYMPHOMA IN THE ELDERLY A DIFFERENT DISEASE? Non-HodgkirTs lymphoma The biology and behavior of NHL in the elderly does not appear to differ significantly from that occurring in younger patients, although some points have been made in the literature (without great consistency), particularly concerning histologic types and the sites of disease. The distribution of histologic subtypes is generally similar in older patients, with diffuse large cell being the commonest and comprising about 40 per cent of most series.4,12,13 Two registry studies have suggested a disproportionate increase in diffuse histology with age,4,14 although this may be attributable to referral bias against low-grade lymphomas, fewer diagnostic biopsies being performed in elderly patients with lymphadenopathy but no other symptoms. There is, however, evidence to suggest less follicular lymphoma, and more immunocytoma and mantle cell lymphoma in the elderly.4,15 The data relating the extent of disease to age are conflicting, suggesting that there is probably no true correlation. One registry study suggested more localized disease among the elderly,4 although this may be a function of less intensive staging investigations. Conversely, in 157 patients, the Nebraska Lymphoma Study Group showed no difference in stage distribution with age,16 a finding confirmed in a single-center study of 192 patients with uniform staging investigations.17 Most critically, the International NHL Prognostic Factors Project, including over 3000 patients treated at different centers in Europe and North America, showed no difference in the distribution of risk categories for patients above or below the age of 60.18 The frequency of extranodal involvement is a further point of contention but again there is probably no substantial difference. The Danish registry study4 and several retrospective analyses from single centers19 suggested a higher rate of extranodal

involvement in the elderly, although this was not apparent in the larger series from the Nebraska Lymphoma Study Group,16 where the rates were identical at all ages. Hodgkin's disease The unusual age distribution of Hodgkin's disease suggests strongly that different pathogenetic processes may be responsible for the younger and older peaks of incidence. Evidence in support of this comes from an epidemiological study of cases in the UK, which showed different geographic associations in patients below the age of 35 and above 50, with trends of risk according to the socioeconomic status of the areas moving in opposite directions.20 The contentious question of the role of the Epstein-Barr virus has impinged upon this issue, with the finding that the viral genome may be more frequently detected in patients below the age of 15 and over the age of 50 than in the young adult group.21 This finding is consistent with the differing pattern of histologic types in the elderly, where mixed cellularity disease is as common as nodular sclerosis.722 The detection of both viral genome and protein has been shown most commonly in mixed cellularity disease.23,24 As well as having an increased proportion of mixed cellularity disease, the elderly more often have B symptoms, advanced stage, poor performance status, raised sedimentation rate and low serum albumin.25,'26 All these features suggest a different biological pattern and may contribute to their poorer prognosis, as outlined later.

IS ADVANCED AGE PER SE A PROGNOSTIC FACTOR? A previous review27 found that the data relating age to the outcome of therapy in NHL were inconclusive. This situation has been largely remedied since that time with the publication of several retrospective series.

Intermediate- and high-grade nonHod gkin's lymphoma The diffuse aggressive lymphomas have been the subject of several studies concerning prognostic factors (Table 28.1). These in general confirm that the elderly tolerate conventional combination chemotherapy less well, are less likely to reach complete remission, have less durable remissions and overall have shorter survival times. The International NHL Prognostic Factors Project has been particularly influential in this analysis, although some doubts remain concerning the variety of treatment regimens employed and their possible impact upon the outcomes. The least secure information concerns the complete

Is advanced age per se a prognostic factor? 387

Table 28.1 Studies relating the outcome of treatment for diffuse aggressive lymphoma to age

16 28 90 91 17 92 93 94 18

CAP/BOP (157) m-/M-BACOD (121) CHOP, etc. (105) LNH-84 (737) CHOP/m-BACOD(192) MACOP-B (126) CHOP-B (250) CHOP-M(118) Various (3273)

63 58 50 55 56 54 56

29 (65) 28 (60) 36 (65) 9(65) 38 (65) 32 (60) 50 (56) 36(60) 41 (60)

Yes

No

No

No

No No

No Yes

No No No Yes Yes

Yes Yes -

Yes (M)

No Yes (M) Yes (M) Yes (M) Yes (M)

Yes Yes Yes (marginal)

(M) = multivariate analyses of overall survival, CR = complete response.

response rates and the durability of remission. Data from one single-center study shows identical responses in the different age groups,28 another shows a non-significant reduction16 and the International Project shows a relatively minor difference in complete response (CR) rates (68 per cent up to age 60 and 62 per cent above). Similarly, durability of remission appears much less in the elderly population in the International Project, although this result was not anticipated from the studies previously published.16,17,28 It is quite likely that the singlecenter series employed more uniform dose intensities than the International Collaborative project and this may account for the differences. An earlier analysis from the Southwest Oncology Group showed that a difference in response rates in the elderly was abolished, if only patients initially receiving full doses of chemotherapy were considered. There was no difference in the duration of remissions.29 Few of the series subsequently published take systematic account of dose reductions, which are often applied ad hoc for the elderly and which the data from SWOG suggest may be responsible for an inferior outcome. Clearly the reasons for initial dose reduction may relate to the condition of the patient in many cases, but the data support the administration of full doses if this is feasible. The impact of age on overall survival seems securely established by the multivariate analyses cited, despite some negative results in other series. The studies which have shown a significant relationship between age and survival include some using standardized chemotherapy and have taken account of the causes of death. In the overwhelming majority of cases, death is due to either lymphoma or toxicity, and comparison of mortality rates to age-matched cohorts of the general population shows a significant reduction in longevity. It has been suggested, however, that, in elderly patients with aggressive lymphomas treated with doxorubicin-based chemotherapy (CHOP), the risk of treatment-related death maybe associated with poor performance status rather than with increasing chronological age.30

Low-grade non-Hodgkin's lymphoma In low-grade lymphomas, the influence of patient age on survival is more difficult to judge, appearing to show significance in proportion to the number of patients with advanced disease over 60 included in the study. In series with only one-quarter to one-third over 60, age has not emerged as significant,31,32 whereas with half or more over 60 it does.33,35 A retrospective analysis of 212 patients with follicular lymphomas treated at St Bartholomew's Hospital over a 20-year period demonstrated age as a significant predictor of survival in multivariate analysis, not only at the time of presentation but also following recurrence.36 The International Prognostic Factor index has been applied to low-grade lymphomas and discriminates groups of differing prognosis as well as in aggressive lymphoma, suggesting that the same factors (including age) predict the outcome of treatment.37

Hodgkin's disease Many studies have established age as an adverse prognostic factor in Hodgkin's disease, with a continuous decline in overall and cause-specific survival rates from the age of 40 onwards.7,25,38 This appears to hold for both limited39,40 and extensive disease.26,38,41 The largest reported series from the USA examined the outcomes in 6314 patients with disease of all stages and found a significant decline in 5- and 10-year survival with advancing age, a decline which persisted when only deaths related to lymphoma or its treatment were included (Fig. 28.2).8 The most comprehensive data on the prognostic significance of age come from the IDHD, as shown in Table 28.2. In stepwise proportional hazards models, the relative risk of death from all causes was 5.09 in patients over 60, for deaths due to Hodgkin's disease it was 3.21 and for deaths from unrelated causes (but including ischemic heart disease and second malignancy) it was 14.28. (All

388 Lymphoma in the elderly

It is important to note that the bad prognostic influence of age in Hodgkin's disease has been tested in multivariate analyses, given the differences in histologic subtype and extent of disease in the elderly, which might anyway be expected to worsen the prognosis. The treatment of Hodgkin's disease at all stages is thus less successful in the elderly: complete response rates are lower, and cause-specific survival is shorter. If remission is achieved, however, the effect of age on its duration is relatively small by comparison with the influence on overall survival, and negligible in early stage disease. The differences in more advanced disease may well be attributable to reduced dosing. It is notable that the results of 'salvage' chemotherapy for recurrence after apparently successful primary treatment are particularly poor in the elderly42,43 and even the incidence of second malignancies is higher.44,46 Clearly, some of these findings may be attributable to suboptimal treatment in frail older patients and their poor tolerance of therapy, but it is difficult to avoid the conclusion that the underlying biology of the disease differs in this age group.

AGE-SPECIFIC CONSIDERATIONS IN LYMPHOMA TREATMENT There is a variety of factors, apart from the different patterns of disease, which may influence the success of treatment for malignant lymphoma in the elderly. Figure 28.2 Ten-year cause-specific survival of patients with Hodgkin's disease, divided by age at diagnosis, o—o = < 75 years (n = 343), •—• = 75-24 years (n = 1572), D—D = 25-34 years (n = 1180), — = 35-49 years (n = 992), — = 50-64 years (h = 1020), m—m = 65 years (n = 911). Reproduced with permission from Kennedy et al. National survey of patterns of care for Hodgkin's disease. Cancer 7985; 56:2547-56.

these figures are statistically significant with P < 0.001). For all clinical stages of disease, age greater than 50 was associated with a significantly lower complete response rate in stepwise logistic regression.

Pharmacology Most early clinical studies of pharmacology, particularly pharmacokinetics, were carried out in a young population of patients. Some observations have been made concerning the different handling of drugs with age but there remain significant gaps in the state of knowledge. Several factors alter pharmacokinetics in the elderly. Although little difference has been demonstrated in absorption, first-pass metabolism or protein binding,47 the rise in body fat and fall in lean mass and body water with age can reduce the volume of distribution,

Table 28.2 Results of stepwise proportional hazards models on relapse-free and overall survival among 14315 patients registered on the International Hodgkin's Disease Database. All the risk ratios are significant with P < 0.001 except *, where P < 0.01

IA IIA IB/MB IMA 1MB IV

2542 4038 1617 1301 1267 819

1.35(40) NS NS 1.47* (50) 1.74* (60) 1.78(50)

9.41 6.07 3.83 4.18 4.00 2.86

4.26 2.93 2.46 2.48 2.99 2.10

23.44 16.34 18.97 8.91 8.75 14.15

Age-specific considerations in lymphoma treatment 389

particularly of water-soluble drugs. More significant is the alteration in excretory capacity of the kidneys and liver with age. The glomerular filtration rate falls by 10 per cent per 10 years after the fourth decade,48 which may have an appreciable effect on renally excreted drugs, such as cyclophosphamide, melphalan and methotrexate. Liver function shows a similar decline, with a reduction in size and hepatic blood flow: from 1400 ml/minute at 30 to 800 ml/minute at 75.49 The interindividual variation of hepatic metabolism at all ages makes it difficult to predict specific alterations in drug handling, but the available studies suggest that oxidative pathways are more likely to decline with age than conjugation.50 ANTITUMOR ANTIBIOTICS

The excretion of doxorubicin and daunorubicin is predominantly biliary. This leads to a reduction in their clearance with age,51 contributing to a lowered threshold for the well-described dose-dependent incidence of cardiotoxicity. Whereas this becomes a significant risk at a cumulative dose of 450 mg/m2 in the younger population, beyond the age of 70 the figure is nearer to 300 mg/m2. Because of this, mitoxantrone is becoming more widely used as an alternative agent on the basis of its considerably lower potential for cardiotoxicity at equitherapeutic doses. Bleomycin-induced pulmonary toxicity is also reported more frequently in the elderly.52 Whether this is due to a decrease in the 50 per cent of excretion, which occurs through the kidneys or slower conversion to inactive metabolites in the lungs, is not known. ALKYLATING AGENTS

Cyclophosphamide metabolism may be influenced unpredictably by increasing age. The volume of distribution (approximating that of body water) is reduced, but so is hepatic oxidative metabolism to 4-hydroxycyclophosphamide and phosphoramide mustard. A reduction in renal clearance may also result in a prolonged half-life, both for the parent drug and its metabolites.53 Overall, the effect of age is likely to relate closely to the renal function and, provided this is maintained, no specific adjustment is required. Chlorambucil at the doses commonly employed does not appear to be handled differently in the elderly. ANTI METABOLITES

Methotrexate is predominantly cleared by the kidneys and, even in the absence of frank renal impairment, the initial half-life increases with age, resulting in increased toxicity.54 A reduction in the dose and, where appropriate, an increase in duration of folinic acid rescue are indicated in the elderly. There are no systematic data regarding the metabolism of fludarabine in older patients, but no undue toxicity has been reported from extensive trials in patients with chronic lymphatic leukemia and low-grade lymphoma.55

PLANT ALKALOIDS

The vinca alkaloids appear to be less rapidly cleared by hepatic metabolism in older patients, with considerably increased neurotoxicity as a consequence.38 In general it is recommended that the dose is electively reduced in patients over the age of 70. The handling of etoposide varies widely between individuals and, although it is not systematically influenced by age,56 unpredictable myelosuppression is more commonly reported.

Hematologic tolerance The most obvious reason for attenuation of treatment intensity in the elderly is the possibility of a decline in hemopoietic reserve. In practice, there is little evidence that this is the case, in the healthy resting state at least. A study comparing the numbers of bone marrow progenitors in healthy subjects over the age of 70 and in a control group aged 20-25 showed no difference in either erythroid or myeloid cell mass.57 Longitudinal studies similarly have shown no decline in hematocrit or cell numbers with age. The response to marrow stimulation is, however, blunted in the elderly at least partly owing to impaired production of colony stimulating factors by the stroma, as has been demonstrated in vitro using interleukin-1 as a trigger.58 Exogenous administration of granulocyte colony-stimulating factor (G-CSF), interleukin-3 (IL-3) or erythropoietin has been shown to produce identical initial responses in patients above or below the age of 65,59 but more prolonged administration reveals a divergence between the age groups, with the older patients apparently unable to sustain the same rate of increase. After 5 days of G-CSF, patients aged 20-30 showed a mean 80-fold increase in the numbers of circulating granulocyte-macrophage colony forming units (CFU-GM), whilst those aged 70-80 showed only a mean 40-fold rise.60 These factors may clearly have an adverse effect on recovery times following myelosuppressive treatment. A recent study from South America has suggested that, within the older population, further subdivision by age may be appropriate: among patients treated with CHOP and granulocyte-macrophage colony stimulating factor (GM-CSF), those over 70 were significantly more prone to myelosuppression, neutropenic fever and dose delays than those between 60 and 70.61 In older patients with malignancy, the proliferative response of the bone marrow may be blunted even before treatment. Studies in small cell lung cancer patients younger than 60 have shown an increase in myeloid cell mass compared to healthy controls, a response absent in those older than 60. Erythroid mass was decreased in both age groups compared to healthy controls, but significantly more so in the older group.62

390 Lymphoma in the elderly

Despite these observations, in patients without other significant illnesses, the incidence and severity of myelosuppression do not appear to be much greater in the elderly. A large South-West Oncology Group trial in diffuse large cell lymphoma failed to demonstrate a significant difference in the frequency of severe leukopenia or thrombocytopenia, even for 23 patients over 65 who received full-dose CHOP as initial therapy.29 This observation is supported by data from a study in 62 patients over the age of 65 also treated for aggressive lymphoma, among whom no increase in marrow toxicity was seen with increasing age.63 In Hodgkin's disease, the Cancer and Leukemia Group B showed a significantly higher incidence of severe hematological toxicity in patients over the age of 60, with 33 per cent affected compared to 14 per cent in the younger group.38 This, however, remains the only large series of lymphoma patients given uniform treatment in which hematologic toxicity and age have been reliably correlated. In general, doses have been electively reduced in the elderly,64 making direct comparisons impossible.

Non-hematologic tolerance and co-morbidity Age-related factors, which may limit the capacity to tolerate chemotherapy or radiotherapy, can apply to almost any bodily system. In general, these assume relevance in proportion to the intensity of treatment, with lesser degrees of toxicity compensated by the normal responses. Adaptation to stress is, however, blunted in almost every respect with advancing age, although there have been few systematic studies in relation to cancer treatment. The capacity for tissue repair is a particular consideration in lymphoma therapy, especially in relation to gastrointestinal, neurologic and pulmonary damage. Toxicity in all these tissues is more marked as a rule in the elderly, with a corresponding increase in mortality from causes other than lymphoma.16,65 The progressive declines in both cell-mediated and humoral immune effectors with age are well documented.66 These may result in both increased toxicity of treatment and a higher rate of recurrence, if host immunity is partly responsible for restraint or elimination of the malignant cell population. The co-existence of other illnesses is a further aspect of medical care in an elderly population that may significantly affect the capacity to deliver curative treatment. One series of elderly patients with Hodgkin's disease included one-third with significant co-morbidity.64 Numerically most important among these is cardiovascular disease. The changes in the healthy cardiovascular system which progress with age include a loss of elasticity both in arterial walls and the myocardium. If hypertension and coronary ischemia are superimposed on

these, the ability to increase cardiac output in response to stress is markedly impaired.67 At least one study has shown a history of cardiac disease to have a significantly adverse prognostic influence on the outcome of treatment for lymphoma, as a consequence of increased early deaths.68

TREATMENT STRATEGIES Diffuse large cell NHL The treatment of aggressive lymphomas in the elderly has been studied increasingly in the last 5 years, to some extent recapitulating the development of successive generations of combination chemotherapy in the younger population. Several regimens have been developed specifically for use in this age group. This followed the anticipated finding of increased treatment-related mortality in older patients treated with full-dose CHOP or similar, often approaching 30 per cent.65,69 As has already been described, elective reduction in dose intensity reduces toxicity at the expense of outcome. The challenge, therefore, is to design a regimen that can be administered with less toxicity than CHOP, but for which the response rate and durability of remission are similar. LOCALIZED DISEASE

The relatively uncommon presentation of Stage I or IIA disease is probably best treated by an abbreviated course of chemotherapy and involved field radiotherapy, with a high expectation of cure.70 An analysis of 75 patients over the age of 70 treated in Omaha, Nebraska, showed the use of combination CAP-BOP chemotherapy with radiotherapy to give a 5-year failure-free survival of 47 per cent, compared to 35 per cent for CAP-BOP alone and 10 per cent for radiotherapy alone (P = 0.016).68 Although this was a retrospective analysis, multivariate statistics suggested a genuine benefit for combined treatment. In a randomized study of all ages by the SouthWest Oncology Group, the use of three cycles of CHOP followed by involved field radiotherapy resulted in a similar response rate and freedom from progression to eight cycles of CHOP, but survival in the latter arm was inferior due to a higher mortality from the complications of therapy, particularly cardiac disease.71 If anything, the results of local radiotherapy alone are less favorable in the older age group and this approach should be reserved for those in whom only symptomatic palliative treatment is possible. ADVANCED DISEASE

As already mentioned, the trade-off between sufficient intensity of treatment and excessive toxicity is more acute

Treatment strategies 391

Table 28.3 Results of treatment with regimens specifically designed for older patients with diffuse aggressive lymphomas (adapted from reference 95)

65 96 72 72 69 16 17 97 98 99 100 101 102 77 77 103 104 105 106 78 107

CHOP

20

75

45

13

25

-

30

CNOP

30 76 72 141 112 60 29 31 21 21 52 55 40 32 63 26 40 60 67 41

70 71 70 71 66 72 76

60 31 49 -

12 13 26 37 15 >18 12 16 22 20 48 9 6 25 >24 >24

26 42 48 36 58 21 30 45 48 40 45 38 -

13 17 -

0 11 6 1 7 0 0 19 0 0 6 2 5 6 8 15 0 2 0 2

CNOP CHOP COPA CAP/BOP m-BACOD VNCOP-B CEMP

E+ P IfmVP

VMP MVP Ld-ACOP-B VABE P/DOCE BECALM

PEN P-VABEC P-VEBEC MiCEP

All > 70

76 75 72 73 75 75 74 67 71 73

61 65 76 58 48 75 46 55 65 63 62 42 59 75 66 68

55 50 63

70 48 12 37 30 52 45 41 50 45 35 -

CR = complete response.

in the elderly. In many cases the threshold for cure is not attainable by conventional approaches, such as CHOP, and considerable effort has been spent in devising means by which the therapeutic index may be improved. The three principal strategies have been different drugs, different schedules and haemopoietic growth factors. To date, few randomized trials have been completed but there is a wealth of phase II data (Table 28.3). The greatest interest in different drugs has related to newer anthracycline derivatives or substitutes. Mitoxantrone in particular has been put forward as a less cardiotoxic agent with apparently comparable cytotoxicity to doxorubicin. Certainly the treatment-related mortality in trials of CNOP (cyclophosphamide, mitoxantrone, vincristine, prednisolone) and VNCOP-B (etoposide, mitoxantrone, cyclophosphamide, vincristine, prednisolone, bleomycin) was much lower than expected. Three randomised studies have been performed. The first report suggested that CNOP using 10 mg/m2 mitoxantrone had an inferior complete remission rate and overall survival rate compared to CHOP using 50 mg/m2 of doxorubicin.72 The median survival in the CNOP arm was 12 months compared to 26 months after CHOP and, disappointingly, there appeared to be no significant difference in hematologic toxicity or the incidence of neutropenic fever. Also, in a European Organisation for Research and Treatment of Cancer (EORTC) Lymphoma Comparative Group study, CHOP

proved significantly superior to VMP (etoposide, mitoxantrone and prednimustine) in patients aged 70 years or over; overall survival was 65% with CHOP and only 30% with VMP.73 The British National Lymphoma Investigation found an opposite result when substituting mitoxantrone 7 mg/m2 for doxorubicin 35 mg/m2 in a weekly alternating schedule in a randomized study of 463 patients older than 60. The treatment failure rate was significantly lower in the mitoxantrone arm, with a significantly higher actuarial 4-year survival of 55 per cent versus 35 per cent.74 The final analysis of data from this study will be important in determining the place of alternative anthracyclines in the elderly. Another recent randomized study by the Group d'Etude des Lymphomes de 1'Adulte (GELA) has demonstrated that, even when an epipodophyllotoxin is used, an anthracycline still adds to the probability of cure in this age group.75 Patients were randomized to receive cyclophosphamide/teniposide/ prednisolone with or without pirarubicin. With a median follow-up of 4 years 7 months, there was a small but significant improvement in the pirarubicin arm (26 per cent projected 5-year survival compared to 19 per cent) despite a higher proportion of patients in this arm having an elevated lactate dehydrogenase level at presentation. The investigation of different treatment schedules has mirrored the studies performed in younger patients.

392 Lymphoma in the elderly

While the large Intergroup study comparing CHOP with third-generation regimens in patients up to 81 failed to demonstrate a difference in any subgroup,76 there are particular reasons to prefer weekly regimens in the elderly. Among these are the opportunities for more frequent medical supervision during treatment and the capacity to reduce doses electively before extreme myelotoxicity develops. The approach of the Vancouver group in modifying weekly regimens by removal of methotrexate, substitution of epirubicin for doxorubicin and shortening to 8 weeks' therapy appears to have produced good results with a 45 per cent 3-year overall survival.77 Similar findings have come from an Italian study of P-VEBEC (prednisolone, vinblastine, etoposide, bleomycin, epirubicin, cyclophosphamide) with a reported 55 per cent overall survival at a median of 24 months.78 Another group has tested consolidation with idarubicin, cisplatin and prednisolone following PVABEC and reported promising results in an initial study with actuarial 4-year survival of 92 per cent, although the median follow-up was less than this.79 Clearly selection bias may have contributed greatly to these results and randomized testing will be an important field in the next few years. The use of hemopoietic growth factors to shorten neutropenia and possibly reduce mucositis is an obvious extension to treatment of aggressive lymphoma in the older patient. A cost-benefit analysis comparing two consecutive cohorts of patients receiving CHVmP/VB (cyclophosphamide, doxorubicin, teniposide, prednisolone, vincristine, bleomycin) with and without GCSF gave comparable response rates but markedly fewer treatment delays, severe myelosuppression, mucositis and days in hospital for those receiving G-CSF.80 The costs of supportive therapy with antibiotics and blood products were significantly lower in the G-CSF arm, although the cost of the growth factor itself overturned this advantage with a mean 57 per cent increase in the total cost per patient. Randomized studies are now required to examine whether the added cost will be justified by an increased cure rate or whether non-hematologic toxicity will become limiting. One such study in Italy has used VNCOP-B with half the patients randomized to receive G-CSF.81 The response rates, recurrencefree survival and overall survival were identical in the two arms, although, as expected, the incidence of severe neutropenia and clinically relevant infection were significantly reduced by G-CSF. There is at least sufficient data to suggest hypotheses worth testing in older patients with aggressive lymphomas, although the apparent lack of progress beyond CHOP in the younger age group is discouraging. Careful randomized trials are under way and in planning to examine the newer regimens, the role of growth factors and other approaches, such as the addition of monoclonal antibodies,82 and the results will be awaited with interest.

Low-grade NHL The relatively straightforward therapies employed against low-grade lymphomas generally require little adjustment in the elderly. Expectant management is often an attractive option for those without compressive symptoms, rapid progression or bone marrow compromise. Involved field radiotherapy may be useful both for long-term control of early disease and palliation of more advanced cases. Age is not necessarily a contraindication to splenectomy, either for hypersplenism or if this is the only site of disease. There is no good evidence that treatment intensity is a critical factor in determining survival following chemotherapy, so that single agents such as chlorambucil or fludarabine may be chosen for their limited toxicity without compromising outcome. Given their minimal contribution to response rates and potential for toxicity, corticosteroids are best avoided unless specifically indicated for autoimmune cytopenias or reversal of marrow suppression prior to starting cytotoxic therapy. The concomitant use of interferon in follicular lymphoma may improve response rates when given with chemotherapy and may prolong remission when used for maintenance.83 The elderly tolerate interferon reasonably well at the doses commonly used in low-grade lymphoma, although there is a higher incidence of toxicity requiring interruption of administration, usually fatigue or myelosuppression. Myocarditis may also be more common. Taken overall, the treatment of low-grade lymphoma in the elderly may be carried out in a way broadly similar to treatment in the younger population, although the results remain inferior. It is not clear why this should be, since the majority of deaths are due to lymphoma and mortality due to the toxicity of treatment does not appear to be more frequent.36 Newer approaches using treatment intensification are clearly not applicable, although the upper age limit is gradually rising as hemopoietic progenitor support becomes more efficient. New agents such as purine analogs are profitably tested in the older population with recurrent disease and, given the shorter survival times with conventional approaches, this may be a group in which improvements in survival will be most readily demonstrated.

Hodgkin's disease From the previous discussion of prognostic factors, it is clear that Hodgkin's disease in the older patient may require a different approach to that in the younger patient. The particular circumstance where age may determine the initial treatment is that of localized disease, since the figures suggest a higher rate of recurrence in patients over 40 treated with radiotherapy alone, except in those rare cases with lymphocyte-predominant

References 393

disease confined above the thyroid notch.40 The EORTC H5U trial showed that the treatment of choice for patients with early-stage Hodgkin's disease over the age of 40 includes chemotherapy. Patients in this age group were randomized between subtotal or total nodal irradiation and six cycles of MOPP with mantle radiotherapy given between the third and fourth cycles. Those treated with the combined modalities showed a significantly better recurrence-free survival, although the overall survival figures are difficult to interpret owing to an excess of apparently unrelated deaths in the radiotherapy arm.84 The documented poor response to 'salvage' treatment in older patients with recurrent disease following initial radiotherapy is a further incentive to the use of a combination approach from the outset,43 although the intensity of chemotherapy required and the extent of radiotherapy have yet to be determined. Both are almost certainly less than the amounts used in H5U, and the current EORTC study employs involved-field irradiation with anthracycline-containing chemotherapy.85 It may be that the VBM regimen developed at Stanford will prove equally effective with less toxicity.86 A further step would be to exclude radiotherapy from treatment altogether, for which there is some support in the data from the National Cancer Institute study comparing MOPP with radiotherapy.87 This might have the advantage of avoiding the high incidence of ischemic heart disease which complicates mediastinal irradiation in the older patient. Advanced Hodgkin's disease offers less scope for different treatment of the elderly. The emerging data concerning the superiority of anthracycline-containing regimens confirms the persistently worse prognosis for older patients despite the improvements overall. No regimens specifically designed for use in the elderly have been tested and, indeed, the relatively small numbers in this group would make randomized trials of sufficient power difficult to complete. Provided the patient can tolerate it, combination chemotherapy at full doses remains the treatment of choice.88 Patients receiving suboptimal doses of chemotherapy have a markedly worse prognosis, both through failure to reach complete remission89 and higher rates of recurrence.64 Hemopoietic growth factors may be helpful in maintaining treatment intensity, although no trial addressing this point has been completed.

lymphoma there is considerable potential for application of new agents to chronic recurring disease with a poor survival pattern, where improvements may be demonstrable in relatively small trials. In diffuse aggressive lymphoma, the approaches of weekly alternating chemotherapy and growth factor support may be rescued from the equivocal position they have occupied since the randomized studies in younger patients.

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27. Sweetenham J, Williams CJ. Malignant lymphoma in the elderly. In: Hamblin TA, ed. Haematological problems in the elderly. Balliere's Clinics in Haematology, Vol. 1. London: BailliereTindall, 1987; 493-511. 28. Shipp M, Harrington D, Klatt M,et al. Identification of major prognostic subgroups of patients with large-cell lymphoma treated with m-BACOD or M-BACOD. Ann Intern Med 1986; 104: 757-65. 29. Dixon D, Neilan B, Jones S, et al. Effect of age on therapeutic outcome in advanced diffuse histiocytic lymphoma: the Southwest Oncology Group experience. J Clin Oncol 1986; 4: 295-305.

groupe Pierre-et-Marie-Curie controlled clinical trial.7 Clin Oncol 1994; 12: 279-87. 42. Bennett J, Andersen J, Begg C, et al. Age and Hodgkin's disease: the impact of competing risks and possibly salvage therapy on long term survival: an ECOG study. LeukRes 1993; 17: 825-32. 43. Specht L, Horwkh A, Ashley S. Salvage of relapse of patients with Hodgkin's disease in clinical stages I and II who were staged with laparotomy and initially treated with radiotherapy alone. A report from the international database on Hodgkin's disease. Int J Radiat Oncol Biol Physics 1994; 30: 805-11.

References 395 44. Biti G, Cellai E, Magrini SM, et al. 2nd solid tumors and leukemia after treatment for Hodgkins-disease - an analysis of 1121 patients from a single institution. IntJ Radial Oncol Biol Phys 1994; 29: 25-31. 45. Dietrich PY, Henry-Amar M, Cosset JM, et al. 2nd primary cancers in patients continuously disease-free from hodgkins-disease-a protective role for the spleen. Blood 1994; 84:1209-15. 46. Van Leeuwen FE, Klokman WJ, Hagenbeek A, et al. Second cancer risk following Hodgkins-disease - a 20year follow-up-study.J Clin Oncol 1994; 12: 312-25. 47. Castleden C, George C. The effect of ageing on hepatic clearance of propranolol. BrJ Clin Pharmacol 1979; 7: 49-54. 48. Wilkinson G. Drug distribution and renal excretion in the elderly. Chronic DisJ 1983; 36: 91-102. 49. Woodhouse K. Drugs and the ageing gut, liver and pancreas. Clinics Gastmenterol 1985; 14: 863-81. 50. Mooney H, Roberts R, Cooksley W, et al. Alterations in the liver with ageing. Clinics Gastroenterol 1985; 14: 757-71. 51. Robert J, Hoerni B. Age dependence of the early phase pharmacokinetics of doxorubicin. Cancer Res 1983; 43: 4467-69. 52. Blum R, Carter S, Agre K. A clinical review of bleomycin -a newantineoplasticagent. Cancer 1973; 31: 903-14. 53. Juma FD, Rogers HJ & Trounce JR. Effect of renal insufficiency on the pharmacokinetics of cyclophosphamide and some of its metabolites. EurJ Clin Pharmacol 1981; 19: 443-51. 54. Hansen HH, Selawry OS, Holland JF, et al. The variability of individual tolerance to methotrexate in cancer patients. BrJ Cancer 1971; 25: 298-305. 55. Hoeck-Pott C, Hiddemann W. Purine analogs in the treatment of low-grade lymphomas and chronic lymphocytic leukemias. Ann Oncol 1995; 6: 421-33. 56. Smyth R, Pfeffer M, Scalzo A, et al. Bioavailability and pharmacokinetics of etoposide (VP-16). Semin Oncol 1985; 12: 48-51. 57. Lipschitz D, Udupa K, Milton K, et al. Effect of age on hematopoiesis in man. Blood 1984; 63: 502-9. 58. Lee MA, Segal GM, Bagby GC. The hematopoietic microenvironment in the elderly: defects in IL-1induced CSF expression in vitro. Exp Hematol 1989; 17: 952-6. 59. Shank WJ, Balducci L. Recombinant hemopoietic growth factors: comparative response in younger and older subjects.J Am GeriatricSoc 1992; 40:151-4. 60. Chatta GS, Price TH, Allen RC, et al. Effects of in vivo recombinant methionyl human granulocyte colonystimulating factor on the neutrophil response and peripheral blood colony-forming cells in healthy young and elderly adult volunteers. Blood 1994; 84: 2923-9. 61. Gomez H, Mas L, Casanova L, et al. Elderly patients with aggressive non-Hodgkin's lymphoma treated with CHOP chemotherapy plus granulocyte-macrophage colonystimulating factor: identification of two age subgroups

62. 63. 64.

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with differing hematologic toxicity. J Clin Oncol 1998; 16: 2352-8. Lipschitz DA. Age-related declines in hemopoietic reserve capacity. Semin Oncol 1995; 22(suppl 1): 3-5. Montgomery P, Beck T, Smith C, et al. Chemotherapy in the elderly. ProcAm Soc Clin Oncol 1982; 1: 56. Levis A, Depaoli L, Urgesi A, et al. Probability of cure in elderly Hodgkin's disease patients. Haematologica 1994; 79: 46-54. Armitage J, Potter J. Aggressive chemotherapy for diffuse histiocytic lymphoma in the elderly: increased complications with advancing age. J Am GeriaticSoc 1984; 32: 269-73. Roberts-Thompson 1C, Whittingham S, Youngchaiyua U, et al. Aging, immune response and mortality. Lancet 1974; 877: 368-70. Bender AD. The effects of increasing age on the distribution of peripheral blood flow in man. J Am Geriatric Soc 1965; 13:192-8. Vose J, Ruby E, Bierman P, et al. Elderly patients with localized diffuse large-cell non-hodgkins-lymphoma (nhl) - improved results with initial chemotherapy. Blood 1994;84: A 383. O'Connell M, EarleJ, Harrington D, et al. Initial chemotherapy doses for elderly patients with malignant lymphoma. J Clin Oncol 1986; 4:1418-22. Oguchi M, Izuno I, Takei K, et al. Treatment for nonHodgkin's lymphoma (stage I, II) of the elderly: usefulness of local and regional irradiation and reduced dose chemotherapy. IntJ Radiat Oncol Biol Phys 1997; 37: 87-92. Miller TP, DahlbergS, CassadyJR, et al. Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade nonHodgkin's lymphoma. N EnglJ Med 1998; 339: 21-6. Sonneveld P, de Ridder M, van der Lelie H, et al. Comparison of doxorubicin and mitoxantrone in the treatment of elderly patients with advanced diffuse non-Hodgkins lymphoma using CHOP versus CNOP chemotherapy. J Clin Oncol 1995; 13: 2530-9. Tirelli U, Errante M, Van Glabbeke M, et al. CHOP is the standard regimen in patients > 70 years of age with intermediate-grade and high-grade non-Hodgkin's lymphoma: results of a randomized study of the European Organization for Research and Treatment of Cancer Lymphoma Cooperative Study Group. J Clin Oncol 1998; 16: 27-34. Cunningham D, Mainwaring PN, Gregory W, et al. A BNLI randomised study of PAdriaCEBO vs PMitCEBO in patients with high-grade lymphoma over 60 years of age. ProcAm Soc Clin Oncol 1998; 17:12a. Bastion Y, Blay J-Y, Divine M, et al. Elderly patients with aggressive non-Hodgkin's lymphoma: disease presentation, response to treatment, and survival -A Groupe d'Etude des Lymphomes de I'Adulte study on 453 patients older than 69 years. J Clin Oncol 1997; 15: 2945-53.

396 Lymphoma in the elderly 76. Fisher Rl, Gaynor ER, Dahlberg S, et al. Comparison of a standard regimen (CHOP) with three intensive chemotherapy regimens for advanced non-Hodgkin's lymphomas. N EnglJ Med 1993; 328:1002-6. 77. O'Reilly S, Klimo P, Connors J. Low-dose ACOP-B and VABE: weekly chemotherapy for elderly patients with advanced-stage diffuse large-cell lymphoma. 7 Clin Oncol 1991;9:741-7. 78. Bertini M, Freilone R, Vitolo U, et al. P-VEBEC: a new 8weekly schedule with or without rG-CSF for elderly patients with aggressive non-Hodgkin's lymphoma (NHL). Ann Oncol 1994; 5: 895-900. 79. Caracciolo F, Capochiani E, Papineschi F, et al. Consolidation therapy with idarubicin, cisplatin and prednisolone after P-VABEC regimen in the treatment of intermediate and high grade non-Hodgkin's lymphoma of the elderly. Leak Lymphoma 1997; 24: 355-61. 80. Zagonel V, Babare R, Merola M, et al. Cost-benefit of granulocyte colony-stimulating factor administration in older patients with non-Hodgkin's lymphoma treated with combination chemotherapy. Ann Oncol 1994; 5: S127-S132. 81. Zinzani PL, Pavone E, Storti S, et al. Randomized trial with or without granulocyte colony-stimulating factor as adjunct to induction VNCOP-B treatment of elderly high-grade non-hodgkins-lymphoma. Blood 1997; 89: 3974-9. 82. Coiffier B, Haioun C, Ketterer N, et al. Rituximab (antiCD20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: a multicenter phase II study. Blood 1998; 92:1927-32. 83. Solal-Celigny P, Lepage E, Brousse N, et al. Recombinant Interferon Alfa-2b combined with a regimen containing doxorubicin in patients with advanced follicular lymphoma. N EnglJ Med 1993; 329:1608-14. 84. Carde P, Burgers J, Henry-Amar M, et al. Clinical Stages I and II Hodgkin's disease: a specifically tailored therapy according to prognostic factors.) Clin Oncol 1988; 6: 239-52. 85. Cosset J, Thomas J, Noordijk E. The current EORTC strategy for stage l-ll Hodgkin's disease. In: Somers R, Henry-Amar M, Meerwaldt JK, Carde P, eds Treatment strategy in Hodgkin's disease. Paris: Colloques INSERM, 1990; 196: 63-5. 86. Horning S, Hoppe R, Hancock SL, et al. Vinblastine, bleomycin and methotrexate: an effective adjuvant in favourable Hodgkin's disease.J Clin Oncol 1988; 6: 1822-31. 87. Longo D, Glatstein E, Duffey P, et al. Radiation therapy versus combination chemotherapy in the treatment of early-stage Hodgkin's disease: seven-year results of a prospective randomized trial.J Clin Oncol 1991; 9: 906-17. 88. Diazpavon JR, Cabanillas F, Majlis A, et al. Outcome of Hodgkin's disease in elderly patients. Hematol Oncol 1995; 13:19-27.

89. Erdkamp F, Breed W, Bosch L, et al. Hodgkin's disease in the elderly - a registry-based analysis. Cancer 1992; 70: 830-4. 90. Slymen D, MillerT, Lippman S, et al. Immunobiologic factors predictive of clinical outcome in diffuse largecell lymphoma. J Clin Oncol 1990; 8: 986-93. 91. Coiffier B, Gisselbrecht C, Vose J, et al. Prognostic factors in aggressive malignant lymphomas: description and validation of a prognostic index that could identify patients requiring a more intensive therapy.J Clin Oncol 1991; 9: 211-9. 92. Hoskins P, Ng V, Spinelli J, et al. Prognostic variables in patients with diffuse large-cell lymphoma treated with MACOP-B. J Clin Oncol 1991; 9: 220-6. 93. Velasquez W, Jagannath S, Tucker S, et al. Risk classification as the basis for clinical staging of diffuse large-cell lymphoma derived from 10-year survival data. Blood 1989; 74: 551-7. 94. Dhaliwal HS, Rohatiner AZS, Gregory W, et al. Combination chemotherapy for intermediate and high Grade non-Hodgkin's Lymphoma. Brj Cancer 1993; 68: 767-74. 95. Coiffier B. What treatment for elderly patients with aggressive lymphoma. Ann Oncol 1994; 873-5. 96. Sonneveld P, Michiels J. Full-dose chemotherapy in elderly patients with non-Hodgkin's lymphoma. A feasibility study using a mitoxantrone-containing regimen. Brj Cancer 1990; 65:105-8. 97. Zinzani P, Bendandi M, Gherlinzoni F, et al. VNCOP-B regimen in the treatment of high-grade non-Hodgkin's lymphoma in the elderly. Haematologica 1993; 78: 378-82. 98. Ansell SM, Falkson G. A phase-ll trial of a chemotherapy combination in elderly patients with aggressive lymphoma. Ann Oncol 1993; 4:172. 99. Tirelli U, Carbone A, Zagonel V, et al. Non-Hodgkin's lymphoma in the elderly: prospective studies with specifically devised chemotherapy regimens in 66 patients. EurJ Cancer Clin Oncol 1987; 23: 535-40. 100. Tigaud J, Demolombe S, Bastion Y, et al. Ifosfamide continuous infusion plus etoposide in the treatment of elderly patients with aggressive lymphoma. A phase II study. Hematol Oncol 1991; 9: 225-33. 101. Tirelli U, Zagonel V, Errante D, et al. A prospective study of a new combination chemotherapy regimen in patients older than 70 years with unfavourable non-Hodgkin's lymphomaj Clin Oncol 1992; 10: 228-36. 102. Salvagno L, Contu A, Bianco A, et al. A combination of mitoxantrone, etoposide and prednisone in elderly patients with non-Hodgkin's lymphoma. Ann Oncol 1992; 3: 833-7. 103. O'Reilly s, Connors J, Howdle S, et al. In search of an optimal regimen for elderly patients with advancedstage diffuse large-cell lymphoma: results of Phase II study of P/DOCE chemotherapy.; Clin Oncol 1993; 11: 2250-7.

References 397 104. McMaster M, Johnson D, Greer}, et al. A brief-duration combination chemotherapy for elderly patients with poor-prognosis non-Hodgkin's lymphoma. Cancer 1991; 67:1487-92. 105. Goss P, Burkes R, Rudinskas L, et al. Prednisone, oral etoposide, and novantrone for treatment for nonHodgkin's lymphoma: a preliminary report. Semin Hematol 1994; 31: s23-s29.

106. Martelli M, Guglielmi C, Coluzzi S, et al. P-VABEC: a prospective study of a new weekly chemotherapy regimen for elderly aggressive non-Hodgkin's lymphoma. J Clin Oncol 1993; 11: 2362-9. 107. Bellesi G, Rigacci L, Alterini R, et al. A new protocol (MiCEP) for the treatment of intermediate or high-grade non-Hodgkin's lymphoma in the elderly. Leuk Lymphoma 1996; 20: 475-80.

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29 Infections BCROSSEANDPJSELBY

Introduction Factors underlying infections Common pathogens

399 399 401

INTRODUCTION Infections are a major problem in lymphoma patients and their treatment is a major part of lymphoma management. These patients are prone to infection because of the underlying disease and its treatment with chemotherapy, radiotherapy and biological therapy. The range and seriousness of infections experienced by lymphoma patients has been significantly increased by recent trends towards more intensive chemotherapy for high-risk and relapsed patients, which results in elective severe myelosuppression. The ability to manage such infections promptly and effectively is a hallmark of highquality care for lymphoma patients. We discuss the management of these infections here; the management of chronic viral or intracellular infections, which predispose to lymphoma, is discussed elsewhere (see Chapter ID-

FACTORS UNDERLYING INFECTIONS The barriers to infection in any patient include those physical barriers in the skin, respiratory and gastrointestinal tract that normally exclude infectious organisms, together with the cellular and humoral immune responses involving lymphocytes, neutrophils, macrophages, immunoglobulins and complement. A defect in any of these can predispose to infection in lymphoma patients. Table 29.1 shows the factors that predispose to infection in lymphoma patients.1 The disease-related immune deficiencies in lymphoma patients are still only partially understood.

Antimicrobial therapy References

404 412

Classical teaching has been that patients with Hodgkin's disease have a longstanding, disease-related cellular immune deficiency, which may persist after effective treatment. Non-Hodgkin's lymphoma patients have defects in humoral immunity, which usually recover after effective treatment. In each case, the immune deficiency is said to be more severe in patients whose disease is more advanced and extensive. In reality, the situation is more complex. The degree of immune deficiencies varies between different types of lymphomas and the situation is always complicated by the effects of surgery, such as splenectomy, radiotherapy, chemotherapy and, more recently, biological therapy. Although neutrophils usually work normally in lymphoma patients,2 modern treatments commonly reduce neutrophil numbers. This myelosuppressive decrease in the ability to counteract infection is the dominant failure in patients undergoing very intensive chemotherapy regimens even with hemopoietic support with peripheral stem cell or bone marrow transplants. Work on the impaired cellular immune responses in Hodgkin's disease has been carried out in the last four decades.3-7 Patients with active disease have evidence of impaired T cell function, and this may persist in some patients for over 10 years following radiotherapy8 or chemotherapy.9 Splenectomy will also add an element of humoral immune deficiency, particularly to encapsulated organisms such as pneumococcus, Haemophilus influenzae type b and Neisseria meningitidis.10,11 This leads to a firm recommendation for pneumococcal, Haemophilus influenzae type b and meningococcal vaccination, and prophylactic penicillin in these patients.12 The mechanisms underlying initial and persistent T lymphocyte dysfunction in Hodgkin's disease patients appear to be complex with an extensive literature

400 Infections

Table 29.1 Factors which predispose to infection in lymphoma patients Malignancy Immune system dysfunction Granulocytopenia Decreased immunoglobulin Defective cellular function Abnormal cytokine activity Organ system dysfunction Obstruction Neurologic dysfunction Invasion Skin ulceration Hypercortisolism Renal failure Malnutrition Co-existing disease HIV infection, congenital immunodeficiency Underlying chronic illness (diabetes mellitus, chronic bronchitis) Specific treatment Radiation therapy Mucositis, fibrosis Granulocytopenia Lymphopenia Chemotherapy Granulocytopenia Mucositis Cell-mediated immune defects Skin ulceration, phlebitis Corticosteroids Cell-mediated immune defects Surgery Postoperative infections Splenectomy Supportive care Invasive devices Parenteral nutrition Transfusion Medication for symptom control

describing partly characterized serum factors and affected cellular populations.13,15 Cytokine production in response to lymphocyte stimulation and failure of response to cytokines may also play a part.15-17 Even in the absence of therapy many patients with nonHodgkin's lymphoma have B lymphocyte-related immune defects. Classical examples are myeloma and chronic lymphocytic leukemia but similar defects are found in diffuse large cell B lymphomas, although they are less persistent after effective therapy.5,6 Patients with reduced B cell function and low immunoglobulin concentrations are particularly predisposed to infection in which antibody, by opsonization, is important. Pneumococcus, Haemophilus and Neisseria are therefore significant infections in chronic lymphocytic leukemia (CLL) and myeloma patients1,18,19 and infections are most commonly

in the lung and less often elsewhere.20 A total of 30-40 per cent of CLL patients have hypogammaglobulinemia with a consequent increase in infection risk.21,22 The expansion of differentiated malignant B cells displaces and probably suppresses normal differentiated B cell function, including the production of immunoglobulin.1,23 These abnormalities are features of well-differentiated lymphocytic lymphomas and occasionally of follicular lymphomas and diffuse large B cell lymphomas. The deficiencies in cell-mediated immunity found in lymphomas, particularly Hodgkin's disease, classically predispose to intracellular pathogens, such as herpes viruses including simplex, zoster and cytomegalovirus, intracellular bacteria such as Listeria and Mycobacteria, and the higher fungi and protozoans.19,24,25 Mechanisms of cell-mediated immune deficiency in lymphoma patients may be in part explained by failure of cytokine release or cytokine response, and the presence of immune suppressive cytokines, such as transforming growth factor b.26 The granulocytopenic lymphoma patient during conventional or intensive chemotherapy is especially vulnerable to infection. Every patient who has a neutrophil count of less than 0.1 x 109/1 for more than 3 weeks will develop an infection27 and the risk depends on the duration of neutropenia particularly. Although granulocytopenia may be defined as a neutrophil count of less than 1 x 10V1, the risk of infection and subsequent fatality does not increase substantially until the neutrophil count is below 0.5 x lo9/1.1,25,27,28 The probability of febrile neutropenia relates very closely to the duration of neutropenia < 0.5 x 109/1. This is illustrated in Fig. 29.1 (from Blackwell and Crawford.29) Fever in severely neutropenic patients are often of unknown origin and no microbiological diagnosis is possible. However, in most large trials, about 60 per cent of these fevers respond to antibacterial treatment suggesting an underlying bacterial cause.30,31 If a lymphoma patient is febrile but not granulocytopenic, it is possible to document an infectious cause for the fever in about 20 per cent of patients; in granulocytopenic lymphoma patients, the figure rises to 50 per cent and above.31,32 In the granulocytopenic

Figure 29.1

The probability of febrile neutropenia related to

the duration of neutropenia. Reprinted from reference 29.

Common pathogens 401

lymphoma patients, over 60 per cent of infections arise from endogenous flora.32,33 Altered endogenous colonizing bacteria are noted during hospitalization and treatment for lymphoma and other cancers.34 These new colonizing organisms are major sources of infection, and are responsible for some of the more severe and antibiotic-resistant bacterial infections in immunecompromised patients. For instance, patients who carry Pseudomonas have a 76 per cent infection rate with that organism when immunocompromised, compared to 13 per cent of non-carriers. Colonization with Klebsiella, Proteus and Pseudomonas is a feature of granulocytopenia.34'35 The significance of colonization and hospital acquired bacteraemia was well illustrated in a study in the 1980s, which showed a 40 per cent mortality from hospital nosocomial infections compared to 30 per cent in those acquired in the community, often from urinary tract infections.36 Physical factors play an important part in the acquisition of infections. Any instrumentation of the pulmonary or gastrointestinal tracts may cause infections.37 However, in oncology, current practice is dominated by infections acquired as a result of indwelling venous catheters and this risk increases with their duration in place.38 Press et al. estimated 1.4 infections per 1000 days of catheter insertion for Hickman lines,39 while others comment that the risk of infection may be higher than this.40 Although recent practice has concentrated on endogenous infections, and altered colonization or indwelling lines, environmental factors are still important and may permit exogenous infection. The association of Legionella, Pseudomonas and Aeromonas with wet places in hospitals, such as air-conditioning systems, sinks and plant pots is well known. Aspergillus is a significant part of the outside air and is increased by building works particularly. Pulmonary involvement resulting from airborne transmission is the rule for Aspergillus-rtlaied infections in hospitals,41 although some of these maybe reactivation of latent infections after intensive therapy.42,43 In lymphoma patients, the principal surgical predisposition to infection arises from splenectomy. This leads to failure to clear encapsulated pathogens early in the infection.44 The British National Lymphoma Investigation studied infection in splenectomized Hodgkin's disease patients, and found that, 5 years after a staging splenectomy, serious infections occurred in 3 per cent and most of these were fatal;45 others have estimated the risk of life-threatening sepsis to be about 5 per cent following splenectomy.11,46 Extended-field radiotherapy may produce long-lived lymphopenia and reduce T lymphocyte function.47 Chemotherapy predisposes to infection in most cases by inducing neutropenia and mucositis. Mucositis after chemotherapy usually occurs towards the end of the first week, lasts for a little over 1 week and heals without scarring. Myelosuppression varies in its timing between

different drugs. Drugs that are cell-cycle specific affect rapidly proliferating hemopoietic precursors and therefore have an early onset (within a week) and a short duration of neutropenia (a week or less). Drugs that are less cell-cycle specific produce neutropenia with a nadir at 10-14 days and neutropenia lasting 1-2 weeks. These include many commonly used cytotoxics, such as doxorubicin and cyclophosphamide. Late onset and prolonged myelosuppression lasting several weeks can occur with stem cell toxic chemotherapy, such as nitrosoureas and melphalan and carboplatin. Chemotherapy-induced immune suppression without myelosuppression can have important clinical effects. Corticosteroids have wide-ranging immunosuppressive effects.1 Feld et ol. noted that procarbazine increased the rate of herpes zoster infections in lung cancer patients;48 Hughes et ol. found that Pneumocystis carinii was greatly increased in leukemia patients treated with cytosine arabinoside.49 Of current importance in the management of lymphoma patients is the lymphocytotoxic effect of halogenated purine analogs, particularly fludarabine and 2-chlorodeoxyadenosine, recently introduced as effective treatments for low-grade lymphomas. These drugs have significant utility.50,52 Infections of the kind usually associated with defects in cell-mediated immunity have been a feature of halogenated purine analog trials.52,55 In Redman's study among 72 patients treated with lowgrade lymphoma,52 eight developed herpes zoster, two Pneumocystis carinii pneumonia and one disseminated cytomegalovirus infection.

COMMON PATHOGENS Pathogens associated with immune deficiency are summarized in Table 29.2 (from McGeer and Feld, 1994).

Bacteria Common respiratory tract bacteria including Streptococcus pneumoniae and Haemophilus influenzae are frequent sources of infection. Gram-negative bacteria remain a frequent cause of infection, with Escherichia coli, Pseudomonas aeruginosa and Klebsiella pneumoniae prominent. Infections with Staphylococcus aureus, Staphylococcus epidermidis, Corynebacterium and, less commonly, Clostridium, also occur. Recently severe infections with Viridans streptococci, such as Streptococcus mitis and sanguis have occurred.56 Infection with multiply resistant strains of enterococci are a problem in some institutions.57 Multiple bacteria may be found in some severely immune-compromised patients.34,58 For bacterial infections in immune compromised patients the principal trend in the last two decades has been an increase in Gram-positive bacteremia and a relative decrease in infections with Gram-negative rods.

402 Infections Table 29.2 Pathogens associated with immune deficiency. Reprinted from reference 1 Granulocytopenia Bacteria Staphylococci Viridans group streptococci Corynebacterium jekeium Enterococci Escherichia coli Klebsiella-Enterobacter-Serratiaspeaes Pseudomonas aeruginosa Fungi Candida species Aspergillus species Zygomycetes Hypogammaglobulinemia Bacteria Streptococcus pneumoniae Haemophilus influenzae Neisseria meningitidis Staphylococcus aureus Pseudomonas aeruginosa Cell-mediated immune dysfunction Viruses Varicella-zoster Herpes simplex Cytomegalovirus Adenovirus Bacteria Salmonella species Listeria monocytogenes Legionella species Nocardia species Mycobacteria Fungi Candida species Aspergillus species Cryptococcus neoformans Histoplasma capsulatum Coccidioides immitis Parasites Pneumocystis carinii Toxoplasma gondii Cryptosporidium species Strongyloides stercoralis

Serial studies by the Antimicrobial Group of the European Organisation for Research and Treatment of Cancer (EORTC) have been evaluated by Klastersky et aly and they showed an increase in Gram-positive bacteremia from 31 to 41 per cent of patients in their studies.34,59 This presumably results from the use of effective antibiotics against Gram-negative organisms and the frequent use of indwelling lines. Staphylococcus aureus is less often a cause of serious infection, whereas Staphylococcus epidermidis is more frequent, reflecting the use of central lines. Current problems include antibiotic-resistant coagulase-negative Staphylococci, such as Staphylococcus epidermidis and an apparent recent increase in Staphylococcus aureus infections.60 The importance of Legionella infection has been recognized and its frequency probably reflects infection sources in heat-exchange units and warm water reservoirs.

Viruses Herpes viruses (particularly herpes simplex, varicellazoster and cytomegalovirus virus) represent an important source of infection and occasional fatality in immunecompromised patients and are particularly important to diagnose because of the potential for effective therapy since the introduction of acyclovir and related antiviral drugs.61 Reactivation of endogenous virus plays an important part in these infections. In addition to herpes viruses, a very wide range of other viral infections occur in severely immune-suppressed patients, particularly after bone marrow and peripheral blood stem cell transplantation, including adenovirus, influenza virus, parainfluenza virus and respiratory syncytial virus.34,62,64

Fungi In severely immune-compromised patients, particularly those with prolonged granulocytopenia, fungal infections can be a major source of morbidity and mortality. This is particularly a problem in heavily treated acute leukemia patients, but may also occur in solid tumor and lymphoma patients.41 Pre-mortem diagnosis is difficult. Risk factors include corticosteroids and indwelling central venous catheters as well as neutropenia. The common pathogens are Candida and Aspergillus species.41,65,66 Neutropenic patients are vulnerable to rare infections with Mucoraceae, Fusarium, Pseudallescheria, Malassezia and Trichosporon infections.34 In addition to the general predisposition to fungal infections seen in most immune-suppressed patients, lymphoma patients appear to have a particular predisposition to invasive infections with Cryptococcus neoformans, Histoplasma capsulatum, Coccidiomycosis and Blastomycosis.19,34,67-69 Broad-spectrum antibiotic usage predisposes to invasive fungal infection probably by reducing gut anaerobic organism content. Fungal infections in neutropenic patients typically occur later than bacterial infections, with a median onset of about 10 days from the onset of granulocytopenia.43 Protozoa Although recently the frequency of Pneumocystis carinii infection in heavily treated lymphoma patients has decreased, this needs to be monitored carefully as prophylactic therapy for neutropenic episodes with cotrimoxazole is replaced in some units with quinolone prophylaxis.

Reactivation of latent infections Some infections, often after an initial acute phase, result in a persistent latent infection. Changes in immune

Common pathogens 403

competence, which result from lymphoma or immunosuppressive therapy, or intensive therapy with peripheral blood or stem cell transplantation, can alter the control of this latent infection and result in an acute reactivation illness. The classical examples are herpes virus infections. Herpes simplex virus (HSV) is a common latent infection and, after intensive chemotherapy or bone marrow transplantation, 50-80 per cent of patients who are seropositive to HSV will develop an acute reactivation.1'70'72 Almost any cancer patient having cyclical conventional doses of chemotherapy may develop an acute reactivation, which is most commonly orolabial but can occasionally be esophageal or systemic. This can happen to head and neck cancer patients having radiation therapy. Cytomegalovirus may be reactivated causing a severe pneumonitis after intensive therapy and bone marrow transplantation.73,74 This may be commoner in cancer patients who have not undergone intensive therapy than has previously been recognized.75 Varicella-zoster virus reactivation is a feature of lymphoma patients, particularly those with Hodgkin's disease, and those who have undergone intensive therapy with peripheral blood or bone marrow transplantation.72,76,78 Less frequently Epstein-Barr virus reactivation may occur and result in a lymphoproliferative syndrome,79 and this may be associated with subsequent large B lymphomas, as discussed elsewhere in this book (see Chapter 5). Human herpes virus-6 reactivation has been described in association with interstitial pneumonitis and bone marrow suppression,80,81 although so far this has only been identified in association with intensive therapy and allogeneic bone marrow transplantation, which is used only infrequently in lymphoma patients. Viruses with major hepatic pathogenicity may be influenced significantly by the use of chemotherapy. A life-threatening syndrome of activation of chronic active hepatitis due to hepatitis B by withdrawal of chemotherapy, steroids or interferon has been described,82,83 and this may also occur with hepatitis C infection.84 Lymphomas complicating organ transplantation are now seen regularly in transplant units and so the infective complications of these complex situations require careful attention. Reactivation of JC virus in the central nervous system causes progressive multifocal leukoencephalopathy. This is described in Hodgkin's disease,85 although now is seen more often in acquired immunodeficiency syndrome (AIDS).1 Adenoviral pneumonia can occur due to reactivation of a latent adenovirus infection62,86 but this is a feature of intensive therapy with transplantation usually. Other organisms that may rarely give rise to reactivation infections include Histoplasma capsulatum, Coccidioides immitis and Blastomyces dermatitidis. Reactivation of tuberculosis is more frequent in patients with lymphoma than the general population.19

Atypical mycobacterial infection of the lung occur more frequently in cancer patients than in the general population.1,87,88 Toxoplasmosis may be reactivated in severely immune-deficient patients.89,90 Pneumocystis carinii pneumonia occurring in immune-deficient patients may result from reactivation or new acquisition.1 Patients who are chronic carriers of the helminth Strongyloides stercoralis may develop hyperinfection when they become immune-suppressed.91 Other rare examples of reactive infections are with Histoplasma capsulatum, Coccidioides immitis and Blastomyces dermatitidis.1

Mycobacterial infections in lymphoma patients Tuberculosis was recognized as having an increased frequency in Hodgkin's disease in the last century, often leading to diagnostic difficulty.92,93 The advent of AIDS has, however, recently increased the incidence and clinical problem of mycobacterial infection in the immunecompromised patient. Atypical mycobacterial infection with Mycobacterium avium (M. avium) is now the single most important cause of systemic bacterial infection in patients with AIDS.92,94 Multiple drug-resistant mycobacteria are characterized in AIDS patients and represent a threat to other immune-suppressed patients. Mycobacterium avium in AIDS patients typically causes a disseminated disease with bacteremia, diarrhea, lymphadenopathy and hepatosplenomegaly. It is not particularly a cause of pulmonary disease. The first patient with M. avium infection complicating acute myelocytic leukemia has been described95 and also complicating chronic myelogenous leukemia.96 A heart transplant patient with Mycobacterium scrofulaceum has been described, and mycobacterial infections are reported in about 1 per cent of renal and liver transplant recipients.97,100 Steroid therapy for sarcoidosis has been associated with an atypical mycobacterial infection.101 It would be expected that atypical mycobacterial infections would be seen in patients with lymphoma. One rare case of central nervous system (CNS) involvement by M. avium has been described in a patient with Hodgkin's disease.102 Treatment of atypical mycobacterium in immunesuppressed patients is a specialist area for physicians with experience in the management of AIDS. New macrolides or azalides, such as clarithromycin and azithromycin, have significant clinical efficacy in atypical mycobacterial infections including M. avium. Roxithromycin has significant activity in experimental systems. Physicians managing lymphoma patients, particularly those receiving intensive therapies, clearly will have to remain alert to the possibility of tuberculosis and atypical mycobacterial infection in a wide range of clinical situations in future.

404 Infections

ANTIMICROBIAL THERAPY The range of microbes that cause infection in immunecompromised cancer patients is very wide. A full review of the treatment of all of them is beyond the scope of this book. However, there are areas of therapeutics that have been developed especially for the management of immune-compromised patients with cancer, particularly lymphoma. These are listed below and reviewed in the following text. 1 empirical use of antibiotics in febrile neutropenic lymphoma patients; 2 prevention of bacterial infections in neutropenic patients; 3 prevention and treatment of herpes virus infections; 4 prevention and treatment of fungal infections; 5 prevention and treatment of Pneumocystis carinii infections; 6 use of hemopoietic growth factors for the prevention and treatment of infections in neutropenic lymphoma patients.

Empirical use of antibiotics in febrile neutropenic lymphoma patients

The principles that underlie the use of antibiotics for the treatment of patients with neutropenia are similar whether that patient has neutropenia from cyclical combination chemotherapy from intensive treatment with peripheral blood stem cell support, or from marrow failure due to lymphoma infiltration or myelodysplasia. The clinical approach to the neutropenic lymphoma patient has evolved over the last three decades to a policy of early elective empirical therapy, where a bacterial infection is suspected. Most commonly, the initial clinical sign pointing towards infection risk will be fever, but it is critically important to recognize that even overwhelming sepsis in severely neutropenic patients may be associated with no fever and no physical signs of a localized infection. The non-specifically 'ill' neutropenic patient should therefore be regarded as having a high risk of infection. The approach to febrile or afebrile

patients who are suspected on clinical grounds of harbouring infection includes a careful history and physical examination, microbiological studies, including blood cultures and cultures of urine and sputum, and an X-ray of the chest. Stool cultures will be appropriate in some patients and serological screening for evidence of viral infection, for example, in others. Cross-sectional imaging studies with computerized tomography or magnetic resonance imaging are rarely indicated. They will have a place in assessing a small number of patients with localizing symptoms and signs of uncertain origin, such as drowsiness, focal CNS signs, persisting jaundice, or derangement of liver function tests and features suggestive of septic collections in the pelvis or under the diaphragm. The recognition that the early (empirical) use of broad-spectrum antibiotics was appropriate emerged during the 1960s and 1970s.103-107 In the absence of early empirical therapy, the mortality of bacterial sepsis is so high and so rapid in severely neutropenic patients that a policy of early introduction of antibiotics has become the cornerstone of management. Although this policy is established, there remains an active field of enquiry into the best antibiotic regimen to be employed. The changing pattern of microbial culture in these patients has been reviewed earlier. The increasing recognition of a higher proportion of Gram-positive cocci as a cause of sepsis in this group and a lower proportion of patients with Gram-negative rods has altered the recommendations for empirical antibiotic therapy. The introduction of new antibiotics has led to reexamination of existing policies. It is recognized that, under different circumstances, different regimens may be appropriate, and the appropriate policy for any hospital or unit must be worked out after careful discussions between specialists in oncology, internal medicine, infectious diseases, microbiology and specialist members of the professions allied to medicine who work in these multidisciplinary teams. The antibiotic policy used in our own hospital is summarized in Table 29.3. It should be emphasized that this is an example of the sort of policy that can be used rather than a prescription for other units. Some options for empirical antibiotic therapy are discussed below.

Table 29.3 An antibiotic policy Initial management Careful history and examination in an attempt to determine any primary site of infection. Note that rectal and vaginal examinations should not be performed in neutropenic patients. The perineum should, however, be inspected if indicated. Criteria for infection: • Single temperature > 38.5°C • Oral temperature > 38.5°C for 2 hours or more • Unexplained clinical deterioration (even without fever) Neutropenia • Total white cell count less than 1 x 10YI

Antimicrobial therapy 405

Initial investigations Blood cultures (including quantitative blood cultures from lines and from the peripheral blood). Repeat daily if remain febrile. • • • •

Urine Swab infected sites Chest X-ray Others as guided by clinical picture

Antibiotics Note special precautions for patients receiving cisplatin or high-dose carboplatin Therapy - low risk of line infection First line3 Gentamicin iv + Piperacillin iv 4 g qid • Response in fever, continue until neutropenic recovers • No response after 48-72 hours, change to second line Second line

Imipenem iv 500 mg qid • Response in fever, continue until neutropenic recovers • No response after 48-72 hours, change to third line

Third line

Add Amphotericin B iv 0.5 mg/kg initially increasing to 1 mg/kg/day following a 1 mg test dose. In serious infections, therapeutic doses should be reached within 24 hours

3

Penicillin allergy • Replace Piperacillin with Ceftazidime • 5-10% chance of cross-reactivity

a

Poor Renal Function • Use Ceftazidime in place of Gentamicin + Piperacillin

3

Cisplatin chemotherapy or high-dose carboplatin • Ceftazidime should be used in place of Gentamicin and Piperacillin as first-line antibiotics in this group of patients since renal handling of Gentamicin may be substantially impaired • Gentamicin may be used in this group of patients on failure of Ceftazidime but special attention to Gentamicin levels will be required with monitoring after the second, or at latest third dose of therapy

Therapy - high risk of line infection High risk of line infection • Inflamed exit site/tunnel • Pyrexia/rigors post-flushing • Previous history of line infection • Other soft-tissue infection First line

Vancomycin iv 1 g bd (dose altering according to levels) + Ceftazidime iv 1 gtid • Response in fever, continue until neutropenic recovers • No response after 48-72 hours, change to second line

Second line

Imipenem iv 500 mg qid • Response in fever, continue until neutropenic recovers • No response after 48-72 hours, change to third line

Third line

Add Amphotericin B iv

Duration of treatment Negative cultures - at least 5 days treatment (at least 72 hours apyrexial) irrespective of WCC Positive cultures - at least 7 days treatment (at least 72 hours apyrexial) irrespective of WCC Systemic fungal infections may require at least 6 weeks treatment Indications for change to second- or third-line antibiotics • Failure of fever to remit within 48 hours • After 72 hours or after initial control of fever, rise in temperature of > 1°C on two consecutive readings • Clinical deterioration, e.g. hypotension, drug intolerance Third-line antibiotics If the temperature remains elevated, or there is clinical deterioration on second-line antibiotics, a third-line regimen is needed. The choice of third-line regimen depends greatly on the patient's condition and the findings on clinical examination. Patients should be discussed with the unit microbiologist. In anerobes are suspected (e.g. perianal infection), Metronidazole iv 500 mg tid may be added (unless receiving Imipenem, which already covers anerobes). iv = intravenously, WCC = white cell count.

406 Infections SINGLE-AGENT ANTIBIOTIC THERAPY

OTHER REGIMENS

Early attempts at single-agent antibiotic therapy involved aminoglycosides or broad-spectrum penicillins, such as carbenicillin.106'108'109 These drugs proved relatively ineffective and toxic, and were abandoned in favor of combination antibiotic treatments. However, recently, potent, broad-spectrum, single agents, such as ceftazidime or imipenem, have become available. They appear to be adequate in many circumstances and have a place in current practice.106,110,111). The broad-spectrum of imipenem and of ceftazidime argues in favor of their use as single-agent treatments but resistant organisms can still emerge. The known pattern of resistance among organisms in a single institution must be considered and the options for modifying therapy have to be carefully set.

Cephalosporins/glycopeptide combinations

COMBINATION ANTIMICROBIAL THERAPY

The rationale for a combination of drugs for treating neutropenic fever and bacterial infection in neutropenic patients is: 1 2 3 4 5

to provide a broad-spectrum of cover; to provide a balance of pharmacokinetic characteristics; to provide penetration of tissues; to reduce the emergence of antimicrobial resistance; to provide potential drug synergy.

The introduction of the combination of gentamicin and carbenicillin by Klastersky and colleagues in the 1970s was a milestone in thisfield.112,113The combination was superior to the then available antipseudomonal blactam antibiotics or single aminoglycosides. The Plactam antibiotics have evolved over recent years with more potent and broader spectrum second- and thirdgeneration drugs. Piperacillin is considerably more potent than carbenicillin and has replaced it in routine clinical practice. Ceftazidime has significantly enhanced activity against Gram-negative bacteria and is widely used as a first choice cephalosporin in this situation. Tobramycin and amikacin have marginal differences from gentamicin but there is little evidence that any of the newer aminoglycosides will supplant gentamicin at present in all patients.114 Single daily dosage of an aminoglycoside has been used quite widely115 but has not yet supplanted multiple daily dosing, and the evidence for greater efficacy of single daily dosing is still incomplete.116 Replacement of the aminoglycosides by a second P-lactam antibiotic has been evaluated in a number of studies. These were initially disappointing.30 More potent penicillins and cephalosporins have been used in combination but again have not found wide acceptance.106 The addition of a third drug to the p-lactam/aminoglycoside policy is not established, although clinical judgement is necessary to allow for the use of an appropriate third drug where there is a high index of suspicion of a resistant infection.

Ceftazidime plus vancomycin has been widely used because of the increasing incidence of Gram-positive infections and its lack of nephrotoxicity An alternative approach is to add vancomycin when a Gram-positive organism has been confirmed by microbiological cultures.107,117,118 Teicoplanin is probably as effective as vancomycin and is well tolerated.119 Quinolone antibiotics

Quinolone antibiotics, such as ciprofloxacin and ofloxacin, have a broad spectrum of activity and the advantage of being orally active for continuation therapy. An initial trial was disappointing for ciprofloxacin120 and it is not widely used as a single agent currently. However, high-dose therapy with quinolones and the use of quinolones in combination remains under evaluation. The recently reported result of the EORTC Antimicrobial Therapy Group121 compared piperacillintazobactam plus amikacin with ceftazidime plus amikacin. There were marginal advantages to the piperacillin-tazobactam arm with shorter time to loss of fever and a higher success rate. The difference, however, did not result in any difference in mortality between the two groups. DURATION AND MODIFICATION OF THERAPY

Changes in therapy have to be guided by the patient's clinical status and microbiological findings. Most practitioners continue with an antibiotic regimen until the patient has recovered from neutropenia with > 1 x 109 neutrophils/1. If the patient fails to improve clinically with reduction in fever, the option for additional or alternative antibiotic regimens exists and examples are given in Table 29.3. Persisting fever despite potent antibacterial therapy should suggest the use of an antifungal or an antiviral agent, particularly when neutropenia is likely to be prolonged.122,'123

Prevention of bacterial infections in neutropenic patients Since the risk of bacterial infection in neutropenic lymphoma patients is high and can be predicted quite accurately, a range of preventive strategies have been tried. A cornerstone of any such strategy remains attention to hand hygiene, and asepsis procedures on the part of medical staff and health care workers. The use of physical protective environments with laminar air flow has declined because of the cost of providing these facilities for large numbers of patients. However, early studies did show a reduction in the risk of pathogenic infection in such environments.124 Suppression of alimentary tract organisms by the

Antimicrobial therapy 407

administration of oral non-absorbable antibiotics, often together with an antifungal agent, has been widely used. This is only possible in patients who have elective intensive procedures. The combination of physical protection and non-absorbable antibiotics was shown to improve remission and survival in non-Hodgkin's lymphoma patients treated in the 1970s.109 However, such facilities may be less necessary in an era of improved antibiotic therapy. Cotrimoxazole (trimethoprim-sulphamethoxazole) was originally evaluated to prevent Pneumocystis carinii infections in myelosuppressed patients.125 These patients also had a significant reduction in bacterial infection; subsequent studies show that they have fewer days of fever, a delay in the onset of new fever and a decreased number of infective episodes compared with untreated controls (Walsh et al).124 The use of cotrimoxazole has been evaluated in acute leukemia, mixed patients including lymphoma, and lung cancer. The results are somewhat conflicting.124 There is an impression that cotrimoxazole prophylaxis will result in a reduction in the incidence of infection but no evidence of improved survival for patients. Concerns about routine cotrimoxazole prophylaxis include myelosuppression by trimethoprim, which is a potent antifolate, the emergence of resistant organisms and toxicity. Bow and Ronald found lower responses to therapeutic antibacterials in patients who had received cotrimoxazole prophylaxis and the use of cotrimoxazole appeared to predict for subsequent antibacterial failure independently.126 Our present policy is to use prophylactic cotrimoxazole in patients at risk of Pneumocystis carinii pneumonia but not to use it routinely for the prophylaxis of bacterial infection. Quinolone antibiotics have potential as prophylactic agents because of their favorable toxicity profiles, a broad spectrum of antibacterial activity and good oral absorption. Trials have not yielded consistent results but, in the setting of acute leukemia at least, one trial suggested ciprofloxacin to be superior to cotrimoxazole.127 This was not confirmed by Donnelly et al.128 Comparison of norfloxacin and ciprofloxacin shows some superiority for ciprofloxacin but no difference in overall survival between the two groups.129 Quinolone antibiotics overall seem to reduce the number of infections in patients when used as prophylactic agents,124 and may be more effective in this respect than cotrimoxazole or oral nonabsorbable antibiotics. However, reports of resistant organisms are emerging and it is not clear at this stage that a routine policy of prophylaxis using quinolone antibiotics is appropriate. It may be more appropriate to reserve these potent antibiotics for therapy in febrile neutropenic patients and minimize the risk of emergence of resistant organisms. Follow-up of the impact of quinolone prophylaxis has been described in one center.130 They studied the development of quinolone-resistant organisms after the introduction of norfloxacin prophylaxis in 1987. The

first resistant bacteremia was noted 3 years later and eventually 37 per cent of E. coli isolated from septic patients were resistant to quinolones. Whether this argues against quinolone prophylaxis or against the wide use of quinolones in the community, both of which might have explained the increasing resistance, is unclear. However, the significance of quinolone resistance and its frequency is well illustrated by these studies. Rubie et al. studied the role of vancomycin flushing of subcutaneous ports to indwelling venous catheters.131 They reduced infections due to coagulase-negative staphylococci from 24 to 4 per cent.131 There were no infections with vancomycin-resistant organisms. Vassilomanolakis et al. studied vancomycin prophylaxis during the insertion of central venous catheters and reduced infection rates from 55 to 6 per cent,132 although these data are inconclusive because the study was abbreviated and some difficulties of data interpretation therefore remain. Nevertheless, the use of vancomycin prophylaxis should be considered a suitable subject for further study.

Prevention and treatment of herpes virus infections The approach to the management of each of the herpes simplex viruses in immune-compromised lymphoma patients is different. However, the drugs available are relatively few. ACYCLOVIR

Acyclovir is a synthetic nucleoside analog. It is selectively phosphorylated by viral thymidine kinase and the acyclovir triphosphate is a selective inhibitor of viral DNA polymerase. This yields an excellent therapeutic ratio against herpes simplex virus and varicella-zoster virus, but limited efficacy against other herpes viruses. Acyclovir was introduced into clinical practice and shown to have efficacy against herpes simplex and varicella-zoster virus in the UK in the late 1970s, and has been the mainstay of the treatment of virus infections in the immune-compromised patient since that time. GANCICLOVIR

Ganciclovir is also a nucleoside analog with a similar mechanism of action to acyclovir. However, it is activated by cellular thymidine kinases and, therefore, has a lower degree of selective toxicity against virus-infected cells and is moderately myelosuppressive. OTHER ANTIVIRAL AGENTS

Foscarnet has significant activity against cytomegalovirus, but also renal and bone marrow toxicity.133 A newer nucleotide analog, hydroxy-phosphonyl-methoxypropyl

408 Infections

cytosine, has potent activity against cytomegalovirus but is also nephrotoxic.134 Antiviral chemotherapy for herpes virus infections in immune-compromised patients has been reviewed by Reusser et al.lK The indications may be summarized briefly as shown below. Herpes simplex virus

Prevention Acyclovir is an effective and well-tolerated agent for the prevention of herpes simplex virus reactivation in patients who are at high risk. This may be used in patients undergoing intensive elective chemotherapy with hemopoietic support, such as lymphoma patients undergoing peripheral blood stem cell transplant supported intensive chemotherapy.70,72,78,136,139 Prophylactic use of acyclovir is justified in patients who are serum positive for previous HSV infection but probably not those who are seronegative because of the lower incidence of infection. Dosage recommendations are given in Table 29.4. Treatment of HSV infection Acyclovir is a highly effective treatment for immune-compromised patients with mucocutaneous or visceral disease. It is sufficiently bioavailable orally to be effective by this route in patients who are otherwise fit with good gastrointestinal function. Dosage recommendations are given in Table 29.4. Herpes simplex virus pneumonia and encephalitis should be treated at a higher dose and intravenously, but the outcome is not always favorable due to established tissue damage.140 Resistance to acyclovir can occur principally through a deficiency in the viral thymidine kinase enzyme. Although uncommon, this is a significant clinical problem, and current evidence135 favors the use of foscarnet in patients with clinically and microbiologically resistant herpes simplex virus infection. Varicella-zoster virus (VZV)

Prevention Lymphoma patients susceptible to varicella-zoster should be isolated from VZV patients

because of a high attack rate of VZV. Non-immune patients may benefit from zoster immune globulin if initiated within 96 hours of exposure.141 Intravenous and oral acyclovir therapy for VZV is given at higher doses than for simplex virus infections because of the lower sensitivity of VZV in vitro and in vivo. Acyclovir is effective in suppressing VZV reactivation in prophylactic studies following intensive therapy for hematological malignancies.72,142 Once long-term oral prophylaxis with acyclovir has been discontinued, VZV reactivation can occur and so treatment needs to be prolonged. Concerns about acyclovir resistance in this setting have been voiced.135 Treatment The goal of therapy for varicella or herpes zoster in immunocompromised patients is the prevention or treatment of visceral dissemination, which is associated with a substantial mortality.141 Acyclovir is an effective treatment for established VZV infection in immunocompromised patients, will prevent progression and dissemination, and has supplanted treatment with vidarabine.143 Pharmacokinetic considerations (poor oral bioavailability) suggests that acyclovir should be administered intravenously in established VZV infections in immunocompromised individuals and the oral route used only with caution. Penciclovir, a newer nucleotide analog, has in vitro efficacy against HSV and VZV, and a prolonged halflife.144 Famciclovir, the oral form of penciclovir, is more bioavailable following oral administration than acyclovir and shows considerable promise as an oral antiviral agent.135 Cytomegalovirus (CMV) infection

Prevention The risk of serious cytomegalovirs infection is principally identified in patients with acute leukemia and is seen in lymphoma patients after bone marrow transplantation. The incidence of CMV infection after allogeneic bone marrow transplantation is 40-50 per cent.145 This is particularly the case in seropositive,

Table 29.4 Dosage recommendations for prophylaxis and treatment of HSV and VZV infections. Reprinted from reference 735

HSV prophylaxis HSV-seropositive patients HSV therapy Mucocutaneous or esophageal disease Encephalitis, pneumonia VZV therapy Varicella, herpes zoster

5 mg/kg (every 12 hours) intravenously 200 mg 5 times daily orally 5 mg/kg (every 8 hours) intravenously 200-400 mg 5 times daily orally 10 mg/kg (every 8 hours) intravenously 10 mg/kg (every 8 hours) intravenously 800 mg 5 times daily orally in selected patients

HSV = herpes simplex virus, VZV = varicella-zoster virus.

Antimicrobial therapy 409

previously infected, bone marrow recipients.146 The incidence of life-threatening CMV pneumonia in bone marrow transplant patients is between 10 and 20 per cent depending on the center.135 CMV exogenous infection can be reduced by the use of seronegative blood products for seronegative bone marrow transplant recipients and the use of leucocyte-depleted blood products.147"148 Unfortunately, despite initial encouraging observations, passive administration of CMV immunoglobulin will not prevent CMV pneumonia. High-dose (500 mg/m2 8-hourly) intravenous acyclovir will reduce CMV infection when followed by high-dose prolonged oral acyclovir for 6 months compared to controls on low-dose treatment. However, the CMV pneumonia rate was not different in the two groups.149 Prophylactic ganciclovir appeared to reduce CMV infection, but again does not prolong survival and gives only incomplete protection against CMV pneumonia. Early treatment with ganciclovir may be a preferable policy.135 Treatment Ganciclovir has a role in the treatment of established CMV pneumonia.150,153 It is usually given at a dose of 5 mg/kg 12 hourly, for 14-21 days. The addition of CMV specific immune globulin has yielded favorable results in uncontrolled trails and the combination of immune globulins plus ganciclovir has become the conventional treatment for CMV pneumonia.135 For other manifestations of CMV infection including gastrointestinal and cerebral infections, ganciclovir should be tried, in some cases in combination with foscarnet.154

Prevention and treatment of fungal infections Fungal infection is a major cause of morbidity in immune-suppressed lymphoma patients, particularly

those who have undergone intensive therapy. A total of 15-30 per cent of patients with leukemia and lymphoma have fungal infection at the time of autopsy.155,156 Fifteen per cent of patients who had undergone bone marrow transplantation for various indications had invasive fungal infection.157 The responsible organisms are listed above (Table 29.2). The drugs available for treating fungal infections are still relatively few and are listed in Table 29.5. AMPHOTERICIN B This is still the most useful single agent for treating active systemic fungal infection because of its broad spectrum, including Aspergillus as well as Candida and rarer fungi. Amphotericin B is the drug of choice for empirical antifungal therapy in neutropenic patients and for the treatment of all other fungal infections, with the exception of oromucosal and oesophageal candidiasis. Its problem lies in its significant toxicity when given intravenously and its lack of oral bioavailability. Following a test does (1 mg) therapeutic doses (1 mg/kg) should be attained within 24 hours for severe infections, although some authors recommend not exceeding 50 mg in the first 24 hours.155 A gradual increase in dosage may be justified in less urgent situations, due to side effects. Lipid vehicles to carry amphotericin significantly reduce or abolish its nephrotoxicity. They should be considered in patients with concomitant renal impairment, or nephrotoxic therapy or those intolerant of conventional amphotericin B.158,159 However, some concerns have been expressed about their efficacy at the same dosages as conventional amphotericin B and higher dosages may be required.160 Early enthusiasm for a bedside emulsion of intralipid 20 per cent and conventional amphotericin B161 has been tempered by the demonstration of instability and the formation of precipitations.162

Table 29.5 Commercially available systemic antifungal agents. Reprinted from reference 155

Amphotericin B-desoxycholate

Empirical therapy in neutropenic cancer patients Invasive candidiasis, aspergillosis, zygomycoses, cryptococcosis, acute disseminated histoplasmosis

Flucytosine (in combination with amphotericin B)

Invasive aspergillosis, acute and chronic (hepatosplenic) disseminated candidiasis with susceptible strains, cryptococcosis

Fluconazole

Prophylaxis of mucosal and invasive candidiasis Mucosal candidiasis Selected cases of invasive candidiasis

Itraconazole

Prophylaxis of fungal infections (investigational) Petriellidiosis, selected cases of invasive aspergillosis

Ketoconazole

Oral thrush, esophageal candidiasis

Rifampicin (only in combination with amphotericin)

Invasive aspergillosis not responding to amphotericin B and contraindications to flucytosine

410 Infections FLUCONAZOLE AND OTHER DRUGS

Fluconazole, the most fully evaluated and least toxic of the azole antifungal antibiotics, is well absorbed orally and can be given parenterally. It is clinically active against Candida species (except naturally resistant krusei and glabrate) and well tolerated. Fluconazole is widely used for mucosal candidiasis and is useful for the treatment of invasive candidiasis.163,164 Itraconazole has a broader spectrum of activity to include some Aspergillus species and it may be used particularly under circumstances where amphotericin is potentially too toxic.165,166 Azole antifungals act by depleting fungal cell membranes of ergosterol, a critical target for amphotericin B. Theoretically azole antifungals and amphotericin B may be antagonistic155,167,168 but this may not be true for all fungal infections.169 FLUCYTOSINE

Flucytosine may be used in addition to amphotericin in the treatment of acute and chronic disseminated candidiasis and invasive aspergillosis.155 ANTIFUNGAL PROPHYLAXIS

There is no routine approach available for prophylaxis of systemic fungal infection. Mucosal infection may be readily avoided by topical non-absorbable agents, such as nystatin, amphotericin B or miconazole. Fluconazole given orally dramatically reduces the development of mucosal thrush155,170,171 and in some studies reduced disseminated invasive fungal infections. However, resistant fungal infections may be seen in patients treated with prophylactic fluconazole.172 None of the available studies showed that prophylactic fluconazole resulted in a reduced mortality in the patients treated.170-172 It is unlikely that prophylactic fluconazole will reduce invasive Aspergillus infections. Prophylactic amphotericin B intravenously has been used in some studies with encouraging claims.173 Although no routine prophylactic regimen can be recommended to avoid systemic fungal infection, if local factors appear to point towards a particularly high risk of invasive candidiasis, then fluconazole should be considered; a similar logic would apply to a center with a very high incidence of invasive aspergillosis and the use of amphotericin B. PLACE OF ANTIFUNGAL THERAPY IN NEUTROPENIC FEVER

In patients with persistent fever after broad-spectrum antibiotic therapy, it is recommended practice to start empirical antifungal therapy with amphotericin B.123 This should only be considered if neutropenia is likely to be prolonged and severe, or if there are concomitant risk factors for fungal infection.174'176 The timing of the introduction of antifungal therapy remains a matter for

clinical judgement and must be influenced by local experience. Our practice is given in Table 29.3.

Prevention and treatment of Pneumocystis carinii infections Lymphoma patients are at risk of infection with Pneumocystis carinii, although the reported incidence is low, with an estimated attack rate between 0.1 and 1 per cent per year.177 Certain chemotherapy regimens may confer greater risk178 and the incidence varies between institutions.179 Pneumocystis pneumonia probably represents reactivation of latent infection, although evidence that the organism is reacquired at the time of clinical disease is accumulating.180 This has implications for prevention; exposure of high-risk patients to infected persons should be avoided, particularly in institutions where the incidence is high. PREVENTION

Standard prophylaxis of Pneumocystis carinii is with oral trimemoprim-sulphamethoxazole (co-trimoxazole) 960 mg bd daily or 2-3 times per week.179 Primary prophylaxis should be considered for patients in institutions where the incidence is high, for those on long-term steroids, and receiving certain chemotherapy regimens.178 Lymphoma patients have a low incidence of adverse reactions to cotrimoxazole in contrast to HIV patients.177,179 Alternative oral prophylactic agents, which could be considered in high-riskpatients unable to tolerate co-trimoxazole include pyrimethamine-sulfadioxine, pyrimethamine-dapsone, dapsone and atovaquone.179 Secondary prophylaxis should be considered for all patients following an acute infection, who continue to be immunosuppressed. TREATMENT

Co-trimoxazole is the treatment of choice for Pneumocystis carinii pneumonia (PCP). It is effective, well tolerated, inexpensive and readily available in both oral and intravenous forms. The intravenous route should be used in all but the mildest cases, and the recommended dose is 15 mg/kg per day trimethoprim plus 75 mg/kg per day sulphamethoxazole, continued for 21 days. Oral therapy, for mild cases and for continuing therapy, is 20 mg/kg per day trimethoprim plus 100 mg/kg per day sulphamethoxazole.179,181 Studies in the AIDS populations have shown that clindamycin-primaquine (600 mg qds iv plus 15 mg/day orally) and dapsone-trimethoprim (100 mg/day plus 20 mg/kg per day oral or iv) are effective alternative first-line agents.181 In patients failing to respond to first-line treatment, intravenous pentamidine (4 mg/kg per day iv) or atovaquone (750 mg tds orally for patients suitable for oral therapy) may be used. Trimetrexate probably has a role in patients who require parenteral treatment, who cannot tolerate or fail to respond to co-trimoxazole and pentamidine.

Antimicrobial therapy 411

The outcome of severe infection with respiratory failure can be improved by the co-administration of corticosteriods. Appropriate regimens are prednisolone 40 mg bd for 5 days, then slowly reducing until day 21, or methylprednisolone 1 g daily for 3 days.180 Corticosteroids probably abrogate the flare in inflammation associated with dying organisms, a process thought to explain the deterioration seen in some patients after anti-Pneumocystis treatment has started.180 They should be prescribed at the commencement of specific anti-Pneumocystis treatment, even if the diagnosis is presumptive at this stage. The data supporting co-administration of steroids is very clear for patients with AIDS-related PCP. In a randomized controlled trial of patients receiving cotrimoxazole, among those receiving concurrent steroids, 9 out of 12 survived while only 2 out of 11 survived in the control group.182 This was confirmed in another trial.183 It is very likely to apply in patients with cancerand chemotherapy-related PCP.184

Use of hemopoietic growth factors for the prevention and treatment of infections in neutropenic lymphoma patients One of the most significant advances of the 1980s has

been the availability of hemopoietic growth factors (colony stimulating factors) for the clinical management and prevention of neutropenia in patients treated with chemotherapy, including those who also receive hemopoietic support in the form of a bone marrow transplant or peripheral blood stem cell transplant.

HEMOPOIETIC GROWTH FACTORS

Recombinant human hemopoietic growth factors of some clinical potential are listed in Table 29.6. Two hemopoietic growth factors are in routine clinical use. Recombinant human G-CSF and GM-CSF have both been demonstrated to reduce the length and severity of neutropenia, and the occurrence of infections in patients after chemotherapy. Both bacterially derived and yeast-derived forms are available. Their use has been reviewed by Lee and Crawford.185 Hemopoietic growth factors will stimulate myelopoiesis and speed up recovery from chemotherapy-induced neutropenia. Since the duration of neutropenia is a powerful determinant of the probability of infection (Figure 29.1), it would be predicted that shortening neutropenia would reduce infection and this is observed in clinical trials.

Table 29.6 Hemopoietic growth factors (HGFs). Reprinted from reference 185

GM-CSF

Neutrophils and neutrophil precursors, macrophages, megakaryocytes, erythroid cells

T lymphocytes, endothelial cells, fibroblasts

5q

G-CSF

Neutrophils and neutrophil precursors, endothelial cells, fibroblasts

Endothelial cells, monocytes, fibroblasts

17q

M-CSF(CSM)

Monocytes

Endothelial cells, monocytes, fibroblasts

5q

IL-3

Neutrophils, endothelial cells, multipotent progenitor cells

T lymphocytes

5q

IL-4

B and T lymphocytes

T lymphocytes

5q

IL-5

B lymphocytes, CFU-eosinophils

T lymphocytes

5q

IL-6

B and T lymphocytes, CFU-GEMM, CFU-GM, BFU-E, macrophages platelets, neural cells hepatocytes

Fibroblasts, leukocytes, epithelial cells

7p

IL-7

B lymphocytes

Leukocytes

8q

IL-8

T lymphocytes, neutrophils

Leukocytes

4

IL-9

BFU-E, CFU-GEMM

Lymphocytes

5q

IL-11

B, T lymphocytes, CFU-GEMM, platelets, macrophages

Macrophages

7

Erythropoietin

CFU-E, BFU-E

Kidney, liver

7q

Stem cell factor (c-kit ligand)

Primitive progenitor cells, mast cells

7

7

GM = granulocyte-macrophage, CSF = colony stimulating factor, G = granulocyte, M = macrophage, IL = interleukin, CFU = colony-forming unit, GEMM = granulocyte erythrocyte monocyte macrophage, BFU = burst forming units, E = erythroid.

412 Infections G-CSF

G-CSF stimulates the development of mature neutrophils from myeloid progenitors. It was initially described by Burgess and Metcalf in 1980,186 named GCSF by Nicola et al. in 1983187 and the gene cloned in 1986.188-189 It exists in a single copy of chromosome 17 q21-22 and codes for a 207 amino acid precursor from which 30 amino acids are removed to yield a 177 amino acid polypeptide of approximate molecular weight 25 kDa. It is made by neutrophils, mononuclear cells, endothelial cells and fibroblasts, and interacts with highaffinity cytokine receptors on the surface of neutrophils. Receptor expression is increased in infected patients. It is likely that G-CSF mediates neutrophil leucocytosis in infection. The encouraging observations of G-CSF in animal models led to its use in humans in volunteers and cancer patients190 in whom it caused an increase in neutrophil count as long as it was continued. Accelerated recovery from myelosuppression was seen in these early studies. The recombinant G-CSF was well tolerated with infrequent episodes of bone pain in the marrow-rich bones. Phase III randomized trials of G-CSF have shown: 1 G-CSF will shorten neutropenia by enhancing recovery; 2 the nadir neutrophil count is usually higher in GCSF-treated patients; 3 febrile episodes are reduced in G-CSF-treated patients with a reduction in antibiotic treatment and days of hospitalization in some studies; 4 there may be an improvement in response, duration and survival in the G-CSF-treated patients;185 5 G-CSF will shorten the period of neutropenia following autologous bone marrow transplantation. GM-CSF

Granulocyte-macrophage colony stimulating factor (GM-CSF) promotes proliferation and differentiation of hemopoietic precursors into differentiated myeloid cells. It is derived from fibroblasts, endothelial cells, monocytes and activated T cells. It was originally purified by Gasson et al.191 The gene is found on the long arm of chromosome 5, close to several other hemopoietic growth factors.185 Its biology is similar to G-CSF with a high-affinity receptor, but its effects are less lineage specific, affecting granulocytes, macrophages, megakaryocytes and eosinophils. Animal experimentation and early phase I/II clinical trials support a role for GM-CSF in increasing neutrophil and macrophage production, and reducing postchemotherapy myelosuppression. It has mild toxicity including fever, some rash and flushing. Initial studies show that it shortens the period of neutropenia following chemotherapy in a range of cancers. Phase III clinical trials show reduction in neutropenia and days of hospitalization, although no benefits in thrombocytopenia.

CLINICAL USE OF HEMOPOIETIC GROWTH FACTORS IN LYMPHOMA

The clinical effects of hematopoietic growth factors in lymphoma patients are not in doubt. They are capable of inducing neutrophilia, shortening neutropenia and reducing infection. However, alternative approaches to managing infection exist and hemopoietic growth factors are complex, inconvenient and expensive. Care has to be taken in deriving appropriate indications.192'193 The following are our recommendations given the current state of knowledge. 1 The stimulation of bone marrow prior to the harvesting of peripheral blood stem cells for hemopoietic support in intensive therapy. This is discussed elsewhere in this volume but there is no doubt that hemopoietic growth factors have an established place in lymphoma care. In one study, cytokine-induced peripheral blood stem cells harvested by leucophoresis were used and compared to autologous bone marrow for hemopoietic support following intensive chemotherapy for lymphoma patients.194 They resulted in reduction in the duration of neutropenia, but no difference in the absolute incidence of infection or in overall survival. 2 In the management of neutropenic and septic patients who are severely ill, responding poorly or slowly to antibiotics and in whom a prolonged period of neutropenia is anticipated. 3 In the reduction of the duration of neutropenia electively in patients receiving combination chemotherapy who are, usually as a result of previous experience or therapy, known to be at risk of prolonged neutropenia but for whom maintenance of the dose of chemotherapy is judged to be clinically valuable. 4 In carefully designed randomized prospective studies, to evaluate whether higher response rates, remission, duration or survival can be achieved by growth factor support compared to chemotherapy alone. Hematopoietic growth factors are not routinely used following peripheral blood stem cell transplantation, where their effects are small, and they are not routinely used for all patients having cyclical combination chemotherapy for lymphoma.

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References 417 129. GIMEMA Infection Program. Prevention of bacterial infection in neutropenia patients with hematologic malignancies. A randomized, multicenter trial comparing norfloxacin with ciprofloxacin Ann Intern Med 1991;115:7. 130. Carratala J, Fernandez-Sevilla A, Tubau F, et al. Emergence of quinolone resistant Escheria coli bacteremia in neutropenic patients with cancer who have received prophylactic norfloxacin. Clin Infect Dis 1995;20:557-60. 131. Rubie H, Juricic M, ClaeyssensS, et al. Morbidity using subcutaneous ports and efficacy of vancomycin flushing in cancer Arch Dis Child 1995; 72: 325-29. 132. Vassilomanolakis M, Plataniotis G, Koumakis G, et al. Central venous catheter related infections after bone marrow transplantation in patients with malignancies: a prospective study with short course vancomycin prophylaxis Bone Marrow Transplant 1995; 15: 77-80. 133. Reusser P, Gambertoglio JG, Lilleby K, et al. Phase l-ll trial of foscarnet for prevention of cytomegalovirus infection in autologous and allogeneic marrow transplant recipients; Infect Dis 1992; 166: 473-9. 134. Drew WL, Lalezari JP, Glutzer E, et al. The safety, pharmacokinetics and anti-CMV activity of weekly HPMPC in HIV positive patients excreting CMV. In: Michelson S, Plotkin S, eds Abstracts of the 4th International Cytomegalovirus Conference. Paris: Institut Pasteur, 1993. 135. Reusser P. Prophylaxis and treatment of herpes virus infections in immunocompromised cancer patients. In: Glauser MP, Calandra T, eds In Balliere's clinical infectious diseases, Vol. 1:3. London: BalliereTindall, 1994: 523-44. 136. Saral R, Burns WH, Laskin OL, et al. Acyclovir prophylaxis of herpes simplex virus infections: a randomized, double blind, controlled, trial in bone marrow transplant recipients N EnglJ Med 1981; 305: 63-7. 137. Gluckman E, LotsbergJ, Devergie A, et al. Prophylaxis of herpes infections after bone marrow transplantation by oral acyclovir. Lancet 1983; 11: 706-8. 138. Hann IM, Prentice HG, Blacklock HA, et al. Acyclovir prophylaxis against herpes virus infections in severely immunocompromised patients: randomised double blind trial BrMedJ 1983; 287: 384-8. 139. Shepp DH, Dandliker PS, Flournoy N, et al. Sequential intravenous and twice daily oral acyclovir for extended prophylaxis of herpes simplex virus infection in marrow transplant patients Transplantation 1987; 43: 654-8. 140. Zaia JA. Viral infections association with bone marrow transplantation Hematol Oncol Clinics North Am 1990; 4: 603-23. 141. Straus SE, OstroveJM, Inchauspe G, et al. Varicellazoster virus infections. Biology, natural history, treatment and prevention Ann Intern Med 1988; 108: 221-37.

142. Ljungman P, Wilczek H, Gahrton G, et al. Long term acyclovir prophylaxis in bone marrow transplant recipients and lymphocyte proliferation responses to herpes virus antigens in vitro Bone Marrow Transplant 1986; 1:185-92. 143. Shepp DH, Dandliker PS, Myers JD. Treatment of varicella-zoster virus infection in severely immunocompromised patients: a randomized comparison of acyclovir and vidarabine N EnglJ Med 1986;314:208-12. 144. Earnshaw DL, Bacon TH, Darlison SJ, et al. Mode of antiviral action of penciclovir in MRC-5 cells infected with herpes simplex virus type 1 (HSV-1), HSV-2 and varicella-zoster virus. Antimicrob Agents Chemother 1992; 36: 2747-57. 145. Wingard JR, Piantadosi S, Burns WH, et al. Cytomegalovirus infections in bone marrow transplant recipients given intensive cytoreductive therapy Rev Infect Dis 1990; 12(suppl 7): S793-S804. 146. Meyers JD, Ljungman P, Fisher LD. Cytomegalovirus excretion as a predictor of cytomegalovirus disease after marrow transplantation: importance of cytomegalovirus viremia J Infect Dis 1990; 162: 373-80. 147. Bowden RA, Sayers M, Flournoy N, et al. Cytomegalovirus immune globulin and seronegative blood products to prevent primary cytomagalovirus infection after marrow transplantation N Engl J Med 1986; 314:1006-10. 148. de Witte T, Schattenberg A, van Dijk BA, et al. Prevention of primary cytomegalovirus infection after allogeneic bone marrow transplant by using leukocyte poor random blood products from cytomegalovirus unscreened blood bank donors Transplantation 1990; 50: 964-8. 149. Prentice HG, Gluckman E, Powles RL, et al. Impact of long term acyclovir on cytomegalovirus infection and surgical after allogeneic bone marrow transplantation Lancet!994; 343: 749-53. 150. Selby P, Powles RL, Jameson B, et al. Treatment of cytomegalovirus pneumonitis after bone marrow transplantation with 9-[2-Hydroxy-1-(hydroxymethyl) Ethoxymethyl] guanine [letter]. Lancet 1986; i: 1377-8. 151. Emanuel D. Treatment of cytomegalovirus disease Semin Hematol 1990; 27(suppl 1): 22-7. 152. Ljungman P, Engelhard D, Link H, et al. Treatment of interstitial pneumonitis due to cytomegalovirus with ganciclovirand intravenous immune globulin: experience of European Bone Marrow Transplant Group Clin Infect Dis 1992; 14: 831-5. 153. Emanuel D, Cunningham I, Jules-Elysee K,et al. Cytomegalovirus pneumonia after bone marrow transplantation successfully treated with the combination of ganciclovirand high dose intravenous immune globulin. Ann Intern Med 1988; 109: 777-82.

418 Infections

154. Van Droogenbroeck J, De Ceuninck M, Snoeck HW,

170. Goodman JL, Winston DJ, Greenfield RA, et al. A

Schroyens W, Berneman Z. Successful treatment of cytomegalovirus encephalitis in a patient with

controlled trial of fluconazole to prevent fungal infections in patients undergoing bone marrow

Hodgkin's disease in remission. Ann Hematol 1998; 76: 179-81. 155. Schaffner A. Prophylaxis and treatment of fungal

transplantation N EnglJ Med 1992; 326: 845-51. 171. Winston DJ, Chandrasekar PH, Lazarus HM, et al. Fluconazole prophylaxis of fungal infections in patients

infections in cancer patients. In: Glauser MP,

with acute leukaemia: results of a randomised placebo-

Calandra T, eds Balliere's clinical infectious diseases,

controlled, double blind, multicenter trial. Ann Intern

Vol. 1:3. London: BalliereTindall, 1994: 499-522. 156. Donhuijsen K, Samandari S. Deep mycoses in leukaemias and malignant lymphomas Deutsche Med Wochensch 1985; 110: 903-7. 157. Meyers JD. Fungal infections in bone marrow transplant patients Semin Oncol 1990; 17:10-13. 158. Lopez Berestein G. Liposomal amphotericin B in the treatment of fungal infections Ann Intern Med 1986; 105:130-1.

Med 1993; 118: 495-503. 172. Wingard JR, Merz WG, Rinaldi MG, et al. Increase in Candida Krusei infection among patients with bone marrow transplantation and neutropenia treated prophylactically with fluconazole N EnglJ Med 1991; 325: 1274-7. 173. Rousey SR, Russler S, Gottlieb M, et al. Low dose amphotericin B prophylaxis against invasive Aspergillus infections in allogeneic marrow transplantation AmJ Med 1991; 91: 484-92.

159. Anaissie E, Paetznick V, Proffitt R, et al. Comparison of the in vitro antifungal activity of free and liposomeencapsulated amphotericin B. EurJ Clin Microbiol Infect 0/51991; 10: 665-8.

174. EORTC International Antimicrobial Therapy Cooperative Group. Empirical antifungal therapy in febrile granulocytopenic patients Am J Med 1989; 86: 668-72.

160. Janknegt R, van Etten EWM, de Marie S. Lipid

175. Sugar AM. Empiric treatment of fungal infections in the

formulations of amphotericin B. In: Andriole VT, Finch

neutropenic host. Review of the literature and

RG, eds Current opinion in infectious diseases, Vol. 9.

guidelines for use. Arch Intern Med 1990; 150:

London: Rapid Science Publishers, 1996; 403-6. 161. Chavanet PY, Garry I, Charlier N, et al. Trial of glucose versus fat emulsion in preparation of amphotericin for use in HIV infected patients with candidiasis Br MedJ 1992;305:921-825. 162. Trissel LA. Amphotericin B does not mix with fat emulsion Am J Health Systems Pharmacol 1995; 52: 1463-4. 163. Anaissie E, Bodey GP, Kantarjian H, et al. Fluconazole therapy for chronic disseminated candidiasis in patients with leukaemia and prior amphotericin B therapy. Am J Med 1991; 91:142-50. 164. Kauffman CA, Bradley SF, Ross SC, et al. Hepatosplenic

2258-64. 176. Walsh TJ, LeeJ, Lecciones J, et al. Empiric therapy with amphotericin B in febrile granulocytopenic patients Rev Infect Dis 1991; 13: 496-503. 177. KovacsJA, HiemenzJW, Macher AM. Pneumocystis carinii pneumonia: a comparison between patients with the acquired immuodeficiency syndrome and patients with other immuodeficienciesAw? Intern Med 1984; 100: 663-71. 178. Browne MJ, Hubbard SM, Longo DL, et al. Excess prevalence of Pneumocystis carinii pneumonia in patients treated for lymphoma with combination chemotherapy Ann Intern Med 1986; 104: 338-44.

treatment of invasive aspergillosis: review of 2,121

179. Masur H. Prevention and treatment of pneumocystis pneumonia. N EnglJ Med 1992; 327: 26,1853-60. 180. Miller RF, Mitchell DM. Pneumocystis carinii pneumonia Thorax 1992;47:305-14.

published cases. Rev Infect Dis 1990; 12:1147-201.

181. Mitchell DM. AIDS and the lung. In: Lever AML, Sissons

candidiasis: successful treatment with fluconazole. AmJ Med 1991; 91:137-41. 165. Denning DW, Stevens DA. Antifungal and surgical

166. Hosteller JS, Denning DW, Steven DA. US experience

P, eds Medicine, Vol. 24: 9. Oxford: The Medicine Group,

with itraconazole in Aspergillus, Cryptococcus and Histoplasma infections in the immunocompromised

182. Gagnon S, Boota AM, Fischl MA, et al. Corticosteroids as

host Chemotherapy 1992; 38(suppl 1): 12-22. 167. Schaffner A, Frick PG. The effect of ketoconazole on amphotericin B in a model of disseminated aspergillosis J Infect Dis 1985; 151: 902-10. 168. Schmitt HJ, Bernard EM, Edwards FF, et al. Combination therapy in a model of pulmonary aspergillosis Mycoses 1991;34:281-5. 169. Sugar AM, Hitchcock CA, Troke PF. Combination therapy of murine invasive candidiasis with fluconazole and amphotericin B. Antimicrob Agents Chemother 1995; 39: 598-601.

1996: 126-30. adjunctive therapy for severe Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. N EnglJ Med 1990; 323:1444-50. 183. Bozzette SA, Sattler FR, Chiu J, et al. A controlled trial of early adjunctive treatment with corticosteroids for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome. N EnglJ Med 1990; 323: 1451-7 184. Pareja JG, Garland R, Koziel H. Use of adjunctive corticosteroids in severe adult non-HIV Pneumocystis carinii pneumonia. Chest 1998; 113:1215-24.

References 419 185. Lee ME, Crawford J. Colony stimulating factors for the prevention and treatment of infections in cancer patients In: Glauser MP, Calandra T, eds Balliere's clinical infectious diseases, Vol. 1:3. London: Balliere Tindall, 1994: 563-600. 186. Burgess AW, Metcalf D. Characterization of a serum factor stimulating the differentiation of myelomonocytic leukaemic cells IntJ Cancer 1980; 39: 647-54. 187. Nicola NA, Metcalf D, Matsumoto M, et al. Purification of a factor inducing differentiation in murine myelomonocytic leukaemia cells: identification as granulocyte colony stimulating factor (G-CSF)y Biol Chem 1983; 258: 9017-23. 188. Nagata S, Tsuchiya M, Asanon S, et al. Molecular cloning and expression of cDNA for human granulocyte colony stimulating factor Nature 1986; 319:415-18. 189. Souza LM, BooneTC, GabriloveJ, et al. Recombinant human granulocyte colony stimulating factor: effects on normal and leukaemic myeloid cells Science 1986; 232:61-5.

190. Bronchud MH, ScarffeJH, Thatcher N, et al. Phase l/ll study of recombinant human granulocyte colony stimulating factor in patients receiving intensive chemotherapy for small cell lung cancer BrJ Cancer 1987; 56: 809-13. 191. Gasson JC, Kaufman SE, Weishart RN, et al. High affinity binding of granulocyte macrophage colony stimulating factor to normal and leukaemic human myeloid cells Proc NatAcadSci USA 1986; 83: 669-73. 192. American Society of Clinical Oncology. Recommendations for the use of hematopoietic colony-stimulating factors: evidence-based, clinical practice guidelines) Clin Oncol 1994; 12: 2471-508. 193. Croockewit AJ, Bronchud MH, Aapro MS, et al. A European perspective on haematopoietic growth factors in haemato-oncology: report of an Expert Meeting of the EORTC EurJ Cancer 1997; 33:1732^6. 194. Schmitz N, Linch DC, Dreger P, et al. Randomised trial of filgrastim mobilised peripheral blood progenitor cell transplantation versus autologous bone marrow transplantation in lymphoma patients Lancet 1996; 347: 353-7.

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30 Long-term problems M HENRY-AMAR

Introduction Non-malignant complications Secondary malignancies Quality of life in long-term survivors

421 421 426 429

INTRODUCTION With the careful application of appropriate staging techniques and treatment methods, the expected proportion of all patients presenting with Hodgkin's disease who should be cured of their disease is as high as 75 per cent as of 1992.1 This result is already achieved in early stage disease because modern treatment methods (high-dose extended-field or total lymphoid radiation therapy and/or cyclical multidrug chemotherapy) are widely applied. Long-surviving Hodgkin's disease patients, however, face new problems. As greater numbers of successfully treated patients are followed for longer periods of time, medical problems associated with residua of the disease and its therapy have become more apparent.2 Among these problems, secondary malignancies are the most serious because they are often fatal and, in a large proportion of cases, they arise as a consequence of treatment. Hodgkin's disease therapy may also result in severe infections, and thyroid, cardiovascular, pulmonary, digestive or gonadal dysfunction. Skeletalcomplications, mostly reported in children treated with extended-field irradiation delivering 30 Gy or more, have been dramatically lowered with the use of low-dose radiation in combination with chemotherapy or chemotherapy alone in pediatric patients. These complications will therefore not be discussed, although one might expect more complications in the skeleton years after the patients have been irradiated.3 Patients previously treated for a non-Hodgkin's lymphoma face a rather different situation than those with Hodgkin's disease. While major Hodgkin's disease treatment improvements occurred during the 1970s, the

Causes of death Conclusion Summary References

430 431 432 432

search for the best treatment strategy for non-Hodgkin's lymphoma is still being sought. Although the nonHodgkin's lymphoma incidence rate in the general population is higher than that of Hodgkin's disease, series available that include large numbers of patients treated according to protocols with sufficient follow-up to allow reliable estimations of long-term complications are very few. Most published studies focused on second cancer risk neglecting that of late non-malignant complications. This review will focus on the variety of medical problems considering successively non-malignant complications, secondary malignancies, long-term patient quality of life and causes of death. Because the vast majority of patients who achieve remission will remain symptomfree and do enjoy a normal life,4 an attempt will be made to provide estimated risk for individual based on available data.

NON-MALIGNANT COMPLICATIONS

Immunologic dysfunction The lymphoid organs are the most common sites involved with Hodgkin's disease and, to lesser extent, with non-Hodgkin's lymphoma, so it is not surprising that immune regulation disorders are observed. Functional status of the immune system is probably important in the maintenance of remission and protection against infection or secondary malignancies. Untreated Hodgkin's disease patients generally present with an immunodeficiency state, which was first reported by Reed in 1902.5

422 Long-term problems

Patients exhibit lymphocytopenia, which is mainly ascribed to a reduction of OKT4+ T cells and to lack of Tjo, cells. Their lymphocytes are poorly activated by mitogens and antigens. Patients are poor responders in the allogeneic mixed lymphocyte reaction. In contrast, B lymphocyte functions are well preserved in these patients, except in those with systemic symptoms. Therapeutic irradiation induces lymphocytopenia, which depends on target volume and dose delivered, and a profound depression of immune functions. While the immediate absolute B lymphocytopenia following irradiation seems to normalize within the first 1-2 years after therapy, in patients with non-Hodgkin's lymphoma in particular, prolonged T cell functional impairment is often observed in long survivors of Hodgkin's disease. Aggressive combination cytotoxic drug therapy, such as the MOPP regimen (mechlorethamine, vincristine, procarbazine and prednisone) and its variants given for Hodgkin's disease, also induce an acute reduction of T and B lymphocytes with prolonged T cell functional impairment after cessation of chemotherapy. Spleen removal may result in persistent blood cell abnormalities, such as neutrophilia, lymphocytosis, eosinophilia and thrombocytosis. Splenectomy also induces delayed reduction of serum immunoglobulin M (IgM), and potentiates the progressive fall in serum IgM secondary to irradiation and cytotoxic drug therapy. All together, the asplenic state (either because of splenectomy or splenic irradiation), reduced IgM levels and impaired B cell responses contribute to the persistent lifelong risk of overwhelming postsplenectomy infections (OPSI).

Infectious complications Bacteria, fungi and parasites, as well as viruses, are microorganisms with a predilection for individuals with Hodgkin's disease.6 Pneumonia (37-57 per cent), bacteremia (25-33 per cent), skin infection (5-19 per cent) and meningitis (3-13 per cent) are the most common serious infections.2 Organisms frequently isolated include Streptococcus pneumoniae (21-32 per cent), Staphylococcus aureus (5-19 per cent) and Staphylococcus epidermidis (4-19 per cent). Gramnegative organisms are less common. A non-negligible number of isolates, however, are polymicrobial (15-21 per cent). Infections are often favored by immunologic dysfunction (Herpes zoster being the most characteristic consequence in Hodgkin's disease patients). The most feared splenectomy-related infection is OPSI, which can lead to death within hours of the first clinical manifestation. Patients to be submitted to splenectomy should be systematically given pneumococcal vaccine prior to surgery. Splenectomized patients and those whose spleen was irradiated should certainly be proposed for antibiotic (penicillin) prophylaxis as well as regular vaccination.

Thyroid dysfunction Thyroid dysfunction is among the most common Hodgkin's disease therapy-related complications, and was early recognized and treated. Because the thyroid is directly exposed to radiation, dysfunction often concerns hypothyroidism with consequent elevation of thyroid stimulating hormone (TSH), while no consistent effect of chemotherapy alone has been demonstrated. In the European Organization for Research and Treatment of Cancer (EORTC) trials, 3 years after treatment completion, patients expressed a 100 per cent increase in TSH level compared with the baseline, whatever the treatment administered, say mantle irradiation alone or combined modality with MOPP or MOPP/ABV (doxorubicin, bleomycin, vinblastine) hybrid chemotherapy.7 Hypothyroidism develops gradually. Thyroid function was evaluated in a series of 1787 Hodgkin's disease patients treated during the 1961-1989 period at Stanford University Medical Center.8 Of those patients, 97 per cent were irradiated as part of their treatment and 32 per cent of patients had clinical or biological evidence of thyroid disease. The 20-year cumulative incidence rate of thyroid disease was 50 per cent; the median time to occurrence was 4.6 years (range 0.2-25.6). Thyroid disease concerned hypothyroidism (20-year cumulative rate, 41 per cent), Graves' disease (20-year cumulative rate, 3.1 per cent), thyroiditis (20-year cumulative rate, 1.3 per cent), thyroidectomy (including 6 out of 26 for thyroid cancer; 20-year cumulative rate, 6.6 per cent) and clinically benign nodule (20-year cumulative rate, 3.3 per cent). Hypothyroidism, Graves' diseases and thyroiditis occurred earlier (median 4.0, 4.8 and 5.0 years from treatment initiation, respectively) than thyroidectomy and clinically benign nodule (median 14.0 and 12.6 years, respectively). In this series, hypothyroidism was dependent on radiation dose, age and sex. The 20-year cumulative incidence was less than 5 per cent in unirradiated patients; it was 30 per cent if radiation dose to thyroid was 7.5-30 Gy, and 45 per cent in patients whose thyroid was irradiated at a dose exceeding 30 Gy. The proportion of patients in whom hypothyroidism developed increased with age, from 17 per cent in those who were less than 5 years of age when treated to 39 per cent in those who were 15-20 years of age when treated; it gradually declined with advancing age to 17 per cent in patients who were over 70 years of age when treated. Risk factors analysis indicated that, in patients aged 17 years or older when irradiated, female sex [relative risk (RR) = 1.60, P < 0.001], chemotherapy (RR = 1.42, P < 0.001) and radiation dose (RR/lGy = 1.02, P = 0.035) significantly correlated with increased risk of hypothyroidism. Hypothyroidism might not only be related to radiation to the thyroid but also to radiodiagnostic iodine surcharge, since lymphangiography and, more recently, abdominal computed tomography are systematically

Non-malignant complications 423

performed during the initial work-up and repeated thereafter.9,10 The literature, however, is conflicting and the question remains to be clarified in larger series than already reported.11

Cardiovascular dysfunction Treatment-related cardiac complications do involve the three cardiac tunica. In Hodgkin's disease patients, they have been described as irradiation and chemotherapy related. Cardiac complications, such as myocardial infarction and coronary artery disease, arrhythmias, myocarditis, pericarditis, pericardial effusion and tamponade, have been well documented after radiation therapy to the mediastinum.12-13 They are related to the total radiation dose delivered, the fraction size and the volume irradiated. An excess of risk has been reported for a total dose over 40 Gy, a dose per fraction > 3 Gy, the use of a single anterior and anteriorily weighted radiation port and irradiation involving the whole pericardium. Pericarditis, both acute and chronic, whether or not associated with pericardial effusion, is the most common symptomatic complication. It has been reported to develop in 11 -50 per cent of patients. With the use of dose restriction to the whole heart, addition of a subcarinal block after 25 or 35 Gy in the absence of lower mediastinal involvement or large mediastinal adenopathies, and high-energy linear accelerator and dose per fraction < 2 Gy, more satisfactory results are obtained with cumulative rates often less than 5 per cent. Uncomplicated chronic pericardial effusions are frequently persistently asymptomatic and consequently are often not recognized. Chronic constrictive pericarditis, with or without effusion, is a more serious consequence of radiation therapy because it requires more invasive and aggressive therapy than effusion alone; it is also associated with a higher incidence of morbidity. The use of modern irradiation techniques, however, should make it exceptional. The availability of noninvasive diagnostic procedures, such as echocardiography and radionuclide cineangiography, has facilitated the recognition of myocardial damage. Complete cardiovascular work-up, however, is available in only a limited number of series.14,17 They generally conclude that myocardial damage is present in 25-50 per cent of long survivors whose mediastinum was irradiated, although a small proportion of patients spontaneously complain of symptoms. Left ventricular ejection fraction, which is used as a measure of systolic function, is usually normal when measured at rest with an abnormal response at exercise in a substantial number of patients. Transient left ventricular ejection fraction decrease was observed even 3 years after treatment completion in both patients treated with mantle irradiation or combined modalities.7,18 As Hodgkin's disease survivors age and become

exposed to the risk factors of coronary artery disease, the excess morbidity and mortality from coronary artery disease observed in large series has led to the conclusion that irradiation might cause, aggravate or accelerate atherosclerosis.19,23 Perhaps the most informative group to look at is the long-term survivors of pediatric Hodgkin's disease. In those children treated on trials at St Jude from 1968-1990, as well as excess mortality from second cancers and infection, there was a significantly increased mortality from cardiac disease (standard incidence ratio 22; 95 per cent confidence interval, 8-48); all patients were male and had had extended-field radiotherapy and no anthracycline-containing chemotherapy.24 In the EORTC series, the 10-year and 15-year cumulative incidence rates of myocardial infarction were 2.4 and 4.6 per cent respectively.25 The role of mediastinal irradiation on myocardial infarction risk was demonstrated in the Institute Gustave Roussy series, where the 10-year cumulative incidence rate was 3.9 per cent in patients who were given irradiation to the heart while no myocardial infarction was observed in patients who had no mediastinal irradiation.21 However, in a multicenter study on the late effect of treatment for early stage Hodgkin's disease in 611 patients, mediastinal radiotherapy was not found to be a significant risk factor for death from myocardial infarction; the radiation doses were lower than in most centers and follow-up shorter.26 Doxorubicin chemotherapy has been reported to induce cadiotoxicity in Hodgkin's disease.2'12 In most protocols, such as ABVD (doxorubicin, bleomycin, vinblastine, dacarbazine), MOPP/ABVD or MOPP/ABV hybrid regimens, the cumulative dose of doxorubicin following six cycles of 100 per cent standard dose is 300 mg/m2 or less, with a rare incidence of clinical cardiomyopathy. In a study of 103 young survivors of high-grade nonHodgkin's lymphomas treated on National Cancer Institute protocols, a predominate late effect was cardiotoxicity related to doxorubicin therapy in doses exceeding 200 mg/m2.27 Whether doxorubicin potentiates irradiation-related cardiotoxicity remains unclear. In the Stanford series, no significant increase in death from acute myocardial infarction was observed after combined therapy with MOPP compared with radiotherapy alone.28,29 However, since average total mediastinal doses were lower, subcarinal blocking was more frequent and less cardiac volume may have been irradiated in patients who received combined therapy, the potentiating role of chemotherapy might have been underestimated.

Pulmonary dysfunction Radiation pneumonitis and pulmonary fibrosis represent the most common complications following mantle irradiation for Hodgkin's disease. Almost 20 per cent of patients develop X-ray changes that are characteristic of acute radiation pneumonitis within 1-3 months after

424 Long-term problems

irradiation, although it may be delayed as long as 6 months.30 These changes are generally asymptomatic. When present, common symptoms include dyspnea on mild exertion, non-productive cough and low-grade fever, which, in most patients, do not require therapy or additional diagnostic evaluation. The incidence of radiation pneumonitis mainly depends on the total dose delivered to the mediastinum, the irradiated volume and the technique.31'32 It also depends on the fraction size for a given dose, with the larger the fraction size, the higher the probability of lung damage.33 The use of lung blocks and the administration of chemotherapy before irradiation in patients with large mediastinal masses limit the dose and reduce incidence to less than 5 per cent. Pulmonary fibrosis begins to appear 6 months after treatment and usually stabilizes after 12-18 months. The volume irradiated appears to be the most important factor for pulmonary fibrosis, although the risk can vary according to the type of combined modality therapy. After MOPP plus irradiation, the incidence of pulmonary changes was 15-22 per cent compared with 49 per cent after ABVD plus irradiation in a nonrandomized study.34 The incidence of radiation-induced lung damage, as determined by computed tomography changes (increase in lung density within the irradiated volume) was prospectively evaluated in patients treated with combined modality treatment with radiation therapy (35 Gy in 20 fractions) together with either MOPP (12 patients), ABVD (16 patients) or MOPP/ ABVD (12 patients).35 The actuarial risk of developing pneumonitis was 71 per cent in patients treated with ABVD and irradiation, 49 per cent in patients treated with MOPP and irradiation, and 52 per cent in patients treated with MOPP/ABVD and irradiation. Minor restrictive ventilatory defects (decreased vital capacity and total lung compliance) are seen after mediastinal irradiation.36 They are increased with combined modality treatment, in particular after ABVD and irradiation.25 37 ABVD-related pulmonary toxicity may be a consequence of bleomycin-induced pulmonary fibrosis and of doxorubicin-induced 'radiation recall' pneumonitis.38 In contrast, the risk of pulmonary dysfunction is low after chemotherapy alone but may have been underestimated, since series of patients initially treated with chemotherapy alone and carefully followed thereafter for late complications are limited.

Digestive complications Most late digestive complications of Hodgkin's disease therapy concern infections, ulcers, gastritis and small bowel obstructions or perforations. They are mainly related to staging laparotomy and/or abdominal irradiation. Among laparotomy-related complications, splenectomy-related OPSI is probably the most serious (see earlier). In a series of 133 patients followed 2.5-28 years

after laparotomy, 6.8 per cent developed OPSI of which one patient died.39 The role of pneumoccocal vaccine was clearly demonstrated: none of the 25 patients who received pneumoccocal vaccine before splenectomy developed OPSI, while 5 out of 44 patients (11 per cent) who were vaccinated after splenectomy and 4 out of 64 patients (6 per cent) who were not vaccinated developed OPSI. The influence of radiation dose was studied in a series of 855 patients (478 with Hodgkin's disease and 377 with seminoma) who were treated with infradiaphragmatic irradiation but with no whole abdominal irradiation. The incidence of major bowel complications (requiring hospitalization for management or surgery) significantly correlated with radiation dose delivered to the para-aortic region; for doses < 35 Gy, the 3-year cumulative rate was 1 per cent compared with 3 per cent for doses > 35 Gy (P = 0.03).40 The role of infradiaphragmatic irradiation technique as well as that of staging laparotomy was assessed in the EORTC trials. In these protocols, irradiation usually delivered 39-41 Gy to the para-aortic region; the proportion of late complications did not vary with radiation dose.41 Late digestive complications did not relate to staging laparotomy in patients whose abdomen was not irradiated. In contrast, both staging laparotomy and fractions > 2 Gy increased the risk, which was maximal in laparotomized patients treated with fractions of 3.3 Gy (5-year cumulative rate, 28 per cent).25 With modern irradiation techniques and withdrawal of staging laparotomy from most treatment strategies, these complications should no longer be observed.

Gonadal dysfunction With the increasing use of chemotherapy in the treatment of Hodgkin's disease, lasting effects on gonadal function have been reported. The magnitude of the effect can vary with the drug class or combination used in treatment, the total dose administered, and'the age and pubertal status of the patient at the time of therapy.42 In adult men, germinal depletion is accompanied by a marked reduction in testicular volume, oligospermia or azoospermia, and infertility. Serum follicle stimulating hormone (FSH) and luteinizing hormone (LH) levels reflect the state of the seminiferous epithelium. Germinal depletion results in a significantly increased FSH level, while LH and testosterone levels tend to remain within normal range. Adult women become amenorrheic and may complain of menopausal symptoms of estrogen deficiency. Low circulating estrogen levels result in marked elevation of serum FSH and LH. Before the onset of puberty in boys, the testicular germinal epithelium appears to be more resistant to moderate doses of alkylating agents than is the adult testis. Chemotherapy administered to male patients during puberty has profound effects on both germ cell production and endocrine

Non-malignant complications 425

function. Gynecomastia, elevated serum FSH and LH levels, and low normal serum testosterone levels are frequently observed after MOPP therapy. In girls, there is a lack of information available concerning the effect of cytotoxic drugs on the prepubertal and pubertal ovary. It seems, however, that the immature ovary is relatively insensitive to cytotoxic chemotherapy. In contrast to a growing literature describing adverse effects of chemotherapy, there is a paucity of data concerning the effects of radiation on gonadal function in humans. The testis is highly sensitive to radiation because of rapid cell division of the germinal epithelium; azoospermia occurs when the testes are irradiated with as little as 1 Gy. Techniques to shield the testes from the radiation beam are available, which considerably limit the dose to the gonads. At a 5-6 Gy total dose, most women remain persistently amenorrheic with variations with age. Women younger than 20 years have approximately a 70 per cent chance of retaining regular cyclic menses, whereas by age 30 or older, only 20 per cent of treated women retain normal ovarian function. Appropriate gonadal shielding is very difficult for the ovary but oophoropexy can reduce ovarian exposure in approximately 50 per cent of women receiving pelvic irradiation. After 6-10 cycles of COPP (cyclophosphamide, vincristine, procarbazine and prednisone) chemotherapy given as sole treatment, 100 per cent (n = 92) of males were azoospermic 1-17 years after treatment completion, 97 per cent had testicular atrophy and germinal aplasia was shown in 100 per cent of the 19 patients submitted to testicular biopsy.43 Serum FSH level was increased threefold, while serum LH level increase was moderate. Similar findings were reported in a series of 50 male patients treated with either MVPP (mechlorethamine, vinblastine, procarbazine and prednisone) or ChlVPP/EVA (chlorambucil, vinblastine, procarbazine, prednisone, doxorubicin, vincristine and etoposide) chemotherapy for 5-8 cycles, with no difference between the two chemotherapy regimens.44 In female patients (n = 39), chemotherapy resulted in 76 per cent amenorrhea; of these, 60 per cent had persistent amenorrhea. As in men, there were no significant differences in the incidence of amenorrhea, or mean of serum FSH and LH levels between MVPP- and ChlVPP/EVAtreated women. These results were confirmed in the EORTC Hodgkin's disease trials in which patients were successively treated with irradiation alone or a combination of irradiation and MOPP, MOPP/ABV hybrid or ABVD, and in the Istituto Nazionale Tumori (Milan) series.7,45 Other chemotherapy regimens have been used in order to reduce the risk of long-term sequelae. VEEP (vincristine, epirubicin, etoposide and prednisone) chemotherapy alone (3-10 courses) was associated with 6 per cent (2 out of 33) abnormal sperm count; in females, none of the 22 patients tested had posttreatment gonadal toxicity.46 In a series of 75 boys treated with OPPA (vincristine, procarbazine, prednisone and

doxorubicin; two courses) and COPP (0-6 courses) chemotherapy, all had normal pubertal development, but 24 per cent and 88 per cent expressed elevated basal and stimulated LH, respectively, indicating chemotherapy-induced Leydig cell damage; in addition, there was 41 per cent and 53 per cent incidence of elevated basal and stimulated serum FSH levels, respectively, indicating severe spermatogenesis impairment.47 In this series, testicular dysfunction was observed in boys treated before as well as during puberty. However, increased basal serum FSH and LH levels were dose dependent: the higher the number of COPP courses, the higher the incidence rate. These results were confirmed in the Stanford series, where 83 per cent (10 out of 12) of boys who were treated with six cycles of MOPP with or without pelvic irradiation were azoospermic with no evidence of recovery after as long as 11 years of follow-up.48 The Stanford series also included gonadal evaluation of 86 girls. Seventy-five (87 per cent) had normal menstrual function but none of the girls who underwent pelvic irradiation without prior oophoropexy has maintained ovarian function. Therefore, the chance of maintaining gonadal function following combined modality treatment appears to be much greater among girls than boys. Series focusing on the effect on fertility of treatments given for non-Hodgkin's lymphoma are very few. After intensive chemotherapy administered in adult patients with intermediate- or high-grade non-Hodgkin's lymphoma, gonadal function was not altered in six out of seven women, and in seven out of 15 men given MACOP-B (cyclophosphamide, doxorubicin, vincristine, methotrexate, bleomycin and prednisone) or VACOP-B (with etoposide replacing methotrexate) chemotherapy alone.49 In contrast, abnormal gonadal function was observed in two out of six patients in whom induction chemotherapy was followed by highdose chemotherapy (cyclophosphamide, BCNU and etoposide) and autologous bone marrow transplantation; a similar observation was made in three out of four patients in whom induction chemotherapy was followed by cyclophosphamide and total lymphoid irradiation given before autologous bone marrow transplantation. Since the same cytotoxic drugs inducing altered gonadal function are used in the treatment of non-Hodgkin's lymphoma and that of Hodgkin's disease, it is likely that similar gonadal dysfunction will be observed as followup increases. After treatment completion, most patients of reproductive age who desire children ask the following questions: Will my child have an increased risk of developing lymphoma? How long should I wait before becoming pregnant? Will the treatment I have had cause congenital defects in my child? The available data do not bring absolute answers since large studies with long-term follow-up have been infrequent. The outcome of pregnancies in patients (or their partners) who were successfully treated for Hodgkin's disease was addressed in a series of

426 Long-term problems

104 adult females and 117 adult males.50 After treatment, 43 females and 51 males actively attempted conception; 35 (81 per cent) females and 25 (49 per cent) partners of male patients had 84 pregnancies, which resulted in 68 living children for a median of 11 years (minimum > 4.5 years). Among the 84 pregnancies, there were one premature birth at 29 weeks, three spontaneous abortions, 11 elective abortions and two stillbirths. There was no apparent increase in complications of pregnancies, spontaneous abortions or congenital abnormalities. The partners of male patients who were treated with combined modality treatment, however, had a lower frequency of pregnancy than did the female patients who attempted conception. There is no convincing evidence that the risk of Hodgkin's disease in offspring is genetically increased, although a large number of families have been reported to have multiple occurrences of Hodgkin's disease.51 Similarly, there is no evidence of significant increase in congenital defects in the offspring of these patients. Therefore, information from studies of progeny in Hodgkin's disease should not discourage patients in remission after treatment of their disease from childbearing.

SECONDARY MALIGNANCIES Several years after therapy, Hodgkin's disease patients have an increased risk of developing acute leukemia, mostly acute non-lymphoblastic leukemia (ANLL), nonHodgkin's lymphoma and second solid tumors.24,26,52,57 Since large series with sufficient follow-up have become available, more accurate risk assessments can be made. They concern patients who were treated during childhood as well as those who were adults when the disease developed. Much less information is available for patients with a previous history of non-Hodgkin's lymphoma, particularly in adult patients, because major therapeutic improvements are recent and because the average follow-up of patients cured from their disease is still short. However, series have recently been published indicating that second solid tumors are of major concern in these patients. Effects of ionizing irradiation The carcinogenic effects of ionizing irradiation have been assessed in several cohorts of people under various conditions of exposure: occupational cohorts, residential radon exposure, atomic bomb survivors, and patients exposed to diagnostic and therapeutic procedures. Ionizing irradiation can cause all types of tumor, with the exception of chronic lymphocytic leukemia.58 Among organs where tumors can develop, the thyroid, female breast and bone marrow are probably the most radiosensitive. Ionizing irradiation effects have been quantified

for low-radiation-dose ranges and extrapolation to highradiation-dose ranges cannot be easily achieved.59 In low-dose ranges, the cancer risk increases with dose. Therapeutic irradiation doses used in Hodgkin's disease fall in a very small range, making it difficult to assess a dose-response relationship between irradiation doses and risk of second tumor. More variations occurred in the past in the number of fractions used for a given dose. Therefore, in the analysis of risk factors for developing a second tumor, similar to that performed in the analysis of the incidence of non-malignant complications, the use of the linear quadratic model might better reflect the impact of irradiation on the risk than does the dose itself.33,41 Effects of chemotherapy The drugs used for cancer therapy have been extensively studied by the International Agency for Research on Cancer (IARC).60,61 Among those carcinogenic to humans (Group 1 of the IARC classification), the largest group is made up of the alkylating agents, including MOPP and other combined chemotherapy incorporating alkylating agents. Among agents probably carcinogenic to humans (IARC Group 2A) are doxorubicin, nitrogen mustard and procarbazine. Among agents possibly carcinogenic to humans (IARC Group 2B) are bleomycin and dacarbazine. All these drugs have been widely used in the treatment of lymphomas, alone or in combination with irradiation. The interpretation of the studies on the risk of second tumor following chemotherapy is difficult because, in patients who are long survivors, multiple agents have often been administered, patients might have relapsed and been treated with salvage chemotherapy, careful clinical follow-up may result in a more diligent case finding, and other confounding factors (sex, age, ethnic origin, smoking) have to be taken into the analysis.62 The most frequent secondary cancer associated with chemotherapy is ANLL. It typically occurs between 2 and 10 years after therapy, with the peak time interval around 5 years, although cases can be observed later.51,56,62,63 Secondary ANLL often presents initially as myelodysplastic syndrome with refractory pancytopenia and high rate of abnormalities of erythrocyte morphology. It is generally of myelogenous type, associated with clonal chromosome aberrations involving chromosomes 5,7,11,17,18 and 21. It is usually, but not always, refractory to treatment with a 76-100 per cent death rate within several months following diagnosis.52,64,65 Secondary ANLL and myelodysplastic syndrome after Hodgkin's disease Hodgkin's disease patients have a cumulative risk of developing secondary ANLL, which has been reported to be as high as 10 per cent at 10 years.66 The risk, however,

Secondary malignancies 427

greatly depends on the type of therapy received. It is much higher in patients treated with chemotherapy or with combined modality therapy than in patients treated with radiation therapy alone. The risk depends on the type of chemotherapy given (the higher risk being associated with MOPP and MOPP-like regimens) and on the amount of chemotherapy administered, and might be associated with the extent of radiation therapy.52'67 After irradiation alone, the 15-year probability of developing an ANLL was 0.2 per cent; it was nil in patients treated with localized (involved- or mantle field) irradiation compared with 3.4 per cent in patients treated with extended field (subtotal or total lymphoid) irradiation.64 In this series, patients treated with chemotherapy alone had a 15-year probability of secondary ANLL of 11.1 per cent, while those treated with combined modality therapy had a 15-year probability of 4.3 per cent. Among the latter, the risk was not increased in patients treated with chemotherapy and extended-field irradiation compared with those treated with chemotherapy and localized irradiation (4.4 vs 4.2 per cent, respectively). These results confirm previous findings concerning the small impact of irradiation when associated with chemotherapy,55-68,73 while opposite results have been reported.74,75 In all studies, however, the cumulative risk of secondary ANLL tends to plateau 10-15 years after treatment completion. An attempt to quantify the risk of developing a secondary ANLL or a myelodysplastic syndrome in relation to the type and/or the amount of chemotherapy delivered has been made in several studies. The risk increased with the number of cycles, the dose or the alkylating score.63,68,72,75,78 The risk of chemotherapy-related secondary ANLL was shown to correlate significantly with various drugs, such as mechlorethamine (alone or associated with procarbazine and/or vincristine), cyclophosphamide and procarbazine, vincristine and procarbazine, lomustine, chlorambucil, and vinblastine.63,68,70,72,77,79,80 Other risk factors reported to correlate with an increased risk of secondary ANLL are age at which Hodgkin's disease developed, clinical stage and splenic treatment (splenectomy and splenic irradiation). The effect of age remains controversial. In many studies, an increase in cumulative probability as well as in relative risk have been found in patients aged above 40 or 50,52,75,81,-83Whileothers the risk was not increased84 or decreased with older age.68,71,85 Advanced clinical stage was found associated with an increased risk, even after confounding factors have been considered in the analysis, which might suggest that the risk of developing a secondary ANLL is related to greater functional defect of the immune system of these patients compared with that of patients with early stage disease.68,69,81,85 Van Leeuwen et al. first pointed out that splenectomy is a risk factor for secondary ANLL.86 This finding was later confirmed in some studies,63,68,78,79,83 while in others no significant increased risk was associated with previous splenectomy.64,69,71,75,81,84,85

When increased, the risk is always limited in magnitude and cannot be compared with that associated with the use of alkylating agents. In a recent study, splenectomy was associated with an increased risk of leukemia (RR =13.3), non-Hodgkin's lymphoma (RR = 16.6) or Hodgkin's disease (RR = 18.2) in patients treated for benign hematological disorders.87 These findings together with the infection risk and other splenectomy-related morbidity have been considered by many investigators to exclude splenectomy from staging and treatment strategy in Hodgkin's disease. Secondary non-Hodgkin's lymphoma after Hodgkin's disease Non-Hodgkin's lymphoma was first described as possibly related to treatment in 1979.88 Significantly increased risk was confirmed in all further studies.69-71,75,81,82,84,89,90 Non-Hodgkin's lymphoma generally develops 5-15 years post-treatment; its cumulative incidence rate ranges from less than 1 per cent to 4-5 per cent at that time but might increase with longer follow-up.82 An increase in risk was associated with various factors, such as older age, male gender, lymphocytic-predominant Hodgkin's disease histological subtype and combined modality therapy.69,71,75,81,82,85,91 In a recent study involving 10 472 patients treated at 14 cancer centers in the USA and Canada, only mechlorethamine was associated with an increased risk (RR = 2.4; 95 per cent confidence interval, 1.2-4.8) of secondary non-Hodgkin's lymphoma.63 Immunodeficiency induced by the therapy or immunologic defects of the Hodgkin's disease itself as well as viruses, such as Epstein-Barr virus (EBV) or more recently human immunodeficiency virus (HIV), might be co-factors for the subsequent development of nonHodgkin's lymphoma, but their respective role remains unclear.92 Secondary solid tumors after Hodgkin's disease While the excess of secondary ANLL and non-Hodgkin's lymphoma is generally significant over the 1-14 year period after the start of initial therapy, that of secondary solid tumors becomes apparent after the fifth year, increasing with time. In large series, the 15-year cumulative incidence rate of secondary solid tumors varies from 10 to 15 per Cent.64,69,71,75,81,82,84 In all series with sufficient follow-up, solid tumors represent 2-3 times as many ANLL and nonHodgkin's lymphoma, indicating that secondary solid tumors have become the most serious complication in long survivors of Hodgkin's disease. In general population comparisons, however, relative risks are generally between 1.5 and 2.5, while that of ANLL or non-Hodgkin's lymphoma often exceed 10. This apparent discrepancy comes from the difference between the natural incidence of

428 Long-term problems

ANLL and non-Hodgkin's lymphoma, which is low (less than 10 cases per 100 000 inhabitants per year), and that of solid tumors, which is much greater.93 Not all localizations have been found in excess; these generally concern lung (RR = 1.9-7.7), female breast (RR = 1.4-4.1), stomach (RR = 1.2-10), thyroid (RR = 2.4-68), bone (RR = 4.5-106) and melanoma (RR = 1.6-16), although other specific sites (such as the salivary glands, head and neck, small intestine and colon in males, pleura, cervix and ovary in females) have been associated with an increased risk.8.54,55,69,82,89,94 The reiatjve rjsk increase is almost inversely proportional to the natural incidence rate of a given site; it generally concerns few numbers, leading to absolute risks that are always less than one case per 100 person-years at risk. The search for risk factors for developing a second solid tumor often ends by demonstrating that, besides host factors (such as gender, age94a or cigarette smoking), radiation therapy is the main risk factor. This finding is not surprising since almost all sites associated with a significantly increased risk concern sites that might have been included in the radiation fields. Of the 23 second solid tumors that occurred in the EORTC series, 16 developed within an irradiated area; 13 of these 16 tumors occurred in patients initially treated with extended-field irradiation.90 In this series, the cumulative risk of second solid tumors was significantly higher in patients initially treated with extended-field irradiation compared with those treated with mantle irradiation when either all solid tumors (P = 0.01) or solid tumors that developed within an irradiated area (P = 0.009) were considered. A similar observation was made at the Institut Gustave Roussy concerning secondary gastric carcinomas. Six out of nine patients referred to this institution for gastric carcinoma presented with linitis plastica; all patients were previously treated with extended-field irradiation (including the stomach within the irradiation volume) and large fraction size (>2.5Gy).95 Chemotherapy given in combination with radiation therapy as part of initial treatment was shown to add to the risk of irradiation alone in one study.64 In a casecontrol study, chemotherapy was associated with a risk of lung cancer that was twice that of irradiation alone or combined modality treatment.96 These findings must be considered together with the results of a recent study in which chemotherapy as a whole or individual drugs were associated with second cancer risk.63 Irradiation to the thorax was associated with an increased risk (RR = 2.7) of solid tumors of the respiratory system and intrathoracic organs developing 10 years or more after exposure, while chemotherapy was associated with an increased risk (RR = 2.2) of these tumors developing early (within the 0-4-year period after exposure). Tumors of the bones, joints, articular cartilage and soft tissues preferentially developed after chemotherapy (RR = 6.0) whatever the period considered; drugs associated with an increase in risk were procarbazine (RR = 3.7), vincristine (RR = 2.8),

doxorubicin (RR = 4.2) and bleomycin (RR = 3.0). Irradiation to the abdomen (RR = 2.4) was associated with tumors of the female genital system developing late (over 10 years after exposure), while chemotherapy (RR = 3.5) was associated with these tumors developing 5 years or more after exposure; vincristine was associated with an increased risk (RR = 4.7), while hormones were associated with a decreased risk (RR = 0.2). Finally, an increased risk (RR = 8.3) of thyroid cancer was observed after chemotherapy for the 0-4-year period after exposure, principally after exposure to lomustine (RR = 7.3). These results, however, must be confirmed from an independent series of patients with sufficient follow-up and treated to modern standards. If confirmed, they should encourage oncologists to use chemotherapy in the treatment of Hodgkin's disease more carefully. Treatment of the spleen as a risk factor for second solid tumor was reported for the first time in 1994.75 The assumption was made that splenic irradiation should induce similar spleen function loss as does splenectomy. In a series of 1003 adult patients continuously disease-free, 56 second tumors developed (37 solid tumors, 11 ANLLs and 8 non-Hodgkin's lymphomas), 17 in patients whose spleen was not treated, 22 in splenectomized patients and 17 in patients whose spleen was irradiated. Splenectomy (RR = 2.95; P = 0.023) and splenic irradiation (RR = 5.35; P - 0.002) were found to be independent risk factors for solid tumors. No correlation between splenectomy and an increased risk of second cancer was found in two previous studies performed on large series of male American servicemen splenectomized for external trauma during World War II97 and Danish people splenectomized for traumatic splenic rupture or other non-carcinologic reasons.87 These findings provide an argument for secondary cancer risk being more likely to be related to the underlying patient conditions than to the splenectomy itself. Spleen treatment (spleen removal or splenic irradiation), however, might have a limited but significant impact in particular patient subgroups, possibly those with pronounced persistent immunodeficiency. In these subgroups, treatment strategies should therefore be carefully adapted to the initial clinical presentation and the patient's ab initio prognosis.

Secondary malignancies in childhood Hodgkin's disease Most of the knowledge on second cancer risk in patients treated for childhood Hodgkin's disease comes from the Late Effect Study Group. Updated results from 1380 patients treated from 1955 to 1986, with a median followup of 11.4 years, have been recently reported.53,98 In this series, 88 second cancers developed (56 solid tumors, 26 leukemias (including 24 ANLL and 6 non-Hodgkin's lymphomas) leading to 15-year cumulative incidence rates of 3.9,2.8 and 1.1 per cent, respectively. The median time to

Quality of life in long-term survivors 429

second cancer was shorter for leukemias (4.4 years) than for solid tumors (13.8 years). The leukemia risk was dependent on advanced stage, treatment type (higher after chemotherapy alone than after irradiation and chemotherapy), chemotherapy (higher after MOPP than after ABVD) and alkylating score; in contrast, the risk of leukemia was not significantly increased in patients who had undergone splenectomy. The only factor associated with an increased risk of secondary non-Hodgkin's lymphoma was the alkylating score (RR = 1.7). In this series, most solid tumors developed within radiation fields. These were most commonly localized to female breast (17 cases; RR = 75.3; cumulative incidence at 40 years of age, 35 per cent) and thyroid (10 cases; RR = 32.7). Overall, the 20-year cumulative incidence rate of secondary solid tumors was 12.6 per cent in female (8.8 per cent after secondary breast cancers have been excluded) and 3.9 per cent in male patients. Secondary solid tumors were also more frequent in children aged 10-16 years at Hodgkin's disease diagnosis than in younger children. Risk factors for breast cancer were age > 10 (RR = 1.9), and total radiation dose between 20 and 39 Gy (RR = 5.9) or > 40 Gy (RR = 23.7). This study confirms that the risk for breast cancer is higher in patients irradiated as children or adolescents than in patients irradiated over age 40 years.56,94,99,101 Children and adolescents are also at higher risk than adults for developing secondary bone sarcoma, connective tissue sarcoma or thyroid cancer.102 Since the treatment of Hodgkin's disease is similar in children and adults, it can be concluded that, for these localizations, children are more sensitive to ionizing radiation effects than are adults. A statistically significant association between secondary ANLLs and previous administration of alkylating agents has been reported, with higher doses inducing higher risks; the risk of ANLL and that of non-Hodgkin's lymphoma also correlated with splenectomy.53,73,98 Host factors such as age and gender might also influence the risk for secondary cancer. In a series of 191 children of whom 109 were initially treated with irradiation alone, 15 patients subsequently developed a second tumor 6-20 years after the diagnosis of Hodgkin's disease for a 15-year cumulative incidence rate of 12 per cent. The rates were 24 per cent in females (10 cases) and 5 per cent in males (5 cases) with a relative risk for female compared with male patients of 4.5 (P = 0.013).10° The 15 patients who developed a second tumor were all irradiated and 4 out of 10 second tumors in females developed in the breast, emphasizing the role played by irradiation in the genesis of second cancers.

Secondary malignancies after nonHodgkin's lymphoma Less information is available for non-Hodgkin's lymphoma but, indeed, in a recent report of young

long-term survivors, second malignancies were uncommon.27 In other series, both leukemias and solid tumors have been seen but, in contrast to that observed in Hodgkin's disease patients, second solid tumors represent 75-95 per cent of all secondary malignancies.103-105 This difference is partly explained by age at diagnosis of primary non-Hodgkin's lymphoma.93,105 In a series of 6171 patients treated during 1965-1980, increased risks (compared with a reference population) concerned secondary leukemias (RR = 3.99, almost all ANLL with RR = 4.83), secondary Hodgkin's disease (RR = 12.02, with 21 out of 22 cases histologically confirmed) and secondary solid tumors (RR = 1.28).105 Among the latter, the risk was significantly increased for lung (RR = 1.36), kidney (RR = 2.07), bladder (RR = 1.77), melanoma (RR = 2.38), brain and central nervous system (RR = 2.33). Overall, the risk was higher in men (RR = 1.51) than in women (RR = 1.18); it was independent of time since non-Hodgkin's lymphoma diagnosis. In this series, the 20-year cumulative incidence rate was 21.1 per cent (expected rate 15.4 per cent) and 19.3 per cent (expected rate 15.0 per cent) for secondary solid tumors taking at a whole. The risk of secondary malignancy, however, did not correlate to any particular therapeutic scheme, confirming that observed in two further studies.103,104 The relationship between the total dose of cyclophosphamide, the total irradiation dose to kidney and bladder, and the risk of kidney or bladder cancer was addressed in a case-control study.106 In this study, there was a significant increased risk (matched RR = 4.5) of bladder cancer in patients treated with cyclophosphamide (alone or in combination with other cytostatic drugs), with or without associated irradiation. The increase in risk also depended on the total dose of cyclophosphamide given (P < 0.005). Neither the cyclophosphamide dose nor irradiation were associated with an increased risk of secondary kidney carcinoma. In the last two decades, most if not all studies have focused on the potential risk for occurrence of a second tumor in relation to initial lymphoma treatment or to a specific agent. Recently, other factors (such as alterations in the retinoblastoma locus, germline mutations in p53, and congenital or acquired immunodeficiency states) have emerged as predisposing factors for the risk of developing a second tumor.102 Although not yet related to solid tumors secondary to Hodgkin's disease or nonHodgkin's lymphoma, the impact of host factors should certainly be considered in the future beyond that of the treatment itself.

QUALITY OF LIFE IN LONG-TERM SURVIVORS Treatment-related acute and chronic medical as well as psychosocial complications can interfere with the quality of life of Hodgkin's disease survivors.107-109 The range and

430 Long-term problems

magnitude of psychosocial problems (physical impairments, social and familial morbidity, sexuality, discrimination in employment and in obtaining insurance) observed in Hodgkin's disease survivors have only recently been explored,110,111 which is not yet the case in patients cured of non-Hodgkin's lymphoma. Psychological and social disturbances are usually reported during and after treatment.110-113 The actual problem of quality of life in long-term survivors has been addressed in only a few studies, most of which are not comparative. In 1995, a study was conducted to compare the type and frequency of psychosocial difficulties among 93 French adult Hodgkin's disease survivors (4-17 years since treatment) with that of 186 healthy controls using a population-based case-control design.4 Hodgkin's disease survivors expressed more limitation in physical activities than controls because of residual physical (P < 0.001) and role-functioning (P < 0.001) impairments, persistence of dyspnea (P < 0.001) and chronique fatigue (P = 0.025) as measured by the EORTC QLQ-C30 core questionnaire.114 These results were in agreement with those previously reported in hospital series.110,111,115 Hodgkin's disease survivors also more often expressed difficulties (P = 0.015) in concentration or with memory than controls as previously reported.116,117 Global health status was equally scored as good by patients and controls, while data in the literature are conflicting.110,115,117 In the study by Joly et al.4 just as in the majority of cancer quality-oflife studies, no major late psychological or psychiatric distress were observed in both survivors and controls,115,118,119 while psychologically vulnerable cancer patient groups who remain distressed over time have been described.120 Familial disturbances are of great concern among long survivors from cancer. Data on interpersonal relationships and sexual activities are conflicting. In the study by Joly et a/.,4 patients experienced fewer separations or divorces, but similar sexual activity compared with controls. Changes in relationships with friends were also less frequent in cases than in controls, who reported to have lost more friends. Whereas married status at the time of diagnosis can influence survival, altered marriage practices were very limited among survivors from childhood and adolescent cancers as were changes in relationships with close friends as a result of the illness.108,110,121122 Other studies demonstrated that long-term Hodgkin's disease survivors might experience more frequent separations and divorces than the general population.110,113 General dissatisfaction with sex life or more changes in interest in sex and attractiveness have been reported.,108.111 Although cases had fewer children than controls, which was often related to chemotherapy-induced sterility, French patients and controls had similar familial status; familial relationships appeared to be satisfactory and did not influence the level of quality of life, in contrast to that observed in studies focusing on adolescent long-term survivors.1

Of the French newly diagnosed cancer patients who were working at the time of disease, 64 per cent reported a return at work after treatment;124 however, changes in employment or working position were mentioned by 38 per cent of patients, which is in agreement with the study by Joly et al.4 In the latter study, Hodgkin's disease survivors more frequently reported less professional ambition, as if they preferred to have more modest goals to allow more time for enjoying life, and they chose not to run after success as described by Siegel and Christ.108 In contrast, compared with their situation before the disease developed, patients enrolled in the Stanford series reported having increased their professional ambition.111 These conflicting results must be viewed cautiously because, in the Stanford series, no control group was available, the study was performed in 1985 in patients treated 1-21 years beforehand and involved people with different educational backgrounds. Most Hodgkin's disease survivors associate work-related problems with their illness.108,115 Work-related problems are reported in long-term cancer survivors concerning promotional and income prospects, closely related with problems in borrowing from banks or difficulties with insurance companies.110,115,117 Even in patients cured from their disease, problems regarding insurance and bank loans remain a major difficulty for long-term survivors in their daily life as well as in their professional life, in particular in those who wish to establish their own business.110,111,125 Although society remains slow to integrate the improved prognosis of Hodgkin's disease patients into its perception of these patients and into its employment and insurance policies, Hodgkin's disease survivors seem to have learned to cope with the problems related to their disease and its treatment.

CAUSES OF DEATH The risk of dying from specific causes after Hodgkin's disease has been reported in limited studies. After nonHodgkin's lymphoma, the risk of dying from causes other than disease progression has not been explored, that of death from secondary malignancy excepted. In 1986, Rubin et al. reported no significant difference between overall survival and survival corrected for second cancer mortality in a series of 320 clinical Stage I—IV patients,126 while the EORTC reported a 5 per cent difference in the 15-year survival rates between crude and corrected survival in a series of 1501 clinical Stage I-II patients.90,127 Similar findings were reported by the Stanford University group, the International Database on Hodgkin's Disease (IDHD) and the British National Lymphoma Investigation (BNLI).28,29,107,128 In these three series, in patients cured of Hodgkin's disease, intercurrent deaths represented the first cause, followed by secondary cancer-related and treatment-related deaths.

Conclusion 431

Intercurrent deaths were mainly from cardiovascular and infective complications. The risk of dying from cardiac failure was investigated in four Hodgkin's disease series. In a cohort of 957 patients diagnosed with Hodgkin's disease during 1942-1975, 25 coronary heart disease deaths were observed, giving a death rate relative to the general population rate of 0.91, not significantly different from 1.19 In contrast, the RRs of death were 1.97 (P < 0.001) in the Dutch series,129 3.2 (P < 0.01) in the Stanford series,29 2.8 (P < 0.001) in the IDHD series (unpublished results) and 8.63 (P < 0.001) in the EORTC series.127 Factors affecting death from cardiac failure were heart irradiation as part of the mantle field irradiation in almost all series, and male gender. In the Stanford series, mediastinal radiation dose above 30 Gy was associated with an increased risk (RR = 3.5) and patients treated with radiation therapy alone had a higher risk than those treated with combined modality therapy; the cumulative probability of dying from cardiac failure was 15.5 per cent in mates, while it was 3.5 per cent in females.22 In this series, the risk of dying from acute myocardial infarction or from other cardiac disease was much greater when patients were treated before the age of 20 (RR = 44.1 and 21.5, respectively); that of acute myocardial infarction decreased thereafter (from 7.3 in patients aged 20-29 to 1.8 in patients aged 50 or above) but remained significantly increased at all ages, whereas the risk of dying from other cardiac disease remained increased only in patients younger than 40 (RR = 8.8 and 4.8 in patients aged 20-29 and 30-39, respectively). The risk of both myocardial infarction-related and other cardiac diseaserelated death also significantly increased with time from initial Hodgkin's disease treatment. In the Stanford series, infective deaths concerned opportunistic infection, pneumonia and chronic disease, and asplenic sepsis.28 They were as frequent as cardiac deaths and were not influenced by the administration of previous MOPP chemotherapy. They might, however, have been a consequence of mediastinal and lung irradiation, splenectomy, or both. In patients treated with a combination of irradiation and MOPP, total nodal irradiation was shown to increase the risk of dying from other causes significantly (4 ANLL and 5 infections in 74 patients) compared with mantle and para-aortic irradiation (1 infection in 121 patients).130 Infective deaths represented 35 per cent of all intercurrent deaths that occurred in 774 patients aged 15-29, who remained disease-free in the BNLI series.128 In the IDHD series, infective deaths represented 34 per cent of all intercurrent deaths, corresponding to a RR of 9.0 (P < 0.001) (unpublished results). Overall, the risk of dying from other causes than Hodgkin's disease progression was analysed relative to that of the general population (matched for sex, age and country) in the IDHD series on all stages, and in the EORTC series on early stages. In the IDHD series, the

risk was 2.01 in males and 2.30 in females; it was 2.07 in patients with early stage disease and 2.13 in patients with advanced stage disease.107 The risk increased with time from initial treatment, from 1.79 in the 0-4-year period to 3.08 in the 15-19-year period; in contrast, the risk decreased with age at Hodgkin's disease diagnosis, from 4.13 in patients aged 15-19 to 1.42 in patients aged 60 or above. In this series, the 20-year cumulative probability of dying from intercurrent disease was above that of dying from Hodgkin's disease progression. In the EORTC series, patients cured from Hodgkin's disease had a risk of dying from causes unrelated to the disease itself multiplied by 3.11 (P < 0.001) compared to that of the general population.127 The risk was higher in females than in males (RR = 3.28 and 3.06, respectively); it was higher in patients aged 15-39 at diagnosis than in patients aged 40 and above (RR = 3.46 and 2.85, respectively). The risk increased with time from initial treatment, from 1.91 in the 0-2-year period to 3.85 in the 15-17-year period with a peak (RR = 5.79) during the 9-11-year period. Similar findings were observed in males and in females, and also in patients aged 15-39 and in older patients. Finally, in the Stanford series, the loss in the 20-year survival rate was 7 per cent due to death from a malignancy other than Hodgkin's disease; it was also 7 per cent due to death from acute myocardial infarction.28,29 In the EORTC series, second cancer and cardiac failure (sudden deaths of unspecified cause excluded) were responsible for a difference in the 20-year survival rate of 7.3 and 5.7 per cent, respectively.127 The BNLI reported a 5.5 per cent difference (deaths from all causes included) at 20 years between observed and expected survival rates in patients aged 15-29.128 In the IDHD series, deaths unrelated to Hodgkin's disease and its treatment were responsible for a decrease in the 15-year survival rate of 7 per cent.107

CONCLUSION Long-term non-malignant as well as malignant complications are seen because the treatment of Hodgkin's disease and, more recently, that of non-Hodgkin's lymphoma is successful. Non-malignant complications are likely to be related to treatment, although some problems might be associated with the disease itself. Modern irradiation techniques, new combination chemotherapies and new strategies should concur to decrease incidence rates. Even though malignant complications are mostly treatment-induced, the exact role of radiation therapy (dose and volume) and chemotherapy as risk factors for solid tumors remains to be assessed. Oncologists who nowadays tend to propose chemotherapy as the unique treatment in all stages of Hodgkin's disease should carefully balance the risk of radiationand chemotherapy-related malignant (leukemias and

432 Long-term problems

solid tumors), and non-malignant complications.131 Treatment duration should also be considered because, the longer the treatment, the higher the probability of psychological distress. Most patients who achieve remission will remain disease-free as well as free of serious complications. Nonetheless, long-term survivors should be carefully followed at regular intervals to help prevent, or diagnose at an early stage, any complication that can occur a long period after the patient has been cured.132 Attempts should also be made by the medical community to convince society, life insurance companies and banks that they can help long-term survivors to enjoy a normal life.

5. Bjbrkholm M, Holm G, Mellstedt H. Immunocompetence in patients with Hodgkin's disease. In: Lacher MJ, Redman JR, eds Hodgkin's disease: the consequences of survival. Philadelphia: Lea & Febiger, 1990:12-150. 6. Amstrong D, Minamoto GY. Infectious complications of Hodgkin's disease. In: Lacher MJ, Redman JR, eds Hodgkin's disease: the consequences of survival. Philadelphia: Lea & Febiger, 1990:151-67. 7. Kluin-Nelemans JC, Henry-Amar M, Carde P, et al. Assessment of thyroid, pulmonary, cardiac and gonadal toxicity in stages l-ll Hodgkin's disease. Abstracts of the Third International Symposium on Hodgkin Lymphoma September 18-23,1995, Kbln, Germany, 1995: 90 (abstract 72). 8. Hancock SL, Cox RS, McDougall IR. Thyroid diseases

SUMMARY

after treatment of Hodgkin's disease. N EnglJ Med 1991; 325: 599-605.

Hodgkin's disease is considered a curable disease. The use of appropriate staging techniques and treatment methods has resulted in long-term cause-specific survival rates as high as 90 per cent in the early stages, and 75 per cent or greater in the advanced stages. In nonHodgkin's lymphomas, new therapeutic approaches are expected to result in a cure rate of 75 per cent or more. Long-surviving lymphoma patients, however, face new problems that have become apparent as larger numbers of successfully treated patients are followed for longer periods of time. These problems mostly concern chronic medical as well as psychosocial complications, which can interfere with quality of life. Lymphoma therapy may result in severe infections, or thyroid, cardiovascular, pulmonary, digestive or gonadal dysfunction. It may also result in secondary malignancy, which is considered the most serious complication. Because the vast majority of patients who are long-term survivors will remain symptom-free and do enjoy a normal life, long-term followup should concentrate on prevention and early detection of treatment-related complications, and of secondary malignancy.

9. Peerboom PF, Hassink EAM, Melkert R, et al. Thyroid function 10-18 years after mantle field irradiation for Hodgkin's disease. EurJ Cancer 1992; 28A: 1716-8. 10. Desablens B, Alliot C, Dierick A, et al. Hypothyroidism after Hodgkin's disease. Pathogenic hypothesis from a study of 51 patients treated by 3 courses of the ABVDMP regimen and 40 Gy radiotherapy. Abstracts of the Third International Symposium on Hodgkin Lymphoma, September 18-23,1995, Koln, Germany, 1995:117 (abstract 99). 11. Redman JR, Bajorunas DR. Therapy-related thyroid and parathyroid dysfunction in patients with Hodgkin's disease. In: Lacher MJ, Redman JR, eds Hodgkin's disease: the consequences of survival. Philadelphia: Lea & Febiger, 1990:222-43. 12. Gerling B, Gottdiener J, Borer JS. Cardiovascular complications of the treatment of Hodgkin's disease. In: Lacher MJ, Redman JR, eds Hodgkin's disease: the consequences of survival. Philadelphia: Lea & Febiger, 1990:267-95. 13. Mauch P. Controversies in the management of early stage Hodgkin's disease. Blood 1994; 83: 318-29. 14. Morgan GW, Freeman AP, McLean RG, et al. Late cardiac, thyroid, and pulmonary sequelae of mantle

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Cancer (Paris) 1982; 69: 393-8. 125. McKenna RJ, Black B, Hughes R, et al. Workgroup #2: insurance and employability. Cancer 1993; 71: 2414-8. 126. Rubin P, Zagars G, Chuang C, et al. Hodgkin's disease: is there a price for successful treatment? A 25-year experience. Int J Radial Oncol Biol Phys 1986; 12: 153-66. 127. Henry-Amar M, Somers R. Long term survival in early stages Hodgkin disease: the EORTC experience. In: Somers R, Henry-Amar M, Meerwaldt JH, Carde P, eds Colloque Treatment strategy in Hodgkin's disease INSERM, Vol. 196. London: John Libbey Eurotext, 1990: 151-66. 128. Vaughan Hudson B, Vaughan Hudson G, Linch DC, et al. Late mortality in young patients cured of Hodgkin's disease. Ann Oncology 1994; 5(suppl 2): S65-6. 129. van Rijswijk REN, Verbeek J, Haanen C, et al. Major complications and causes of death in patients treated for Hodgkin's disease.J Clin Oncol 1987; 5:1624-33. 130. Mauch P, Canellos GP, Rosenthal DS, et al. Reduction of fatal complications from combined modality therapy in Hodgkin's disease.; Clin Oncol 1985; 3: 501-5.

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childhood or adolescence. J Clin Oncol 2000; 18:1492-9.

31 The way forward BW HANCOCK, PJ SELBY, JO ARMITAGE AND KA MACLENNAN

This book has been written in the early aftermath of a wave of reclassification of malignant lymphoma, which has introduced into recognition and usage the Revised European-American Lymphoma classification and the World Health Organisation classification derived from it. This has taken the field forward and brought together histopathological subdivisions with the recognition of entities useful to clinical lymphoma specialists. Closer links between lymphoma morphology, clinical features and molecular pathology have emerged with a few quite specific associations, such as the chromosome 2'-5'translocation and anaplastic lymphoma, to add to those previously identified. Within each division and subdivision of the new classification, there is still considerable heterogeneity not only in morphology, clinical features and tempo but also, most importantly for the patient, in outcome. It is still not possible to predict for an individual in any category the likely outcome. Broad predictors are helpful to patients and healthcare professionals. For example, patients with localized asymptomatic Hodgkin's disease can be given a great deal of very real reassurance about their outcome, following one of several treatment routes. The difficulty for them may be to choose the best treatment route to achieve cure without lasting toxicity; patients with mantle cell lymphoma have to know that their chances of cure are relatively small whatever approach to treatment is taken. Although considerable progress has been made in the development of prognostic indices, their limitations have been highlighted in the chapters of this textbook when it comes to individual patient prediction. They still have not achieved sufficient accuracy to allow tailor-made choices to be made for many patients, apart from the appropriate choice for their histopathological category refined by the existing prognostic indices. Future work will allow further refinement of the identification of appropriate prognostic groupings, more accurate descriptions of likely outcomes and better choices of treatment for each individual patient. Most work to date has concentrated on histopathology and

clinical manifestations. The residual variance in outcome seems to depend on the biological features of the tumor and its chemosensitivity. There are already encouraging indications that biological predictors will be helpful, using cytokines, cytokine receptors and molecular characteristics of the tumors themselves. Prediction of chemosensitivity, in advance of exposure to drugs, is still a vexed question and assays based on drug exposure in vitro remain disappointing. Perhaps the accurate detection and quantification of drug targets and co-factors will be more useful in future. Individual drug selection remains a relatively distant ambition for the management of lymphoma patients. The treatments for lymphoma have improved steadily over the years, due to both the more intelligent use of previous treatments and the development of previously unrecognized therapies. In terms of conventional management certain treatment guidelines can be given. For localized Hodgkin's disease (HD) and nonHodgkin's lymphoma (NHL), radical radiotherapy may be curative. However, there is now good evidence, at least for localized NHL, that chemotherapy (for example, three courses of CHOP) prior to involved-field radiotherapy improves overall survival. For localized HD, 'minimal' chemotherapy prior to involved-field radiotherapy reduces the risk of relapse and of long-term sequelae, but the effect on overall survival is likely to be minimal (given the already acknowledged excellent survival in this group). Thirty years of experience with cyclical combination chemotherapy in advanced HD with MOPP descendants and alternatives (particularly ABVD) has improved the ultimate prognosis only marginally. Further significant improvements are unlikely to come from manipulation of such conventional therapies and long-term toxicities must be better addressed. For intermediate/high-grade NHL, CHOP remains 'standard' therapy - but not with any degree of complacency, since cure rates remain below 50 per cent. For both HD and aggressive NHL, future success may depend on altering the doses or schedules rather than the chemotherapeutic agents

438 The way forward

themselves. High-dose chemotherapy with autologous or allogeneic stem cell support is slowly finding its place; intensive or escalated, growth factor-supported regimens (often involving combined modality, chemotherapy/ radiotherapy, approaches) are also showing promise. Low-grade NHL remains a frustrating and worrying lymphoma to treat; experimental (including immunemodulatory) approaches seem particularly relevant to this indolent disease. For all types of lymphoma, it would be nice if we could select patients for different approaches on the basis of predicted prognosis but, as we have seen, this is presently not possible for the majority of patients. For example, we still do not know the best strategy for the utilization of dose escalation as treatment in each subtype of lymphoma. In some types of lymphoma, the best strategy will be utilization of high-dose therapy and transplantation as a rescue for patients who have failed initial therapy, while in others it may be that this will be best used as an adjuvant to primary therapy. In still other types of lymphoma, high-dose therapy and transplantation may not be effective. The optimal type of cellular rescue product in transplantion is unknown. The relative merits of allogeneic cells, autologous cells, cord blood cells, cells from related or unrelated donors, and the value of in vitro marrow treatment are all uncertain. Once again,

the same answer is unlikely to be correct for each disease and clinical situation. The place of immunological therapy for lymphoma, after a long gestation, is beginning to be established with the recognition of modest but consistent activity for anti-B cell monoclonal antibodies - so far principally anti-CD 20. Other approaches hold promise, such as adjuvant immune therapy in patients undergoing highdose therapy and transplantation. Whether this should be done with infusion of immunologically active cells, the use of various drugs, such as interferon or other cytokines, or other as yet undiscovered approaches remains unknown. Modifications in the transplant process in an attempt to alter the incidence of graft versus host disease and to increase the likelihood of a graft versus lymphoma effect are promising. Finally, transplantation may be the best setting for the application of gene therapy in the treatment of patients with lymphoma. Collaboration between scientists and clinicians remains essential and patients should be given the opportunity to be involved in well-designed clinical trials whenever possible. They should be treated by multi-disciplinary teams working in well-resourced centers. We have seen exciting advances in diagnosis, classification and treatment of lymphomas with great benefits to patients in recent decades. We are confident there are more benefits to come.

Index Page numbers in bold type refer to main discussions, those in italics indicate figures and tables.

abdominal disease Burkitt's lymphoma, 49, 86 pediatric non-Hodgkin's lymphoma, 373 and pelvic disease AIDS-related lymphoma, 215 imaging, 207-10,211,215 ABMTsee bone marrow transplantation, autologous ABVD (Adriamycin (doxorubicin), bleomycin, vinblastine, dacarbazine), 236, 378, 379, 381 plus radiation, long-term side-effects, 423,424 acquired immune deficiency syndrome (AIDS)-related lymphomas,

351-8 clinical features, 353 clinicopathologic correlations, 353 epidemiology, 351 etiology and pathogenesis, 351-2 Epstein-Barr virus (EBV), 87,120,165 p53 mutations, 143, 352 and HIV in Hodgkin's disease, 195-6, 215 imaging, 214-16 pathological aspects, 352-3 prognostic factors, 353 treatment options, 353-6 following initial chemotherapy failure or relapse, 356 see also human immunodeficiency virus (HIV) acute lymphoblastic leukemia (ALL), B and T lineage, 56-7 and lymphoblastic lymphoma, 299-300 acute non-lymphoblastic leukemia (ANLL), secondary, 426-8 acyclovir, 407 adrenal involvement, imaging, 209 adult T cell leukemia/lymphoma (ATLL), 58-9, 288 HTLV-1 infection, 115-16,121 age factors Hodgkin's disease, 161-3,164,181,191 familial longevity, 193 and incidence, 385-6 as prognostic factor, 387-8 non-Hodgkin's lymphoma, 770, 777 agriculture, 173 AIDS see acquired immune deficiency syndrome AIL see angioimmunoblastic T cell lymphoma ALCL see anaplastic large cell lymphoma ALK see anaplastic lymphoma kinase alkylating agents see chlorambucil; cyclophosphamide ALL see acute lymphoblastic leukemia (ALL), B and T lineage allogeneic bone marrow transplantation see bone marrow transplantation, allogeneic alopecia, 238 amphotericin B, 409 anaplastic large cell lymphoma (ALCL) chromosome translocation, 141-2 pediatric, 373

of T cell lineage (KM), 60-1 AIDS-related, 353 chromosome translocation, 96,141-2 cutaneous, 80-1, 261-2, 368 anaplastic lymphoma kinase (ALK), 61, 96 angiocentric T and/or NK cell lymphoma, 82 angiofollicular lymphoid hyperplasia of the hyalin-vascular type see Castleman's disease angioimmunoblastic T cell lymphoma (AIL), 62-3, 327 angiotropic large cell lymphoma, 86, 87 Ann Arbor staging system Hodgkin's disease, 184,191-2,196, 225 pediatric, 377-8 stage III, 236 lymphoblastic lymphoma, 300 non-Hodgkin's lymphoma, 196,197,248, 289 antibody therapy, 279, 315, 340, 365 anti-B4 (CD 20), 356 antimetabolites see fludarabine; methotrexate antimicrobial therapy, 404-12 combined, 406 duration and modification, 406 H. pylori eradication, 253-4, 326 pediatric, 379 postsplenectomy, 422 prophylaxis herpes virus infections, 407-9 in neutropenic patients, 406-7 and treatment of fungal, 409-10 single-agent, 406 use in febrile neutropenic patients, 404 antisense therapy, 315 hRLsee acquired immune deficiency syndrome, (AIDS)-related lymphomas ataxia-telangiectasia, 56 ATLL see adult T cell leukemia/lymphoma ATM tumor suppressor gene, 56, 58 autologous bone marrow transplantation see bone marrow transplantation, autologous (ABMT) axillary lymphadenopathy, 214 BACT (carmustine, cytarabine, cyclophosphamide, 6-thioguanine), 331 bacterial infections, 401-2 Bcell centroblast and centrocyte, 4, 21, 22, 27, 29 centrocyte-like (CCL), 73 disruption in angioimmunoblastic T cell lymphoma, 62 germinal centre-derived, 10-11, 21,22, 33, 34 immunocytochemistry, 11, 31 infiltration of bone marrow in follicular lymphoma, 23 lymphocytic lymphoma phenotypes, 33 in mucosa-associated lymphoid tissue (MALT), 72-3

440 Index

B cell chronic lymphocytic leukemia (B-CLL) (small lymphocytic lymphoma), 43-4,45, 325 B cell lymphomas aerodigestive tract, 82 AIDS-related, 351 associated viruses, 119-21 bladder, 85 breast, 86 classification ILSG, 6 Lukes and Collins, 4 updated Kiel, 5 WHO, 7 cutaneous, 81, 261, 359, 367-8 diffuse aggressive, 49-54 diffuse indolent (low-grade), 43-7 diffuse large B cell lymphoma (DLBCL), 50, 61 follicular, 21-2 marginal zone, 326-7 non-Hodgkin's lymphoma, 5, 11-12 pediatric, 372-3 pulmonary, 79 splenic, 84 T cell-rich, 51 testicular, 85 thymic, 51, 83-4, 262 bcl-1/PRAD-1 gene rearrangement, 31-2, 135-7 bcl-2 oncogene, 137-40, 315 bcl-3 and REL/NF kappa B transcription factors, 144 bc/-6/laz-3 gene rearrangements, 140-1 bc/-10 and mucosa-associated lymphoid tissue (MALT) lymphoma, 74, 142 B-CLL see B cell chronic lymphocytic leukemia BCNUseecarmustine biological therapy, 314-15, 365-6 infection prevention, 411-12 biopsy CT-guided, 207, 210, 215, 217 lymph node, 184 nasopharangeal, 211 bladder involvement, imaging, 209 bladder lymphomas, 85 non-Hodgkin's lymphoma, 257 bleomycin, 271, 272 pulmonary effects, 379, 389 seeo/soABVD; CHVmP/VB; MACOP-B; m-BACOD; PACEBOM; P-VEBEC P microglobulin, 190 BNLI see British National Lymphoma Investigation bone imaging marrow involvement, 210, 211 osseous involvement, 210, 211 bone involvement, Hodgkin's disease, 187, 239 bone lymphomas, primary, 85-6 non-Hodgkin's lymphoma, 258-9 bone marrow imaging, 210, 211 bone marrow infiltration angioimmunoblasticTcell lymphoma, 63 B cell chronic lymphocytic leukemia, 44 follicular lymphoma, 23, 310, 311 Hodgkin's disease, 187-8 lymphoplasmacytic lymphoma, 45 mantle cell lymphoma, 29-30, 34-5 marginal zone lymphoma, 45 bone marrow transplantation allogeneic, 302, 3 0 3 - , 341-2 cytomegalovirus infection risk, 408-9 versus autologous (ABTM), 342-3

autologous (ABTM), 302-3 versus peripheral blood, 303, 304, 313-14, 331, 340-2 Borrelia burgdorferi, 261 brain lymphomas, 259-60 breast cancer, secondary, 239, 428, 429 breast lymphomas, 86 imaging, 214 non-Hodgkin's lymphoma, 258 British National Lymphoma Investigation (BNLI), 10, 14 grading system, 12, 14 nodular sclerosis, 12, 13 Burkitt's-like lymphoma, 49-50, 76, 87 Burkitt's lymphoma, 49, 76, 288 chromosomal translocation, 94-4 and c-myc oncogene, 134-5 endemic, 49, 86 Epstein-Barr virus (EBV), 118-19, 172 p53 mutations, 143 pediatric, 49,170,288,373 treatment, 376 sporadic, 86 cardiac failure, Hodgkin's disease, 431 cardiovascular dysfunction, iatrogenic, 423 chemotherapy, 379, 423 radiation therapy, 238 carmustine (BCNU), 260, 270, 272 topical, 364 see also BACT Castleman's disease, 14, 33, 117, 262 causes of death, 430-1 CBCLsee cutaneous B cell lymphomas CCL cells see centrocyte-like (CCL) cells CD 2, 22, 56-7 CD 3, 13,22 CD 3/TCR alpha/beta, 58, 59, 85 CD 4, 13, 22, 56, 58, 59, 62, 63 AIDS-related lymphomas, 351, 355 CD 5, 22, 31, 33, 34, 44, 50, 56 CD 8, 13,56,58,59,62 CD 10, 22, 31, 34, 49, 50, 57 CD 15, 11,13, 109 CD 19, 19, 22, 44, 45, 49, 50, 51 CD 20, 11, 22, 31, 44, 45, 49, 50, 51, 57 anti-B 4 monoclonal antibody, 356 CD 21, 11,74 CD 22, 22, 31, 45, 50 CD 23, 22,31,44 CD 30, 11, 13, 23, 60, 81, 96, 109, 368, 373 ligand interaction, 111 CD 35, 11, 74 CD 38, 44, 58, 59 CD 43, 22, 31, 33 CD 45RO, 13, 58, 59, 62, 63 CD 57, 11, 22, 58 CD 71, 61, 109 CD 79a, 11, 45, 49, 50 CDE infusional chemotherapy (cyclophosphamide, doxorubicin, etoposide), 354-5 celiac disease, 76-7 central nervous system (CNS) lymphomas, 83 AIDS-related, 215, 353, 356 angiotropic large cell, 86, 87 Hodgkin's disease, 187 imaging, 213-14, 215 immunodeficiency-associated, 87, 215, 353, 356 non-Hodgkin's lymphoma, 259-61 centrocyte and centroblast cells, 4, 21, 22, 27, 29

Index 441 centrocyte-like (CCL) cells, 73 centrocytic lymphoma see mantle cell lymphoma cephalosporins/glycopeptide combinations, 406 cerebral spinal fluid analysis, 289 cervix uteri, 258 chemotherapy acronyms, 277,297 blood-brain barrier penetrating, 260 infusional, 354-6 metabolism in elderly, 388-9 in pregnancy, 195 relapse after initial, 277-8 and secondary malignancies, 426, 428 versus combined modality, 235-6,250 versus radiation therapy, 235 see also combined modality therapy; high-dose chemotherapy/stem cell transplantation; salvage therapy chest, imaging, 206-7 chlorambucil, 312, 389 ChlVPP (chlorambucil, vincristine, procarbazine, prednisolone), 378, 379 ChlVPP/EVA (chlorambucil, vinblastine, procarbazine, prednisolone, doxorubicin, vincristine, etoposide), 425 CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone), 297, 295-6, 354, 356 adult T cell leukemia/lymphoma (ATLL), 58 and autologous transplantation, 339 in elderly, 389, 390, 391, 392 follicular lymphoma, 313 mantle cell lymphoma, 35-6 and radiotherapy, 250 testicular lymphoma, 257 versus MACOP-B, 295 versus ProMACE-CytaBOM versus MACOP-B, 295 versus m-BACOD, 294-5 versus PACEBOM, 295 chromosomal abnormalities, 133-4 11q23, 142 anaplastic large cell lymphoma, 61 clonal rearrangements t(14)(q11) lesions, 96, 98 mucosa-associated lymphoid tissue (MALT), 74, 142 non-Hodgkin's lymphoma, 97-9 'primary'acquired, 92 probable 'secondary' acquired, 92 t(2;5)(p23;q35), 96, 97,141-2 t(3;14)(q27;q32), 94, 95,140 t(3;22)(q27;q11), 140-1 t(8;14)(q24;q32), 93-4 t(9;14)(p13;q32), 96 t(11;14)(q13;q32), 94-6, 135-7 t(11;18)(q21;q21), 96,97 t(14;18)(q32;q21), 94,99,137-40 T cell acute lymphoblastic leukemia, 57 CHVmP/VB (cyclophosphamide, doxorubicin, teniposide, prednisolone, vincristine, bleomycin), 392 classification systems, 3-8 extranodal lymphomas, 71-2 pediatric non-Hodgkin's lymphoma, 372 see also specific classification systems ClUPLsee prolymphocytoid transformation CMV see cytomegalovirus c-myc oncogene, 22, 51, 93-4 and Burkitt's lymphoma, 134-5 CNOP (cyclophosphamide, mitoxantrone, vincristine, prednisolone), 391 CODOX-M (cyclophosphamide, vincristine, doxorubicin, methotrexate), 376 combined modality therapy

brain lymphoma, 260 gastric lymphoma, 253 Hodgkin's disease advanced, 275-6 in elderly, 393 localized, 236 pediatric, 378-9 stage IMA, 237 intestinal lymphoma, 254 lymphoblastic lymphoma, 300-2 mycosis fungoides, 366 non-Hodgkin's lymphomas, 250 in elderly, 390-2 testes, 257 versus chemotherapy, 235-6, 250 versus radiation therapy, 234-5 co-morbidity in elderly, 390 COMP (cyclophosphamide, oncovin, methotrexate, prednisolone), 376 computed tomography (CT) abdomen and pelvis, 207-8, 209-10, 211 AIDS-related lymphoma, 215, 216 central nervous system, 213-14 chest, 206-7 follow-up, 216 -guided biopsy, 207, 210, 215 head and neck, 211,212-13 lymph nodes, 205-6 skeletalsystem, 210, 211 COPP (cyclophosphamide, vincristine, procarbazine, prednisolone), 425 cotrimoxazole, 407, 410 Cotswold staging system, Hodgkin's disease, 184, 785 pediatric, 377-8 cutaneous lymphomas, 80-1, 359-70 anaplastic large cell lymphoma (ALCL) of T cell lineage (CD30/Ki-1), 80-1,261-2,368 B cell lymphomas (CBCL), primary, 81,261, 367-8 Hodgkin's disease, 188 large cell lymphomas of T cell phenotype (T-LCL), primary, 261 non-Hodgkin's lymphoma, 261-2 CVP (cyclophosphamide, vincristine, prednisolone), 327 in elderly, 36 follicular lymphoma, 372, 313 CVPP (cyclophosphamide, vinblastine, procarbazine, prednisolone), 235-6 cyclin 01,32,117,136-7 cyclophosphamide, 260,271, 272, 312, 314, 376 metabolism in elderly, 389 see also BACT; CDE; CHOP; CHVmp/VB; CNOP; CODOX-M; COMP; COPP; CVP; CVPP; EPOCH; PACEBOM; P-VEBEC cytarabine, 260, 376 cytogenetics, 91-103 clinical and prognostic correlations, 99 Hodgkin's disease, 92-3,108-9 mantle cell lymphoma (MCL), 31-3 methods, 91-2 non-Hodgkin's lymphoma, 93-9 pediatric lymphomas, 372 cytomegalovirus (CMV), 403 prevention, 408-9 treatment, 409 dexamethasone, 260 DHAP (dexamethasone, cytarabine, cisplatin), 336 diaphragmatic invasion, 206,207, 231 didanosine, 355 diffuse immunoblastic lymphoma, 288

442 Index

diffuse large B cell lymphoma (DLBCL), 50-1, 61 morphology, 50 pediatric, 372-3 phenotype, 50 rare subtypes, 51 diffuse large cell non-Hodgkin's lymphoma, 287-8 treatment in elderly, 390-2 diffuse small non-cleaved cell lymphoma see Burkitt's lymphoma digestive system see gastrointestinal tract DLBCL see diffuse large B cell lymphoma doxorubicin, 272-3 age-specific considerations, 389 bladder lymphoma, 257 cardiotoxicity, 423 secondary malignancy, 426 see also ABVD; CDE; ChlVPP/EVA; CHOP; CHVmP/VB; CODOX-M; EPOCH; MACOP-B; m-BACOD; PACEBOM dysphagia, 237-8 EATL see enteropathy-associated T cell lymphoma EBNAssee Epstein-Barr nuclear antigens EBT see electronic beam therapy ECPPsee photopheresis, extracorporeal elderly, 385-97 advanced age as prognostic factor, 386-8 age-specific treatment considerations, 36, 388-90 Hodgkin's disease, 110, 226, 386, 387-8, 392-3 incidence of lymphoma in population, 385-6 manifestations of lymphoma, 386 non-Hodgkin's lymphoma, 385-7, 390-2 treatment strategies, 390-3 advanced disease, 390-2 localized disease, 390 electron beam therapy (EBT), 364-5, 366, 367 emesis, 237, 238 enteropathy-associated T cell lymphoma (EATL), 76-7 EORTC see European Organisation for Research and Treatment of Cancer (EORTC) eosinophilia, 189 epidermotropic small cerebriform cell lymphomas see mycosis fungoides EPOCH (etoposide, vincristine, doxorubicin, cyclophosphamide, prednisolone), 355-6 Epstein-Barr nuclear antigens (EBNAs), 117,118 Epstein-Barr virus (EBV), 117-18 angioimmunoblastic T cell lymphoma, 62 Burkitt's lymphoma, 118-19,172 Hodgkin's disease, 110-11, 164-5 pediatric, 372 immunodeficiency-associated lymphomas, 87 B cell, 119-20 HIV, 196 nasal lymphoma, 252, 255 primary effusion lymphoma (PEL), 51 T/natural killer cell lymphomas, 121-2 types A and B, 118, 120, 121 European Organisation for Research and Treatment of Cancer (EORTC), 10, 224, 234 extracorporeal photopheresis (ECPP), 366 extradural lymphoma, 260-1 extranodal lymphomas classification, 71-2 sites, 71, 196-8 Hodgkin's disease, 186-8 non-Hodgkin's lymphoma, 251-62 extranodal marginal zone lymphoma of MALT type, 326-7 eye lymphomas see ocular adnexa and eye lymphomas

FDC see follicular dendritic cells female genital tract lymphomas, 85, 258 fertility, treatment effects, 195, 239, 380, 424-6 fine-needle aspiration biopsy (FNAB), 210, 217 FISH see fluorescence In situ hybridization FLsee follicular lymphoma fluconazole, 410 flucytosine, 410 fludarabine, 313, 314, 327-8, 389 fluorescence In situ hybridization (FISH), 92, 99-100 FNAB see fine-needle aspiration biopsy follicular dendritic cells (FDC), 11, 22, 23 follicular lymphoma (FL), 21-6, 309-24 diagnosis, 311 extranodal disease, 23, 76 immunophenotype, 22 investigation, 311 management, 311-16 morphology, 21-2 pathology, 309-10 presentation features, natural history and clinical course, 310-11 transformation, 22-3 treatment options, 312-15 biological therapy, 314-15 chemotherapy, 312-13 high dose therapy/stem cell rescue, 313-14 radiotherapy, 312 treatment strategy, 311-12, 315-16 fungal infections, 402 prevention and treatment, 409-10 gallium-67 scanning, 206 withSPECT, 207, 216-17 ganciclovir, 407 gastric lymphomas mucosa-associated lymphoid tissue (MALT), 75 therapeutic strategies, 253 gastric wall thickening, 270 gastrointestinal tract B cell nodal lymphomas, 76 Burkitt's and Burkitt-like lymphoma, 76 complications, long-term, 424 enteropathy-associated T cell lymphoma (EATL), 76-7 Hodgkin's disease, 188 imaging, 209-10 immunodeficiency-associated lymphomas, 87 immunoproliferative small intestinal disease (IPSID), 76,254,326-7 mantle cell lymphoma (MCL), 30-1, 34, 35, 76 mucosa-associated lymphoid tissue (MALT) lymphomas, 74-7, 253-1, 326-7 non-Hodgkin's lymphomas, 75, 253-4, 326-7 radiation therapy side-effects, 238 G-banding methods, 92 G-CSF see granulocyte colony stimulating factor gender female predominance, 51 Hodgkin's disease, 161, 762 prognostic factor in, 191 male predominance, 76, 299, 367 gene amplification, 144 gene mutations, 142-4 genes see bdl; c-myc oncogene; latent membrane protein (LMP), gene deletion; p53 gene; PRAD-1 gene; TAL-1 gene; TCR gene gene sequences, non-Hodgkin's lymphoma, 172 gentamicin/carbenicillin combination, 406 GM-CSF see granulocyte-macrophage colony stimulating factor gonadal dysfunction, 424-6 MOPP in children, 380

Index 443

see also fertility; ovaries; testes 'graft versus lymphoma effect', 341-3 granulocyte colony stimulating factor (G-CSF) in elderly, 389, 392 in neutropenic patients, 411, 412 granulocyte-macrophage colony stimulating factor (GM-CSF) AIDS-related lymphoma, 354 in elderly, 389 follicular lymphoma, 315 in neutropenic patients, 411, 412 granulocytopenic lymphoma patient, 400-1 HAART see highly active antiretroviral therapy Haemophilus influenzae type b, 399, 400,401 vaccination, 379, 399 'hallmark' cell, 60-1 Hashimoto's disease, 79,252, 255 HCV see hepatitis C HD see Hodgkin's disease head and neck cutaneous B cell lymphomas, 367 imaging, 211-13 somatostatin receptor scintigraphy, 218 non-Hodgkin's lymphoma, 212-13 pediatric, 373 Helkobacter pylori, 75, 252, 253-4, 326 hemopoietic growth factors, infection prevention, 411-12 hepatitis C (HCV), 124 herpes viruses, 402 herpes simplex virus (HSV), 403 prevention and treatment, 408 human herpes virus 6 (HHV-6), 123-4, 403 human herpes virus 8 (HHV-8), 51 Kaposi's sarcoma-associated (KSHV), 116-17,173 prevention of infection, 407-9 high-dose therapy/stem cell transplantation, 331-50 comparison of rescue sources, 340-3 current status, 344 in first remission, 302^1 source of stem cells, 303-4 future directions, 344 preparative regimens, 339-40 prospects for pediatric treatment, 380 purging, 343 results, 313-14, 328, 332-5 comparison with conventional salvage therapy, 304-5, 335-7 early transplantation, 337-9 Hodgkin's disease, 334-5 non-Hodgkin's lymphoma, 332-4 highly active antiretroviral therapy (HAART), 351, 354, 355 hilar adenopathy, 231-2 HIV see human immunodeficiency virus Hodgkin-cell leukemia, 188 Hodgkin's disease (HD), 9-19, 107-14, 161-7, 181-204, 221-45, 269-85 age factors, 161-3, 164, 181, 191 familial longevity, 193 and incidence, 385-6 as prognostic factor, 387-8 in AIDS/HIV, 195-6, 215 and anaplastic lymphoma of T cell lineage (ALCL), 61 atypical immune reaction, 110-12,165 EBV infection, 110-11, 164-5 H-RS as antigen-presenting cells, 111 causes of death, 430-1 cell of origin, 10 classification systems, 9-10 ILSG, 6 Lukes and Collins, 4, 9

WHO, 7 clinical approach to patient, 188-94 clinical significance of morphological pattern, 14 contrasts with non-Hodgkin's lymphoma, 196-8 cytogenetics, 92-3 diagnosis and staging, 184-8, 190-1, 222-6 extranodal, 186-8 lymphatic, 185-6 in elderly age as prognostic factor, 387-8 manifestations, 386 treatment strategies, 392-3 epidemiology, 110, 161-7 analytical, 163-5 descriptive, 161-3 Epstein-Barr virus association, 110-11,164-5 fertility in, 195 histological morphology, 11, 12, 13-14 as prognostic factor, 14, 192 HIV/AIDS-related, 195-6, 215 immunocytochemistry, 11,13 incidence and age factors, 385-6 and mortality, 221-2 infection risks, 399^100 investigations, 189-91 alternative markers of disease severity, 190 biochemistry, 189-90 hematological, 189 staging, 190-1,222-6 lymphocyte-depleted, 13 lymphocyte-predominant, 10-12 lymphocyte-rich classical (LRCHD), 14 mixed cellularity, 13-14,107,108 naming of, 3, 9 nodular, 10-12 nodular sclerosis (NS), 12-13, 107, 183, 184 paraneoplastic manifestations, 188 patient history, 188 patterns of recurrence, 194 physical examination, 188-9 in pregnancy, 195,279 presenting features, 181-4 prognostic factors, 191-4 advanced age, 387-8 definition of, 224-6 individual patient, 191-3 multivariate analysis and models, 193-4 transplantation, 334-5 quality of life, long-term survivors, 429-30 secondary ANLL and myelodysplastic syndrome, 426-7 secondary non-Hodgkin's lymphoma after, 427 secondary solid tumors, 427-8 stage MIA, 236-7, 270 staging see diagnosis and staging of thymus, 83 treatments, advanced stage initial therapy, 270-7 salvage therapy, 277-6 treatments, high dose chemotherapy/stem cell transplantation, 334-5, 336-7 treatments, localized disease radiation therapy, 226-34 systemic, 234-6 treatments, stage MIA, 236-7, 270 variant of Richter's syndrome, 44 see also Hodgkin's and Reed-Stern berg cells; pediatric lymphomas, Hodgkin's disease

444 Index Hodgkin's and Reed-Stern berg (RS/H-RS) cells as antigen-presenting cells, 111 in B cell chronic lymphocytic leukemia, 44 cell lines and animal models, 109 detection of chromosome abnormalities in, 93 Epstein-Barr virus, 12,110,123 genetic aberations, 108-9 lineage origin and clonality, 107-9 malignant proliferation of, 107-9 in mixed cellularity HD, 14 in nodular sclerosis, 13 p53 mutations, 143-4 in reticular lymphocyte-depleted HD, 13 variants, 11,12 H-RS cell see Hodgkin's and Reed-Stern berg (H-RS/RS) cell HSV see herpes simplex virus under herpes viruses HTVL-1 see human T cell leukemia virus type 1 human herpes virus 6 (HHV-6), 123-4,403 human herpes virus 8 (HHV-8), 51 human immunodeficiency virus (HIV), 172-3, 351 Epstein-Barr-positive lymphocytes, 120,165 Hodgkin's disease, 195-6, 215 Kaposi's sarcoma-associated herpes virus (KSHV), 116-17 primary effusion lymphoma (PEL), 51 see also acquired immune deficiency syndrome (AIDS)-related lymphomas human T cell leukemia virus type 1 (HTLV-1), 58-9,115-16,173, 288 p53 mutations, 143 IFN see interferon therapy IL-1, 59,111 IL-2, 111 IL-2-diphtheria toxin fusion protein, 365-6 IL-2R, 59 IL-4, 59 IL-6, 62,190,352 IL-10, 59,190,352 ILSG see International Lymphoma Study Group imaging, 205-20 abdomen and pelvis, 207-10 AIDS-related lymphomas, 214-16 breast, 214 central nervous system (CMS), 213-14 chest, 206-7 children, 216 clinical staging, 222 follow-up, 216-17 assessment of residual mass, 216-17 assessment of response to treatment, 216 detection of late relapse, 217 head and neck, 211-13 new techniques, 217-18 in pregnancy, 195, 279 skeletalsystem, 210-11 immunoblastic lymphoma, diffuse, 288 immunocytochemistry, Hodgkin's disease, 11,13 immunocytomassee lymphoplasmacytic lymphomas immunodeficiency, 399-401 associated pathogens, 401-3 B cell lymphomas, 119-20 due to past medical history, 172 extranodal lymphoma associated with, 86-7 as long-term complication, 421-2 immunoglobulin G (IgG), 21-2, 31,44 immunoglobulin M (IgM), 21-2, 31, 44,45,49 postsplenectomy, 422 immunophenotypes B cell chronic lymphocytic leukemia (B-CLL), 44

diffuse large B cell lymphoma (DLBCL), 50 follicular lymphoma (FL), 22 large granular lymphocytosis (LGL), 58 lymphoplasmacytic lymphoma, 45 mantle cell lymphoma (MCL), 31 mucosa-associated lymphoid tissue (MALT), 74 pediatric lymphomas, 372, 373 T cell acute lymphoblastic leukemia (T-ALL), 56-7 immunoproliferative small intestinal disease (IPSID), 76, 254, 326-7 immunosuppression drug therapy, 172,401 lifestyle and other exposures, 174 occupational links, 173 viral, 172-3 infections, 422 as cause of death, 431 of 'childhood' in adult life, 163-4 common pathogens, 401-3 factors underlying, 399-401 reactivation of latent, 402-3 treatment and prevention see antimicrobial therapy; hemopoietic growth factors infectious mononucleosis, 58, 110, 122, 123, 164 inherited syndromes, 172 interferon (IFN) therapy, 314, 365, 367 International Lymphoma Study Group (ILSG), 5-6, 44, 45 intestinal lymphomas, 76-7, 254 intraocular lymphoma, 80 intravascular large cell lymphoma, 51 iodine-131,315 IPSID see immunoproliferative small intestinal disease jaw involvement, Burkitt's lymphoma, 49, 86 Kaposi's sarcoma-associated herpes virus (KSHV), 116-17, 173 Ki-1 lymphoma see anaplastic large cell lymphoma (ALCL), of T cell lineage (Ki-1) Kiel classification, 4, 44, 55, 372 mantle cell lymphoma, 36 revised, 5-6 low grade non-Hodgkin's lymphomas, 325-6, 327 L&H cells see lymphocytic and histiocytic cells lamina propria, 72 Langerhans cells, intradermal, 80 laparotomy, staging, 190-1, 222-4 pediatric, 377, 379 large cell anaplastic lymphoma (LCAL), 51 large granular lymphocytosis (LGL), 57-8 latent membrane protein (LMP), 110 gene deletion, 117-18, 119, 122 LBL see lymphoblastic lymphoma Lennert's lymphoma (lymphoepithelioid lymphoma), 63 leucocytosis, 189 leucopenia, 189 leukemia see acute lymphoblastic leukemia (ALL), B and T lineage; ANLL, secondary; B cell chronic lymphocytic leukemia (B-CLL); Hodgkin-cell leukemia; peripheral T cell lymphoproliferative disorders, predominantly leukemic LGL see large granular lymphocytosis liver involvement, Hodgkin's disease, 786,187 liver lymphomas, 86 AIDS-related, 215 imaging, 209 LMP see latent membrane protein LRCHD see lymphocyte-rich classical Hodgkin's lymphoma LSA2-L2 (10 drug leukemia-like regimen), 376 Lukes and Collins classification, 4, 9,21

Index 445 lung cancer, 428 lymph nodes B cell chronic lymphocytic leukemia (B-CLL), 43, 44 biopsy, 34 imaging characteristics, 205-6 lymphoplasmacytic lymphoma, 44-5 mantle cell lymphoma (MCL), 27-9 marginal zone lymphoma (MZL), 45 lymphoblastic lymphoma (LBL), 299-307 clinicopathological features, 299-300 pediatric, 372, 373 prognostic factors, 302 treatments, 300-5 combined modality, 300-2 high-dose therapy in first remission, 302-4 salvage therapy, 304-5 lymphocyte-depleted Hodgkin's disease, 13,107,108 lymphocyte-predominant Hodgkin's disease, 10-12 immunocytochemistry, 11 morphologic features, 11 non-Hodgkin's lymphoma arising in patients with, 11-12 lymphocyte-rich classical Hodgkin's lymphoma (LRCHD), 14 lymphocytic and histiocytic (L&H) cells, 10 morphology and immunocytochemistry, 11, 107, 108 lymphoepithelioid lymphoma (Lennert's lymphoma), 63 lymphomatoid granulomatosis, 78 lymphomatoid papulosis, 61, 81, 368 lymphopenia, 189 lymphoplasmacytic lymphomas, 44-5, 325 of central nervous system, 83 MACOP-B (methotrexate, Adriamycin (doxorubicin); cyclophosphamide; Oncovin; prednisolone; bleomycin), 297, 293-4, 425 and autologous transplantation, 339 versus CHOP, 295 versus ProMACE-CytaBOM versus MACOP-B, 295 versus ProMACE-MOPP, 294 macrophages, epithelioid, 63 magnetic resonance imaging (MRI) abdomen, 208-9, 210 central nervous system, 213-14, 216 chest, 207 follow-up, 217 head and neck, 211,212-13 lymph nodes, 206 skeletalsystem, 210, 211,259 MAI see Mycobacterium avium intracellulare MALT see mucosa-associated lymphoid tissue mantle cell lymphoma (MCL), 11,27-41, 325-6 clinical features, 34-5 cytogenetic and molecular genetic features, 31-3 differential diagnosis, 33-4 immunological features, 31 and mucosa-associated lymphoid tissue (MALT), 76 normal cellular counterpart, 33 pathological features, 27-31 cytology, peripheral blood and bone, 29-30 gastrointestinal tract, 30-1 lymph nodes, 27-9 spleen, 30 Waldeyer's ring, 30 prognostic factors, 35-6 treatments stem cell rescue, 328 and survival, 35-6 tumor grade, 36-7 mantle zone hyperplasia, 33

marginal zone lymphoma (MZL), 45, 326 cutaneous, 81 extranodal, of MALT type, 326-7 m-BACOD (methotrexate; bleomycin; adriamycin (doxorubicin); cyclophosphamide; oncovin; decadron), 297, 292-3 modified, AIDS-related lymphoma, 353-4, 356 versus CHOP, 294-5 versus ProMACE-CytaBOM versus MACOP-B, 295 mediastinal disease Hodgkin's disease, 193 radiotherapy, 231-2 lymphoblastic lymphoma, 299 non-Hodgkin's lymphoma, 262 pediatric, 373 mediastinal large B cell lymphomas, 51 thymic origin, 83-4,262 mediastinal nodes, 206, 216 mediastinal radiotherapy, 231-2 and cardiac dysfunction, 423 MESA see myoepithelial sialadenitis methotrexate, 260, 292-3, 376 seeo/soCODOX-M; COMP; MACOP-B; m-BACOD; PACEBOM MF see mycosis fungoides mixed cellularity Hodgkin's disease, 13-14,107,108 monoclonal antibodies see antibody therapy monocytoid lymphoma, 327 MOPP (mustine, vincristine, procarbazine, prednisolone) alternatives, 272-3 combined therapy, long-term side-effects, 423, 424 Hodgkin's disease, 234, 235, 236 elderly, 393 fertility, 380 pediatric, 378, 379, 380, 381 -like regimens, 271-2 secondary malignancies, 426 mucosa-associated lymphoid tissue (MALT) lymphomas, 71, 72-6, 248,252, 255, 256 acquired, 72 fccMOgene, 74,142 bladder lymphomas, 85 breast lymphomas, 86 clinical presentation, 73 extranodal marginal zone B cell lymphoma, 326-7 female genital tract lymphomas, 85 functional properties, 72 gastrointestinal tract, 74-7 high-grade B cell lymphoma, 74 high-grade gastric lymphoma, 75 histology of, 72 liver lymphomas, 86 low-grade B cell lymphomas gastrointestinal tract, 74 thymus, 83 Waldeyer's ring, 82 low-grade gastric lymphoma, 75 low-grade lymphomas, 73-4 clinical behaviour, 74 histopathology, 73 immunophenotype, 74 lymph node involvement and distant spread, 74 molecular genetics, 74 lymphomas of the intestine, 76 MALT lymphoma concept, 72-3 ocular adnexa and eye, 79-80 pulmonary lymphomas, 77-9 salivary glands, 77 thyroid, 79 mucositis, 237-8

446 Index MVPP (mechlorethamine, vinblastine, procarbazine, prednisole), 425 mycobacterial infections, 403 Mycobacterium avium intracellulare (MAI), 215, 403 mycosis fungoides (epidermotropic small cerebriform cell lymphoma) (MF), 80, 359-67 clinical presentation and natural history, 360-1 etiology and epidemiology, 359-60 HTLV-1 infection, 59, 115, 116 pathology, 360 staging, 361-3 treatments, 363-7 biological agents, 365-6 chemotherapy, 365 combined modality, 366 guidelines, 366-7 photopheresis, 366 phototherapy, 363 radiation, 364-5 systemic, 365-6 topical, 363-4 see also Sezary syndrome myelodysplastic syndrome, 334, 426-7 myoepithelial sialadenitis (MESA), 77, 255 MZLsee marginal zone lymphoma nasal lymphomas non-Hodgkin's lymphoma, 254-5 pediatric, 373,374 T/natural killer cell, 121, 252, 255 nasopharangeal biopsy, 211 National Cancer Institute (NCI) lymphoma classification project, 4-5, 55 see also Working Formulation natural killer (NK) cell lymphomas, 6 angiocentric T and/or, 82 associated viruses, 121-2 large granular lymphocytosis (LGL), 57, 58 nausea, 237, 238 MOPP therapy in children, 378 Neisseria meningitidis, 399, 400 neutropenia, 58, 355, 399, 400 febrile patients antibiotic therapy, 404 antifungal therapy, 410 prevention of infection, 406-7, 409 and treatment, hemopoietic growth factors, 411-12 NHL see non-Hodgkin's lymphomas nitrogen mustard, 363, 364, 365, 366, 367 secondary malignancy, 426 NK see natural killer (NK) cells nodal-based peripheral T cell lymphomas, 60-3 nodal marginal zone B cell lymphoma, 327 nodular Hodgkin's disease, 10-12 nodular sclerosis (NS), 12-13, 107, 183, 184 immunocytochemistry, 13 morphological features, 12 non-epidermotropic pleomorphic large T cell lymphoma, 80 non-epidermotropic small cerebriform cell lymphoma, 80 non-Hodgkin's lymphoma (NHL), 21-6, 27-41, 43-7, 49-54, 55-69, 71-90,169-77, 247-68, 287-98, 299-307, 309-24 aggressive, 287-98 advanced stage chemotherapy, 292-5 clinical features and staging, 289-90 early stage chemotherapy, 290-2 transformation of follicular into, 22-3 types, 287-8 in AIDS patients, 215 chemotherapy

aggressive disease, 290-6 localized disease, 250 low-grade disease, 327-8 see also high dose chemotherapy/stem cell transplantation classification, 3 ILSG, 6 Kiel, revised, 5-6 problems, 169 contrasts with Hodgkin's disease, 196-8 cytogenetics, 93-9 chromosomal translocations, 93-6 other chromosomal abnormalities, 97-9 in elderly age and incidence, 385-6 age as prognostic factor, 386-7 manifestations, 386 treatment strategies, 390-2 epidemiology, 169-77 analytical, 172-4 descriptive, 170-2 extranodal see under specific sites follicular see follicular lymphoma (FL) high dose chemotherapy/stem cell transplantation, 332^1 early treatment, 337-9 preparative regimens, 340 versus conventional salvage chemotherapy, 336 infection risks, 399 localized management, 247-51 see also non-Hodgkin's lymphoma under specific sites low grade not follicular, 325-30 transplantation results, 333-4 treatment, 327-8 treatment strategies in elderly, 392 types, 32S-7 lymphoblastic see lymphoblastic lymphoma (LBL) p53 mutations, 143 principles of treatment, 249 assessment of response and follow-up, 251 prognostic factors, 247-8 and patterns of failure, 248-9 transplantation results, 332-4 radiation therapy, 249-50 secondary, after Hodgkin's disease, 427 secondary malignancies after, 429 staging classification, 248 surgery, 249 working formulation for clinical usage, 5 see also pediatric lymphomas, non-Hodgkin's lymphoma (NHL) non-malignant complications, 421-6 NS see nodular sclerosis occupational factors, 165,173 ocular adnexa and eye lymphomas, 79-80 non-Hodgkin's lymphoma, 212,255-6, 260 OPSI see overwhelming postsplenectomy infections organ transplantation, 172 osteonecrosis, 239 ovaries non-Hodgkin's lymphoma, 257-8 radiotherapy to, 239 overwhelming postsplenectomy infections (OPSI), 422,424 p53 gene, 32, 142-4, 352 PACEBOM (prednisolone, doxorubicin, cyclophosphamide, etoposide, bleomycin, vincristine, methotrexate) versus CHOP, 297,295 pancreas, 209 paranasal sinuses, 81-2, 212, 254-6

Index 447 parotid gland, 77, 237 PBPCs see peripheral blood progenitor/stem cells (PBPCs) PCR see polymerase chain reaction pediatric lymphomas, 371-84 biology cytogenetics, 372 immunophenotyping, 372 Burkitt's lymphoma, 49,170, 288, 373 treatment, 376 epidemiology, 371-2 Hodgkin's disease (HD), 376-80 clinical presentation, 376-7 diagnosis and staging, 377-8 epidemiology, 161, 163, 164, 372 long-term effects of therapy, 379-80 secondary malignancies, 428-9 treatment, 378-9, 380, 381 imaging, 216 non-Hodgkin's lymphoma (NHL), 372-6 chemotherapy, 375-6 classification, 372-3 clinical features, 373 diagnosis and staging, 373-4, 375 epidemiology, 371-2 prospects for therapy, 380-1 secondary malignancy, 380 treatments, 375-6 siblings, 165 T cell acute lymphoblastic leukemia (T-ALL), 56, 57 PEL see primary effusion lymphoma pericardial invasion, 206 Hodgkin's disease, 188 non-Hodgkin's lymphoma, 262 peripheral blood progenitor/stem cells (PBPCs) versus bone marrow transplantation, 303, 304, 313-14, 331, 340-2, 412 peripheral T cell lymphoma, common type, 63 peripheral T cell lymphoproliferative disorders, predominantly leukemic, 57-60 personality factors, Hodgkin's disease, 193 PET see positron emission tomography petrochemical industry, 173 Peyer's patches, 72, 76, 82 phosphocholines, 364 photopheresis, extracorporeal (ECPP), 366 phototherapy (PUVA), 363, 364, 365, 366, 367 plain radiographs, 211 pleural effusions, 206 Hodgkin's disease, 186 non-Hodgkin's lymphoma, 262 pleural lymphoma, 79 pneumococcal vaccination, 328, 379, 424 Pneumocystis carinii infection, 401, 410 prevention, 410 treatment, 410-11 pneumonia, 401, 410-11,422 polymerase chain reaction (PCR), 32, 55, 62 polymorphic immunoblastic B lymphoproliferations, 87 popcorn cell see lymphocytic and histiocytic (L&H) cells positron emission tomography (PET), 217 bone marrow disease, 211 PRAD1 gene, 37, 32, 32-3, 94,136-7 precursor B lymphoblastic lymphoma, 372 precursor T cell lymphoblastic lymphoma, 56-7 pediatric, 373 prednisolone (prednisone), 271,272 see also ChlVPP; ChlVPP/EVA; CHOP; CHVmP/VB; CNOP; COMP; COPP; CVP; CVPP; EPOCH; MACOP-B; MOPP; PACEBOM; P-VEBEC; VEEP

pregnancy, 195, 279 primary effusion lymphoma (PEL), 51 procarbazine, 260,426 see also ChlVPP; ChlVPP/EVA; COPP; CVPP; MOPP; MVPP prolymphoblasts, 43 prolymphocytic leukemia, 325 Tcell(T-PLL),56, 58 prolymphocytoid transformation (CLL/PL), 44 ProMACE see under MACOP-B protozoan infections, 402 pseudofollicles, 43 pseudo-T cell lymphoma, 51 psychosocial and psychosexual function, 239, 430 pulmonary dysfunction, iatrogenic bleomycin, 379, 389 radiation, 238, 239, 423-4 pulmonary fibrosis, 379, 424 pulmonary lymphomas, 77-9 Hodgkin's disease, 186 imaging, 206 non-Hodgkin's lymphoma, treatment, 259 PUVA see phototherapy P-VEBEC (prednisolone, vinblastine, etoposide, bleomycin, epirubicin, cyclophosphamide), 392 quality of life, long-term survivors, 429-30 quinolone antibiotics, 406, 407 race, 161,170 radiation pneumonitis, 423-4 radiolabeled antibodies, 279, 315, 340, 365 radiotherapy and CHOP (cyclophosphamide, doxorubicin, vincristine, prednisolone), 250 and fertility, 195 follicular lymphoma, 312 Hodgkin's disease (HD), localized, 226-34 dose, fractionation and tumor control, 226 field size (radiation volume), 227-32 relapse rates, 227, 228, 229, 230 salvage of recurrent disease, 233-4 technical aspects, 232-3 mycosis fungoides, 364-5 non-Hodgkin's lymphomas (NHL), 249-50, 328 bladder, 257 bone, 259 orbital, 256 pediatric, 375 relapse after initial, 277 shielding, 232, 233, 238, 256, 364, 425 side effects acute, 237-8 chronic, 238-9, 422, 423-4, 426, 428, 429 targeted therapy, 315 testes, 256-7 total body irradiation (TBI), 314, 339-40 versus chemotherapy, 235 versus combined modality, 234-5 see also combined modality Rappaport classification, 3-4 REAL classification see Revised European-American Lymphoma classification Reed-Sternberg cells see Hodgkin's and Reed-Stern berg (RS/H-RS) cells REL/NF kappa B transcription factors and bcl-3,144 renal function, 189, 239 renal lymphoma, 209, 215 retinoids, 366

448 Index

Revised European-American Lymphoma (REAL) classification, 6-7, 12, 14, 45,49, 71-2, 368 non-Hodgkin's lymphoma, 325-7 pediatric B neoplasms, 372-3 T cell and natural killer (NK) cell lymphomas, 55-6 rheumatoid disease, 57-8, 172 Richter's syndrome, 44, 325 RS see Hodgkin's and Reed-Sternberg (RS/H-RS) cell salivary glands, 212-13, 255 mucosa-associated lymphoid tissue (MALT) lymphoma, 77, 78 parotid, 77, 237 salvage therapy, 277-8, 304-5, 356 chemotherapy versus transplantation results, 336 secondary malignancies, 426-9 as cause of death, 431 in children, 380 following radiotherapy, 239 Sezary syndrome, 60, 80 siblings, 165 single photon emission computed tomography (SPECT), 207, 216-17 Sjogren's syndrome, 77, 255, 327 skin lymphomas see cutaneous lymphomas skin reactions phototherapy, 363 radiotherapy, 237, 364 small bowel lymphoma see intestinal lymphoma small lymphocytic lymphoma (B cell chronic lymphocytic leukemia),

43-4, 45, 325 socioeconomic status, Hodgkin's disease, 163-4 soft tissue lymphomas, 86 solid tumors, secondary, 427-8 somatostatin receptor scintigraphy, 218 Southern blotting, 55 spinal cord compression, Hodgkin's disease, 187 spinal lymphoma see extradural lymphoma spleen, 84-5 AIDS-related lymphoma, 215 in follicular lymphoma, 23 in lymphoplasmacytic lymphoma, 45 in mantle cell lymphoma, 30,35 in marginal zone lymphoma, 45 secondary malignancy, 239, 428 splenectomy staging, 222-3, 224 as treatment, 328 impaired immunity, 399, 422, 424 pediatric, 377, 379, 380 secondary malignancy, 239, 428 splenic gamma/delta T cell lymphoma, 85 splenic marginal zone lymphoma, 34, 45, 84-5 with or without villous lymphocytes, 327 splenomegaly, imaging, 207-8 staging abdominal lymphoma, 210 AIDS-related lymphoma, 215 central nervous system lymphoma, 213-14 Hodgkin's disease early, 222-4 pediatric, 377-8 lymphoblastic lymphoma, 300 non-Hodgkin's lymphomas (NHL), 289-90 classification, 248 head and neck, 213 investigations, 247-8 pediatric lymphomas, 216, 377-8 skeletal,211 testicular lymphoma, 209

thoracic lymphoma, 207 see also Ann Arbor staging system; Cotswold staging system; laparotomy, staging stem cell transplantation see high-dose therapy/stem cell transplantation superior vena caval obstruction, 186-7 surgery gastric lymphoma, 253 intestinal lymphoma, 254 non-Hodgkin's lymphomas (NHL), 249 pediatric, 375 see also laparotomy, staging; splenectomy TAL-1 gene, 57 T-ALL see T cell acute lymphoblastic leukemia taste perception, altered, 237 Tcell bone marrow infiltration in follicular lymphoma, 23 immunocytochemistry, 11, 13, 22, 31 -rich B cell lymphoma, 51 Tcell acute lymphoblastic leukemia (T-ALL), 56-7 T cell lymphomas, 4, 5, 55-69 AIDS-related, 352-3 associated viruses, 121-2 classification ILSG, 6 WHO, 7 cutaneous, 80-1, 261-2, 359, 368 non-Hodgkin's lymphomas, 12, 288, 327 pediatric, 373-6 pulmonary, 78-9 splenic, 84, 85 thymic, 83 T cell prolymphocytic leukemia (T-PLL), 56, 58 T cell receptor see TCR TCR alpha/beta/CD 3, 58, 59, 85 TCR gene, 96, 98 rearrangements, 10 testes, radiotherapy to, 239 testicular lymphomas high-grade B, 85 imaging, 209 non-Hodgkin's lymphoma, 256-7 thymus enlargement, 206 primary lymphomas, 51, 83-4, 262 thyroid cancer, 428 thyroid dysfunction, 238-9, 379-80,422-3 thyroid involvement, Hodgkin's disease, 188 thyroid lymphomas, 79, 252, 255 TIB see total body irradiation T-LCLsee cutaneous large cell lymphomas of T cell phenotype, primary tonsillar lymphoma, 212 total body irradiation (TIB), 314, 339-40 toxoplasmosis, 45 T-PLL see T cell prolymphocytic leukemia transgenic mouse models, 32-3, 134-5, 137 tumor bulk, 251 upper aerodigestive tract lymphomas, 81-2 urogenital tract lymphomas, 85 uterus, 258 vaccination DNA, 315 Haemophilus B, 379, 399 meningococcal, 399

Index 449

pneumococcal, 328, 379, 424 vagina, 258 varicella-zoster virus (VZV), 403 prevention and treatment, 408 VEEP (vincristine, etoposide, epirubicin, prednisolone), 381 venous catheters, 407 vinblastine, 271, 272, 389 see also ABVD; ChlVPP/EVA; CVPP; MVPP; P-VEBEC vinca alkaloids, metabolism in elderly, 389 vincristine, 260, 271,272, 312, 389 see also ChlVPP; ChlVPP/EVA; CHOP; CHVmP/VB; CNOP; CODOX-M; COPP; CVP; EPOCH; MOPP; PACEBOM; VEEP viruses, 115-31,402 immunosuppression, 172-3

reactivation of latent, 403 see also specific viruses VZV see varicella-zoster virus Waldeyer's ring, 71, 81-2,254 mantle cell lymphoma (MCL), 30, 35 weight loss, 237, 238 'western-type' intestinal MALT lymphoma, 76 Working Formulation classification, 36, 93, 287, 288, 372 World Health Organisation (WHO) classification, 7-8,14, 36 Ytrium-90, 315 zidovudine, 351, 354