Renaldo Guzmán

Treatment of non-Hodgkin's lymphoma of waldeyer's ring: Radiotherapy versus chemotherapy versus combined therapy

Treatment of stage IA non-Hodgkins lymphoma (NHL) of Waldeyers ring remains controversial, probably because of the small number of patients and the scarcity of controlled studies. Between 1981 and 1991, 316 patients with stage I NHL of Waldeyers ring were randomised for treatment with radiotherapy alone (extended fields), 101 patients; combined chemotherapy with a regimen of CHOP (cyclophosphamide, vincristine, doxorubicin, and prednisone) or CHOP-like (epirubicin instead of doxorubicin), 106 patients; and combined therapy (radiotherapy followed by the same combination chemotherapy), 109 patients. Median follow-up was 6.8 years. Complete response was achieved in 93, 87 and 97%, respectively. Relapses were least frequent in patients treated with combination therapy. The 5-year rate for failure-free survival was 48% for radiation therapy, 45% for the patients who were treated with chemotherapy, which was statistically significantly less than the 83% for patients treated with combined therapy (P < 0.001). Overall survival was also better in the combined therapy arm: 90%, statistically different to 58% for the patients treated with chemotherapy alone and 56% for patients treated with radiation therapy (P < 0.001). Toxicity was mild and late side-effects were not observed in any patients. From these results combined therapy should be considered as the best therapeutic approach in patients with localised NHL of Waldeyers ring.

Interferon alpha 2b as maintenance therapy in low grade malignant lymphoma improves duration of remission and survival.

We assessed the efficacy and toxicity of interferon alpha 2b (IFN) as maintenance therapy in patients with low grade malignant lymphoma. Between March 1986 and December 1989, 98 patients with low-grade malignant lymphoma in complete remission after conventional chemotherapy were randomly assigned to received IFN, 5.0 MU three times a week for one year, as maintenance therapy (n = 48), or to receive no treatment (control group, n = 50). In March 1994, the median duration of response had not yet been reached in the patients treated with IFN compared to 46 months in the control group. At 9-years 62% of the patients in the IFN arm remain in first complete remission compared to only 25% in the control group (p <.001). In addition, the median duration of survival has not yet been reached in either the IFN arm compared to 74 months in the control group (p <.001). Quality of life was excellent in both groups and severe side effects secondary to IFN treatment were not observed. All patients completed the planned dose of IFN. We conclude that IFN as maintenance therapy in low-grade malignant lymphoma is an excellent therapeutic option because it improves the duration of remission and survival without producing severe side effects or reducing the quality of life.

Non-Hodgkin's lymphomas and pregnancy: Presentation of 16 cases

Chemotherapy and obstetric care of 16 pregnant patients with non-Hodgkins lymphoma are reported in this paper. All patients received chemotherapy during the various trimesters of pregnancy, including 8 cases during the first trimester, and there was no evidence of congenital malformations in any offspring. Fifteen babies are alive, healthy, and at a normal level of growth 3 to 11 years after birth. Eight mothers who achieved complete remission are alive and free of disease, 4 to 9 years after delivery, without maintenance treatment and would be considered cured. On the basis of the present study it was concluded that pregnancy is not a contraindication for treatment of non-Hodgkins lymphomas, cytotoxic drugs do not necessarily cause congenital malformations, and long-term remission can be achieved in these mothers.

Is Surgery Necessary in the Treatment of Primary Gastric Non-Hodgkin Lymphoma?

Fifty-two patients with primary gastric lymphoma were randomly assigned to two different surgical approaches. Twenty-eight cases were diagnosed by endoscopy and treated with chemotherapy CHOP-Bleo (cyclophosphamide, adriamycin, vincristine, prednisone and bleomycin) alternating with CMED (cyclophosphamide, metothexate, etoposide and dexamethasone). Twenty four cases underwent debulking surgery (partial or total gastrectomy) followed by the same chemotherapy. No differences were observed in relapse free disease or survival in resected or unresected patients. Complications were more frequent and severe in patients who underwent surgery. We believe that surgery is not necessary in the treatment of patients with primary gastric lymphoma.

Maintenance therapy with interferon alfa 2b in patients with diffuse large cell lymphoma

SummaryForty-eight consecutive patients with diffuse large cell lymphoma (DLCL) in complete remission (CR) after conventional chemotherapy were enrolled in a prospective clinical trial. The maintenance therapy was a random either nothing or interferon alfa 2b (IFN) 5.0 MU three times a week for one year.The median duration of CR in the patients treated with IFN has not been reached. After five years 60% of patients remain in CR compared to the control group who had a median CR of 40 months (p<0.001). Actuarial five-years survival in the IFN treated patients was 88% compared to 42% in the control group (p <0.001).Maintenance therapy with IFN has been beneficial in patients with DLCL with improvement of duration of CR and survival without the excessive toxicity of most common third generation regimen chemotherapy. We felt that IFN could be explored in most controlled clinical trials in patients with DLCL in CR after conventional chemotherapy.

Beta 2 Microglobulin Level as an Indicator of Prognosis in Diffuse Large Cell Lymphoma

We report results of our investigation of prognostic factors for patients with diffuse large cell lymphoma (DLCL) who were entered on the same treatment protocol and who had known pretreatment serum beta 2 microglobulin levels. Serum beta 2 microglobulin, bone marrow involvement, performance status and lactic dehydrogenase (LDH) levels were associated with a poor prognosis in univariate analysis. However, only beta 2 microglobulin remained of prognostic significance in a multivariate analysis with statistical differences at different cut off levels. We believe that beta 2 microglobulin levels accurately separate patients into low-, intermediate- and high-risk patients. It is concluded that serum beta 2 microglobulin is the most significant prognostic factor currently available for DLCL and should be incorporated in the initial staging in order to provide a basis for designing the therapeutic approach in these cases.

Intensive brief chemotherapy with hematopoietic growth factors as hematological support and adjuvant radiotherapy improve the prognosis in aggressive malignant lymphoma.

An intensive brief chemotherapy and radiotherapy regimen including high doses of cyclophosphamide (5 g/m2), etoposide (1 g/m2), epirubicin (180 mg/m2), and ifosfamide (5 g/m2) administered in a period of 30 days followed by involved field radiotherapy to sites of initial bulky disease was administered to 46 untreated patients with high‐intermedium and high‐risk malignant lymphoma. G‐ or GM‐CSF were used as hematological support instead of bone marrow transplantation. All patients had more than 3 adverse prognostic factors at diagnosis.

Value of Serum Beta 2 Microglobulin as an Indicator of Early Relapse in Diffuse Large Cell Lymphoma

In patients with diffuse large cell lymphoma treated with chemotherapy the presence of high levels of serum beta 2 microglobulin has been considered as a bad prognostic factor. Until now, attempts to detect early relapse in patients with diffuse large cell lymphoma have been sparse. To address this issue we began a prospective clinical trial to evaluate the role of different clinical, laboratory and radiographic tests in the detection of early relapse in non-Hodgkins lymphoma (NHL). Only serum beta 2 microglobulin levels had clinical significance and 26 of 53 patients (49%) had abnormal levels, 3 to 23.1 months (mean 8.5 months) before evident relapse. Elevated serum lactic dehydrogenase (LDH) levels and beta 2 microglobulin were observed in six patients and all relapsed, suggesting that the combination of these two tests should be considered in future prospective clinical trials in order to define the utility of both tests to detect early relapse. This information may allow us to begin chemotherapy when the tumor mass is still low thereby making the probability of achieving a long second remission more likely.