Silvia Mappa

Chlamydophila Psittaci Eradication With Doxycycline As First-Line Targeted Therapy for Ocular Adnexae Lymphoma: Final Results of an International Phase II Trial

PURPOSE The pathogenic association between Chlamydophila psittaci (Cp) and ocular adnexal marginal zone lymphoma (OAMZL) and the efficacy of doxycycline monotherapy have been investigated in retrospective series with variations in stage, management, and follow-up duration. To our knowledge, this is the first international phase II trial aimed at clarifying Cp prevalence and activity of first-line doxycycline in a homogeneous series of consecutive patients with newly diagnosed stage I OAMZL. PATIENTS AND METHODS Forty-seven patients were registered. Tumor tissue, conjunctival swabs, and peripheral blood from 44 patients were assessed for seven Chlamydiaceae infections by three polymerase chain reaction protocols. Thirty-four patients with measurable or parametrable disease were treated with doxycycline and assessed for chlamydial eradication and lymphoma response (primary end point). RESULTS Cp DNA was detected in biopsies of 39 patients (89%); no other Chlamydiaceae were detected. Twenty-nine patients had Cp DNA in baseline swabs and/or blood samples and were evaluable for chlamydial eradication, which was achieved in 14 patients (48%). Lymphoma regression was complete in six patients and partial in 16 (overall response rate, 65%; 95% CI, 49% to 81%); 11 had stable disease, and one had progressive disease. At a median follow-up of 37 months (range, 15 to 62 months), 20 patients remained relapse free (5-year progression-free survival [PFS] ± standard deviation, 55% ± 9%). Cp eradication was associated with improved response rate (86% v 47%; P = .02) and 5-year PFS (68% v 47%; P = .11). CONCLUSION Upfront doxycycline is a rational and active treatment for patients with stage I Cp-positive OAMZL. Lymphoma regression is consequent to Cp eradication, which can easily be monitored on conjunctival and blood samples. Prospective trials aimed at identifying more effective administration schedules for doxycycline are warranted.

Prevalence of Borrelia Burgdorferi Infection in a Series of 98 Primary Cutaneous Lymphomas

Borrelia burgdorferi has been variably associated with different forms of primary cutaneous lymphoma. Differences in prevalence rates among reported studies could be a result of geographic variability or heterogeneity in the molecular approaches that have been employed. In the present study, we investigated the prevalence of Borrelia burgdorferi sensu lato DNA in diagnostic tissue samples from fresh cutaneous biopsies of 98 primary cutaneous lymphomas and 19 normal skin controls. Three different polymerase chain reaction (PCR) protocols targeting the hbb, flagellin, and Osp-A genes were used. Direct sequencing of both sense and antisense strands of purified PCR products confirmed the specificity of the amplified fragments. Sequence specificity was assessed using the Basic Local Alignment Search Tool, and MultAlin software was used to investigate the heterogeneity of target gene sequences across the different samples. Borrelia DNA was not detected in 19 controls, 23 cases of follicular lymphoma, 31 cases of extranodal marginal zone lymphoma, or 30 cases of mycosis fungoides. A single case of 14 diffuse large B-cell lymphoma cases was positive for B. burgdorferi. This study does not support a pathogenic role of B. burgdorferi in primary cutaneous B- and T-cell lymphomas from areas nonendemic for this microorganism and the consequent rationale for the adoption of antibiotic therapy in these patients.

Salvage chemoimmunotherapy with rituximab, ifosfamide and etoposide (R‐IE regimen) in patients with primary CNS lymphoma relapsed or refractory to high‐dose methotrexate‐based chemotherapy

Despite a high proportion of patients with primary CNS lymphoma (PCNSL) experiences failure after/during first‐line treatment, a few studies focused on salvage therapy are available, often with disappointing results. Herein, we report feasibility and activity of a combination of rituximab, ifosfamide and etoposide (R‐IE regimen) in a multicentre series of patients with PCNSL relapsed or refractory to high‐dose methotrexate‐based chemotherapy. We considered consecutive HIV‐negative patients ≤75 years old with failed PCNSL treated with R‐IE regimen (rituximab 375 mg/m2, day 0; ifosfamide 2 g/m2/day, days1–3; etoposide 250 mg/m2, day 1; four courses). Twenty‐two patients (median age 60 years; range 39–72; male/female ratio: 1:4) received R‐IE as second‐line (n = 18) or third‐line (n = 4) treatment. Eleven patients had refractory PCNSL, and 11 had relapsing disease. Twelve patients had been previously irradiated. Sixty (68%) of the 88 planned courses were actually delivered; only one patient interrupted R‐IE because of toxicity. Grade 4 hematological toxicity was manageable; a single case of grade 4 non‐hematological toxicity (transient hepatotoxicity) was recorded. Response was complete in six patients and partial in three (overall response rate = 41%; 95%CI: 21–61%). Seven patients were successfully referred to autologous peripheral blood stem cell collection; four responders were consolidated with high‐dose chemotherapy supported by autologous stem cell transplant. At a median follow‐up of 24 months, eight responders did not experience relapse, two of them died of neurological impairment while in remission. Six patients are alive, with a 2‐year survival after relapse of 25 ± 9%. We concluded that R‐IE is a feasible and active combination for patients with relapsed/refractory PCNSL. This regimen allows stem cell collection and successful consolidation with high‐dose chemotherapy and autologous transplant. Copyright

A Reappraisal of the Diagnostic and Therapeutic Management of Uncommon Histologies of Primary Ocular Adnexal Lymphoma

Lymphoma is the most common malignancy arising in the ocular adnexa, which includes conjunctiva, lachrymal gland, lachrymal sac, eyelids, orbit soft tissue, and extraocular muscles. Ocular adnexal lymphoma (OAL) accounts for 1%-2% of non-Hodgkin lymphoma and 5%-15% of extranodal lymphoma. Histology, stage, and primary localizations are the most important variables influencing the natural history and therapeutic outcome of these malignancies. Among the various lymphoma variants that could arise in the ocular adnexa, marginal zone B-cell lymphoma (OA-MZL) is the most common one. Other types of lymphoma arise much more rarely in these anatomical sites; follicular lymphoma is the second most frequent histology, followed by diffuse large B-cell lymphoma and mantle cell lymphoma. Additional lymphoma entities, like T-cell/natural killer cell lymphomas and Burkitt lymphoma, only occasionally involve orbital structures. Because they are so rare, related literature mostly consists of anecdotal cases included within series focused on OA-MZL and sporadic case reports. This bias hampers a global approach to clinical and molecular properties of these types of lymphoma, with a low level of evidence supporting therapeutic options. This review covers the prevalence, clinical presentation, behavior, and histological and molecular features of uncommon forms of primary OAL and provides practical recommendations for therapeutic management.

Safety and activity of a new intensive short-term chemoimmunotherapy in HIV-positive patients with Burkitt lymphoma

The treatment of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients with Burkitt lymphoma (HIV-BL) is a difficult challenge, requiring multidisciplinary efforts and demanding strategies. While the worldwide use of highly active antiretroviral therapy (HAART) resulted in improved tolerability and efficacy of standard chemotherapy in HIV-positive patients with diffuse large B-cell lymphomas, it has not been associated with better outcome in HIV-BL, with respect to the pre-HAART era, suggesting that more intensive treatments should be used (Lim et al, 2005). Currently, a few, small studies addressing feasibility and activity of dose-dense chemotherapeutic regimens in HIV-BL are available (Table S1). Reported regimens display high efficacy, but are often associated with important dose-limiting side-effects, prolonged hospitalization and treatment-related mortality (TRM) of 15–20%. A dose-dense, short-term chemotherapy program including seven active drugs and intrathecal drug delivery has showed excellent activity and safety profiles in HIV-negative patients with BL in the pre-rituximab era (Di Nicola et al, 2004). We introduced a few changes to this regimen to maintain efficacy and improve tolerability in HIV-BL. In particular, six doses of rituximab were added and methotrexate dose was reduced, from 150 and 250 mg/kg to 3 g/m, mostly to avoid mucositis, which constitutes an important route of access for infectious agents and one of the main causes of death in these patients (Galicier et al, 2007). We used this modified chemoimmunotherapy regimen in 15 consecutive HIV-BL (median age 42 years old, range 27–63) between July 2009 and July 2011 (Table S2). Treatment consisted of a 36-day induction phase including sequential doses of fractionated cyclophosphamide, high doses of methotrexate and cytarabine, doxorubicin, vincristine, and etoposide, rituximab and intrathecal prophylaxis/ treatment (Table I). Subsequent treatment was then tailored according to the objective response to induction phase (Fig. 1): patients in complete response (CR) were referred to a high-dose cytarabine-based consolidation phase (Table I); patients in partial response (PR) were referred to consolidation followed by BEAM (carmustine, etoposide, cytarabine, melphalan) plus autologous stem cell transplant (ASCT); patients with stable or progressive disease were referred to intensification phase, followed by BEAM + ASCT. At the end of chemoimmunotherapy, patients with initial bulky disease or with a residual positron emission tomography-positive single lesion were evaluated for 36-Gy involved-field irradiation. Treatment was safe and well tolerated. All patients but one completed the induction phase (median duration: 49 d; range 34–108); methotrexate and etoposide occasionally required delivery delay due to G3 transaminase increase or G4 neutropenia. Cytostatics dose reductions were recorded only in two patients. There was a single toxic death, which was due to pneumonia in a patient with extensive bone marrow infiltration and baseline CD4+ count of 0 017 9 10/l. As expected, haematological toxicity was common, but manageable (Table S3); with conventional antimicrobial prophylaxis and rHuG-CSF support, infective complications were mild and no systemic fungal infections occurred. The most relevant toxicity was recorded after consolidation: the original cytarabine-cisplatin consolidation regimen (Di Nicola et al, 2004) used in the first four patients was too toxic, with prolonged G4 neutropenia and severe infections in all cases. The exclusion of cisplatin, the change of cytarabine administration schedule and the addition of rituximab (Table I) were associated with a strikingly improved tolerability in subsequent patients, with only two cases of well-controlled febrile neutropenia. Of note, there was a single case of G4 non-haematological toxicity (transient diarrhoea). Patients with hepatitis B virus or hepatitis C virus positivity completed the planned treatment (ASCT in three), and experienced only transient G3 increase of transaminase serum level, without significant chemotherapy delay. HAART was discontinued during chemoimmunotherapy in four patients: three patients exhibited an increase of plasmatic HIV-RNA levels at day 45 followed by undetectable levels at day 90 in two cases, while the third patient needed for a further HAART line; the fourth patient was the toxic death. CD4+ cell counts remained unchanged in the three assessed patients, but were < 0 05 9 10/l in two of them. Response after induction phase was complete in six patients and partial in seven [overall response rate risk (ORR) = 87%; 95% confidence interval CI: 70–100%], one patient had meningeal dissemination and one died of sepsis (Fig. 1). Thirteen patients were referred to consolidation phase, 11 of them were referred to APBSC collection, which was successful in nine (median: 14 10 CD34+ cells/ kg; range 7 20–20 02). The six patients in CR after inducCorrespondence

Prevalence of chlamydial infection in a series of 108 primary cutaneous lymphomas.

MADAM, Several infectious agents have been associated with lymphomagenesis. The identification of new causative agents allows a better understanding of pathophysiology and the development of specific treatments. Chlamydophila psittaci, the causative agent of psittacosis, is a ubiquitous, obligate intracellular bacterium that is transmitted to humans through exposure to infected reservoirs (wild and household animals). This bacterium has been linked to the development of ocular adnexal lymphomas, and bacterial eradication with doxycycline resulted in lymphoma regression in 50% of patients. Moreover, in a series of 205 consecutive cases of nodal and extranodal lymphomas, chlamydial infection has been detected in some forms of cutaneous lymphomas and in diffuse large B-cell lymphomas (DLBCL) arising in the Waldeyer’s ring, suggesting a preferential distribution of this microorganism in lymphomas occurring at extranodal organs considered as ‘first barriers’ to air-transported antigens. The limited number of cases investigated did not allow us to draw definitive conclusions, but these intriguing observations prompted us to analyse more extensively the prevalence of chlamydial infection in primary cutaneous Band T-cell lymphomas. The presence of C. psittaci infection was investigated in DNA from fresh frozen samples of skin biopsies from 108 cases of cutaneous lymphoma of four different histotypes. The samples were reviewed by one expert dermatopathologist and two haemopathologists and categorized according to the European Organisation for Research and Treatment of Cancer ⁄World Health Organization (WHO) classification: DLBCL (n = 18; including six cases of ‘leg type’ lymphoma), follicular lymphoma (n = 24), marginal zone lymphoma (MZL; n = 31) and mycosis fungoides (n = 35). Nineteen normal skin samples from surgical quadrantectomies were used as negative controls. The presence of chlamydial DNA was investigated by using three polymerase chain reaction (PCR) protocols allowing the amplification of the 16SrRNA gene and the 16S23S region: touchdown enzyme time release–PCR, outer membrane protein (ompA) and heat-shock protein 60 (hsp60). The last protocol allows the distinction between C. psittaci and other Chlamydiae (C. abortus, C. caviae, C. felis). Chlamydia trachomatis and C. pneumoniae infections were analysed by amplifying the 16S rRNA gene, and amplification of the b-globin gene was carried out as control of DNA suitability. All PCR products were analysed by agarose gel electrophoresis, fragment size quantification and direct sequencing. C. psittaci DNA sequences were found in one (5%) of the skin biopsies used as controls. Among the lymphomas, C. psittaci DNA was detected in one DLBCL (6%; Fisher exact test P = 1Æ00), in four follicular lymphomas (17%; P = 0Æ36) (Fig. 1) and in one MZL (3%; P = 1Æ00), whereas all cases of mycosis fungoides were negative (0%; P = 0Æ35). One case of follicular lymphoma was positive for C. pneumoniae. The different PCR protocols showed a good concordance, with positivity in at least two of the three PCRs in all positive cases (Table 1). This study showed that the prevalence of chlamydial infections is low in primary cutaneous lymphomas, with similar rates between DLCBL, MZL, mycosis fungoides and normal skin samples, whereas a nonsignificant trend to a higher prevalence of C. psittaci infection was observed in follicular lymphomas. This nonsignificant difference may simply be due to the relatively small subgroup size; however, the observation that C. psittaci prevalence is significantly higher in follicular lymphoma (four of 24, 17%) in comparison to all the other cutaneous lymphomas as a whole (two of 84, 2%; Fisher exact test P = 0Æ02) suggests that this association deserves to

The clinical features, management and prognosis of primary and secondary indolent lymphoma of the bone: a retrospective study of the International Extranodal Lymphoma Study Group (IELSG #14 study)

Abstract Indolent lymphomas primarily involving the skeleton (iPBL) represent < 1% of all primary bone lymphomas. The management and prognosis have not been previously described. Patients with primary and secondary iPBL were selected from an international database of 499 patients with a histopathological diagnosis of non-Hodgkin lymphoma and skeleton involvement, and clinical features, management and prognosis were analyzed. Twenty-six (5%) patients had an iPBL. Ten patients had small lymphocytic lymphoma, 10 had follicular lymphoma and six had lymphoplasmacytic lymphoma. Eleven patients had limited stage and 15 had advanced disease. The overall response rate was 73% (95% confidence interval [CI] = 57–89%). Median follow-up was 58 months, and the 5- and 10-year progression-free survival (PFS) rates were 37 ± 10% and 25 ± 12%, respectively. Nine patients are alive, with 5- and 10-year overall survival (OS) rates of 46 ± 10% and 29 ± 11%, respectively. Patients with small lymphocytic lymphoma showed significantly better outcome than patients with follicular lymphoma. Performance status and stage of disease were independently associated with OS. The prognosis of patients with primary bone lymphoplasmacytic or follicular lymphoma was less favorable.