Consecutive Follicular Lymphoma Patients Research Articles

P1132: PET INTERIM RESULTS PREDICT PROGRESSION-FREE-SURVIVAL IN FOLLICULAR LYMPHOMA PATIENTS WITH ADVANCED STAGE

Background: Follicular lymphoma (FL) is the second most common NHL. It is generally associated with an indolent course, but a subgroup of patients has worse outcome, lower progression-free-survival (PFS) and higher risk of histological transformation (HT). Since Lugano classification, the Deauville criteria using the 5-point scale (D5PS) is validated as the interpretation method for response assessment PET scans in HL and NHL. Nevertheless, the prognostic value of D5PS in the interim evaluation in FL (PETINT) is not well stablished. Additionally, the quantitative value of SUVmax parameter in the response assessment is almost not studied. Aims: The aim of this study is to evaluate the prognostic value of PETINT evaluation and quantitative mid-induction SUVmax parameter in a cohort of FL patients followed and treated in a single, academic centre with chemo-immunotherapy. Methods: 179 consecutive FL patients were newly diagnosed between 2011 and 2020. 40 patients that did not require systemic treatment and 68 that did not have a PETINT evaluation were excluded. As well, patients with HT (9) and FL grade 3B (4) were excluded. From the 58 remaining patients, clinical, laboratory and PET examinations data was recorded. All patients were Ann-Arbor stage III-IV and were treated with chemo-immunotherapy. PET/CT examinations were acquired at baseline, mid-induction (after 4 cycles of treatment) and end of treatment (EOT). PET positive was considered when Deauville score (DS) was 4 or 5. Statistical analysis was performed with SPSS® using Cox regression, Kaplan-Meier survival curves and log-rank test. Results: The median age at diagnosis was 64 years (26-95) and 29 (50%) patients were female. 33/58 (57%) patients had a high risk FLIPI and 18/55 (33%) had a high risk PRIMA-PI. 37 (64%) patients were treated with R-CHOP and 21 with R-bendamustine. 44 (76%) patients received maintenance with rituximab. After a median follow-up of 43 months, 20 (34%) patients had progression. On PETINT, 19 (32%) patients were PET(+), and 10 of them remained PETEOT(+). Only one patient with PETINT(-), became PETEOT(+). PETINT(+) patients had a median PFS of 31 months compared with a median PFS of 88 months in PETINT(-) (p < 0.001), Figure 1. 38.2% PETINT(+) presented progression of disease in less than 24 months (POD24) vs 5.2% on those who were in PETINT(-), with a p<0.001. PETINT(-) presented a negative predictive value of 95%. No differences in OS was observed. 3/19 (16%) patients with PETINT(+) presented HT vs 1/39 (2%) with PETINT(-). Transformation-free survival was lower in patients with PETINT(+), with a trend towards significance (p= 0.057). Similar PFS results were obtained independently of prognostic index, treatment or maintenance received. Analysing the prognostic value of quantitative SUVmax, patients with SUVmax< 3,8 (28/58; 48%) presented better outcomes, with larger PFS (p < 0.001) and less HT (p= 0.004). Figure 2. Additionally, PET/CT findings at EOT were predictive of relapse, with a median PFS of 30 months in PETEOF (+) vs 88 months in PETEOT(-) (p = 0.005). PETEOT (+) presented a higher risk of HT (p= 0.004). Figure 3. Image:Summary/Conclusion: This study suggests that response assessment by PET at mid-induction is predictive of relapse in advanced stage FL patients treated with 1st line chemo-immunotherapy. With previous conflicting results, further studies are needed to confirm this preliminary data. Probably, new laboratory tests such as MRD monitored by liquid biopsy could improve the detection of this subgroup of high risk patients and help to develop a response-adapted precision therapy.

Safety and Early Efficacy of Obinutuzumab in Combination with Chemotherapy in Treatment Naive Patients with Follicular Lymphoma - Report of Polish Lymphoma Research Group (PLRG)

Safety and Early Efficacy of Obinutuzumab in Combination with Chemotherapy in Treatment Naive Patients with Follicular Lymphoma - Report of Polish Lymphoma Research Group (PLRG)

Low absolute CD4+ T cell counts in peripheral blood are associated with inferior survival in follicular lymphoma

Host immunity and tumor microenvironment significantly influence follicular lymphoma (FL) outcomes. Lymphopenia has been identified as a negative prognostic factor for FL. However, there is limited data regarding prognostic value of peripheral blood T lymphocyte subsets, especially absolute CD4+ T cell counts (ACD4C) in FL. We studied 127 consecutive FL patients to investigate whether peripheral blood ACD4C or absolute monocytes (AMC) at diagnosis had an impact on FL prognosis. In our cohort, both low ACD4C and high AMC were the parameters associated with inferior progression-free survival (PFS) (P = 0.021 and P = 0.013, respectively) and inferior overall survival (OS) (P = 0.020 and P = 0.005, respectively) by univariate analysis. Multivariate analysis revealed that only low ACD4C was statistically significant in worse PFS (hazard ratio, 2.811; 95% confidence interval, 1.137-6.950; P = 0.025) and shorter OS (hazard ratio, 3.393; 95% confidence interval, 1.037-11.105; P = 0.043) independent of FLIPI-2. Evaluation of blood ACD4C could be a useful indicator of outcome in previously untreated FL patients.

Long-term complication in follicular lymphoma: assessing the risk of secondary neoplasm in 242 patients treated or not with 90-yttrium-ibritumomab-tiuxetan.

Non-Hodgkin lymphoma patients have a 25% increased risk of secondary primary neoplasms (SPNs). Regarding the controversy about the increased risk of SPN in patients exposed to radioimmunotherapy (RIT), we have analyzed this issue in a cohort of follicular lymphoma (FL) patients treated with/without RIT. A retrospective study including all consecutive FL patients diagnosed since 2001 was performed. Demographic, clinical data including the incidence of any kind of neoplasm (excluding basocellular skin carcinoma) were recorded. A total of 242 patients were registered, male/female: 103/139, mean age: 59.9 yr (15-86), stage IV (57.8%), and Follicular Lymphoma Prognostic Index (FLIPI) low-risk (62.15%) predominance. Ninety-six patients (39.7%) were treated with 90Y-IT. The median follow-up for patients treated or not with 90Y-IT was 61 (8-273) and 38 (1-171) months. With respect to SPN incidence, 38 (15.6%) patients have at least two cancers, in 17 (44.7%), FL was the SPN; for the rest (226), the global incidence of SPNs was 9.3% (21), but there were no differences related to the exposition or not to 90Y-IT (P = 0.26). In seven patients, more than two (2-6) different therapies were registered; four were exposed to fludarabine-based therapy, three to radiotherapy and two to autologous stem-cell transplantation, and in the RIT cohort, two patients developed myelodysplastic syndrome. This is one of the largest single institution reports assessing the risk of SPN in FL patients treated (96) or not (146) with 90Y-IT. It seems that 90Y-IT does not increase significantly the risk of SPN but avoiding its use after fludarabine and other intense cytotoxic schemes is recommended.

Combination of High Serum Lactate Dehydrogenase Levels at the Time of First Diagnosis and Progression Predicts Early Lymphoma Related Death in Patients with Follicular Lymphoma Receiving R-CHOP Regimen

Background: Rituximab-combined chemotherapy improves survival in patients with follicular lymphoma (FL), however, many patients have a risk of eventual relapse. Recently, early progression of FL within the first 2 years has been reported to be associated with poor outcomes (Casulo C. et al., 55th ASH Annual Meeting abstract # 510). We conducted a retrospective study to analyze clinical features and prognostic factors of patients with FL in early progression.Methods: Among 181 consecutive FL patients newly diagnosed in our institute, data were available for 95 patients who were diagnosed as clinical stage II to IV and received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) based chemotherapy. Early relapse was defined in this study as early progression within the first 2 years after initial diagnosis.Results: With a median follow-up of 6.3 years (range: 0.7-14.0 years), the 6-year overall (OS) and progression-free survival rates (PFS) of the 95 patients were 89% (95%CI: 81 to 94) and 60% (95%CI: 49 to 70), respectively. Cumulative incidence of relapse at 2 and 6 years was 19% (95%CI: 12 to 28) and 36% (95%CI: 25 to 46), respectively. Of the 95 patients, a total of 35 patients experienced relapses, of which 18 patients with 8 male had early relapse. Patients with early relapse demonstrated worse OS compared with that of patients who experienced relapses beyond the first 2 years [the 6-year OS rates: 100% vs. 65% (P = 0.0083, Log-rank)].At initial diagnosis, the median age of the 18 early relapsed cases was 55 years (range: 39 to 72) and 7 patients were more than 60 years of age. Seventeen patients were initially diagnosed as stage III and IV. Serum lactate dehydrogenase (LDH) levels at the time of first diagnosis and progression were elevated in 10 and 7 patients, respectively. Fourteen patients had high tumor burden defined by Groupe d’Etude des Lymphomas Folliculaires (GELF) criteria. According to Follicular lymphoma international prognostic index 2 (FLIPI2), 6 and 9 patients were classified as the groups of intermediate and poor risk, respectively. Pathological diagnosis was performed in 16 of the 18 patients at the time of first progression. Transformation of FL to diffuse large B-cell lymphoma (DLBCL) occurred in two patients and tumor sample from one patient included FL with a component of DLBCL.After progression, salvage chemotherapy was undergone in 18 patients and 3 patients received transplantation. Seven patients, all of whom died of FL, showed disease progression within 13 months after initial diagnosis, while no patients died of FL when diagnosis was made after that. With a median follow-up of 3.7 years (range: 1.1-12.0 years), the 3-year OS rate of the early relapsed patients was 67% (95%CI: 40 to 83). Patients with high levels of serum LDH both at initial diagnosis and at the time of first progression showed worse survival [P = 0.0001, Log-rank (Figure 1)]. Deaths due to FL was not observed in patients with low risk groups defined by FLIPI2 and with low tumor burden defined by GELF criteria at initial diagnosis.Conclusions: Early relapse was observed in 19 % of the patients who were diagnosed as clinical stage II to IV and received first-line R-CHOP therapy. Deaths due to FL occurred in patients who had early progression within 13 months after initial diagnosis. Two factors of high levels of LDH both at initial diagnosis and at the time of first progression might be useful prognostic tool to predict deaths from FL. [Display omitted] Abbreviations: LDH high, patients with high levels of serum LDH both at initial diagnosis and at the time of first progression; LDH low, the remaining patients DisclosuresNo relevant conflicts of interest to declare.

VEGF 2578 c>a, a Functional Angiogenic Polymorphism, Is Associated with Aggressiveness and Clinical Outcome of Follicular Lymphoma

Introduction: Follicular lymphoma (FL) is the second most prevalent non-Hodgkin lymphoma worldwide, and is characterized by an indolent course and frequent relapses. Better understanding of FL has shown that angiogenesis (AG) has an important role in its progression to a more aggressive form. The most important mediator of AG is the vascular endothelial growth factor (VEGF), which is encoded by a polymorphic gene. It is already known that allele C of the VEGF 2578C/A polymorphism (rs699947) is related to higher serum concentration of VEGF compared to the A allele. The roles of this genetic polymorphism in clinical manifestations and outcome of FL are still unknown, and therefore these were the aims of the present study.Methods: Our analysis included 86 consecutive FL patients seen at diagnosis at the university hospital. The patients were treated with 6 to 8 cicles of R-CHOP. The clinical data of these patients were obtained from medical records. Genomic DNA was extracted from peripheral blood samples, and genotyping of the VEGF -2578C/A (rs699947) polymorphism was performed with real-time qPCR. Overall-survival (OS) was defined as time from diagnosis until death from any cause or last follow-up. The differences between groups were analyzed by the logistic regression model. Kaplan-Meier and log-rank analyses were used to assess survival information from the patients’ data. Furthermore, we examined survival data using univariate Cox proportional hazards regression, with the respective hazard ratios (HR) and 95% Confidence Intervals (CIs). Adjustement of Cox regression for clinical features was also performed. A p-value smaller than 0.05 was used to denote statistical significance.Results: The FL patients had a mean age of 56.2 years at diagnosis. The majority of the patients were caucasians (87.6%), and there was an equivalent distribution between genders: 43 male and 43 female patients (50% each). Thirty-nine (45.3%) patients had B-symptoms and 48 (54.7%) had no B-symptoms at diagnosis. Sixty-three (73.2%) patients presented at diagnosis with tumors of III or IV Ann Arbor stage, and 30 (34.8%) had bone marrow infiltration. Follicular Lymphoma International Prognostic Index (FLIPI) was assessed and patients were classified as follows: low-risk FLIPI (≤ 1 point) was seen in 34 cases (39.5%), medium-risk FLIPI (2 points) in 28 cases (32.5%), and high-risk FLIPI ( ≥ 3 points) was seen in 24 patients (27.9%).The VEGF 2578CC genotype was more common in patients with B-symptoms at diagnosis than in those without B-symptoms (51.2% versus 29.7%, p=0.04). The frequency of VEGF 2578CC genotype was also higher in patients with high-risk FLIPI than in those with medium and low-risk FLIPI (58.3% versus 32.2%, p=0.03). We found no association between genotypes and bone marrow infiltration at diagnosis.Considering clinical course of the patients, Kaplan Meier curves of OS showed that at 60 months of follow up, B-symptoms at diagnosis (65.2% of OS versus 87.1%, p=0.02), high-risk FLIPI (52.5% of OS versus 90%, p=0.002), and 2578CC genotype (62.1% of OS in 2578CC patients versus 89.4% in 2578CA plus 2578AA patients, p=0.01) had negative impacts on outcome. In univariate Cox analysis, presence of B-symptoms (p=0.03, HR=3.2, 95% CI: 1.09-9.38), high-risk FLIPI (p=0.01, HR= 3.91, 95% CI: 1.38-11.03) and 2578CC genotype (p=0.02, HR=3.70, 95% CI: 1.16-11.82) were also associated with a worse outcome. The prognostic role of the abovementioned polymorphism was still present after adjustment for age (p=0.04, HR=3.23, 95% CI:1.01-10.36) and Ann Arbor stage (p=0.02, HR=3.58, 95% CI:1.1-11.6) in univariate regression. After adjustment for FLIPI status as a whole, only a trend of association of 2578CC genotype with a worse outcome was found in the study (p=0.05, HR=3.24, 95% CI: 0.95-13.05).Conclusion: Our results present, for the first time, preliminary evidence that FL patients with the VEGF 2578CC genotype, related to higher production of VEGF, are more likely to develop aggressive form of the disease at diagnosis, and to succumb earlier to death. We recognize, however, that our study is based on a small sample size and that more numerous cohorts should be analyzed in order to assess additional associations. Also, further studies, such as correlations between relevant AG genes and tumor vascularization, should be done in order to clarify this issue in the context of FL. DisclosuresNo relevant conflicts of interest to declare.

Prognostic Value Of GELF Criteria and FLIPI2 For Newly Diagnosed Follicular Lymphoma Receiving R-CHOP Chemotherapy

Follicular lymphoma (FL) is the most frequent low-grade lymphoma and survival duration is heterogeneous. Follicular lymphoma international prognostic index 2 (FLIPI2) is a useful prognostic tool for the identification of patients with FL at different risk in the rituximab era. On the other hand, Groupe d'Etude des Lymphomas Folliculaires (GELF) criteria is defined for patients in whom immediate therapy is necessary. In this study, we determined the value of FLIPI2 and GELF criteria as prognostic tools for follicular lymphoma.Among 181 consecutive FL patients newly diagnosed in our institute from 2000 to 2011, data of FLIPI2 and GELF criteria were available for 147 patients. Of the 147 patients, a total of 102 patients were diagnosed as clinical stage II to IV and received R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone) based chemotherapy. The remaining 45 patients were treated with CHOP like regimens or other treatment modalities. Of the 102 patients who had rituximab usage, 2 patients (2%) received rituximab maintenance therapy. Detailed patients characteristics were shown in Table 1. Survival analysis was carried out using the Kaplan–Meier product-limit method.Table 1Baseline patients' characteristics (stage ≥II, received R-CHOP)ALL (n=102)Cross-validation cohort (n=65)n (%)n (%)Sex (Male)45 (44)33 (51)Median age (range)58.5 (39-84)58 (39-79)Age (>60)38 (37)24 (37)ECOG PS (>1)2 (2)1 (2)Stage ≥III85 (83)52 (80)Bulky (≥7 cm)19 (19)13 (20)Serum LDH level (>normal)29 (28)19(28)Histology (Grade1/2/3)15/74/1110/46/8FLIPI2Low17 (17)14 (22)Intermediate58 (57)38 (58)High27 (26)13 (20)GELF criteria (High)56 (55)32 (49)Rituximab maintenance2(2)1(2)First, we performed analysis using 102 patients who were diagnosed as clinical stage II to IV and received R-CHOP based chemotherapy. With a median follow-up of 6.3 years (range: 0.7-14.0 years), the 6-year overall (OS) and progression-free survival rates (PFS) of the 102 patients were 89% (95%CI: 78 to 98) and 62% (95%CI: 51 to 71), respectively. According to FLIPI2, three risk groups (low risk, intermediate risk and poor risk) were separated in OS analysis. Estimated 6-year OS rates in patients with high and low tumor burden defined by GELF were 82% and 98%, respectively (P=0.02, Log-rank). PFS rates of patients with high tumor burden defined by GELF criteria were worse compared to those with low tumor burden (53% vs. 72%, p=0.02, Log-rank). When we divided patients into two group using both FLIPI2 and GELF criteria (FLIPI2-GELF combined model), patients, who had high tumor burden defined by GELF criteria and who were classified intermediate risk or poor risk group defined by FLIPI2 (FLIPI2-GELF high) showed worse OS rates compared to the remaining (FLIPI2-GELF low) patients (83% vs. 95%, p=0.03, Log-rank). Patients with FLIPI2-GELF high also represented worse PFS rates compared to FLIPI2-GELF low patients (51% vs. 72%, p<0.01, Log-rank). The results suggested that FLIPI2-GELF combined model could more precisely separate patients into each risk group.For validation, we next performed cross-validation analysis using 65 patients who were diagnosed as clinical stage II to IV and received R-CHOP based chemotherapy. The patients were selected from the first cohort of 102 cases (Table 1). With a median follow-up of 6.2 years (range: 0.7-14.0 years), estimated 6-year OS rates in patients with high and low tumor burden defined by GELF were 80% and 97%, respectively (P=0.03, Log-rank). Estimated 6-year PFS rates in patients with high and low tumor burden defined by GELF were 51% and 66%, respectively (P=0.12, Log-rank). Using FLIPI2-GELF combined model, estimated 6-year OS rates in patients with FLIPI2-GELF high and low were 78% and 97%, respectively (P=0.02, Log-rank). Estimated 6-year PFS rates in patients with FLIPI2-GELF high and low were 47% and 68%, respectively (P=0.04, Log-rank). In 147 cases treated with R-CHOP, CHOP based regimens,or other treatment modalities, FLIPI2-GELF combined model also could divide the two group in OS (p=0.01) and PFS (p<0.01) analyses.In conclusion, we confirmed GELF criteria could be used for reproducible prognostic tool for newly diagnosed follicular lymphoma receiving R-CHOP based chemotherapy. GELF criteria combined with FLIPI2 might be a more precise and repeatable prognostic indicator for survival after first-line therapy in patients with follicular lymphoma. Disclosures:No relevant conflicts of interest to declare.

Absolute monocyte count in follicular lymphoma patients treated with rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone

Elevated absolute monocyte counts (AMCs) have been reported to indicate poor prognosis for patients with lymphoproliferative disease, including those with follicular lymphoma (FL) receiving various treatments. We evaluated the prognostic impact of AMC in 150 consecutive FL patients who received rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) therapy. Progression-free survival (PFS) did not differ significantly according to the AMC level. Univariate and multivariate analyses did not indicate a prognostic significance of AMC for PFS. Thus, the AMC is not a prognostic factor for FL patients treated with R-CHOP. However, immunochemotherapy might influence the prognostic impact of AMC.

FDG PET/CT predictive role in follicular lymphoma

We present findings concerning (18)F-fluorodeoxyglucose (FDG) positron emission tomography (PET) at end-treatment evaluation in follicular lymphoma (FL) in order to establish possible predictive factors for progression-free survival (PFS) and patient outcome. We retrospectively analysed data from 91 consecutive FL patients (M:F = 51:40, mean age 61) referred to our PET Unit at therapy completion: 38 with an indolent form (grade 1-2) and 53 with an aggressive FL (grade 3a and b) according to the World Health Organization (WHO) classification. A total of 148 FDG PET/CT scans were analysed and findings reported as positive or negative for disease. The overall response to treatment was assessed according to the revised International Workshop Criteria (IWC). The final outcome was defined as remission or disease by taking clinical, instrumental and histological data as standards of reference, with a mean follow-up period of 3 years (range 1-8). A statistical analysis was performed with respect to PFS and patient outcome for FDG PET result, tumour grading, Follicular Lymphoma International Prognostic Index (FLIPI), disease stage and number of relapses, on uni- and multivariate analyses, with p < 0.05 considered as significant. Overall patients presented a mean PFS of 35 months (range 3-86), with a relapse rate of 42%. At final outcome, remission was achieved in 67 of 91 patients (74%). Of the different predictive factors, only FDG PET result significantly correlated with patient outcome (p = 0.0002). PET/CT performance at the end of treatment was as follows: 100% sensitivity, 99% specificity, 89% positive predictive value and 100% negative predictive value. The Kaplan-Meier analysis demonstrated a statistically significant correlation with PFS for FDG PET (p < 0.0001), FLIPI score (0-1 versus ≥ 2) (p = 0.0451) and number of relapses (none versus ≥ 1) (p = 0.0058). These findings were confirmed at the univariate analysis, whereas at the multivariate analysis only FDG PET (p = 0.0006892) and number of relapses (p = 0.01947) were independent predictive factors for PFS. End-treatment PET/CT in FL has high accuracy and appears to be a good predictor of PFS and patient outcome, irrespective of grading. As expected, patients facing more than one relapse seem to have significantly shorter PFS in the presence of a positive FDG PET.

Molecular Evaluation of t(14;18)(bcl-2/IgH) Translocation in Follicular Lymphoma at Diagnosis Using Paraffin-Embedded Tissue Sections.

Objective: Follicular lymphoma (FL) is one of the most common lymphomas, and is characterized by t(14;18)(q32;q21) in more than 80% of patients. The aim of this study was to determine the rate of t(14;18) positivity based onthe detection of mbr or mcr in paraffin-embedded tissue samples.Material and Methods: The study included 32 paraffin-embedded tissue samples collected from 32 consecutive FL patients that were diagnosed and followed-up at our hospital between 1999 and 2006. The MBR breakpoint wasidentified based on real-time PCR using a LightCycler v.2.0 t(14;18) Quantification Kit (MBR), multiplex PCR, and seminestedPCR. To identify the mcr breakpoint, real-time PCR was performed using specific primers and the FastStart DNAMaster SYBR Green I Kit. To detect t(14;18) via fluorescence in situ hybridization (FISH) nuclei from paraffin-embeddedtissue sections were extracted and used together with LSI IgH (immunoglobulin heavy chain) (spectrum green)/bcl-2(B-cell leukemia-lymphoma 2) (spectrum orange) probes.Results: The DNA and nuclei isolation success rate for B5 formalin-fixed, paraffin-embedded tissue sections (n = 12)was 42% and 33%, respectively, versus 95% and 60%, respectively, for 20 tissue sections fixed in formalin only. In all,24 paraffin-embedded tissue sections were analyzed and mbr positivity was observed in the DNA of 82.14% via seminested PCR, in 53.57% via multiplex PCR, and in 28.57% via real-time PCR. We did not detect mcr rearrangementin any of the samples. In all, 15 of 16 patients (93.75%) whose nuclei were successfully isolated were observed to bet(14;18) positive via the FISH method.Conclusion: Semi-nested PCR and FISH facilitated the genetic characterization of FL tumors. As such, FISH and PCR complement each other and are both essential for detecting t(14;18) translocation.

Clinical Benefit Associated With Idiotypic Vaccination in Patients With Follicular Lymphoma

Follicular lymphoma is considered incurable, although cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy can induce sequential remissions. A patient's second complete response is typically shorter than that patient's first complete response. Idiotype vaccines can elicit specific immune responses and molecular remissions in patients with follicular lymphoma. However, a clinical benefit has never been formally proven. Thirty-three consecutive follicular lymphoma patients in first relapse received six monthly cycles of CHOP-like chemotherapy. Patients who achieved a second complete response were vaccinated periodically for more than 2 years with autologous lymphoma-derived idiotype protein vaccine. Specific humoral and cellular responses were assessed, and patients were followed for disease recurrence. Statistical tests were two-sided. Idiotype vaccine could be produced for 25 patients who had a second complete response. In 20 patients (80%), a humoral (13/20) and/or a cellular (18/20) idiotype-specific response was detected. The median duration of the second complete response has not been reached, but it exceeds 33 months (range = 20+ to 51+ months). None of the 20 responders relapsed while undergoing active vaccination. All responders with enough follow-up for the comparison to be made experienced a second complete response that was statistically significantly (P<.0001) longer than both their first complete response (18 of 18 patients) and than the median duration of a CHOP-induced second complete response, i.e., 13 months (20 of 20 patients). The five nonresponders all had a second complete response that was shorter (median = 10 months; range = 8-13 months) than their first complete response (median = 17 months; range = 10-39 months). Idiotypic vaccination induced a specific immune response in the majority of patients with follicular lymphoma. Specific immune response was associated with a dramatic and highly statistically significant increase in disease-free survival. This is the first formal demonstration of clinical benefit associated with the use of a human cancer vaccine.

Quantitative PCR Detection of t(14;18) bcl-2/JH Fusion Sequences in Follicular Lymphoma Patients : Comparison of Peripheral Blood and Bone Marrow Aspirate Samples

In patients with follicular lymphoma (FL), it is unresolved whether peripheral blood (PB) can replace bone marrow (BM) aspirate samples for detection of bcl-2/JH fusion sequences that result from the t(14;18)(q32;q21). We compare here the results of quantitative polymerase chain reaction (q-PCR) analysis for bcl-2/JH involving the major breakpoint cluster region (mbr) on paired PB and BM aspirate samples from 60 consecutive FL patients. There was a significant correlation between the level of bcl-2/JH fusion sequence obtained from PB and BM aspirate samples (r = 0.886), with 82% of samples showing less than one log of difference. Patients who had histological evidence of FL involving concurrent BM biopsy specimens had moderate to high levels of bcl-2/JH in both PB and BM aspirate samples, allowing unequivocal determination of translocation status (median bcl-2/JH to cyclophilin level was 8.014%). In contrast, patients with no detectable FL in their BM biopsy specimens often showed low levels of bcl-2/JH in both PB and BM aspirate samples (bcl-2/JH to cyclophilin median level = 0.006%), in a range similar to background levels that could be detected in patients without FL (n = 15, median bcl-2 mbr/JH to cyclophilin level = 0.002%). We conclude that PB can be used in place of BM aspirate samples to test for the presence of bcl-2 mbr/JH fusion sequence in FL patients and that either PB or BM aspirate testing yields a rough approximation of the degree of BM involvement by FL. However, in patients with minimal levels of bcl-2/JH in PB or BM aspirate samples, confirmation of this result by testing the primary tumor is recommended to confirm the presence of an identical bcl-2/JH fusion sequence and exclude false-positive results.