Low-grade Follicular Lymphoma Research Articles

Correlation of IFNγ, CD107 and CD137 at the Single Cell Level Can Be Used To Monitor T Cell Responses in Patients after Immunotherapy.

As immunotherapies become increasingly important in the treatment of various cancers, monitoring the immune response to reflect the efficacy of the therapy also becomes increasingly important. Previously, tumor antigen-specific humoral responses in patients receiving vaccines for low-grade follicular lymphoma (FL) correlated with clinical outcomes, including tumor regression, molecular remission, progression free survival (PFS) and overall survival (OS). By contrast, T cell immune responses have been difficult to validate. T cell proliferation assays, mostly, measure CD4 T cell responses; whereas, CD8 T cells may be the important effectors generated by immunotherapies. However, assays designed to measure CD8 T cells, i.e. chromium release CTL assays, and IFN-γ ELISPOT and intracellular flow cytometry assays, are difficult to make reproducible. To address this issue, PBL were obtained from FL patients, cryopreserved, and thawed, then used to design a standardized method for detection of intracellular IFN-γ by flow cytometry. The combined stimulus of soluble anti-CD3 and anti-CD28 antibodies provides a robust stimulation, typically about 5% of normal PBL CD8+ T cells respond. By using a panel of irradiated B cell lymphoma cell lines as stimulators, we demonstrated that, on average, 1 – 2% of these T cells were capable of mounting a response in this assay. Surprisingly, CD8+ PBL T cells from several patients with FL were more responsive to combined anti-CD3 and anti-CD28 stimulation as well as to allo-stimulation, 15 – 22% and 2 – 6%, respectively. This response was accompanied by surface expression of CD107, a surrogate marker for CTL degranulation, in the same population of cells as demonstrated by multi-color flow cytometry. Both the IFN-γ and the CD107 responses were inhibited by an anti-class I antibody, W6/32, suggesting a class I restricted T cell receptor-mediated response. Furthermore, at later time points, these T cells also up-regulated CD137 on their surface. This activation molecule is upregulated on CD8 T cells in response to specific antigen recognition and provides an anti-apoptotic signal to the cells. In conclusion, immune competency of CD8 T cells isolated from FL patients can be assessed through allo-stimulation by a panel of B cell lymphoma cell lines. More importantly, correlation by flow cytometry of 3 independent indicators of response (IFN-γ, CD107 and CD137) within single populations of cells to both allo-stimulation and to the specific target, may lead to better understanding of the role of T cells in the immune response. Ultimately, these responses will need to be validated with patient outcomes in clinical trials of vaccines in lymphoma.

Progressive multifocal leukoencephalopathy in a lymphoma patient with complete remission after treatment with cytostatics and rituximab: case report and review of the literature

A 44-year-old woman presented with dysarthria, visual disturbances, ataxia and cognitive impairment. There was a rapid progression of her neurological disease, and she died 8 months later. She was previously treated for a low-grade follicular B-cell lymphoma; complete remission was achieved by conventional radiotherapy and chemotherapy, including rituximab. Two years later, the neurological symptoms and signs started. MRI revealed a cerebral demyelinating process. Serology was negative. Autopsy disclosed areas in cerebral white matter with grey discoloration. Microscopy revealed demyelination, oligodendroglial viral inclusions and gliosis with bizarre astrocytes. Polymerase chain reaction (PCR) was positive for JC virus. These findings were consistent with progressive multifocal leukoencephalopathy (PML). This is one of recent reports on PML occurring in a patient treated with the anti-20 monoclonal antibody rituximab.

MUM1 expression dichotomizes follicular lymphoma into predominantly, MUM1-negative low-grade and MUM1-positive high-grade subtypes

We investigated the expression of MUM1 (multiple myeloma oncogene 1)/IRF4 (interferon regulatory factor 4) in 46 cases of follicular lymphoma (FL) and correlated this with grade and expression of CD10, Bcl-6 and Ki-67. The analysis suggests that MUM1 expression dichotomises FL into low-grade FL of CD10+/Bcl-6+/MUM1-/Ki-67low phenotype, and high-grade FL of CD10+/- /Bcl-6+/weak/MUM1+/ Ki-67high phenotype.

Low Histologic Grade Follicular Lymphoma with High Proliferation Index: Morphologic and Clinical Features

Low Histologic Grade Follicular Lymphoma with High Proliferation Index: Morphologic and Clinical Features

Value of Positron Emission Tomography in Staging Ocular Adnexal Lymphomas and Evaluating Their Response to Therapy

An observational case series to assess the value of positron emission tomography (PET) in staging ocular adnexal lymphomas and evaluating their response to therapy. The clinical records of 16 consecutive patients with ocular adnexal lymphoma for whom pretreatment and posttreatment PET scans and corresponding computed tomography (CT) and magnetic resonance imaging (MRI) scans were available were compared. Pretreatment PET scans demonstrated fluorine 18-fluorodeoxyglucose (FDG) positive lesions in 15 orbits of 12 patients. In 1 patient with low-grade follicular lymphoma of the orbit, PET revealed an additional focus of lymphoma in the deltoid muscle that was missed on clinical examination and conventional radiography. All of the posttreatment PET scans showed complete resolution of FDG uptake, suggesting good response to therapy. However, posttreatment CT and MRI scans demonstrated residual masses in 3 patients. PET is valuable for initial staging of ocular adnexal lymphomas and may be a good adjunct to conventional imaging in evaluation of response to therapy.

Low‐grade follicular lymphoma in the dura: Rare mimic of meningioma

Lymphomas rarely present as a localized mass within the dura. We report a case of a 72-year-old woman, normally fit and well, who presented with a sudden episode of grand mal seizure. Imaging studies showed an extra-axial mass arising from the dura, with radiologic features characteristic of a meningioma. The mass was surgically excised, and the histologic features were of a grade 1 follicular lymphoma. Analysis using fluorescent in situ hybridization (FISH) demonstrated t(14:18) translocation. A bone marrow aspirate showed focal infiltration of lumbar vertebra by low-grade follicular lymphoma. Intracranial meningeal involvement by non-Hodgkin lymphoma usually occurs in the form of diffuse leptomeningeal spread. It is seen in high-grade lymphomas, often in association with widespread systemic disease. The majority of cases of dural lymphomas reported in the literature have been primary mucosa-associated lymphoid tissue (MALT)-type lymphomas. Most of these presented as localized dural masses mimicking meningiomas. Low-grade follicular lymphoma, either primary or secondarily involving the dura, appears to be an exceedingly rare occurrence.

Adaptive Immunotherapy with Autologous CD25-Depleted and CD3/CD28-Costimulated T-Cells Enhances Lymphocyte Recovery after Cyclophosphamide - Fludarabine Chemotherapy in Patients with Low-Grade Follicular Lymphoma.

BACKGROUND: Fludarabine-based chemotherapy combinations are highly effective in patients (pts) with low-grade follicular lymphoma (FL), but cause severe and long-lasting immunosuppression due to depletion of normal CD4+ T-cells. Aside from increasing the risk of serious infections, this toxicity may limit the ability of the immune system to eliminate minimal residual disease. Adoptive immunotherapy using autologous CD25-depleted, CD3/CD28-costimulated T-cells (ACTC) expanded ex vivo may enhance immune reconstitution and improve disease control.METHODS: We initiated a phase I study in pts with purine analog-naive relapsed/refractory FL (grades 1 and 2). After leukapheresis, pts receive 4 cycles of fludarabine (25 mg/m2) days 1–3 and cyclophosphamide (250 mg/m2) days 1–3. Four weeks after the last cycle, responding patients (CR/CRu, PR) receive escalating doses of ACTC prepared ex vivo from autologous T-cellss collected prior to chemotherapy and depleted of regulatory CD4+/CD25+ cells, then expanded and activated using anti-CD3 and anti-CD28.RESULTS: Eleven pts have been enrolled to date. Median age is 49 y (range: 33–64y). Median number of prior therapies is 2 (range: 1 – 3). Two pts were withdrawn from the study due to hematologic toxicity related to chemotherapy, one patient was withdrawn for progressive disease during chemotherapy, and one patient has not yet completed chemotherapy. Of the 7 pts completing chemotherapy and proceeding to T-cell infusion, 5 pts achieved a CR/CRu and 2 pts achieved a PR; 5 pts received 1 – 5 x 109 CD3+ cells and 2 patients received 5 – 10 x 109 CD3+ cells. There have been no adverse events related to T-cell infusions. Median follow-up after ACTC infusion is 19 mos (range: 3 – 26 mos). CD4+ counts increased in all patients by 1 month after T-cell infusion, with a median increase of 3.2 fold (range: 1.5 – 70, p= .028)(see figure). For patients at dose level 1, the median increase was 2.2 fold (n=4; range: 1.5 – 3.3); at dose level 2 it was 37 fold (n=2; range: 3.8 – 70). CD8+ counts also increased, with a median increase of 8.1 (range: 1.0 – 30, p= .046)(see figure). All 7 pts receiving ACTC were anergic to candida antigen by delayed type hypersensitivity (DTH) skin testing before chemotherapy. Four pts developed a positive DTH response to candida antigen 60 days after ACTC infusion. For patients receiving ACTC, median follow-up is 24 mos (range: 7 – 31 mos) with a median progression-free survival of 18 months which is significantly longer than the time to progression from last therapy (p= .024).CONCLUSIONS: ACTC infusion results in significant CD4+ and CD8+ numerical and functional lymphocyte recovery after cyclophosphamide-fludarabine chemotherapy in pts with low-grade FL. This compares very favorably to historical controls treated with fludarabine-based regimens. T-cell dose escalation is ongoing. [Display omitted]

Preliminary Report on a Phase I/II Study of Intratumoral Injection of PF-3512676 (CpG 7909), a TLR9 Agonist, Combined with Radiation in Recurrent Low-Grade Lymphomas.

Background: Low-grade lymphomas are considered incurable, but they are among the most immune-responsive of all human cancers. CpG belongs to a new class of immunomodulators, which activates B cells and plasmacytoid dendritic cells through Toll-like Receptor 9 (TLR 9). We have developed a novel immunotherapy approach that combines low-dose radiation with intra-tumoral injection of CpG for recurrent low-grade lymphomas. We hypothesized that CpG would stimulate tumor-antigen uptake and presentation by dendritic cells in vivo. Tumor cells induced to die by irradiation release tumor antigens and recruit dendritic cells. In this setting, CpG injected into the irradiated tumor stimulates dendritic cell uptake and presentation of tumor antigens. Having demonstrated the validity of this hypothesis in animal models, we developed a clinical trial based on this combination regimen for patients with recurrent low-grade lymphoma. Our primary objective was to test the safety of this combination CpG-radiation regimen. The secondary objective was to assess systemic anti-tumor effect by monitoring tumor regression at sites other than the irradiated/injected site.Patients and Methods: Patients with biopsy confirmed low-grade follicular B-cell lymphoma (FL) of any initial stage or mycosis fungoides (MF) with stage IB-IVA were eligible for the study. B-cell lymphoma patients failed at least one prior treatment. Mycosis fungoides patients failed or were intolerant of at least 2 topical or one systemic treatment. Patients had at least one site of disease accessible for intratumoral injection of CpG and had a Karnofsky Performance Status (KPS) of ≥ 70 with adequate organ and bone marrow functions. Patients received low-dose radiotherapy to a single tumor site on days 1 and 2 (2 Gy each day). PF-3512676 (CpG 7909) injections were administered at a dose of 6mg into the same tumor site within the 24 hours before and the 24 hours after the radiation, and on days 8 and 15. Weekly injections of PF-3512676 were then administered at the same dose subcutaneously in the region of previous injections for 6 additional doses.Results: Of seven patients treated to date (5 with FL and 2 with MF), 7/7 experienced grade 1 and 2 injection site reactions, including erythema, swelling and tenderness; 3/7 had grade 1 fevers after the injection; 4/7 experienced myalgia or arthralgia, 6/7 reported fatigue. All adverse reactions were transient. No hematological adverse reactions or SAEs occurred. One patient experienced transient swelling of the lymph nodes draining the CpG injection site. One of 4 FL and 1 of 2 MF patients who have completed treatment achieved a partial response with tumor regression observed at all un-irradiated sites and the remaining patients had stable disease.Conclusion: Intra-tumoral injection of PF-3512676 (CpG 7909), at a fixed dose of 6mg, combined with low-dose radiation (2Gy x 2) is a safe and well tolerated regimen in patients with recurrent low-grade lymphomas. In addition, an anti-tumor effect has been observed. The study is ongoing.

Possible Role for Mutations in the Transactivation Domain of C-MYC in the Clinical Transformation of Follicular Lymphomas.

Introduction: Follicular lymphoma (FL) is the second most prevalent non-Hodgkins lymphoma (NHL) in the United States. Although the clinical course is usually indolent, about 50% of low-grade FL transform to an aggressive lymphoma within 15 years of diagnosis. Somatic hypermutation (SHM) is a normal process in B cells which targets the immunoglobulin locus and introduces point mutations and small insertions/deletions. In diffuse large B cell lymphoma, the SHM misfires and aberrantly targets multiple loci, including some proto-oncogenes (PIM-1, PAX-5, RhoH/TTF and C-MYC).Hypothesis: We hypothesized that acquired mutations in the same proto-oncogenes could be responsible for the clinical transformation of follicular lymphoma.Materials and methods: The clinical database of the Department of Pathology, Washington University School of Medicine, St. Louis was searched to find patients with serial biopsies and the diagnosis of either stable (sFL) or transformed follicular lymphoma (tFL). Thirty-five (35) formalin-fixed paraffin-embedded (FFPE) tissue samples from 17 patients were identified. Eleven of seventeen patients had transformed to large cell lymphoma and six had stable low-grade follicular lymphoma. To exclude the possibility of a second unrelated lymphoma the common clonal origin of the original and follow-up lymphoma was confirmed by comparing immunoglobulin heavy and/or light chain variable gene sequences. Previously identified mutational hot spots in four genes, BCL-6, PAX-5, RhoH/TTF and C-MYC, were amplified and sequenced directly.Results: Fifty-five mutations were found in the four genes sequenced; all patients had at least one mutation. The number of mutations was similar in both the low grade and the transformed specimens overall, and most paired specimens had identical mutations or a single mutation change over time. Of the mutations identified, only mutations in Myc exon 2 correlated with the transformation. Acquired missense mutations were detected in the trans-activation domain of Myc in two of the eleven transformed FL specimens but none of the 24 low-grade follicular lymphoma specimens. The first case had two mutations: Pro57 to Ser57 and Glu39 to Asp39. The second case had a single Glu39 to Asp39 change. One of the mutations (Pro57 to Ser57) is close to a functionally critical phosphorylation site, Thr58, and has been reported in both Diffuse large B cell and Burkitt's lymphomas. The other mutation (Glu39 to Asp39) has also been reported in both Burkitts and DLBCL cases, and is not reported as a normal variant.Conclusion: There is not an accumulation in the overall number of SHM with transformation as the frequency of SHM is similar in low-grade FL and transformed FL. However, mutations in the trans-activation domain in c-Myc, caused by an aberrant SHM, may play a role in the transformation of low-grade FL to a diffuse, large cell lymphoma in a subset of patients.Somatic Hypermutation Analysis of 17 serial Follicular Lymphoma cases (35 specimens)Gene Name% Specimens with SHMMutation frequency per 100 bpNumber of unique single base pair substitutionsNumber of unique deletions or insertionsNumber of substitutions targeting G+C vs A+TBCL-663%0.1425316 vs 9PAX-543%0.06727 vs 0Rho/TTF17%0.03821 vs 7C-MYC31%0.02616 vs 0All genes83%NA47831 vs 17NA = Not applicable

Bcl-2 Antagonist ApoGossypol (NSC736630) Displays Single-Agent Activity in Bcl-2 Transgenic Mice and Has Superior Efficacy and Pharmacology with Less Toxicity Compared to Gossypol (NSC19048).

Altered expression of Bcl-2-family proteins plays a central role in apoptosis dysregulation in cancer and leukemia, promoting malignant cell expansion and contributing to chemoresistance. In this study, we compared the toxicity, pharmacology, and efficacy in mice of Gossypol (NSC19048) and ApoGossypol (NSC736630), a semi-synthetic analog of natural product Gossypol, in which two reactive aldehydes were eliminated from the compound (Becattini, et al Chem & Biol 11(3):389-95, 2004 Mar.). Gossypol and ApoGossypol mimic endogenous BH3 peptide-containing antagonists of anti-apoptotic Bcl-2-family proteins, competing with the BH3 peptide binding sites on Bcl-2, Bcl-XL, Mcl-1, Bcl-W, and Bcl-B, but not Bfl-1, with IC 50 of 0.5-2 M (Zhai, et al. Cell Death & Differ 13:1419-21, 2006). These compounds thus represent broad-spectrum antagonists of anti-apoptotic Bcl-2-family proteins. ApoGossypol displayed biostability comparable to Gossypol in plasma from mice, rats, dogs, and humans. Liver microsome analysis demonstrated no metabolites of either ApoGossypol or Gossypol, though both compounds underwent some glucuronidation. Apogossypol appeared more stable in human and mouse liver microsomal preparations than gossypol. Pharmacokinetic studies of i.v. and orally delivered Gossypol and ApoGossypol in mice showed that ApoGossypol has improved AUC (50–75% higher) due principally to reduced clearance rate. Both Gossypol and ApoGossypol exhibited similar oral bioavailability (10–13%) and have similar Cmax (10-20 M). Toxicity studies of i.p. and orally administered compounds showed that ApoGossypol is far less toxic than Gossypol. Daily dosing studies showed that mice tolerate doses of ApoGossypol 2–4-times higher than Gossypol. Hepatotoxicity and gastrointestinal toxicity (intestinal edema and ileus) represented the major adverse activities of these compounds, with ApoGossypol far less toxic than Gossypol. Efficacy of Gossypol and ApoGossypol was compared in a transgenic mouse model of Bcl-2-driven disease, where a human Bcl-2 gene from a t(14;18)-containing lymphoma drives continuous Bcl-2 expression in B-cells (Katsumata, et al. Proc Natl Acad Sci 89: 11376; 1992). These mice develop splenomegally and have expanded populations of mature non-cycling B-cells in lymph nodes, resembling low-grade follicular lymphoma in humans. In vitro, Bcl-2-expressing B-cells were more sensitive to ApoGossypol than Gossypol, with LD50 values of 3–5 M and 7.5–10 M, respectively. In vivo, using the maximum tolerated dose of Gossypol (0.06 mmoles/kg) for sequential daily dosing (daily × 5 days × 3 weeks), ApoGossypol displayed superior activity to Gossypol in terms of reducing splenomegally and reducing B-cell counts in spleen. At higher does (0.12–0.24 mmole/kg), ApoGossypol showed still greater in vivo activity, producing larger reductions in splenomegally and in B-cell counts in spleen. Taken together, these studies indicate that ApoGossypol is superior to parent compound Gossypol with respect to pharmacology, toxicology, and efficacy, suggesting that further development of this compound for cancer therapy is warranted. (Supported by NCI-RAID and NCI contract funds N01-CM-07110 and N01-CM-52205, and by a grant to the CLL Research Consortium P01-CA081534).

Serial cytogenetic alterations resulting in transformation of a low-grade follicular lymphoma to Burkitt lymphoma

Follicular lymphoma (FL) is the most common indolent or low-grade non-Hodgkin lymphoma (NHL). Histologic transformation to high-grade lymphoma, generally to diffuse large B-cell lymphoma, occurs in 25–35% of cases. Although t(14;18), the cytogenetic hallmark of FL, has been found in ∼85% of these cases, multiple secondary cytogenetic and molecular genetic changes underlie the transformation process. We report the case of a 58-year-old patient who presented with stage IVA, grade 2 FL that subsequently transformed to Burkitt lymphoma. Multiple chromosomal aberrations, including three novel translocations, were observed related to this transformation. Inversion (1)(p36.3q12) and t(3;14;18)(p23;q32;q21) occurred prior to transformation and may have contributed to the transformation process. A t(1;11)(q25;q13) was acquired simultaneously with t(8;22) and, in conjunction with other chromosomal abnormalities, coincided with an extremely aggressive clinical course. The frequent breakage of 1q observed in this case suggests that the region harbors important genomic signals for the transformation of FL.

Follicular Lymphoma of the Dura

Abstract OBJECTIVE: We present an unusual dural-based follicular lymphoma with radiological and macroscopic features similar to a meningioma. The unusual location of this tumor and its distinction from meningioma, mucosa-associated lymphoid tissue-type marginal zone B-cell lymphoma of the dura, and intraparenchymal central nervous system lymphoma, dramatically alters the patient's postoperative treatment. The case illustrates the clinical, radiological, and histological relevance of this rare entity. CLINICAL PRESENTATION: A 41-year-old Caucasian man with chronic bifrontal headaches and a raised area over his left frontal cranium that persisted for 1 year presented to the emergency room with nausea and vomiting. His family reported that the patient demonstrated increased irritability and aggressive behavior. A computed tomographic scan revealed a large mass of the left frontal convexity with edema and mass effect. Magnetic resonance imaging scans showed a 5-cm homogeneously enhancing mass in the left posterior frontal lobe. INTERVENTION: Preoperatively, the patient underwent angiography and embolization of the tumor. The patient underwent gross total resection of tumor. The dural-based tumor invaded the cranium and scalp. Neuropathological findings were consistent with low-grade follicular lymphoma. The patient is currently undergoing radiation and chemotherapy. CONCLUSION: The current case represents the first report of extensive intracranial dural involvement by a follicular lymphoma that shows a classic immunophenotype by immunohistochemistry and flow cytometry. The case illustrates the clinical and radiographic similarities between dural-based lymphoma and meningioma. Distinguishing dural-based follicular lymphoma from mucosa-associated lymphoid tissue-type lymphoma and from intraparenchymal primary central nervous system lymphomas, which are more often large cell lymphomas with more aggressive biological behavior, is essential for proper clinical management.

Renal parenchymal tumors and lymphoma in the same patient: Case series and review of the literature

We reviewed the incidence of diagnosis of renal cell carcinoma and lymphoma in the same patient and analyzed the characteristics of this association. Nine patients in 4 years had the diagnosis of renal cell carcinoma (RCC) and lymphoma, including 2 with Hodgkin disease, 1 with chronic lymphocytic leukemia (CLL), and 3 each with low-grade follicular and intermediate-grade non-Hodgkin lymphoma (NHL). In SEER data, the observed/expected (O/E) ratio of NHL and RCC is 1.86 to 2.07. In our series, 2 patients were diagnosed with NHL after the diagnosis of RCC, 1 was diagnosed concurrently, and in the other 6, lymphoma preceded diagnosis of RCC. In reviews of second malignancies following treatment of Hodgkin disease, RCC is less common (O/E 1.5, with 1/3 being transitional cell carcinoma and 2/3 being adenocarcinoma). We report 2 cases with Hodgkin disease preceding RCC, and in both, Hodgkin disease occurred as an adult. There is a male predominance for patients with both diagnoses, which is greater than the male predominance for either RCC or NHL alone (2.2 vs. 2.0 vs. 1.2). There is an increased likelihood of the lymphoma being extranodal. There is an increased association of RCC and NHL more often among male patients, and often with extranodal lymphoma. Potential common etiological factors include prior treatment for malignancy, genetic predisposition, environmental factors, including a search for viral sequences, and possible immune dysregulation generating the lymphoma and subsequently leading to solid tumors such as RCC or melanoma.

Adoptive Immunotherapy with Autologous CD25-Depleted and CD3/CD28-Costimulated T-Cells (ACTC) Enhances Numeric and Functional Lymphocyte Recovery after Cyclophosphamide - Fludarabine Chemotherapy in Patients with Low-Grade Follicular Lymphoma.

Fludarabine-based chemotherapy combinations are highly effective in patients (pts) with low-grade follicular lymphoma (FL), but cause severe and long-lasting immunosuppression due to depletion of normal CD4 T-cells. Aside from increasing the risk of serious infections, this toxicity may limit the ability of the immune system to eliminate minimal residual disease. Adoptive immunotherapy using autologous CD25-depleted, CD3/CD28-costimulated T-cells expanded ex vivo (ACTC) may enhance immune reconstitution and improve disease control. We initiated a phase I study in pts with purine analog-naive relapsed/refractory FL (grades 1 and 2). After leukapheresis, pts receive 4 cycles of fludarabine (25 mg/m2) days 1–3 and cyclophosphamide (250 mg/m2) days 1–3. Four weeks after last chemotherapy, responding patients (CR, CRu, PR) receive escalating doses of ACTC prepared ex vivo from autologous T-cells collected prior to chemotherapy and depleted of regulatory CD4+/CD25+ cells, then expanded and activated using anti-CD3 and anti-CD28. Eight pts have been enrolled to date. Median age is 40.5 y (range: 32–64). Median number of prior therapies is 2 (range: 1–3). Two pts were withdrawn from the study due to hematologic toxicity related to the chemotherapy; one patient has not completed chemotherapy. Of the 5 pts completing chemotherapy, 3 pts achieved a CR and 2 pts achieved a PR; 4 pts received 5 x 109 and 1 patient received 1 x 1010 CD3+ ACTC. There have been no adverse events related to T-cell infusions. Median follow-up after ACTC infusion is 9 months (range: 2–15 months). Median time to CD4 count >200 /uL was 29 days following T-cell infusion (range 28–127 days). CD4 counts increased in all patients by 1 month after T-cell infusion, with a median increase of 126% from baseline (range 50 to 484%). CD8 counts also increased, with a median increase of 82% (range −4 to 976%). All 5 pts receiving ACTC were anergic to candida antigen by Delayed Type Hypersensitivity (DTH) skin testing before chemotherapy. Three pts developed a positive DTH response to candida antigen 60 days after ACTC infusion. From the start of therapy for patients receiving T-cells, median follow-up is 14 months (range 7–20 months) with median progression-free survival not reached; 4 pts remain in remission and 1 patient had progression of disease. ACTC results in significant CD4+ lymphocyte recovery in previously treated pts receiving cyclophosphamide-fludarabine chemotherapy and compares very favorably with historical controls. T-cell dose escalation is ongoing.

Reduced Intensity Allogeneic Transplantation for Non-Hodgkin's Lymphoma: Extended Follow-Up of an Alemtuzumab-Containing Regimen.

Allogeneic transplantation with reduced intensity conditioning is increasingly being used in patients with non-Hodgkin's Lymphoma (NHL) who fail standard therapy. We report extended follow-up on 121 patients with NHL, who underwent allogeneic transplantation with reduced intensity conditioning at 8 UK centres. Conditioning was with fludarabine 150mg/m2, melphalan 140mg/m2 and alemtuzumab (60–120mg). Cyclosporin A was administered at 3mg/kg from day-1, and stem cell source was bone marrow or PBSC. Diagnoses were in 3 categories: low grade follicular NHL (n=50), mantle cell lymphoma (n=21), and high-grade NHL (n=50, including transformed low grade disease n=15). Donors were HLA-matched siblings in 75 (62%), and unrelated in 46 (38%), of whom 18 were HLA-mismatched at up to 3/10 loci. 48% of patients had failed previous autologous transplantation. Median follow-up was 35 months (1–78). For the group with low grade follicular NHL (n=50), estimated overall survival (OS) was 76% at 1yr and 67% at 4yrs, and non-relapse mortality (NRM) was 16% at 4yrs. Disease relapse or progression occurred in 12 patients, of whom 8 received donor lymphocyte infusions (DLI), with responses in 6. Current progression-free survival (cPFS) is 68% at 4yrs. For the group with mantle cell lymphoma (n=21), estimated OS was 83% at 4yrs, NRM was 11% at 4yrs and relapse or progression occurred in 6 patients. Three patients received DLI, with non-sustained responses in 2. Current PFS is 43% at 4yrs. For high-grade NHL (n=50), estimated OS was 52% at 1yr and 45% at 4yrs. Prior autologous transplantation was common in this group (72%), and NRM was higher at 34% at 1yr and 40% at 4yrs. Progression/relapse occurred in 15 patients, of whom 10 received donor lymphocytes, with responses in 5. Current PFS is 48% at 1yr and 43% at 4yrs. These results, from patients who were often heavily pre-treated, including having failed autologous transplantation, provide encouraging evidence to support the application of reduced intensity allogeneic transplants in NHL. NRM in low grade follicular or mantle cell lymphoma is low, consistent with the use of T cell depletion, and graft-versus-lymphoma effects can be induced with DLI in a subset of cases. The data in follicular lymphoma, in particular, supports consideration of this therapy earlier in the disease. In high-grade disease, NRM appears to be higher, but durable remissions are attainable in a proportion of patients.

Rituximab and Yttrium-90 Ibritumomab Tiuxetan Radioimmunotherapy May Be Feasible Options in Patients with Low-Grade Lymphoma of the Orbit.

Objective: To report a cohort of patients with lymphoid tumors of the orbit, including 1 with benign lymphoid hyperplasia of the orbit whose disease responded to immunotherapy with rituximab alone or rituximab followed by Zevalin (yttrium-90 ibritumomab tiuxetan) radioimmunotherapy.Methods: Between October 2002 and January 2005, 8 patients with low-grade non-Hodgkin's lymphoma and 1 with benign lymphoid hyperplasia of the orbit were treated with monoclonal antibodies against CD20. Five patients with low-grade lymphoma of the orbit (3 with follicular B cell or 2 with MALT) received rituximab followed by yttrium-90 ibritumomab tiuxetan, 2 patients with low-grade orbital lymphoma (1 with follicular B-cell and the other with small lymphocytic lymphoma) and 1 patient with benign lymphoid hyperplasia received rituximab alone. Three out of the 5 patients who received yttrium-90 ibritumomab tiuxetan were part of a prospective trial evaluating the efficacy of yttrium-90 ibritumomab tiuxetan for low-grade B-cell lymphoma of the orbit; the other 2 had been treated in other open label trials at M. D. Anderson Cancer Center. For each patient, clinical records and imaging studies were reviewed to establish the diagnosis and document response.Results: Three men and 5 women in this cohort were between the age of 23 and 83 years old (median age, 63 years). Of the 7 patients with orbital lymphoma, 4 had stage IE and the other 3 had stage IVE, and 6 had previously untreated disease. All 8 patients experienced resolution of the orbital tumor in response to treatment with monoclonal antibodies against CD20. Follow-up time ranged from 6 months to 32 months (mean, 12 months) after completion of immunotherapy. There were no serious systemic or ocular side effects during the study period. The most commonly experienced side effect was mild fatigue. All 5 patients treated with yttrium-90 ibritumomab tiuxetan had transient pancytopenia, which normalized as expected within 3 months after treatment. One patient who received yttrium-90 ibritumomab tiuxetan developed shingles 6 weeks after treatment. There were no sequelae from this infection, which resolved with the usual course of oral antiviral therapy.Conclusions: Rituximab and yttrium-90 ibritumomab tiuxetan may be considered as alternative treatment modalities to external beam radiation therapy for low-grade B-cell follicular non-Hodgkin's lymphoma or MALT of the orbit. Systemic targeted immunotherapy may potentially have the advantage of lower rate of distant (out-of-field) relapse and less ocular toxicity compared with external beam radiotherapy; these potential advantages would have to be verified in long-term studies and in larger numbers of patients.

Low Histologic Grade Follicular Lymphoma With High Proliferation Index

Histologic grading has been used as a guide for clinical management in follicular lymphoma (FL). Proliferation index (PI) of FL generally correlates with tumor grade; however, in cases of discordance, it is not clear whether histologic grade or PI correlates with clinical aggressiveness. To objectively evaluate these cases, we determined PI by Ki-67 immunostaining in 142 cases of FL (48 grade 1, 71 grade 2, and 23 grade 3). A total of 24 cases FL with low histologic grade but high PI (LG-HPI) were identified, a frequency of 18%. On histologic examination, LG-HPI FL often exhibited blastoid features. Patients with LG-HPI FL had inferior disease-specific survival but a higher 5-year disease-free rate than low-grade FL with concordantly low PI (LG-LPI). However, transformation to diffuse large B-cell lymphoma was uncommon in LG-HPI cases (1 of 19; 5%) as compared with LG-LPI cases (27 of 74; 36%). In conclusion, LG-HPI FL appears to be a subgroup of FL with clinical behavior more akin to grade 3 FL. We propose that these LG-HPI FL cases should be classified separately from cases of low histologic grade FL with concordantly low PI.

Acute Tumor Lysis Syndrome Induced by Rituximab in Diffuse Large B-Cell Lymphoma

Acute tumor lysis syndrome (ATLS) is a well-known complication of chemotherapy in patients with rapidly proliferative hematopoietic malignancies such as lymphoma and leukemia. Rituximab anti-CD20 monoclonal antibody, an alternative to chemotherapy in the treatment of low-grade follicular lymphoma, also has been associated with ATLS. Rituximab-induced ATLS has been reported in 2 patients with chronic lymphocytic leukemia and in 2 patients with non-Hodgkin's lymphoma. I report another case of rituximab-induced ATLS in a patient with diffuse large B-cell lymphoma and review the cases in the literature.

Long-term outcome and mortality trends in early-stage, Grade 1–2 follicular lymphoma treated with radiation therapy

To analyze long-term outcomes and causes of death in patients receiving radiation therapy (RT) for localized, low-grade follicular lymphoma. Between 1972 and 2000, 106 patients with Stage I-II, Grade 1-2 follicular lymphoma received RT alone or radiation and chemotherapy (RT/CT). Seventy-four percent had Stage I, and 26% had Stage II disease. Seventy-six percent received RT alone, and 24% received combined RT/CT. Second malignancy rates were compared with an age- and sex-matched population. Median follow-up was 12 years. Median survival time was 19 years. The 5-, 10-, and 15-year overall survival (OS) rates were 93%, 75%, and 62%, respectively. Age > or = 60 was the only significant adverse prognostic factor with respect to OS. There were 35 deaths, 20 of which were attributable to lymphoma. Freedom from treatment failure (FFTF) rates at 5, 10, and 15 years were 72%, 46%, and 39%, respectively. Forty-seven patients (48%) relapsed. Tumor size > 3 cm was the only significant adverse factor for FFTF. Observed incidence of second malignancy did not significantly exceed expected incidence. Although patients with early-stage, low-grade follicular lymphoma have long median survival, the leading cause of death remains lymphoma. However, patients receiving RT do not have significantly elevated cumulative incidence of second malignancy.

Long-term event-free survivors after high-dose therapy and autologous stem-cell transplantation for low-grade follicular lymphoma

Although follicular lymphoma (FL) is generally responsive to conventional-dose chemotherapy, improved survival in patients with this disease has been difficult to demonstrate. High-dose chemo/radiotherapy followed by autologous stem-cell transplantation (ASCT) can improve response rates, although its effects on survival remain controversial. Between 1990 and 2003, we transplanted 49 patients with low-grade FL at our institution. Twenty-two patients (45%) had undergone histologic transformation at the time of ASCT. In all, 44 patients (90%) had relapsed disease and five patients (10%) were resistant to chemotherapy at the time of transplantation. After ASCT, 30 patients (61%) were in complete remission (CR). The median overall survival (OS) has not been reached, while the median event-free survival (EFS) is 2.4 years. At a median follow-up of 5.5 years (longest 12.4 years), a plateau has been reached with 56% of patients remaining alive, and 35% event-free. ASCT was well tolerated except for two (4%) treatment-related deaths. In multivariable analysis, CR after ASCT and age less than 60 years are the best predictors of EFS and OS. ASCT is thus a safe therapeutic approach in FL, resulting in long-term EFS and OS for some patients, even with transformed disease.