Clinical characteristics and outcome of pediatric patients with stage IV Hodgkin lymphoma.

BACKGROUND AND OBJECTIVES: While treatment outcomes for patients with Hodgkin lymphoma (HL) have improved remarkably, patients with disseminated disease still have a poorer outcome. Stage IV HL is often reported with other 'advanced stage' categories, confusing the specific contribution of disease dissemination to the outcome. This single-institution report looks at characteristics and outcomes of this specific category. PATIENTS AND METHODS: The medical records of pediatric HL patients (< 14 years) from 1975 through 2003 were retrospectively reviewed and the data analyzed. RESULTS: Stage IV patients (n = 67) had more poor-risk characteristics than patients in stages I-III (n = 300) (B symptoms 86.6% vs. 19.3%, bulky disease 57.6% vs. 45.5% and mediastinal mass 77.6% vs. 29.7%; P < .001 for all characteristics). The liver was the most common extralymphatic site (in 51.5% of patients with stage IV disease. Stage IV patients received chemotherapy (CT) alone (n = 55) or combined modality therapy (CMT) (n = 12). Fifty-four patients (80.6%) achieved complete remission, 2 (3%) partial remission, 10 (14.9%) had progressive disease and 1 was lost to follow up. Overall survival was 79.4% and event-free survival (EFS) was 63.9% at 5 years. There was a non-significant benefit for CMT (OS = 91.7% v. 77.1%, P = .3; EFS = 70.7% v. 62.7%, P = .3). Ten of 12 relapsed and only 1 of 10 progressive disease patients were salvaged. On multivariate analysis, failure to achieve complete remission with CT was associated with a poorer outcome. CONCLUSION: Stage IV disease is associated with poor risk features and confers a worse outcome than stage I-III disease. Achievement of complete remission with CT is an important prognostic feature. Slow responders may require novel and/or aggressive therapy to achieve complete remission.

Hodgkin lymphoma in very young children: Clinical characteristics and outcome of treatment.

In developed nations, Hodgkin lymphoma (HL) is rare in <5-year olds and represent a minority in developing countries. Little is reported about the biology and behavior of these very young patients compared with older children. 18.75% of our pediatric HL patients (0 - 14 years) were <5 years at diagnosis. This group had more boys, similar incidence of B-symptoms and stage distribution, less mediastinal involvement and bulky disease, and more mixed cellularity subtype than older children. Treatment included chemotherapy (CT; n = 55), combined modality therapy (CMT; n = 12) and XRT only (n = 2). Ten-year EFS and OS was 81.5% and 90.4%, respectively, versus 75.5% and 90.5% for older children (p > 0.5). A trend toward better survival was seen with CMT, using very LD-XRT, than with CT (OS 100% vs. 86.4%[p = 0.3]; EFS 90.9% vs. 81.0%[p = 0.4]). Although CT could be effective in a subset of LR patients, LD-XRT may be needed to effectively treat most of these patients. This dose reduction may reduce XRT-related toxicity, which can be significant in very young children.

Treatment of a clinically determined lower-risk stage III non-lymphoblastic Non-Hodgkin lymphoma with less intensive therapy does not impact negatively on outcome.

Stage III NHL was divided into lower-risk (LR) or high-risk (HR) groups. Results of treatment were retrospectively reviewed for patients between 1993 through 2000. An intensive multiagent protocol was used for IIIHR, and a CHOP-based, milder treatment for IIILR. Most LR therapy was outpatient, while treatment for HR patients was primarily inpatient. Five year EFS and OS for HR (n = 29) and LR (n = 23) groups was 86.2% and 95.6% (P = 0.26), and 93.1% and 100%, respectively (P = 0.4). LR had less toxicity. While these results need prospective confirmation, the data shows that less intensive therapy of a LR group of stage III NHL may not impact negatively on outcome.

High throughput tissue microarray analysis of FHIT expression in diffuse large cell B-cell lymphoma from Saudi Arabia.

Recent studies have suggested a potential prognostic role of alterations of the fragile histidine triad (FHIT) gene in diffuse large B-cell lymphoma. To evaluate possible mechanisms of FHIT inactivation and to further clarify its potential prognostic relevance, we analyzed a set of 114 diffuse large B-cell lymphoma with clinical follow-up information. Tissue microarrays were analyzed by immunohistochemistry for protein expression, and corresponding DNA samples were analyzed for FHIT promotor hypermethlyation. Reduced or absent FHIT expression was found in 75 of 114 diffuse large B-cell lymphoma (66%), but was unrelated to clinical tumor stage or patient prognosis. FHIT promotor hypermethylation was observed in 29 of 93 (23%) interpretable diffuse large B-cell lymphoma. Hypermethylation was not significantly correlated to protein expression loss, which could be explained by competing mechanisms for FHIT inactivation in a substantial fraction of non FHIT hypermethylated diffuse large B-cell lymphoma. Hypermethylation was significantly associated with poor prognosis of diffuse large B-cell lymphoma patients and predominantly seen in nongerminal center diffuse large B-cell lymphoma (27%), but less frequent (13%) in germinal center diffuse large B-cell lymphoma. In summary, these data suggest that promotor hypermethylation is responsible for reduced FHIT expression in a substantial subset of diffuse large B-cell lymphoma, which is primarily composed of nongerminal center subtype with poor patient prognosis.

Precursor B-cell lymphoblastic lymphoma (PBLL) in children: pattern of presentation and outcome.

PURPOSE AND BACKGROUND: Precursor B-cell lymphoblastic lymphoma (PBLL) is a rare subtype of NHL seen primarily in children or young adults. There are approximately 100 immunophenotyped cases of PBLL; reported in the literature; most as single case reports or very small series. In this report, we describe patterns of presentation, and results of a retrospective study looking at patients with PBLL treated at KFSH and RC between 1993 and 2000. PATIENTS AND METHODS: We present results of a retrospective study looking at patients with PBLL treated at KFSHRC between 1993 and 2000, younger than 14 years of age (cut-off age for pediatric department). Six cases of PBLL were lacking evidence of blood and bone marrow involvement. Histologic sections were available for review in all cases. RESULTS: Twenty one patients were treated for lymphoblastic lymphoma, of which six had a precursor Bcell phenotype. There were three boys and the median age at diagnosis was 6 years (range 3-13). In four of the patients the primary involved were oro-nasopharynx or the paranasal sinuses. One patient had a soft tissue mass in the upper thigh while one patient had a solitary bone lesion in the distal tibia. Four of the patients had limited stage disease (2 stage I and stage II), while 2 were stage IV. Both patients with stage IV disease had CNS involvement with blasts in the CSF. Both had paranasal primaries and had bone infiltration involving the base of the skull, with radiological documentation of intracranial extension in one patient. Median LDH level was 542 IU/L (range 463-5000). Five patients were treated according to B-cell NHL type protocols. Because of the specific diagnosis of PBLL, two of these patients were switched to an ALL-type protocol following post induction intensification; one died in remission due to encephalitis, while the other remained in CR almost 2 years after diagnosis. A third patient suffered a loco-regional relapse 17 months after completing first line therapy, and was re-treated on an ALL-type protocol, and currently is in remission 25 months following relapse. The fourth patient, who received 9 months of post induction therapy, remains free of disease 7 years following diagnosis. The fifth patient had local and CNS progression on therapy, and died of his disease. The last patient with a solitary bone lesion was misdiagnosed as Ewings' Sarcoma and received treatment for that disease. He suffered an isolated CNS relapse, and is in CR 12 months following the relapse, on an ALL treatment protocol. CONCLUSION: PBLL is a distinct B-cell NHL which involves extralymphatic sites, with particular predisposition for the upper aerodigestive tract. Patients should not be treated on short intensive protocols used for other B-cell NHL but should receive treatment based on ALL protocols like those for treating T-cell LL.