Living through pelvic radiotherapy:A mixed method study of self-care activities and distressful symptoms.

PURPOSE: To explore patients' experience of their illness when undergoing pelvic radiotherapy by describing the presence and severity of distressful symptoms and to explore initiated self-care activities in response to illness and symptoms. METHODS: A mixed-method study was performed which included a core qualitative dataset and a supplementary quantitative dataset. Twenty-nine women undergoing five weeks of radiotherapy were prospectively interviewed during five weeks of treatment in order to capture experiences, distressful symptoms and quality of life during treatment. Grounded theory formed collection and analysis of the qualitative dataset and statistics were used to analyze the quantitative dataset. RESULTS: A maintained self-identity was concluded as being central during the trajectory of treatment. Initiated self-care activities served to alleviate physical, emotional, and social suffering; helping the respondents keep their integrity and sense of self. Previous life experiences influenced the process of being able to maintain self-identity. The gastrointestinal symptoms and pain caused most distress. CONCLUSIONS: In order to be able to maintain self-identity patients endure treatment by focusing on symptoms, on getting cured and on their self-image. Several distressful symptoms implied social limitations and a sense that the body would not take the strain. The result of this study can help health care professionals to gain a better understanding of the struggle to endure pelvic radiotherapy. Further, health care professionals should be more proactive in alleviating their patients' distressful symptoms. The results imply that previous life experiences should precede initiated interventions because these life experiences affect the patients' self-care activities.

Anal carcinoma - Survival and recurrence in a large cohort of patients treated according to Nordic guidelines.

OBJECTIVE: To evaluate treatment outcome in a large population-based cohort of patients with anal cancer treated according to Nordic guidelines. MATERIAL: Clinical data were collected on 1266 patients with anal squamous cell carcinoma diagnosed from 2000 to 2007 in Sweden, Norway and Denmark. 886 of the patients received radiotherapy 54-64Gy with or without chemotherapy (5-fluorouracil plus cisplatin or mitomycin) according to different protocols, stratified by tumor stage. RESULTS: High age, male gender, large primary tumor, lymph node metastases, distant metastases, poor performance status, and non-inclusion into a protocol were all independent factors associated with worse outcome. Among patients treated according to any of the protocols, the 3-year recurrence-free survival ranged from 63% to 76%, with locoregional recurrences in 17% and distant metastases in 11% of patients. The highest rate of inguinal recurrence (11%) was seen in patients with small primary tumors, treated without inguinal irradiation. CONCLUSIONS: Good treatment efficacy was obtained with Nordic, widely implemented, guidelines for treatment of anal cancer. Inguinal prophylactic irradiation should be recommended also for small primary tumors.

A population-based study of 135 lymphomas after solid organ transplantation: The role of Epstein-Barr virus, hepatitis C and diffuse large B-cell lymphoma subtype in clinical presentation and survival.

BACKGROUND: Epstein-Barr virus (EBV) plays a major role in the development of post-transplant lymphoproliferative disorder (PTLD), but there is an increasing awareness of EBV-negative PTLD. The clinical presentation of EBV-negative PTLD has not been as well characterised as EBV-positive cases. Further, there is limited knowledge on the clinical importance of diffuse large B-cell lymphoma (DLBCL) cell of origin subtype post-transplant. MATERIALS AND METHODS: We studied the role of EBV, hepatitis C (HCV) and DLBCL subtype in clinical presentation and survival in 135 post-transplant lymphomas diagnosed 1980-2006 in a population-based cohort of 10 010 Swedish solid organ transplant recipients. The lymphomas were re-evaluated according to WHO 2008, examined for EBV, and clinical data were collected from medical records. RESULTS: Lymphoma incidence rate was 159/100 000 person-years and is also reported by lymphoma subtype. EBV-negative lymphomas constituted 48% and were associated with HCV infection (p = 0.02), bone marrow involvement (p < 0.001), and T-cell phenotype (p = 0.002). Among DLBCL, 78% were of non-germinal centre subtype, which was associated with EBV-positivity (69%, p = 0.001), early occurrence (p = 0.03), heart/liver/lung/pancreas recipients (p = 0.02), anti-T-cell globulin (p = 0.001), and tacrolimus treatment (p = 0.02). DLBCL subtypes had similar overall survival. Five-year overall survival was 42% in all treated patients. Independent poor prognostic factors were older age, B symptoms, ECOG 2-4, kidney/pancreas/heart recipients, T-cell lymphoma, and HCV-infection. CONCLUSIONS: With long follow-up, a large part of PTLD is EBV-negative, due to a high proportion of T-cell lymphomas and low of polymorphic PTLD. EBV-negative PTLD have a different clinical presentation. HCV may play an aetiological role in late-onset PTLD and was revealed as a new prognostic factor for inferior survival that needs to be confirmed in larger studies. The heavier immunosuppression in non-kidney transplantations seems to play a role in the development of non-germinal centre DLBCL. DLBCL cell of origin subtype lacks prognostic importance in the transplant setting.

Population impact of heart failure and the most common forms of cancer: a study of 1 162 309 hospital cases in Sweden (1988 to 2004).

BACKGROUND: The contemporary impact of heart failure (HF) versus the most common forms of cancer as reflected by related first-ever hospitalizations and subsequent case-fatality rates is unknown. METHODS AND RESULTS: Using a national registry in Sweden, we compared the rate of first-ever hospitalization and associated short- and long-term survival for HF, acute myocardial infarction (AMI), and the most common forms of cancer on an age and sex-specific basis during 1988 to 2004 in 949 733 Swedish patients (1 162 309 hospital admissions in total). Annual incidence of first-ever hospitalization for HF, AMI, and cancer in Sweden were 484, 424, and 373 (lung, colorectal, prostate, and bladder cancer combined) per 100 000 men and 470, 280, and 350 (lung, colorectal, bladder, breast, and ovarian cancer combined) per 100 000 women age >20 years. The ratio of individual cases of HF to cancer was 1.37:1 (465 998 versus 340 738). Despite improvements in 30-day and 5-year survival (adjusted 7% and 6% increase per calendar year for men and women, respectively), HF was associated with unadjusted case-fatality rate of 59% within 5 years and 196 400 deaths versus 58% and 131 000 deaths in patients with cancer. During 10-year follow-up, HF was associated with 66 318 versus 55 364 premature life-years lost than all common forms of cancer in men. In women, the equivalent figures were 59 535 versus 64 533 premature life-years lost. CONCLUSIONS: These data confirm that, like most common forms of cancer combined, HF exerts a major health burden in respect to age-adjusted rates of first hospitalization, poor overall survival, and premature life-years lost.

Exploring a link between fatigue and intestinal injury during pelvic radiotherapy.

BACKGROUND: The association between cancer-related fatigue and pathological processes in the body is largely unknown. This study was designed to investigate a possible linkage between fatigue and intestinal injury during pelvic radiotherapy. METHODS: Twenty-nine women undergoing pelvic radiotherapy for anal or uterine cancer were prospectively followed. Fatigue and diarrhea were assessed using patient self-reported questionnaires. Plasma citrulline concentration, as a sign of intestinal injury, and C-reactive protein, orosomucoid, albumin, α(1)-antitrypsin, and haptoglobin, as signs of systemic inflammation, were analyzed. RESULTS: Fatigue increased significantly (p < .001) and citrulline decreased significantly (p < .001) during treatment. A significant negative correlation (r = -0.40; p < .05) was found between fatigue and epithelial atrophy in the intestine (as assessed by plasma citrulline) after 3 weeks of treatment and a significant positive correlation (r = 0.75; p < .001) was found between fatigue and diarrhea. Signs of systemic inflammation were evident, with significant increases in serum orosomucoid, serum haptoglobin (p < .05) and serum α(1)-antitrypsin (p < .001) and a significant decrease in serum albumin (p < .001). CONCLUSION: The present study indicates a link between fatigue and intestinal injury during pelvic radiotherapy. This observation should be considered as a preliminary finding because of the small sample size but may serve as a rationale for therapeutic interventions aimed at alleviating both fatigue and gastrointestinal symptoms during pelvic radiotherapy.

Defining stage III disease in colorectal cancer--aspects on treatment and evaluation of survival.

BACKGROUND AND OBJECTIVE: Stage III in colorectal cancer is defined by presence of node metastasis, whereas distant growth constitutes stage IV. The aim was to describe prognosis in high risk groups of stage III in relation to survival in stage IV, along with possible effect on research and treatment. METHODS: All patients operated for stage III-IV colorectal cancer 1999-2003 (n = 591) were assessed by demography, pathology and treatment towards survival. Stage III patients were grouped by lymph node ratio (LNR) tenths and stage IV by node status (N0-2). Comparison was by cancer specific survival (CSS). Disease free survival (DFS) was also assessed for stage III. RESULTS: LNR predicted CSS and DFS (P < 0.001) as a higher ratio correlated with a worse prognosis and an increased risk of early recurrence. With high ratios the stage III survival prognosis resembled stage IV. A survival crossover phenomenon was found for stage III patients with a high LNR (0.9-1) compared to some stage IV patients (N0/M1). CONCLUSIONS: The prognosis in stage III is heterogeneous and can be differentiated by LNR. The survival difference towards stage IV can be limited which could affect the use and evaluation of chemotherapy and the further development of staging terminology.

Components that influence assessment and management of cancer-related symptoms: an interdisciplinary perspective.

PURPOSE/OBJECTIVES: To describe, from an interdisciplinary perspective, how cancer-related symptoms are assessed and managed in a cancer care setting and to describe the components that influence symptom management. DESIGN: Descriptive, qualitative, and cross-sectional. SETTING: An oncology and hematology department in a university hospital in western Sweden. SAMPLE: 31 nurses, physicians, physical therapists, dietitians, occupational therapists, and a medical social worker who all cared for patients with cancer-related symptoms. METHODS: Data were collected in focus groups and analyzed using content analysis. MAIN RESEARCH VARIABLES: Cancer-related symptoms and symptom management. FINDINGS: Symptom management, from a clinician's perspective, is a process involving different components. Four themes emerged from the data analysis: creating a relationship with the patient, understanding the patient, assessing the symptoms, and cooperating as a team. CONCLUSIONS: This study highlights several components that should be discussed in an effort to enhance symptom management. Discussion will help ensure that barriers to effective symptom management are acknowledged and addressed when implementing clinical routines designed to enhance management of different symptoms. In addition, these components should be acknowledged in the interest of facilitating adherence to symptom management strategies. Whether these components are important factors from patients' perspectives remains unknown. IMPLICATIONS FOR NURSING: Enhancing symptom management is not only a matter of implementing clinical guidelines; it must be preceded by teamwork, assessment, and evaluation method discussions and the ability to create a relationship with the patient. Nurses should be aware that their understanding of a patient affects their assessment of that patient's symptom experience.

Gut toxicity during hemopoietic stem cell transplantation may predict acute graft-versus-host disease severity in patients.

Graft-versus-host disease (GVHD) is the primary complication of allogeneic, hemopoietic, stem cell transplantation (HSCT). Murine models suggest that gut toxicity, induced by the intensive chemotherapy preceding hematopoietic stem cell infusion, aggravates systemic GVHD. In HSCT patients gut toxicity correlates with chemotherapy intensity. The present study investigates acute GVHD severity and intestinal toxicity in patients undergoing allogeneic HSCT. In 38 patients intestinal permeability was assessed before and after chemotherapy (on days -1, +4, +7 and +14 as related to the stem cell infusion). Cumulative acute GVHD (days 0-100) and clinical intestinal toxicity (days 0-14) were evaluated in parallel. Patients with mild, acute GVHD (grades 0-I) had better-preserved intestinal barrier function (P=0.04) and less pronounced cumulative clinical intestinal toxicity (P=0.02) compared with patients with more severe acute GVHD (grades II-IV). Gut toxicity predicts acute GVHD severity. Therefore, gut protective strategies may diminish GVHD severity in allogeneic HSCT patients.

Epoetin alfa and darbepoetin alfa for the treatment of chemotherapy-related anemia in cancer patients in Sweden: comparative analysis of drug utilization, costs, and hematologic response.

A retrospective chart review was performed at 3 Swedish hospitals to evaluate the utilization, outcomes, and cost of using epoetin alfa or darbepoetin alfa to treat cancer patients with chemotherapy-related anemia. Data on dosage, duration of treatment, hematologic response, red blood cell transfusions, and healthcare resource consumption were collected and analyzed at various time points following the initiation of drug therapy. A significantly faster hematologic response and increase in hemoglobin were observed in patients treated with epoetin alfa. Dosages used in clinical practice appeared to be lower than those recommended by Swedish treatment guidelines. There were no significant differences in resource utilization or healthcare costs between the 2 treatment groups. By day 112, the mean treatment cost per patient, in Swedish kronors (SEK), was SEK74,701 (approximately US$9800 or approximately 8300) with epoetin alfa and SEK85,285 (approximately US$11,000 or approximately 9500) with darbepoetin alfa. Drug acquisition and administration accounted for 81% and 67% of the total cost of epoetin alfa and darbepoetin alfa therapy, respectively; the remainder of the total cost was for hospitalization and transfusions.

Fatigue, psychological distress, coping resources, and functional status during radiotherapy for uterine cancer.

PURPOSE/OBJECTIVES: To evaluate how patients diagnosed with uterine cancer experience fatigue, psychological distress, coping resources, and functional status before, during, and after treatment with radiation therapy and to study whether significant correlations exist among these variables. DESIGN: Longitudinal, descriptive, and correlational. SETTING: The Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden. SAMPLE: 60 women diagnosed with uterine cancer who were receiving curative external radiation therapy. Typical participants were 64 years old, married, and on sick leave or retired from work. METHODS: Data were collected through self-report instruments. Demographic and clinical data were extracted from the patients' records. MAIN RESEARCH VARIABLES: Cancer-related fatigue, psychological distress, coping resources, and functional status. FINDINGS: Patients' fatigue scores increased significantly during and after completion of radiotherapy. The participants reported normal levels of anxiety and depression, and their coping resources changed over time. After completing therapy, all dimensions of function had decreased; for social function, the decrease was significant. The correlation over time was significant among fatigue and physical function, role function, and cognitive function. The variation of the change in fatigue after therapy was completed was explained only by the level of fatigue experienced at baseline. CONCLUSIONS: Fatigue is a symptom that increases in connection with radiotherapy. Functional status is influenced by the variation in fatigue levels. Fatigue level before treatment may be an important variable when trying to find a risk factor for the development of fatigue over the course of treatment. IMPLICATIONS FOR NURSING: Nurses must inform patients receiving radiotherapy about the expected changes in fatigue and functional status. Pretreatment screening for fatigue is needed to identify patients at risk for developing fatigue.

Alternative EBNA1 expression in organ transplant patients.

In order to identify patients at risk for developing post-transplant lymphoproliferative disease (PTLD), a sensitive nested RT-PCR method for detection of EBNA1 gene expression in peripheral blood cells was used. EBNA1 expression in peripheral blood samples from 60 organ recipients was analyzed and compared with 24 healthy controls in a retrospective study. Overall, EBNA1-positive samples were detected at least once in 43% of the transplant patients with post-transplant lymphoproliferative disease, in 18% of the other transplant patients and in none of the healthy controls. The odds ratio for EBNA1 expression in patients with post-transplant lymphoproliferative disease was 3.42 (95% CI=1.02-11.54) compared to other transplant recipients. Together with normal EBV Q promoter initiated EBNA1 transcripts, an alternatively spliced form was expressed in peripheral blood cells in the above-mentioned transplant patients. This transcript lacks the U leader exon in the 5'-untranslated region (UTR). We have previously identified and characterized a functional internal ribosome entry site, the EBNA IRES, in the untranslated U leader exon of EBNA1. Transfection experiments with EBNA1 coding plasmids followed by Western blot showed that the EBNA IRES promotes cap-independent translation and increases the EBNA1 protein level. The alternative EBNA1 transcript lacking this function is expressed in the majority of the investigated EBNA1-positive patient samples as well as in some EBV-positive B-cell lines. Alternative splicing in this form gives EBV potential to regulate the translation of EBNA1 by modifying the 5' UTR. These findings indicate a new mechanism for EBNA1 expression in vivo.

The experience of fatigue, other symptoms and global quality of life during radiotherapy for uterine cancer.

This paper reports on how patients with uterine cancer, receiving radiotherapy, experience fatigue, other symptoms and global quality of life. The results showed that fatigue increased significantly during the therapy. Also the other symptoms; loss of appetite, nausea/vomiting and diarrhoea increased significantly and were significantly correlated to general fatigue. Global quality of life decreased significantly during treatment compared to baseline. The variation of the level in general fatigue after completed therapy was only explained by the level of general fatigue experienced at baseline. The result can lead to a better understanding of the severity of symptoms experienced by patients with uterine cancer treated with radiotherapy.

Maintaining normality and support are central issues when receiving chemotherapy for ovarian cancer.

The aim of this study was to enrich the understanding of patients' perspective of being diagnosed and treated for ovarian cancer. A qualitative approach was used to obtain knowledge and insight into patients' experiences and thoughts. Ten Swedish women, diagnosed with ovarian cancer, participated in a total of 23 interviews on 3 occasions: at the time of diagnosis, during chemotherapy, and after completion of chemotherapy. The results of the interpretation of the interviews were formulated in the form of 3 themes: (1) feeling the same despite radical castrating surgery, (2) accepting chemotherapy, and (3) maintaining normality and support. Suggestions of caring implications from our interpretation of the interview data underscore the need to support these women in learning to cope with their feelings of weakness and anxiety. The findings further indicate the potential in narrative methods to identify important issues in comprehensive cancer care.

Levels of fatigue compared to levels of cytokines and hemoglobin during pelvic radiotherapy: a pilot study.

Cancer-related fatigue (CRF) is a prevalent and distressing symptom experienced by patients during cancer therapy. One proposed mechanism for the development of fatigue is the increased secretion of proinflammatory cytokines and/or the development of anemia. The major purpose of this pilot study was to investigate the levels of fatigue and cytokines during radiation therapy and determine whether there was a correlation between the two. A secondary purpose was to explore the relationships among hemoglobin values, cytokines, and fatigue. Participants included 15 women diagnosed with uterine cancer, who received curative external radiation therapy. Fatigue was assessed by a self-report instrument (Multidimensional Fatigue Inventory [MFI-20]) and hemoglobin and cytokines (Il-1, Il-6, and TNF-alpha) were measured before, during, and after radiotherapy. The degree of fatigue increased during radiotherapy without a significant change in IL-1, IL-6, or TNF-alpha levels. There was no significant correlation between changes in general fatigue and the changes in IL-1 and TNF-alpha. There was a significant negative correlation between the change in IL-6 and general fatigue. The hemoglobin levels did decrease significantly during radiotherapy, but there was no significant correlation between general fatigue and hemoglobin after 3 weeks of therapy or after the completion of therapy. In conclusion, pelvic radiotherapy in women with uterine cancer is associated with increased fatigue. There were no significant relationships between anemia or cytokine levels and fatigue. The pathogenesis of fatigue during radiation therapy remains to be elucidated.

Fatigue, psychological distress, coping and quality of life in patients with uterine cancer.

BACKGROUND: Cancer-related fatigue (CRF) is a subjectively experienced symptom that is multidimensional and multifactorial. Patients with cancer have identified fatigue as one of the major troubling symptoms and the primary cause of distress in their lives. AIMS: The major aim of the study was to examine how patients diagnosed with uterine cancer describe their experience of fatigue, psychological distress, coping resources and quality of life. A secondary aim was to describe the relationship between selected variables. METHOD: A descriptive and correlational design was used and the study was conducted at a university hospital in Sweden. The study population consisted of women, diagnosed with uterine cancer, who where scheduled to receive curative external radiation therapy. Sixty women participated in the study and data were collected through self-report instruments. Demographic and clinical data were extracted from patient records. The data were collected during year 2000-2002. The Conceptual Model of Symptom Management was used as a framework to guide the study. FINDINGS: Patients experienced a low grade of fatigue and psychological distress, but their functional status and global quality of life was high. Significant correlations were found between general fatigue and anxiety and also between general fatigue and depression. There was a significant negative correlation between general fatigue and coping resources. Depression explained 44% of the variance in general fatigue. CONCLUSIONS: The findings provide knowledge about predictors of CRF in women with uterine cancer, and can serve as a basis for future longitudinal studies in which different prophylactic strategies against therapy-related fatigue are prospectively studied.

Testicular lymphoma--a retrospective, population-based, clinical and immunohistochemical study.

From a population-based registry, 35 patients with histologically verified testicular lymphomas were identified: diffuse large B-cell lymphomas (DLBCL) in 33 and peripheral T-cell lymphomas in two cases. Twenty-two patients had localized disease (Pe stage I and II). Twenty-eight patients received systemic chemotherapy, 17 of whom also received intrathecal prophylaxis, and 12 out of these 17 also received radiotherapy to the contralateral testis. In the Pe stage I/II group, 7 out of 21 patients in complete remission (CR) relapsed. In 5 of them the CNS was involved (isolated CNS relapse in three). Remarkably late relapses occurred (up to 127 months). Intrathecal prophylaxis seemed to reduce the frequency of relapses involving the CNS, but the relatively short follow-up (median 45 months, range 34-88, for censored patients) prevents firm conclusions regarding efficacy. The outcome for the stage IV patients was poor, with only 1 out of 11 patients in continuous CR. Immunohistochemical analysis of the DLBCL tumours revealed that 31% had the germinal centre B-cell-like phenotype. CD44 was expressed in all the tumours of stage IV patients but in less than half of the Pe stage I/II patients. A high intratumoural microvessel density was correlated with a high degree of Ki-67 positive tumour cells and an inferior overall survival.

Assessment and management of cancer-related fatigue in adults.

Fatigue is one of the most prevalent and distressing symptoms of cancer, and is a common side-effect of many of the treatments available for the management of malignant disease. We critically assess the evidence for cancer-related fatigue and its treatment in adults. Little is known about the cause and mechanisms of fatigue, and research into methods of alleviating the condition has focused on treatment for anaemia and behavioural interventions, such as exercise, both of which are effective in reducing fatigue. Although research into the condition has increased considerably in the past decade, important gaps in knowledge remain.

Early and intermediate stage Hodgkin's lymphoma--report from the Swedish National Care Programme.

In Sweden a National Care Programme provides treatment principles for Hodgkin's lymphoma (HL) since 1985, for early and intermediate stages often less extensive than international recommendations. The purpose is to evaluate long-term results of these principles. A total of 308 patients (167 men and 141 women), 17-59 yr old (median 31), diagnosed during 1985-92, pathological stage (PS) I-III1A and I-IIB and clinical stage (CS) I-IIA, mean follow-up 8.8 yr, were studied. Staging laparotomy was recommended in CS IIA. Recommended treatment was mantle or mini-mantle radiotherapy (RT) alone in CS IA, and PS I-IIA and subtotal nodal irradiation in PS III1A if the disease was not bulky. Patients in PS I-IIA and III1A with bulky disease, and PS I-IIB received one cycle of mechlorethamine, vincristine, prednisone, procarbazine/doxorubicin, bleomycin, vinblastine, lacarbazine (MOPP/ABVD) before irradiation. The remaining patients received three to four cycles of MOPP/ABVD with RT to bulky disease. Relapse-free (RFS), Hodgkin specific (HLS), and overall survival (OS) at 10 yr were 74%, 92% and 85%. In the individual stages, RFS ranged from 53% (PSIII1A) to 90% (PS IA). RFS (P = 0.006), HLS, and OS were significantly better in patients treated with chemotherapy compared with those treated with RT alone, especially in patients with bulky disease (P = 0.0005). The international prognostic score did not provide any prognostic information. The OS rates are in agreement with results from international centres during that time. The recommended treatment was sufficient to produce the desired results of <20-30% recurrences, except in PS III1A. Most relapses could be salvaged. Patients with risk factors treated with one MOPP/ABVD and RT had an excellent outcome, superior to those without risk factors treated with RT alone. These results favour the trend to treat early and intermediate stages with a short course of chemotherapy followed by limited RT.

A population-based study of the outcome for patients with first relapse of Hodgkin's lymphoma.

BACKGROUND: Our aims were to evaluate the response to salvage treatment in relation to initial treatment and to evaluate prognostic factors at the time of relapse in an unselected population of relapsing patients with Hodgkin's lymphoma (HL). PATIENTS AND METHODS: In total, 124 patients younger than 60 yr of age with initial diagnosis of HL in Sweden relapsed between 1985 and 1995. RESULTS: Fifty-eight patients relapsed after initial treatment with radiotherapy (RT) only, 62 after combination chemotherapy (CT), of whom 30 had received additional involved-field RT, and four after a short course of CT followed by extended-field RT. For 37 patients among the 58 relapsers after initial RT treated according to the recommendations of the National guidelines, the 5-yr Hodgkin-specific survival (HLS) was 85%, overall survival (OS) 73% and event-free survival (EFS) 62%, which is not inferior to survival in patients with primarily advanced stages. It was poorer in the 21 patients who initially had received RT only, even though they had been recommended for more extensive treatment. For patients initially treated with a full course (6-8 cycles) of CT the 5-yr HLS was 60%, OS 58% and EFS 22%. Bulky disease and age at diagnosis strongly affected survival in a multivariate analysis. CONCLUSIONS: Patients initially treated with RT who relapse have a favourable outcome, provided they have been treated according to the recommendations of the guidelines at the time of diagnosis. Initially bulky disease and, as a consequence, additional RT as part of the initial treatment negatively affect survival at relapse in patients initially treated with a full course of CT.

Age-adjusted chemotherapy for primary central-nervous system lymphoma--a pilot study.

Patients with primary central-nervous-system lymphoma (PCNSL) are treated with chemotherapy and cranial irradiation, which increase the risk of late neurotoxicity. The aim of this phase II trial was to investigate whether chemotherapy alone could induce durable remissions. Thirty non-immunocompromised patients were enrolled in two treatment groups, according to age. Patients in group A (< 65 years; n = 17) received carmustine, vincristine, dexamethasone, high-dose methotrexate and high-dose cytarabine. Patients in group B > 65 years: n = 13) were treated with carmustine, vincristine, dexamethasone and high-dose cytarabine. Both groups received intrathecal treatment. Radiotherapy was reserved for patients with stable or progressive disease. The overall response rate in group A was 65% (complete response 35%; partial response 29%) and in group B. 61% (complete response 23%; partial response 38%), but only 6 remissions were maintained without irradiation. In all, there were five treatment-related deaths. Responses were induced, but were mostly of short duration, and the treatment was associated with profound toxicity.