Age and lymphocyte/monocyte ratio as prognostic factors for autologous transplantation in the treatment of patients with follicular lymphoma.

OBJECTIVE: Follicular lymphoma (FL) is an indolent, lymphoproliferative disease of B-cell origin that has a heterogeneous disease course with varying outcomes. Certain patients may undergo autologous stem cell transplantation. We investigated the outcome of autologous stem cell transplantation in patients with FL. METHODS: Patients who received autologous stem cell transplantation at the University of Debrecen's Department of Hematology between 2004 and 2021 were retrospectively analyzed. The overall survival (OS) and progression-free survival (PFS) after transplantation of patients with FL were examined. Prognostic factors that may influence the course of the disease were chosen. RESULTS: Data were collected from 49 patients. OS was influenced only by age, whereas PFS was affected by age and the lymphocyte/monocyte ratio. The combination of age and lymphocyte/monocyte ratio defined a patient population with a particularly unfavorable prognostic risk profile: patients over 47 years of age with a pre-transplant lymphocyte/monocyte ratio greater than or equal to 2.675. CONCLUSION: Age and lymphocyte/monocyte ratio were identified as useful prognostic factors for PFS in patients with FL following autologous stem cell transplantation.

Parallel testing of liquid biopsy (ctDNA) and tissue biopsy samples reveals a higher frequency of EZH2 mutations in follicular lymphoma.

BACKGROUND: Recent genomic studies revealed enhancer of zeste homolog 2 (EZH2) gain-of-function mutations, representing novel therapeutic targets in follicular lymphoma (FL) in around one quarter of patients. However, these analyses relied on single-site tissue biopsies and did not investigate the spatial heterogeneity and temporal dynamics of these alterations. OBJECTIVES: We aimed to perform a systematic analysis of EZH2 mutations using paired tissue (tumor biopsies [TB]) and liquid biopsies (LB) collected prior to treatment within the framework of a nationwide multicentric study. METHODS: Pretreatment LB and TB samples were collected from 123 patients. Among these, 114 had paired TB and LB, with 39 patients characterized with paired diagnostic and relapse samples available. The EZH2 mutation status and allele burden were assessed using an in-house-designed, highly sensitive multiplex droplet digital PCR assay. RESULTS: EZH2 mutation frequency was found to be 41.5% in the entire cohort. In patients with paired TB and LB samples, EZH2 mutations were identified in 37.8% of the patients with mutations exclusively found in 5.3% and 7.9% of TB and LB samples, respectively. EZH2 mutation status switch was documented in 35.9% of the patients with paired diagnostic and relapse samples. We also found that EZH2 wild-type clones may infiltrate the bone marrow more frequently compared to the EZH2 mutant ones. CONCLUSION: The in-depth spatio-temporal analysis identified EZH2 mutations in a considerably higher proportion of patients than previously reported. This expands the subset of FL patients who most likely would benefit from EZH2 inhibitor therapy.

Clinical and biological prognostic factors in follicular lymphoma patients.

INTRODUCTION: Follicular lymphoma (FL) is an indolent, yet heterogeneous, B-cell lymphoproliferative disorder. Although most FL patients respond well to treatment, few with specific traits have a poor prognosis; the latter are difficult to define. PATIENTS AND METHODS: We retrospectively analyzed data from 143 FL patients treated at the University of Debrecen since 2009 and investigated prognostic factors that may influence the survival of FL patients. RESULTS: A maximum standardized uptake value (SUVmax) cut-off of 9.85 at the staging positron emission tomography/computed tomography (PET/CT) (p = 0.0001, hazard ratio [HR]: 0.2535, 95% confidence interval [CI]: 0.1118-0.4878) and a lymphocyte/monocyte (Ly/Mo) ratio of 3.41 (p = 0.0027, HR: 2.997, 95% CI: 1.463-6.142), drawn at diagnosis, significantly predicted FL patients' progression-free survival (PFS). A staging SUVmax >9.85 with Ly/Mo <3.41 could delineate a high-risk group of FL patients (p<0.0001, HR: 0.0957, 95% CI: 0.03416-0.2685). Similarly, a significant difference was shown with an SUVmax cut-off of 3.15 at the interim PET/CT (p<0.0001, HR: 0.1614, 95% CI: 0.06684-0.3897). A staging SUVmax >9.85 in conjunction with interim SUVmax >3.15 predicted poor prognosis (p<0.0001, HR: 0.1037, 95% CI: 0.03811-0.2824). The PFS difference was translated into overall survival (OS) advantage (p = 0.0506, HR: 0.1187, 95% CI: 0.01401-1.005). CONCLUSION: Biological prognostic factors, such as the Ly/Mo ratio, may improve the prognostic assessment of staging PET/CT. The survival advantage observed in PFS is translated into OS when determined using a combination of staging and interim SUVmax. We recommend investigating additional biological prognostic factors while highlighting the role of PET/CT in FL.

Pulmonary Toxicity of Hodgkin Lymphoma Treatment: A Prospective Single-Center Study.

BACKGROUND: Standard bleomycin-containing first-line therapy and/or irradiation may cause pulmonary toxicity in Hodgkin lymphoma (HL) patients. Our aim was to prospectively assess effects of chest irradiation, bleomycin administration, and other factors on lung function in the treatment of patients with HL. METHODS: Pulmonary function of newly diagnosed HL patients was assessed via a St. George Respiratory Questionnaire, dynamic inhalation lung scintigraphy, spirometry, and an assessment of the diffusion capacity of the lung for carbon monoxide (DLCO) before, during, and after treatment. RESULTS: This prospective study was conducted at the University of Debrecen. The study included 84 patients with classical HL. Most patients received standard doxorubicin, bleomycin, vinblastine, and dacarbazine chemotherapy. Both intramuscular and intravenous administrations of bleomycin were used. Brentuximab vedotin combination chemotherapy was administered to 12 patients. Mediastinal involved-field irradiation therapy (IFRT) was used to treat 16 patients. Lung scintigraphy revealed pulmonary toxicity more sensitively than DLCO. Intravenous bleomycin administration decreased diethylenetriamine pentaacetic acid clearance. Intramuscular bleomycin had the lowest level of pulmonary toxicity among considered treatments. Currently used, mediastinal IFRT had a lower level of pulmonary toxicity than bleomycin. The current prospective evaluation confirmed previous results that determined that cumulative bleomycin dose and administration are major risk factors for pulmonary toxicity, while the currently used treatment method, mediastinal irradiation, was determined to be relatively safe for treating for HL patients. CONCLUSION: We agree with decreasing bleomycin dosage and number of cycles administered and we do not recommend avoiding mediastinal IFRT, unless multiple pulmonary risk factors are present.

Hypoxia-related carbonic anhydrase IX expression is associated with unfavourable response to first-line therapy in classical Hodgkin's lymphoma.

AIMS: The present study evaluates the impact of hypoxia-related carbonic anhydrase IX and XII isoenzyme expression as a basic adaptive mechanism to neutralise intracellular acidosis in classical Hodgkin's lymphoma (cHL). METHODS AND RESULTS: Eighty-one primary biopsies and 15 relapsed tissue samples diagnosed with cHL were analysed for necrosis, CAIX and CAXII expression and cell proliferation to compare hypoxia-related histological and functional data with survival characteristics. Variable, but highly selective cell membrane CAIX expression could be demonstrated in Hodgkin-Reed-Sternberg (HRS) cells in 39 of 81 samples (48.1%), while virtually no staining presented in their microenvironment. In contrast, CAXII expression in HRS cells could be demonstrated in only 18 of 77 samples (23.4%), with significant stromal positivity (50 of 77, 64.9%). The CAIX+ positive phenotype was strongly associated with lymphocyte depletion (four of four, 100%) and nodular sclerosis (29 of 51, 56.9%) subtypes. CAIX/Ki-67 dual immunohistochemistry demonstrated suppressed cell proliferation in CAIX+ positive compared to CAIX- negative HRS cells (P < 0.001). Seventy-two months' progression-free survival (PFS) was significantly lower for the CAIX positive group (0.192) compared with the CAIX negative group (0.771) (P < 0.001), while the overall survival (OS) did not differ (P = 0.097). CONCLUSION: Hypoxic stress-related adaptation - highlighted by CAIX expression - results in cellular quiescence in HRS cells, potentially contributing to the short-term failure of the standard chemotherapy in cHL.

[Treatment of relapsed Hodgkin lymphoma after autologous stem cell transplantation]. / Így kezeljük az autológ ossejt-transzplantáció után kiújult Hodgkin-lymphomát.

Approximately 10-30% of Hodgkin lymphoma patients relapses or experience refractory disease after first line treatment. Nowadays, autologous stem cell transplantation can successfully salvage half of these patients, median overall survival is only 2-2.5 years. Several prognostic factors determine success of autologous stem cell transplantation. Result of transplantation can be improved considering these factors and using consolidation treatment, if necessary. Patients who relapse after autologous transplantation had worse prognosis, treatment of this patient population is unmet clinical need. Several new treatment options became available in the recent years (brentuximab vedotin and immuncheckpoint inhibitors). These new treatment options offer more chance for cure in relapsed/refractory Hodgkin patients. Outcome of allogenic stem cell transplantation can be improved by using haploidentical donors. New therapeutic options will be discussed in this review. Orv Hetil. 2017; 158(34): 1338-1345.

Rapidly Progressing Refractory Hodgkin Lymphoma: A Case Report and a Possible Explanation.

Introduction. Hodgkin lymphoma is a highly curable lymphoid malignancy; however treatment of a significant number of patients remains challenging. Case Report. The authors present an unusually rapidly progressing case of refractory advanced stage classical nodular sclerosis subtype Hodgkin lymphoma with unfavorable prognosis. A 66-year-old male patient was refractory for first-line doxorubicin, bleomycin, vinblastin, dacarbazine (ABVD) treatment with persistent disease; therefore physicians changed treatment for dexamethasone, cytarabine, and cisplatin (DHAP) and later ifosfamide, gemcitabine, and vinorelbine (IGEV) regimen. Unfortunately the patient developed acute kidney and respiratory failure and died after 6 months of treatment. Current and retrospective histological examination of the patient's lymph node biopsy, skin lesion, and autopsy revealed the same aberrantly expressing CD4 positive nodular sclerosis subtype Hodgkin lymphoma. Conclusion. Aberrant expression of T-cell antigens on the Hodgkin and Reed/Sternberg cells could be associated with inferior outcome. T-cell associated antigens should be investigated more often in patients not responding sufficiently to treatment and hence treatment should be intensified or targeted therapy (brentuximab vedotin) should be considered.

Effect of Bleomycin Hydrolase Gene Polymorphism on Late Pulmonary Complications of Treatment for Hodgkin Lymphoma.

BACKGROUND: Bleomycin hydrolase (BLMH), an enzyme that inactivates bleomycin, may be a potential candidate that could influence pulmonary function in ABVD (doxorubicin, bleomycin, vinblastin, dacarbasine)-treated Hodgkin lymphoma (HL) patients. PATIENTS AND METHODS: We hypothesized that the BLMH gene SNP A1450G (rs1050565) influences BLMH activity and late pulmonary toxicity. St. George Respiratory Questionnaire, lung scintigraphy and spirometry were used to determine lung function. TaqMan genotyping assay was used to determine genotype distribution of 131 previously treated HL patients. RESULTS: Significantly more favorable results were seen in the wild-type A/A genotype group than those in the group containing the mutated allele: A/G+G/G in retrospective pulmonary tests of ABVD treated patients. CONCLUSION: Besides limitations of the current study, bleomycin pharmacokinetics should be further evaluated in patients with BLMH variations, hence identify those cases even in the frontline setting, where bleomycin should be omitted and replaced with targeted therapy.

[Pulmonary alterations in Hodgkin lymphoma]. / Pulmonalis eltérések Hodgkin-lymphomában.

Most of Hodgkin lymphoma patients survive due to combined chemo/radiotherapy. Improved survival brings long-term side effects to the front, which may determine the patients' subsequent quality of life and expected lifetime. This manuscript aims to analyze lung manifestations of Hodgkin lymphoma and treatment related pulmonary complications, demonstrated with own cases. The lung involvement in Hodgkin lymphoma is often secondary, and primary pulmonary involvement is very rare. The authors found 8-12% of lung involvement among their patients. Side effects of treatment consist of pulmonary infections in conjuction with immunosuppression, while on the other hand bleomycin and chest irradiation as part of current standard of care induced pneumonitis and fibrosis are reported. The pulmonary involvement in Hodgkin lymphoma may cause differential diagnostic difficulty. Lung involvement could modify stage and consequently treatment, and the development of side effects might determine later quality of life and expected lifetime. Therefore, identification of lung involvement is crucial.

[Novel treatment options in relapsed and refracter Hodgkin lymphomas]. / Új lehetoségek a refrakter és relabált Hodgkin-lymphomás betegek kezelésében.

INTRODUCTION: Hodgkin lymphoma is a curable lymphoma with an 80-90% long-term survival, however, 30% of the patients develop relapse. Only half of relapsed patients can be cured with autologous stem cell transplantation. AIM: The aim of the authors was to analyze survival rates and incidence of relapses among Hodgkin lymphoma patients who were treated between January 1, 1980 and December 31, 2014. Novel therapeutic options are also summarized. METHOD: Retrospective analysis of data was performed. RESULTS: A total of 715 patients were treated (382 men and 333 women; median age at the time of diagnosis was 38 years). During the studied period the frequency of relapsed patients was reduced from 24.87% to 8.04%. The numbers of autologous stem cell transplantations was increased among refracter/relapsed patients, and 75% of the patients underwent transplantation since 2000. The 5-year overall survival improved significantly (between 1980 and 1989 64.4%, between 1990 and 1999 82.4%, between 2000 and 2009 88.4%, and between 2010 and 2014 87.1%). Relapse-free survival did not change significantly. CONCLUSIONS: During the study period treatment outcomes improved. For relapsed/refractory Hodgkin lymphoma patients novel treatment options may offer better chance for cure.

Brentuximab vedotin for treating Hodgkin's lymphoma: an analysis of pharmacology and clinical efficacy.

INTRODUCTION: Hodgkin's lymphoma (HL) is a highly curable lymphoma with a 70 - 90% long-term survival; however, patients with relapsed or refractory disease may need additonal therapies and have significantly worse prognosis. Brentuximab vedotin (BV) is an anti-CD-30 antibody-drug conjugate, which was approved for treating classical HL patients following autologous stem cell transplantation or failure of at least two prior multi-agent chemotherapies within a year. AREAS COVERED: Current clinical trials are investigating the role of BV in frontline, salvage and adjuvant setting of treatment. Safety and efficacy results of completed trials are summarized in this review. Metabolic, pharmacokinetic issues of BV are also discussed. EXPERT OPINION: BV is a targeted therapeutic option for treating HL, which is a significant improvement compared to conventional multiagent chemotherapy. It may represent a valid option for heavily pretreated patients. Currently running clinical trials are seeking a role for BV in the first-line setting, as well as treating autologous stem cell transplant candidate patients, relapsing after autologous stem cell transplant, bridging to allogenic stem cell transplant and treating elderly patients. Indication of drug may change, expand and an exact role may be established in the upcoming 5 years based on the results of currently running trials.

Late pulmonary complications of treating Hodgkin lymphoma: bleomycin-induced toxicity.

INTRODUCTION: Survival of Hodgkin lymphoma (HL) patients has significantly improved in recent decades. The current first-line therapy is doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) ± irradiation and may cause pulmonary toxicity. Strategies to reduce late toxicity as well as increase survival rate are of interest. PATIENTS AND METHODS: Pulmonary function of previously treated HL patients was collected over a 12-month period using St. George Respiratory Questionnaire (SGRQ), chest X-ray, dynamic inhalation lung scintigraphy and spirometry. RESULTS: A total of 137 patients' data were reviewed. Median time elapsed since diagnosis was 11 years (range was 2 - 30 years). Chest irradiation did not significantly worsen pulmonary function. Number of ABVD cycles with consequential bleomycin dose showed significant correlation with SGRQ total score in patients receiving ABVD plus chest irradiation (p = 0.01). Scintigraphy results correlated with bleomycin dose in patients receiving ABVD without chest irradiation (right side: p = 0.099, left side: p = 0.051). DISCUSSION: An additive negative effect of chest irradiation was not confirmed as reflected in the literature; however, increasing cumulative bleomycin dose worsened pulmonary function.

Immunologic pathomechanism of Hodgkin's lymphoma.

Hodgkin's lymphoma is a lymphoid malignancy of the immune system. The pathognomonic Hodgkin and Reed-Sternberg cells (HRS) are derived mainly from monoclonal, preapoptotic B cells, and they carry rearranged, somatically mutated immunoglobulin heavy chains. In an appropriate microenvironment, HRS cells escape from apoptosis by several mechanisms, including single mutations, aberrant signaling pathways. Eventually, weakened immune surveillance leads to uncontrolled, disproportional B cell proliferation. This review summarizes the latest findings on the pathogenesis of Hodgkin lymphoma, with a special emphasis on immunologic processes, and depicts current and future immunotherapeutic regimens, which improve treatment outcomes and reduce late toxicities.

[Diagnostic difficulties caused by a pulmonary infiltrate]. / Diagnosztikai nehézséget okozó pulmonalis infiltrátum.

UNLABELLED: Lung infiltration still causes differential diagnostic difficulties, which may delay the start of definitive treatment. CASE REPORT: The examination of a 30-year-old man began due intermittent, remittent and permanent fever. Chest X-ray confirmed infiltration in the right upper lobe, which was accompanied by elevated CRP and physiological levels of procalcitonin. Most likely atypical pneumonia, tuberculosis, Wegener's granulomatosis or a malignant process was suspected. Throughout his examination infection could not be verified, repeated CT guided transthoracic needle biopsy suggested the possibility of a malignant process. Through surgical exploration the intraoperative histology was not informative; thus, the pneumonitis-remodelled right lung was removed due to the possibility of malignant transformation. Histological examination revealed lymphocyte rich classical Hodgkin lymphoma, which was found to be stage IV/B based on the 18FDG-PET/CT scan; therefore, eight cycles of ABVD (adriablastin, bleomycin, vinblastine, and dacarbazine) therapy was administered successfully. The patient is currently (for 30 months) in a complete metabolic remission. CONCLUSION: Primary pulmonary Hodgkin lymphoma is a rare disease entity (in this case it might be the original process), in which the diagnosis is often difficult. 18FDG-PET/CT may be a useful early diagnostic tool investigating fever of unknown origin.

Changing patterns in the clinical pathological features of hodgkin lymphoma: a report from debrecen, hungary.

Introduction. Hodgkin lymphoma shows a well-known geographic pattern, but temporal changes have been found recently as well. Patients and Methods. 439 Hodgkin lymphoma patients' clinicopathological and treatment data were processed in calendar periods of approximately ten years. The patients were treated at our department from 1980 until the end of 2008. Results. The first period (1980-89) contained 177 patients, the second (1990-99) 147, and the third (2000-08) 115 Hodgkin lymphoma patients. The mean age of the patients was 40.1, 35.9, and 36.8 years in order. The male/female ratio: 1.42, 1.45, 1.05 in order. Contrary-wise a unimodal age group pattern could have been seen with an incidence peak between 30 and 39 in the past decades. The incidence of classical mixed cellularity histological subtype is decreasing (43.7%, 58.23%, 42.6%, P = 0.0098 (it is only significant in the second period)); classical nodular sclerosis shows an increasing tendency (25%, 27.32%, 34.78%, P = 0.1734). The first incidence peak is predominantly created by classical nodular sclerosis, meanwhile the second peak by classical mixed cellularity. The number of early-stage patients (59.12%) is beyond the advanced stage (40%) in the last decade. Meanwhile, the number of second-stage patients was increasing (25.8%, 26.35%, 49.56% P < 0.0001) and of patients in third stage was decreasing (53.4 %, 50.67%, 20% P < 0.0001). The 5- and 10-year overall survival data were progressing: 59.7 %, 77.4 %, and 90.5 % and 44.1 %, 70.6 % and 90.5 % (expected survival) in the last decade. Conclusions. Changes can be explained by the altered nature of Hodgkin lymphoma, the changes in socioeconomic status and the development of diagnostic and therapy methods.

The histone deacetylase inhibitor entinostat (SNDX-275) induces apoptosis in Hodgkin lymphoma cells and synergizes with Bcl-2 family inhibitors.

OBJECTIVE: Based on promising in vitro and in vivo activity of several histone deacetylase inhibitors in Hodgkin lymphoma (HL), we investigated SNDX-275, an oral class 1 isoform-selective histone deacetylase inhibitors in HL-derived cell lines. MATERIALS AND METHODS: Proliferation and cell death were examined by MTS assay, Annexin V/propidium iodide, and fluorescence-activated cell sorting analysis. Gene and protein expression were measured by reverse transcriptase polymerase chain reaction, Western blotting, and immunohistochemical analysis. A multiplex assay was used to determine cytokines and chemokines. RESULTS: SNDX-275 induced cell death in a dose- and time-dependent manner with an IC(50) at the sub- and lower micromolar range at 72 hours. At the molecular level, SNDX-275 increased histone H3 acetylation, upregulated p21 expression, and activated the intrinsic apoptosis pathway by downregulating the X-linked inhibitor of apoptosis protein. SNDX-275 downregulated expression of antiapoptotic Bcl-2 and Bcl-xL proteins without altering Mcl-1 or Bax levels. Combination studies demonstrated that two Bcl-2 inhibitors (ABT-737 and obatoclax) significantly enhanced the effect of SNDX-275. SNDX-275 modulated the level of several cytokines and chemokines, including interleukin-12 p40-70, interferon-inducible protein-10, RANTES (regulated on activation, normal T expressed and secreted), interleukin-13, interleukin-4, and thymus and activation-regulated chemokine and variably induced the cancer/testis antigen expression of MAGE-A4 and survivin in HL cell lines. CONCLUSIONS: SNDX-275 has antiproliferative activity in HL cell lines, involving several mechanisms: induction of apoptosis, regulation of cytokines and chemokines, and alteration of cancer/testis antigens. Clinical investigation of SNDX-275 alone or in combination with Bcl-2 inhibitors is warranted in patients with HL. Phase 2 studies with SNDX-275 in HL are ongoing, and future clinical studies should investigate combinations with SNDX-275.

[Changing patterns in the clinical, pathological features of Hodgkin lymphoma]. / Változnak-e a Hodgkin-lymphoma klinikopatológiai jellemzoi?

UNLABELLED: Hodgkin lymphoma shows a well-known geographic pattern, but temporal changes have been found recently as well. PATIENTS AND METHODS: The Authors analyzed 439 Hodgkin lymphoma patients' clinicopathological and treatment data. Patients were treated at our department from 1980 until the end of 2008. RESULTS: The first period contained 117 patients, the second 147 and third 115 Hodgkin lymphoma patients. The mean age of the patients was 40.1, 35.9 and 36.8 years in order. The male/female ratio: 1.42, 1.45, 1.04 in order. The incidence of mixed cellularity histological subtype is decreasing; nodular sclerosis shows an increasing tendency. The number of early stage patients (59.12%) is beyond the advanced stage (40%) in the last decade. The 10-year overall survival data were progressing 44.1%, 70.6% and 90.5% (survival prognosis) in the last decade. CONCLUSIONS: Changes can be explained by the altered nature of Hodgkin lymphoma, the changes in socioeconomic status and the development of diagnostic and therapy methods.

Novel treatment strategies for patients with relapsed classical Hodgkin lymphoma.

The treatment of patients with relapsed and refractory Hodgkin lymphoma (HL), especially those who relapse after autologous stem cell transplantation, remains challenging. Patients with HL whose disease relapses after stem cell transplantation are rarely cured with current treatment modalities, and have a median survival of less than 3 years. Since no new drugs have been approved by the FDA for HL in more than three decades, there is a clear unmet medical need for drug development for this patient population. New treatment strategies that are based on targeting oncogenic signaling pathways are currently explored. This review will focus on emerging new treatment modalities that are currently under investigation for patients with relapsed classical HL.