Follicular lymphoma in Sweden: nationwide improved survival in the rituximab era, particularly in elderly women: a Swedish Lymphoma Registry study.

Treatment for follicular lymphoma (FL) improved with rituximab. In Sweden, first-line rituximab was gradually introduced between 2003 and 2007, with regional differences. The first national guidelines for FL were published in November 2007, recommending rituximab in first-line therapy. Using the population-based Swedish Lymphoma Registry, 2641 patients diagnosed with FL from 2000 to 2010 were identified and characterized by year and region of diagnosis, age (median, 65 years), gender (50% men), first-line therapy and clinical risk factors. Overall and relative survivals were estimated by calendar periods (2000-2002, 2003-2007 and 2008-2010) and region of diagnosis. With each period, first-line rituximab use and survival increased. Survival was superior in regions where rituximab was quickly adopted and inferior where slowly adopted. These differences were independent in multivariable analyses. Ten-year relative survival for patients diagnosed 2003-2010 was 92%, 83%, 78% and 64% in the age groups 18-49, 50-59, 60-69 and ⩾70, respectively. With increasing rituximab use, male sex emerged as an adverse factor. Survival improved in all patient categories, particularly in elderly women. The introduction and the establishment of rituximab have led to a nationwide improvement in FL survival. However, rituximab might be inadequately dosed in younger women and men of all ages.

Dose-densified chemoimmunotherapy followed by systemic central nervous system prophylaxis for younger high-risk diffuse large B-cell/follicular grade 3 lymphoma patients: results of a phase II Nordic Lymphoma Group study.

BACKGROUND: Many patients with aggressive B-cell lymphomas and high clinical risk score still die of lymphoma after conventional R-CHOP chemoimmunotherapy. We hypothesized that intensified chemoimmunotherapy including systemic central nervous system (CNS) prophylaxis improves outcome and reduces the incidence of CNS-related events. PATIENTS AND METHODS: Inclusion criteria were age 18-65 years, primary diffuse large B-cell lymphoma or grade III follicular lymphoma without clinical signs of CNS disease and negative cerebrospinal fluid cytology, age-adjusted International Prognostic Index 2-3 and WHO performance score 0-3. Treatment consisted of six courses of R-CHOEP-14 followed by a course of high-dose cytarabine and a course of high-dose methotrexate. Primary end point was failure-free survival (FFS) at 3 years. RESULTS: A total of 156 eligible patients with a median age of 54 years (range 20-64) were included. Three toxic deaths were observed. Three-year overall survival (OS) and FFS rates (median observation time 52 months for survivors) were 81% and 65%, respectively. Seven patients experienced CNS relapse, all within 6 months. CONCLUSIONS: The results are promising with favorable 3-year OS and FFS rates, a low toxic death rate and a lower than expected number of CNS events. CNS progression might be further reduced by earlier CNS prophylaxis. CinicalTrials.gov. identifier NCT01502982.

Overexpression of c-erbB-2 is related to a higher expression of vascular endothelial growth factor (VEGF) and constitutes an independent prognostic factor in primary node-positive breast cancer after adjuvant systemic treatment.

The aim of this study was to investigate possible associations between the expression of c-erbB-2 and the angiogenic factors vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), p53 status, routine breast cancer prognostic factors and survival. Expression of c-erbB-2, VEGF, bFGF, and p53 protein was determined with an enzyme-linked immunosorbent assay (ELISA) in 656 patients with primary breast cancer (median follow-up time of 83 months). In 60 cases, we also used immunohistochemistry (IHC) for c-erbB-2 evaluation, to be used as a reference for the ELISA. Overexpression of c-erbB-2 was significantly related to a higher expression of VEGF, lower bFGF content, negative steroid receptor status, and a high S-phase fraction. In multivariate analysis, c-erbB-2 was an independent prognostic factor for relapse-free survival (RFS) and overall survival (OS) in all patients, and in node-positive patients, irrespective of the adjuvant systemic therapy. Combined survival analyses regarding c-erbB-2 and VEGF yielded additional prognostic information.

Prognostic implications of p27 and cyclin E protein contents in malignant lymphomas.

The G1/S transition in the cell cycle is one of the checkpoints that can be deregulated in tumor development potentially causing increased proliferation and impaired capacity to arrest genetically damaged cells. The balance between activating and inhibitory molecules acting in the check point area seems to be critical and overexpression of cyclins and/or downregulation of the cdk inhibitors have been observed in many malignancies including lymphomas. In this review we have focused on two of the interplayers in the G1/S transition namely cyclin E and p27, and present the current knowledge of aberrations affecting these proteins in lymphomas as well as associations with clinico-pathological data including survival.

Monitoring referral and treatment in soft tissue sarcoma: study based on 1,851 patients from the Scandinavian Sarcoma Group Register.

This report is based on 1.851 adult patients with soft tissue sarcoma (STS) of the extremities or trunk wall diagnosed between 1986 and 1997 and reported from all tertiary referral centers in Norway and Sweden. The median age at diagnosis was 65 years and the male-to-female ratio was 1.1:1. One third of the tumors were subcutaneous, one third deep, intramuscular and one third deep, extramuscular. The median size was 7 (1-35) cm and 75% were high grade (III-IV). Metastases at presentation were diagnosed in 8% of the patients. Two thirds of STS patients were referred before surgery and the referral practices have improved during the study. The preoperative morphologic diagnosis was made with fine-needle aspiration cytology in 81%, core-needle biopsy in 9% and incisional biopsy in 10%. The frequency of amputations has decreased from 15% in 198688 to 9% in 1995-1997. A wide surgical margin was achieved in 77% of subcutaneous and 60% of deep-seated lesions. Overall, 24% of operated STS patients had adjuvant radiotherapy. The use of such therapy at sarcoma centers increased from 20% 1986-88 to 30% in 1995-97. Follow-up has been reported in 96% of the patients. The cumulative local recurrence rate was 0.20 at 5 years and 0.24 at 10 years. The 5-year metastasis-free survival rate was 0.70.

Local recurrence of deep-seated, high-grade, soft tissue sarcoma: 459 patients from the Scandinavian Sarcoma Group Register.

This study was based on 459 adult patients with deep, high-grade, soft tissue sarcoma of extremities or trunk wall reported to the Scandinavian Sarcoma Group Register (1986-1993). All patients had their definitive surgery for primary tumor at a sarcoma center. The median follow-up was 7.5 (3-12) years. 204 patients are still alive. 68 patients had amputations and 391 underwent limb-sparing surgery. Among 183 patients with intralesional or marginal margins after limb-sparing surgery, 65% had postoperative radiotherapy and 9% of the 198 patients with wide margins. The local recurrence rate after limb-sparing surgery was 26%. The rate with an intralesional or marginal margin was 39% without postoperative radiotherapy versus 24% when radiotherapy was given. It was 25% after a wide margin, and no recurrences were noted among the 10 patients with a compartmental surgical margin. Among patients with a wide margin, a subset fulfilling criteria for a myectomy was defined. The local recurrence rate was 26% among these 62 and there was no advantage of myectomy over other wide margins. More radical surgical margins would improve the local recurrence rate, but this can hardly be achieved in center-operated patients without increasing the amputation rate. Instead, increased use of radiotherapy in all patients with inadequate margins, and to a larger extent in those with wide margins will improve local control.

Treatment outcome in patients younger than 60 years with advanced stages (IIB-IV) of Hodgkin's disease: the Swedish National Health Care Programme experience.

BACKGROUND: Despite improved treatment results achieved in Hodgkin's disease (HD), only about 70% of patients with advanced stages are cured. The primary aim of this study was to evaluate the outcome of advanced stages (IIB-IVB) of HD in younger patients in an unselected population-based group of patients. The patients were recommended individualized treatment with respect to number of chemotherapy (CT) courses and post-CT radiotherapy (RT) based on pretreatment characteristics and tumour response. Secondly, we investigated if variables of prognostic importance could be detected. PATIENTS AND METHODS: Between 1985-92, 307 patients between 17-59 yr of age (median 36) were diagnosed with HD in stages IIB-IVB in 5/6 health care regions in Sweden. Median follow-up time was 7.8 yr (1.3-13). Retrospectively, laboratory parameters were collected. RESULTS: In total, 267 (87%) patients had a complete response (CR). The overall and disease-free 10-yr survivals in the whole cohort were 76% and 67%, respectively. There was no difference in survival between the groups of patients who received 6 or 8 cycles of CT. Survival was not higher for patients in CR after CT when RT was added. For those in PR after CT, additional RT raised the frequencies of CR. A selected group of pathologically staged patients was successfully treated with a short course (2 cycles) of CT + RT. In univariate analyses survival was affected by age, stage IVB, bone-marrow involvement, B-symptoms, S-LDH, S-Alb and reaching CR or not after 2, 4 and 6 cycles of CT. In a multivariate analysis, age and reaching CR after 6 cycles of CT remained statistically significant. CONCLUSIONS: The lack of difference in survival between the groups of patients who received 6 versus 8 cycles of CT indicates a successful selection of patients for the shorter treatment. Reaching a rapid CR significantly affected outcome. Whether some patients need less CT than the generally recommended 8 courses can properly only be evaluated in a randomised study. Additional RT may play a role in successful outcome, particularly if residual tumours are present, but its precise role can also only be defined in prospectively randomised studies. Reaching CR after CT was the most important variable affecting survival besides age.

Consequences of local recurrence of soft tissue sarcoma: 205 patients from the Scandinavian Sarcoma Group Register.

From the Scandinavian Sarcoma Group Register, information on 1,224 surgically-treated patients with soft tissue sarcoma (STS) of the extremity or trunk wall, diagnosed between 1987 and 1995, was collected. 205 patients, one third of whom were referred to a center with a local recurrence, had a total of 284 local recurrences. This analysis describes the treatment for these local recurrences, complications and risk of further recurrences. 169 patients were surgically treated for their first local recurrence. An intralesional or marginal margin was achieved in 110 of these patients, 59 of whom were also given radiotherapy. 54 of the 169 patients had a second local recurrence. The second local recurrence rate was 0.50 if the first local recurrence had been treated with only surgery with a marginal margin, compared to 0.28 if treated with surgery with a marginal margin and radiotherapy or with a wide margin (p = 0.0008). In extremity STS, the crude amputation rate for local recurrences was 0.22 (31 of 142)-i.e., higher than for primary tumors 0.09 (96 of 1065) (p < 0.0001). A high local recurrence rate after treatment outside of sarcoma centers has earlier been shown. We conclude that the consequences of local recurrence in terms of morbidity and costs justifies referral of STS patients for multidisciplinary evaluation and multimodality treatment.

Immunohistochemical analysis of the proliferation associated nuclear antigen CENP-F in non-Hodgkin's lymphoma.

CENP-F is a newly characterized cell cycle-associated nuclear antigen that is expressed in low amounts in G0/G1 cells and that accumulates in the nuclear matrix during S phase with a maximal expression in G2/M cells. CENP-F can be analyzed by flow cytometry and used as a proliferation marker. In the present study, therefore, we characterized the expression of CENP-F in non-Hodgkin's lymphoma by immunohistochemical techniques to detect potential dysregulation of the protein or to establish CENP-F as a reliable proliferation marker. A polyclonal rabbit antibody reacting with CENP-F was prepared and used for immunohistochemical analyses after antigen retrieval. The rabbit antibody produced immunofluorescence patterns, flow cytometric profiles, and Western blot reactivity identical to those of the human autoantibody used in earlier studies. The percentage of CENP-F-positive and Ki-67-positive cells, as well as the labeling index, S-phase time, and potential doubling time, derived from in vivo iododeoxyuridine incorporation, were evaluated in 41 non-Hodgkin's lymphomas. Aggressive lymphomas showed higher CENP-F values than did indolent cases (10.1 vs. 3.4%). The percentage of CENP-F-positive cells correlated significantly to the S-phase fraction (r(s) = 0.68), the Ki-67 index (r(s) = 0.56) and the labeling index of iododeoxyuridine (r(s) = 0.47), as well as to S-phase time and potential doubling time (r(s) = 0.34 and -0.40). A lower fraction of CENP-F-positive cells was found, compared with the Ki-67 index (4.9 vs. 9.4%), supporting previous observations that CENP-F was expressed in a fraction of actively growing cells. These correlative data indicate that CENP-F expression defines a specific subpopulation of growing cells and that no clear evidence for dysregulation was found. Accordingly, CENP-F seems to be a useful proliferation marker for formalin-fixed and paraffin-embedded material.

Expression of cyclin E and the cyclin-dependent kinase inhibitor p27 in malignant lymphomas-prognostic implications.

Cyclin E and the cyclin-dependent kinase inhibitor p27 are two important regulators of the G1-S transition modulating the activity of cyclin-dependent kinases. Aberrations in the cell cycle control are often observed in tumors and might even be mandatory in tumor development. To investigate the importance of cell-cycle defects in malignant lymphomas we have characterized the expression of cyclin E and p27 in 105 newly diagnosed lymphomas using immunohistochemistry. A significant, inverse correlation between p27 and cyclin E expression was observed (rs = -.24, P = .02) and both proteins correlated with the S-phase fraction (rs = -.35, P < .001 and rs = . 45, P < .001, respectively). The inverse relationship between p27 expression and proliferation was abrogated in some lymphomas, suggesting that p27 downregulation can represent a genuine aberration. Survival analysis was performed in 105 patients with a median observation time of 86 months. Low p27 and high cyclin E expression were significantly associated with a poor prognosis (P = . 0001 and .03, respectively). In a multivariate Cox analysis, p27 expression, stage, serum lactate dehydrogenase level, grade, and age were independent prognostic factors, in contrast to S-phase fraction and cyclin E expression. This is the first report showing that p27 expression in malignant lymphomas has independent prognostic significance, which necessitates future studies regarding its more precise biological role in lymphoid tumorogenesis.

Flow cytometric quantification of cyclin E in human cell lines and hematopoietic malignancies.

Cyclins are important in the regulatory system controlling cell cycle progression and overexpression or aberrant expression of G1 cyclins, as cyclin E, may result in an inadequate G1-S transition. In this study, the expression of cyclin E was analyzed in 12 human cell lines and 18 hematological malignancies by flow cytometry, and protein levels were quantified using calibrating microbeads. The majority of the tested cell lines demonstrated a cell cycle-specific expression of cyclin E, even though some cell lines expressed lower and more constant cyclin E levels throughout the cell cycle. No correlation between the fraction of cyclin E-positive cells and cyclin E content could be observed in the cell lines. Similar cyclin E levels were observed in the tumor samples as for the cell lines, although the fractions of positive cells were low. The flow cytometric quantification of cyclin E was compared with densitometric quantification of cyclin E Western blots, and a significant correlation between the two methods was observed (rs = 0.56, P = 0.03). The variation of cyclin E levels between cell lines was significantly higher than the variation for repetitive analyses of the same cell line, suggesting that the expression of cyclin E could reliably be quantified using flow cytometry. Because of the potential to analyze specific subgroups such as cyclin E-positive cells, this method may facilitate the detection of cyclin E-overexpressing tumor cells.

Telomerase activity in Hodgkin's disease.

Telomere maintenance executed by the action of telomerase seems to be a prerequisite for immortalization. Telomerase is found in most cell lines and malignant tumors. A telomerase-independent mechanism for telomere maintenance in Hodgkin's disease has been proposed in the absence of detectable telomerase activity. In this study, telomerase activity was detected in 31 of 77 Hodgkin's disease samples and a strong correlation between eosinophilia and absence of detectable telomerase activity was found. Purified eosinophils and specifically eosinophil-derived neurotoxin and eosinophilic cationic protein, both ribonucleases, were found to degrade telomerase. Purified neutrophils also exhibited weak telomerase degradative activity. Reanalysis of previously telomerase-negative Hodgkin's disease samples with eosinophilia using ribonuclease inhibitors resulted in the detection of telomerase activity. Ribonuclease-containing cells in vivo thus have a considerable impact on the detectability of telomerase. In Hodgkin's disease samples without eosinophilia, 24 of 27 exhibited telomerase activity at decreased levels compared with non-Hodgkin's lymphomas and at increased levels compared with reactive nodes indicative of a telomerase positive tumor component in Hodgkin's disease. Telomerase positivity of the Hodgkin's and Reed-Sternberg cells in vivo was also supported by high levels of telomerase expression in Hodgkin's disease cell lines. Based on our data, Hodgkin's lymphomas are potential targets for antitelomerase therapy.

Expression of activation markers CD23 and CD69 in B-cell non-Hodgkin's lymphoma.

The activation associated proteins CD23 and CD69 are expressed on cells of different lineages upon mitogenic stimulation. CD23 is a well characterized multifunctional protein in lymphocyte development recognized as a diagnostic marker for chronic lymphocytic leukaemia. CD69 is one of the earliest markers expressed after activation of T cells, but its function is unclear. The aim of this study was to investigate the expression of these antigens in B-cell non-Hodgkin's lymphomas (NHL) in relation to clinical behaviour. Ninety samples from 84 patients with NHL of B cell type were studied for the expression of CD23 and CD69 in CD20+ B cells by flow cytometric dual parameter analysis. In individual lymphomas the CD23 and CD69 antigens showed an "on or off" pattern with most or very few cells positive for each antigen. The CD23 antigen was expressed in 23 of 53 (43%) indolent lymphomas and in 2 of 37 (5%) aggressive cases. Most indolent lymphomas (81%) and about half the aggressive cases (53%) expressed the CD69 antigen. Thus, both markers were associated with indolent type. CD23 expression correlated with chronic lymphocytic leukaemia subtype and CD69 expression with male gender, advanced stage, newly diagnosed lymphoma and shorter survival.

[Late side-effects are common after treatment of Hodgkin's disease. Muscular atrophy following radiotherapy is a neglected risk]. / Ofta sena biverkningar av Hodgkinbehandling. Muskelatrofi förbisedd risk efter radioterapi.

As Hodgkin's disease (HD) is amenable to treatment, especially in the young, the majority of patients are long-term survivors and late treatment-related side-effects can become a clinical problem. After a retrospective review of the records of 134 patients treated for HD at Umeå during the period, 1975-90, and 15-50 years of age at diagnosis, a questionnaire on late side-effects of treatment was sent to the 110 survivors, of whom 90 per cent responded. Many patients reported late side-effects such as hypothyroidism, dryness of the mouth, cardiac and pulmonary problems, and fertility disorders. Of the 20 patients who reported pain and weakness of the neck and shoulders, 18 had undergone mantle field irradiation (i.e., of the lymph nodes of the neck, axillae and mediastinum). If shown to be equally effective, lower irradiation doses might be given in future, thus perhaps minimising long-term side-effects.

Ifosfamide and continuous infusion etoposide in advanced adult soft tissue sarcoma. A Scandinavian Sarcoma Group Phase II Study.

The purpose of this study was to evaluate tumour response and toxicity to ifosfamide and continuous infusion etoposide in metastatic or locally advanced soft tissue sarcoma, with dose escalations under G-CSF (granulocyte colony-stimulating factor) support. Of 92 eligible patients (median age 51 years), 85% had tumours of high-grade malignancy and 82% had metastatic disease. Chemotherapy, the baseline dose, consisted of etoposide 600 mg/m2 as a 72 h infusion and ifosfamide 1500 mg/ m2/day for 3 days, followed by G-CSF support (VIG regimen). Stepwise 10% dose escalations were performed depending on haematological toxicity. For patients considered operable after induction chemotherapy, surgical resection of all identifiable residual tumour was attempted. Complete and partial response rates were 11% and 31%, for an overall response rate of 42% (95% CI 31-52%). Forty-eight per cent of courses were dose escalated by a median of 20%. Complete responders had significantly higher, and patients with progressive disease had significantly lower, dose levels than other patients. None of 20 patients with liver metastases responded despite high dose levels. Compared to a preceding pilot study, the addition of G-CSF led to significantly higher dose levels, improved schedule adherence and less haematological toxicity, but no apparent increase in response rate. In view of the modest dose of ifosfamide applied in this study, it is possible that the prolonged infusion of etoposide made a significant contribution to the regimen's antitumour activity, although this can only be determined definitively in a randomised study.

Flow cytometric evaluation of proliferating cell nuclear antigen expression in human hematopoietic malignancies.

Cell proliferation is a strong prognostic factor in various malignancies including non-Hodgkin's lymphoma's (NHL). Several methods to evaluate tumour proliferation are available based on immunohistochemical and flow cytometric techniques, but none has been widely accepted for multicenter studies. In the present study 51 samples from patients with haematological disorders were analysed for the expression of proliferating cell nuclear antigen (PCNA) by a previously described flow cytometric approach. S-phase specific PCNA (PCNA-S) as well as growth fraction-associated PCNA (PCNA-tot) expression were evaluated. The mean value for PCNA-S was 9.0% and for PCNA-tot 17,4%. PCNA-S and PCNA-tot correlated strongly to each other (r(s) = 0.969, p < 0.001) and to the S-phase fraction determined by DNA histogram analysis (r(s) = 0.927 and 0.934 respectively, p < 0.001). In 23 cases with NHL in vivo iododeoxyuridine (IdUrd) labelling was performed to assess the labelling index (IdUrd-LI, i.e. S-phase fraction), S-phase duration time (Ts) and potential tumour doubling time (Tpot). IdUrd-Li correlated significantly to both PCNA-S and PCNA-tot (r(s) = 0.704 and 0.622 respectively, p < 0.001 and 0.02). In conclusion, especially the PCNA-S seemed to be a candidate for future larger studies of proliferation related aspects of haematological malignancies.

Nuclear autoantigen p330d/CENP-F: a marker for cell proliferation in human malignancies.

p330d, also known as CENP-F, is a newly characterized cell cycle specific nuclear autoantigen which is associated both with the centromeres and the nuclear matrix. It is expressed in low amounts in G0/G1-cells and accumulates in the nuclear matrix during S-phase with a maximum expression in G2/M-cells. In the present study we have investigated if p330d/CENP-F could be used as a marker for proliferation in different human malignancies. A flow cytometric method was developed by which p330d/CENP-F expression and DNA-content could be assessed on hematopoietic and solid tumors. Twenty-four different human hematopoietic malignancies, 12 breast cancers, and several cell lines were analyzed and the number of p330d/CENP-F positive cells and the S-phase fraction were determined. The percentage of p330d/CENP-F positive cells correlated with the fraction of S-phase cells in all human malignancies tested. Various cell lines revealed a similar cell cycle specific distribution. The association of p330d/CENP-F with the nuclear matrix facilitated the flow cytometric analysis of this protein due to its resistance to different preparation and fixation procedures. In summary, p330d/CENP-F seems to be a potentially valuable proliferation marker which can be applied to different tumors.