Intensified alemtuzumab–CHOP therapy for peripheral T-cell lymphoma

BackgroundThe prognosis of T-cell lymphoma is poor. To explore the addition of the monoclonal antibody alemtuzumab, we studied the efficacy and tolerability of an intensified alemtuzumab–chemotherapy combination for aggressive T-cell lymphoma in a phase II study by Dutch-Belgian Hemato-Oncology Group (HOVON).Patients and methodsPatients (≤65 years) with newly diagnosed T-cell lymphoma received eight CHOP cycles (cyclophosphamide, doxorubicin, vincristine, prednisone) 2-weekly, each cycle with three doses of 30 mg alemtuzumab. Prophylaxis consisted of cotrimoxazole, fluconazole and valaciclovir. Cytomegalovirus (CMV) monitoring took place at least every fortnight.ResultsTwenty patients from 10 centers, median age 50 years, were included. Eighty-five percent received six or more cycles. The overall response was 90% [12 complete remissions (CRs), 1 CR unconfirmed, 5 partial remissions]. Median duration of follow-up of patients still alive was 29 months (range 19–41 months). Median overall survival (OS) and event-free survival (EFS) were 27 and 10 months, with 55%/27% OS/EFS at 2 years. Adverse events consisted of neutropenic fever (n = 8) and CMV reactivation (n = 7), with one CMV disease. Three patients developed secondary Epstein-Barr virus (EBV)-related lymphoma, all after end of treatment.ConclusionsAlthough intensified alemtuzumab–CHOP induces high responses, many patients relapse, and the scheme is associated with serious infection-related adverse events. EBV monitoring after end of treatment is required.     

Diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) remains a curable lymphoma, with improved outcome resulting in large part from the incorporation of rituximab in standard regimens. The disease is heterogeneous clinically, morphologically, and molecularly. Recent insights into the molecular heterogeneity of DLBCL are beginning to yield novel therapeutics with significant promise for key subsets of patients. Although cyclophosphamide, hydroxydaunorubicin, vincristine, and prednisone chemotherapy with rituximab remains a standard therapeutic approach for most patients who have DLBCL, it is anticipated that novel agents will be included in treatment regimens for many patients in the near future.     

Management of advanced stage Hodgkin lymphoma

Although advanced Hodgkin lymphoma is highly curable, balancing the high cure rate with long-term toxicity is challenging. ABVD (doxorubicin [Adriamycin], bleomycin, vinblastine, dacarbazine) is the standard chemotherapy regimen, producing a high cure rate with acceptable toxicity. Stanford V and BEACOPP (bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone) are new regimens with encouraging results and are undergoing randomized clinical trials. The International Prognostic Score provides a clinical tool that may help identify patients with high-risk disease who may require a more aggressive regimen. Consolidative radiation's role in managing advanced Hodgkin lymphoma is still controversial, but it is most accepted for bulky or residual disease or after brief chemotherapy. The development and integration of newer imaging tools, such as fluorodeoxyglucose-positron emission tomography imaging, may allow a more precise evaluation of disease and help define which patients might benefit from consolidative treatment.     

Nonmyeloablative transplantation for lymphoma

Opinion statement Nonmyeloablative stem cell transplantation, also referred to as minitransplantation or reduced-intensity transplantation, is a novel approach to lymphoma treatment offering the lure of harnessing graft-versus-lymphoma (GVL) effects while decreasing regimen-related toxicity. The general concept is to provide a sufficiently immunosuppressive and moderately myelosuppressive treatment regimen to allow donor and host hematopoietic coexistence or chimerism. The most popular regimens incorporate a purine analog (eg, fludarabine) and an alkylating agent (eg, cyclophosphamide or melphalan). Newer regimens include the monoclonal antibody alemtuzumab, which may reduce the incidence of acute graft-versus-host disease (GVHD). Early reports demonstrate a GVL effect; however, the underlying lymphoma subtype and pace of disease often dictate which patients can capitalize on GVL benefits. Clinical reports show mixed results, which may reflect variations in patient selection. Although most patients successfully engraft, the effect on lymphoma control and GVHD must be evaluated carefully. Future investigations continue to delineate the optimal timing of nonmyeloablative transplantation, the optimal patient population, the optimal preparative regimen, and the optimal GVHD prophylaxis. Supportive care remains a critical component of management because the reduced-intensity regimens do not abrogate the risk of serious infection and many do not appear to decrease the incidence of chronic GVHD. Nonmyeloablative hematopoietic stem cell transplantation may broaden the applicability of allogeneic transplantation in malignant lymphomas, especially for indolent subtypes.     

Mantle cell lymphoma

Opinion statement Mantle cell lymphoma is an aggressive non-Hodgkin’s lymphoma that remains incurable with current chemotherapeutic approaches. Despite response rates to many regimens of 50% to 70%, the disease typically progresses after chemotherapy with a median survival time of approximately 3 years. There is no clear standard approach for treating mantle cell lymphoma, making it critical that appropriate patients be enrolled in clinical trials. Off protocol, chemotherapy with chlorambucil, CVP (cyclophosphamide, vincristine, and prednisone), or CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) can be used in patients who are not candidates for aggressive therapy. Intensive combination chemotherapy regimens have high response rates and may prolong time to progressive disease. High-dose therapy with autologous stem cell transplantation may, but does not appear to, provide longer time to progression, although it may improve survival. For young patients with matched donors, allogeneic transplant is promising in the limited numbers of patients treated. Other agents, including rituximab, fludarabine, and cladribine, have demonstrated activity, but these agents do not appear to offer survival advantages over combination chemotherapy.     

Intensive chemotherapy with cyclophosphamide,doxorubicin, high-dose methotrexate/ifosfamide,etoposide, and high-dose cytarabine (CODOX-M/IVAC) for human immunodeficiency virus-associated Burkitt lymphoma

BACKGROUND: In the era of highly active antiretroviral therapy (HAART), standard-dose chemotherapy for human immunodeficiency virus (HIV)-associated diffuse large B-cell lymphoma is becoming the standard of care. In contrast, the safety and efficacy of intensive regimens have not been established for Burkitt lymphoma (BL), a highly aggressive lymphoma for which moderate-dose chemotherapy is substandard in the HIV-negative population. METHODS: To evaluate the feasibility of intensive chemotherapy in HIV-associated BL, the authors retrospectively reviewed 14 HIV-positive adults with BL treated at their center between 1988 and 2000. Eight patients were treated between 1996 and 2000 with cyclophosphamide, doxorubicin, high-dose methotrexate/ifosfamide, etoposide, and high-dose cytarabine (CODOX-M/IVAC), one of the currently preferred intensive-dose chemotherapy regimens for BL. Six received other chemotherapy. Outcomes were compared with those of 24 HIV-negative adult patients with BL who had similar patient characteristics and were treated concomitantly (13 with CODOX-M/IVAC; 11 with other regimens). RESULTS: Of the 14 HIV-positive patients, 63% had a complete response after CODOX-M/IVAC treatment, compared with 67% of patients receiving other chemotherapy. The 2-year event-free survival (EFS) rates were 60% and 60% after CODOX-M/IVAC or other regimens, respectively. Similar outcomes were seen despite the fact that 88% of CODOX-M/IVAC-treated HIV-positive patients had Stage IV disease, compared with one-third of HIV-positive patients treated with other chemotherapy. HIV status did not adversely affect long-term EFS independent of the treatment regimen (P = 0.88). When EFS was evaluated according to chemotherapy regimen independent of HIV status, CODOX-M/IVAC was found to be associated with improved EFS (P = 0.05) in all patients, and particularly those at high risk. HIV-positive patients treated with CODOX-M/IVAC tolerated chemotherapy well with similar rates of myelosuppression and infectious complications as HIV-negative patients. CONCLUSIONS: The current nonrandomized retrospective study suggested that intensive chemotherapy with CODOX-M/IVAC is feasible and well tolerated in HIV-positive adults with BL. In the post-HAART era, intensive chemotherapy such as CODOX-M/IVAC may be appropriate in all adult patients with BL, and especially those with poor prognostic factors, regardless of HIV status.     

Advances in the management of HIV-related non-Hodgkin lymphoma

PURPOSE OF REVIEW: Human immunodeficiency virus infection is associated with an increased risk of non-Hodgkin lymphoma. Even with a decrease in AIDS-defining illnesses after the advent of highly active antiretroviral therapy, HIV-associated non-Hodgkin lymphoma remains an important problem. RECENT FINDINGS: Low CD4+ T-lymphocyte count, disease stage, performance status, serum lactate dehydrogenase, and number of extranodal sites of disease are all important prognostic factors for HIV-non-Hodgkin lymphoma. Recent studies have examined the role of infusional chemotherapy, as well as immunotherapy, in the treatment of aggressive HIV-non-Hodgkin lymphoma, and autologous stem cell transplantation for relapsed or refractory HIV-non-Hodgkin lymphoma. New developments in the association of viral infection and pathogenesis of certain subtypes of HIV-non-Hodgkin lymphoma have also recently been reported. SUMMARY: Outcomes of HIV-non-Hodgkin lymphoma are improving with the routine use of highly active antiretroviral therapy and combination chemotherapy. For aggressive HIV-non-Hodgkin lymphoma, infusional chemotherapy regimens are well tolerated and lead to complete response in about 50-75% of cases and a 2-3 years overall survival of 40-60%. The potential benefit of adding rituximab to combination chemotherapy may be offset by infectious complications in severely immunosuppressed patients. HIV-associated Burkitt lymphoma should be treated with an intensive regimen rather than standard cyclophosphamide, doxorubicin, vincristine, prednisone-like chemotherapy. Autologous stem cell transplantation should be considered for selected patients with relapsed or refractory HIV-non-Hodgkin lymphoma.     

Long-term survival with allogeneic stem cell transplant and donor lymphocyte infusion following salvage therapy with anti-CD52 monoclonal antibody (Campath) in a patient with alpha/beta hepatosplenic T-cell non-Hodgkin's lymphoma

Hepatosplenic T-cell non-Hodgkin's lymphoma (HSTCL) is a rare, aggressive form of NHL, with a median survival of approximately 8 months. We were able to successfully induce complete remission in a patient with alpha/beta HSTCL who was refractory to multiple prior chemotherapy regimens, using the humanized anti-CD52 monoclonal antibody alemtuzumab (Campath). Once disease was controlled, the patient was able to undergo allogeneic stem cell transplantation (SCT), which resulted in complete remission. Furthermore, upon relapse, we were able to re-induce complete clinical and molecular remission with donor lymphocyte infusions. At Day 655 (post-SCT), the patient remains in complete remission. These data suggest a potential role for alemtuzumab and allogeneic SCT in the treatment of T-cell NHL.     

Radioimmunotherapy and stem-cell transplantation in the treatment of aggressive B-cell lymphoma

High-dose chemotherapy and autologous stem-cell transplantation (ASCT) have an established therapeutic role in the treatment of chemo-sensitive relapsed aggressive lymphoma, but has limited success in chemo-refractory disease or in heavily pretreated, multiple relapsed patients. Recurrent disease is the major cause of treatment failure in all patient subsets and the majority is not cured. Methods for better eradication of underlying lymphoma are needed to improve outcome. Radioimmunotherapy (RIT) combines radiation delivered by radio-isotopes with the targeting effect of monoclonal antibodies. Two radioimmunoconjugates are currently approved for relapsed/resistant low-grade or transformed lymphoma: iodine-131 tositumomab and yttrium-90 ibritumomab tiuxetan. These agents are also effective in aggressive lymphoma. Radio-labeled antibodies are ideal candidates to combine with high-dose chemotherapy and ASCT. Their major toxicity is myelosuppression, which is easily reversed by ASCT and they can target disease sites with almost no added toxicity to normal tissues. RIT has been used in escalated doses as the sole treatment prior to ASCT or in standard or escalated doses combined with standard high-dose chemotherapy regimens. RIT was also combined with reduced-intensity conditioning and allogeneic SCT. Preliminary results are promising and suggest improved disease control with no added toxicity; however randomized studies are needed to confirm these initial observations.     

Macrophage Expression of Interleukin-1 in Lymphoepithelioid Cell (“Lennert's”) Lymphoma

Macrophage activation was studied in three cases of a genuine form of T cell non-Hodgkin's lymphoma particularly rich in epithelioid histiocytes, the so-called “lymphoepithelioid cell lymphoma” or “Lennert's lymphoma”. Host tumor infiltrating macrophages actively produced Interleukin-1 as demonstrated by immunocytochemistry. The activated histiocytes also contained intracytoplasmic tumor cells which were either intact or at various stages of apoptosis. We postulate that in Lennert's lymphoma, tumor cells are capable of activating host macrophages. Initial macrophage activation is followed by IL-1 production with recruitment of additional macrophages accounting for the characteristic histological appearance of this tumor. The activated macrophages are also engaged in a phagocytic antitumoral response. Future studies should investigate if this host response can be potentiated.     

Salvage chemotherapy in follicular non-Hodgkin's lymphoma: focus on tolerability

Follicular lymphoma (FL) is typically characterized by repeated remissions and relapses, and many patients receive a number of therapeutic interventions during their disease course. Although treatment options are evolving rapidly, stem cell transplantation offers a potentially favorable impact on survival. In general, many patients with FL are not eligible for this approach by virtue of age and/or comorbid disease. Salvage chemotherapy consequently remains the mainstay of treatment, being individualized according to disease and patient characteristics, goals of therapy, and patient preference. Many of the cytotoxic agents used in relapsed FL are highly myelotoxic, leading to significant morbidity and mortality, including febrile neutropenia, hemorrhage, and impaired quality of life. Nausea and vomiting can also be problematic, particularly with regimens incorporating carmustine, cisplatin, and high-dose cyclophosphamide. Other acute toxicities include mucositis, alopecia, extravasation injuries, and neurotoxicity. Late toxicities can also occur, sometimes months or even years after the administration of antineoplastic agents. Acute myeloid leukemias, myelodysplastic syndromes, or solid tumors can occur after chemotherapy with alkylating agents. The cardiotoxic profile of anthracycline antibiotics is well recognized, and several agents, including carmustine and cyclophosphamide, can cause lung injury. Persistent neurotoxicity, nephrotoxicity, ototoxicity, and vascular toxicity have also been reported in association with chemotherapeutic agents used in patients with relapsed FL. Novel therapeutic strategies might allow patients to achieve longer remissions, potentially reducing lifetime exposure to repeated cycles of chemotherapy and their attendant toxicities. These could include the use of more efficient preparative and purging approaches in the transplantation setting or the administration of rituximab maintenance therapy after (immuno) chemotherapy induction or transplantation.     

Rapidly progressive Lennert's lymphoma terminating in fulminant hepatic failure

A 65-year-old male with rapidly progressive Lennert's lymphoma terminating in fulminant hepatic failure is presented. Staging radiological studies revealed that he had cervical and mediastinal lymph node swellings and multiple nodular lesions in the spleen. Lymph node biopsy specimens showed the proliferation of epithelioid cells interspersed with large blastic lymphocytes. These lymphocytes were CD3+, CD45RO (UCHL-1)+, CD4-, CD8+, CD56-, CD30-, CD15-, T-cell intracellular antigen-1+, granzyme B+ and perforin+, suggestive of the cytotoxic T-cell lineage. Under the diagnosis of Lennert's lymphoma, he was treated with standard CHOP chemotherapy. After two courses of the chemotherapy, despite the decreased size of cervical lymph nodes, high-grade fever and constitutional symptoms appeared. As multiple low-density nodules were observed in the liver by computed tomography, needle biopsy was performed. The biopsy specimens showed the proliferation of CD3+, CD4- and CD8+ lymphoma cells. Thereafter, the liver function deteriorated rapidly, and disseminated intravascular coagulation emerged. He died of rapidly progressive hepatic failure. This case is another example demonstrating that at least some of the Lennert's lymphomas phenotypically correspond with cytotoxic T-cell lymphomas, as was previously suggested by us [Am. J. Surg. Pathol.24 (2000) 1627]. It should be also emphasized that Lennert's lymphomas containing cytotoxic proteins may have a fulminant clinical course, which cannot be rescued by the conventional chemotherapy.     

Mantle cell lymphoma: Therapeutic strategies are different from CLL

Opinion statement In contrast to the typical course of chronic lymphocytic lymphoma and despite an indolent lymphoma-like presentation, the clinical outcome of mantle cell lymphoma (MCL) is dismal, with a median survival time of 3 years and virtually no long-term survivors. Most patients are diagnosed with advanced stage III/IV disease. Although clinical studies did not prove a clear superiority of anthracyclin-containing combinations, CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone)-like regimens represent the standard therapeutic approach in MCL. Recent randomized studies have shown a benefit of a combined immunochemotherapy strategy (chemotherapy plus rituximab) increasing the complete and overall response rates, whereas further followup is pending for evaluation of the progression-free and overall survival. In patients younger than 65 years, a dose-intensive consolidation comprising high-dose radiochemotherapy and subsequent autologous stem cell transplantation after a CHOP-like induction results in an improved progression-free survival. However, despite the benefits of this multimodal approach, most patients relapse even after high-dose therapy. The only curative approach is allogeneic stem cell transplantation, which may be adapted to the elderly MCL patient cohort by modified dose-reduced conditioning regimens. Prospective randomized trials remain critical to further improve the clinical course of MCL with the addition of newer treatment modalities, such as radioactively labeled antibodies and targeted therapies (eg, flavopiridol and PS-341).     

Diagnosis and management of lymphoma

The 42nd Annual Meeting of the American Society of Clinical Oncology was held in Atlanta, GA, June 2-6, 2006. Some of the presentations pertaining to the diagnosis and management of non-Hodgkin's lymphoma are summarized in this review. Principal issues in indolent lymphoma included the role of maintenance therapy, novel agents such as bendamustine and pixantrone, and updates of predictive factors. Studies in aggressive lymphomas included standard regimens, such as rituximab-based chemotherapy and radioimmunotherapy, as well as novel salvage regimens. Advances in the management of mantle cell lymphoma with radioimmunotherapy, hyper-CVAD (cyclophosphamide/vincristine/doxorubicin/dexamethasone) and emerging agents, such as bortezomib and temsirolimus, were presented.     

Bcl-2 gene expression as a predictor of outcome in diffuse large B-cell lymphoma

Diffuse large B-cell lymphoma (DLBCL) is an aggressive lymphoma with a 5-year survival rate of 35%-60%. Various clinical factors included in the International Prognostic Index have failed to identify the patients with DLBCL who will not benefit from the standard R-CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone plus rituximab) treatment regimen. Bcl-2 has been implicated in conferring resistance to chemotherapy in non-Hodgkin's lymphoma and is therefore a candidate prognostic marker in DLBCL. To identify the correlation between Bcl-2 expression and response to rituximab-containing treatment regimens, histologic materials were analyzed from 292 elderly patients with confirmed DLBCL. Of these, 155 patients had received R-CHOP (53%) and 137 had received CHOP (47%). One hundred ninety-three patients (66%) were found to express high levels of Bcl-2 protein in > 50% of the tumor cells. Of the 193 Bcl-2-positive patients, the patients who received R-CHOP had a better 5-year overall rate than patients treated with CHOP (56% vs. 42%; P = 0.01), whereas in the patients with Bcl-2-negative disease, there was no statistically significant difference in the 5-year overall survival rates between the R-CHOP and CHOP regimens (58% vs. 52%; P = 0.6). Therefore, the addition of rituximab to the standard chemotherapy regimen seems to have overcome the Bcl-2-associated resistance to chemotherapy.     

Primary bladder lymphoma: management and outcome of 12 patients with a review of the literature

Primary bladder non-Hodgkin's lymphoma (NHL) is rare. Optimal management remains controversial. Using the Scotland and Newcastle lymphoma group database, 12 patients with primary bladder lymphoma were identified between 1980 and 2001, the largest single group of patients available to date. Histology and immunocytochemistry was reviewed in 9 of the 12 cases. Six cases were low-grade extranodal marginal zone lymphoma, 4 diffuse large B-cell lymphoma, one an ALK 1 positive anaplastic large cell lymphoma (ALKoma) and one a low-grade lymphoma unspecified. Two patients (low-grade NHL) were treated with oral antibiotics (n = 1) or diathermy (n = 1) alone with complete resolution of disease. One patient with high-grade NHL gained complete remission without conventional therapy. Nine patients were treated with single or combined modality surgery, chemotherapy and/or radiotherapy. Overall survival was 75%, mean follow up of 4.8 (range 1 - 10) years. A review of 88 additional cases in the literature support the findings that primary bladder lymphoma is associated with a good prognosis. Patients with low-grade extranodal marginal zone lymphoma may respond well to simple therapies. Patients with diffuse large B-cell lymphoma respond well to first-line chemotherapy regimens. Ureteric obstruction and acute renal failure are serious complications. Repeat cystoscopy is mandatory for follow-up.     

Autologous bone marrow transplantation for adult poor-risk lymphoblastic lymphoma in first remission.

PURPOSE: Adult patients with poor-risk lymphoblastic lymphoma (LBL) treated with intensive multiagent chemotherapy (acute lymphoblastic leukemia [ALL]-like regimens) have a poor prognosis, with a disease-free long-term survival rate of less than 20%, caused by a very high relapse rate. Thus, adult patients with poor-risk LBL are candidates for alternative intensive consolidation therapy. PATIENTS AND METHODS: Nine adult patients with poor-risk LBL in first remission after treatment with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP; six patients) or ALL-like regimens (three patients), were treated with high-dose cyclophosphamide and total body irradiation (TBI) followed by nonpurged autologous bone marrow transplantation (ABMT). RESULTS: Two of nine patients relapsed at 4 and 8 months, respectively, after BMT, and one patient died of acute myeloblastic leukemia (AML) 7 months after ABMT without recurrence of his lymphoma. Six patients are in unmaintained first remission with a follow-up of 12 to 113 months (median, 53 months) after transplantation. CONCLUSIONS: These results suggest that intensive consolidation therapy with high-dose cyclophosphamide and TBI followed by nonpurged ABMT may improve the long-term prognosis of this disease.     

Maintenance therapy in lymphoma

As treatment regimens have emerged that increase the proportion of patients with lymphoma achieving responses to therapy, maintenance regimens have followed to provide means for improving progression-free survival and overall survival for responders. An ideal maintenance regimen would have limited toxicity, be easy to administer, and demonstrate a survival benefit over administration of the same agent in the relapsed disease setting. Numerous phase II and randomized trials are now maturing that examine the benefits of maintenance therapies for indolent and aggressive lymphomas. We provide a comprehensive review of existing data describing the shortcomings and benefits of interferon maintenance and rituximab maintenance therapies for patients with non-Hodgkin lymphoma (NHL). Notably, rituximab maintenance has demonstrated benefits for patients with follicular lymphoma after CVP (cyclophosphamide/vincristine/prednisone) induction therapy and after rituximab-containing chemotherapy combinations at relapse. Benefits have also been demonstrated in diffuse large B-cell lymphoma after CHOP (cyclophosphamide/doxorubicin/vincristine/prednisone) induction but not after R-CHOP (rituximab plus CHOP) induction. Randomized trials in patients with mantle cell lymphoma demonstrate a benefit for rituximab maintenance after R-FCM (fludarabine/cyclophosphamide/mitoxantrone plus rituximab) chemoimmunotherapy but not after single-agent rituximab. Further studies are needed to characterize the benefits of other agents in maintenance therapy and other strategies for maintaining remissions for patients with NHL.     

Primary colorectal lymphoma in Taiwan.

BACKGROUND. Sixteen patients with primary lymphoma of the colon and rectum were studied. METHODS. The median age of these patients was 34 years, and 13 were men. These patients often experienced abdominal pain, diarrhea, a palpable abdominal mass, weight loss, bloody stools, and tumor of the cecum. Intermediate or high-grade lymphomas occurred in 14 patients, and 5 patients had T-cell lesions. The diagnoses were established by using laparotomy in 14 patients and colonoscopic biopsy in 2 patients. Fourteen patients had surgical resections followed by chemotherapy: cyclophosphamide, doxorubicin, vincristine, and prednisolone in 10; cyclophosphamide, vincristine, and prednisolone (COP) in 2; and cyclophosphamide, vincristine, methotrexate, and prednisolone in 1 patient. Two patients underwent biopsy alone followed by chemotherapy with COP in one and chemotherapy with prednisolone in the other. RESULTS. The median follow-up time was 38 months (range, 2-82 months). Eight patients are alive with no evidence of disease (range, 10-82+ months). Six patients died of disease from 2 to 44 months after diagnosis. One patient who had no evidence of lymphoma died of esophageal carcinoma at 61 months. The median survival time was 59 months. CONCLUSIONS. The authors' experience with colorectal lymphoma in Taiwan is different from that reported from Japan and other countries. The patients of this study were significantly younger and many had T-cell lesions. Despite the frequently poor histologic types, surgical resection and adjuvant chemotherapy can result in long-term, disease-free survival in many patients with primary colorectal lymphoma.     

State-of-the-art therapeutics: Hodgkin's lymphoma.

Presently Hodgkin's lymphoma can be cured in at least 80% of patients. The major challenge to the clinician in 2005 is how to cure the disease while inducing the least irreversible toxicity. This review focuses on clinical trials and institutional experiences to identify the best choice of treatment, individualized to the stage of the lymphoma permitting minimization of late toxicity such as infertility, premature menopause, cardiac disease, and most importantly, risk of second neoplasms. More than 90% of patients with limited Hodgkin's lymphoma can be cured with either short-course chemotherapy alone or even briefer chemotherapy followed by involved-field radiation. Accumulating evidence suggests that chemotherapy alone is suitable for the large majority of patients with limited disease. For the 80% of patients with advanced disease but without a large number of adverse prognostic factors, standard multi-agent chemotherapy with the well-established ABVD regimen (doxorubicin, bleomycin, vinblastine, and dacarbazine) provides the best balance of effectiveness and minimization of toxicity. More intensified regimens currently under investigation are appropriate for the 20% with numerous adverse prognostic factors. In 2005 it is insufficient to focus solely on cure of Hodgkin's lymphoma. The treatment program must maximize chance of cure and minimize late toxicity. Fortunately, brief chemotherapy alone or with radiation for patients with limited disease and standard ABVD chemotherapy for patients with advanced disease offer the appropriate balance of these two requirements. Patients with advanced disease plus multiple indicators of a poor prognosis and patients with disease that persists despite optimized primary treatment require specially intensified treatment.