Phase II trial of short-course CHOP-R followed by 90Y-ibritumomab tiuxetan and extended rituximab in previously untreated follicular lymphoma.

PURPOSE: Radioimmunotherapy has been approved for relapsed follicular lymphoma (FL), including rituximab-refractory FL. This study was designed to determine the CR rate with short-course chemoimmunotherapy with cyclophosphamide, doxorubicin, vincristine, prednisone, and rituximab (CHOP-R) followed by 90-Y ibritumomab tiuxetan (RIT) with extended rituximab as first-line treatment. EXPERIMENTAL DESIGN: Between March 2004 and February 2007, 60 patients with stage II to IV symptomatic or bulky FL from a single institution supported by a large community network entered this phase II trial. Patients received CHOP-R for three treatment cycles before RIT followed by four additional weekly treatments with rituximab. Response was determined using fusion [(18) F] fluorodeoxyglucose-positron emission tomography (PET)-computed tomography (CT) imaging. RESULTS: Of the 60 patients entering this trial, 55 patients completed all protocol therapy. The median follow up was 19.7 months (range, 0.26-35.9 months). For intent-to-treat analysis, the complete response (CR) rate after CHOP-R, as assessed by CT and PET imaging, was 40% and 46%, respectively. After RIT, the CR rate improved, as assessed by CT and PET imaging, to 82% and 89%, respectively. Ten patients have progressed, including eight from best response of CR. Seven of 18 patients who were PET positive after CHOP-R progressed compared with 3 of 37 patients who were PET negative (P=0.010). CONCLUSIONS: In patients with previously untreated, symptomatic or bulky FL, short-course chemoimmunotherapy and consolidation RIT and extended rituximab resulted in a high CR rate. Failure to achieve an early PET CR after CHOP-R indicated high risk of relapse.

Pulmonary embolism incidence is increasing with use of spiral computed tomography.

BACKGROUND: Pulmonary embolism causes significant morbidity in hospitalized patients, yet few studies have explored the impact of spiral computed tomography (CT) scanning on diagnosis and clinical outcome. METHODS: Incidence rates of pulmonary embolism, chest and spiral CT rates, D-dimer assay, anticoagulation, and in-hospital mortality were assessed on statewide pulmonary embolism discharge data (1997-2001) from the Pennsylvania Health Care Cost Containment Council. RESULTS: The incidence of pulmonary embolism increased from 47 to 63 per 100,000 patients from 1997 to 2001 (mean of 0.004% per year, P < .001). Mean pulmonary embolism incidence rates were higher for African American patients (0.031% per year higher than for white patients), patients aged 70 years or more (0.007% higher than for patients aged<70 years), and female patients (0.013% higher than for male patients) (all P < .001). Concomitantly, the proportion undergoing CT (including spiral) scans increased from 23.23% to 45.18% (odds ratio=1.30; P<.001), controlling for age, gender, race, and cancer, whereas rates for other procedures remained unchanged. By comparing 1999 and before with 2000 and after, there was a significant decrease in the 2 highest Atlas Severity of Illness categories (49.4%-37.7%) and a significant increase in the 3 lowest categories (50.6%-62.3%; P < .001). The risk of in-hospital deaths among patients with pulmonary embolism decreased in this period from 12.8% to 11.1% (P < .001). CONCLUSION: The incidence of pulmonary embolism is increasing with the increasing use of spiral CT scans, with a lower severity of illness and lower mortality, suggesting the increase is due to earlier diagnosis.

Serum sickness in a patient with follicular lymphoma after rituximab and radioimmunotherapy with ibritumomab tiuxetan.

A previously healthy 47-year-old woman was treated for follicular lymphoma, grade III, with cyclophosphamide, adriamycin, vincristine, prednisone with rituximab (CHOP-R) followed by ibritumomab tiuxetan and rituximab. She developed a serum sickness-like illness during immunotherapy with fever, myalgias, arthralgias, and pleural and pericardial effusions. Despite anti-inflammatory therapies her symptoms persisted for 10 months before ultimate resolution. Her clinical course and literature are reviewed.

Focal radiation fibrosis after radioimmunotherapy for follicular non-Hodgkin lymphoma.

A 75-year-old man with relapsed follicular non-Hodgkin lymphoma confined to a solitary lung mass was treated with radioimmunotherapy (RIT) using yttrium 90-ibritumomab tiuxetan. Imaging with positron emission tomography/computed tomography showed a complete response 3 months after RIT. Thirteen months after RIT, his positron emission tomography/computed tomography scan showed a fluorodeoxyglucose-avid infiltrate in the area of the previous lung mass. Bronchoscopy revealed the area to be obstructed with fibrosis, and cytologic washings and brushings did not show lymphoma. The patient remains asymptomatic, and the fluorodeoxyglucoseavid pulmonary infiltrate was unchanged 19 months after RIT. In view of the lack of respiratory symptoms or progressive imaging abnormalities, we believe radiation fibrosis is the most likely etiology. Radiation-induced lung injury after therapy with yttrium 90 was previously reported in the setting of intraarterial microspheres used to treat inoperable hepatic tumors. This is the first case in which radiation-induced radiographic changes are reported after RIT for lymphoma.