Prognostic significance of immunohistochemistry-based markers and algorithms in immunochemotherapy-treated diffuse large B cell lymphoma patients.

AIMS: To reassess the prognostic validity of immunohistochemical markers and algorithms identified in the CHOP era in immunochemotherapy-treated diffuse large B cell lymphoma patients. METHODS AND RESULTS: The prognostic significance of immunohistochemical markers (CD10, Bcl-6, Bcl-2, MUM1, Ki-67, CD5, GCET1, FoxP1, LMO2) and algorithms (Hans, Hans*, Muris, Choi, Choi*, Nyman, Visco-Young, Tally) was assessed using clinical diagnostic blocks taken from an unselected, population-based cohort of 190 patients treated with R-CHOP. Dichotomizing expression, low CD10 (<10%), low LMO2 (<70%) or high Bcl-2 (≥80%) predicted shorter overall survival (OS; P = 0.033, P = 0.010 and P = 0.008, respectively). High Bcl-2 (≥80%), low Bcl-6 (<60%), low GCET1 (<20%) or low LMO2 (<70%) predicted shorter progression-free survival (PFS; P = 0.001, P = 0.048, P = 0.045 and P = 0.002, respectively). The Hans, Hans* and Muris classifiers predicted OS (P = 0.022, P = 0.037 and P = 0.011) and PFS (P = 0.021, P = 0.020 and P = 0.004). The Choi, Choi* and Tally were associated with PFS (P = 0.049, P = 0.009 and P = 0.023). In multivariate analysis, the International Prognostic Index (IPI) was the only independent predictor of outcome (OS; HR: 2.60, P < 0.001 and PFS; HR: 2.91, P < 0.001). CONCLUSIONS: Results highlight the controversy surrounding immunohistochemistry-based algorithms in the R-CHOP era. The need for more robust markers, applicable to the clinic, for incorporation into improved prognostic systems is emphasized.

Evaluation of treatment outcome in 175 patients with Hodgkin lymphoma aged 60 years or over: the SHIELD study.

The SHIELD program for Hodgkin lymphoma in patients 60 years of age or older, prospectively evaluated clinical features and outcome in a large patient cohort (n = 175). The central element was a phase 2 study of VEPEMB chemotherapy (n = 103, median age 73 years) incorporating comorbidity assessment. A total of 72 other patients were treated off-study but registered prospectively and treated concurrently with: ABVD (n = 35); CLVPP (n = 19), or other (n = 18). Of VEPEMB patients, 31 had early-stage disease (stage 1A/2A) and received VEPEMB 3 times plus radiotherapy. Median follow-up was 36 months. Complete remission (CR) rate (intention-to-treat) was 74% and 3-year overall survival (OS) and progression-free survival (PFS) were 81% and 74%, respectively. A total of 72 patients had advanced-stage disease (stage 1B/2B/3 or 4) and received VEPEMB 6 times. CR rate was 61% with 3-year OS and PFS of 66% and 58%, respectively. Of patients achieving CR, 13% with early-stage and 5% with advanced-stage disease progressed. Overall treatment-related mortality was 7%. In patients treated with curative intent with VEPEMB, ABVD, and CLVPP (n = 157), CR linked to several factors in univariate analysis. In a Cox regression model only, obtaining CR remained significant for OS and CR plus comorbidity and age for PFS. RS-EBV status had no significant effect on outcome.

Enhanced engraftment of a very low-dose cord blood unit in an adult haemopoietic transplant by addition of six mismatched viable cord units.

The report describes the feasibility of the addition of multiple viable HLA-mismatched unrelated cord blood units, to a low cell number matched unrelated cord, to assist clinical engraftment. An ablative stem cell transplant was performed in an adult with relapsed acute lymphoblastic leukaemia (ALL), using a single HLA-matched cord blood unit (mononuclear cell dose 0.8 × 10(7)), supported by six mismatched cord blood units (one unit per 10 kg recipient weight). No adverse reaction occurred following the infusion of mismatched units and engraftment of the suboptimal-dose matched unit occurred rapidly, with no molecular evidence of engraftment of mismatched cords. Early molecular remission of ALL was demonstrated using a novel PCR for a mitochondrial DNA mutation in the leukaemic clone. The cell dose of the matched cord was well below that recommended to engraft a 70 kg recipient. We suggest that a factor or factors in the mismatched cords enhanced/supported engraftment of the matched cord.

A 9 series microRNA signature differentiates between germinal centre and activated B-cell-like diffuse large B-cell lymphoma cell lines.

The microRNAs are endogenous, non-coding RNAs that play key roles in a range of pathophysiological processes by up- or down-regulating gene expression. Recent studies have shown that some microRNAs have oncogenic or tumour suppressor activity. Diffuse large B-cell lymphoma (DLBCL) is an aggressive non-Hodgkin's lymphoma with a heterogeneous biology, which has impeded the clinical assessment of patients. The currently-used clinically-based IPI provides useful information for treatment decision making, but has limited predictive power. Recent immunohistochemical approaches have identified two different prognostic groups: the more indolent germinal centre (GC)- and the higher risk activated B-cell (ABC)-like phenotypes. Although useful, prediction based on immunophenotype has limitations. The present study uses microRNA profiling and a number of well-characterised B-cell lymphoma cell lines to identify microRNA signatures that are correctly assigned to the DLBCL prognostic subgroups and distinguish DLBCL from other more indolent lymphoma, including follicular lymphoma (FL). MicroRNA microarray analysis was based on miRBase version 12.0 and analysis was performed using an unsupervised hierarchical clustering model. Discriminatory microRNAs were validated by qRT-PCR. We identified a 9 microRNA signature that discriminated between ABC- and GC-like DLBCL. This included 3 newly identified microRNAs, not previously associated with DLBCL and predicted to target genes that are de-regulated in lymphoma. DLBCL was distinguished from FL by 4 microRNAs and a total of 18 microRNAs were identified that differentiated between all lymphoma and control populations. Most of the discriminatory microRNAs have been reported previously to be known oncomiRs or act as tumour suppressors. In conclusion, the present study identified a microRNA signature that correctly classified GC and ABC phenotypes in DLBCL cell lines. This signature has yet to be assessed for prediction in clinical samples.

Evaluation of enteropathy-associated T-cell lymphoma comparing standard therapies with a novel regimen including autologous stem cell transplantation.

Enteropathy associated T-cell lymphoma (EATL) is a rare type of peripheral T-cell lymphoma. At present, there are no standardized diagnostic or treatment protocols for EATL. We describe EATL in a population-based setting and evaluate a new treatment with aggressive chemotherapy and autologous stem cell transplantation (ASCT). From 1979 onward the Scotland and Newcastle Lymphoma Group prospectively collected data on all patients newly diagnosed with lymphoma in the Northern Region of England and Scotland. Between 1994 and 1998, records of all patients diagnosed with EATL were reviewed, and 54 patients had features of EATL. Overall incidence was 0.14/100 000 per year. Treatment was systemic chemotherapy (mostly anthracycline-based chemotherapy) with or without surgery in 35 patients and surgery alone in 19 patients. Median progression-free survival (PFS) was 3.4 months and overall survival (OS) was 7.1 months. The novel regimen IVE/MTX (ifosfamide, etoposide, epirubicin/methotrexate)-ASCT [corrected] was piloted from 1998 for patients eligible for intensive treatment, and 26 patients were included. Five-years PFS and OS were 52% and 60%, respectively, and were significantly improved compared with the historical group treated with anthracycline-based chemotherapy (P = .01 and P = .003, respectively). EATL is a rare lymphoma with an unfavorable prognosis when treated with conventional therapies. The IVE/MTX-ASCT regimen is feasible with acceptable toxicity and significantly improved outcome.

A population-based cytogenetic study of adults with acute lymphoblastic leukemia.

Chromosomal abnormalities are increasingly used to risk stratify adults with acute lymphoblastic leukemia. Published data describing the age-specific incidence of chromosomal abnormalities and their prognostic relevance are largely derived from clinical trials. Trials frequently have age restrictions and low recruitment rates. Thus we investigated these factors in a population-based cohort of 349 patients diagnosed during the course of 19 years in the northern part of England. The incidence of most chromosomal abnormalities varied significantly with age. The incidence of t(9;22)(q34;q11) increased in each successive decade, up to 24% among 40- to 49-year-old subjects. Thereafter the incidence reached a plateau. t(4;11)(q21;q23) and t(1;19)(q23;p13) were a rare occurrence among patients older than 60 years of age. In contrast, the frequency of t(8;14)(q24;q32) and t(14;18)(q32;q21) increased with age. High hyperdiploidy occurred in 13% of patients younger than 20 years of age but in only 5% of older patients. The incidence of low hypodiploidy/near-triploidy and complex karyotype increased with age from 4% (15-29 years) to 16% (>or= 60 years). Overall survival varied significantly by age and cytogenetics. Older patients and those with t(9;22), t(4;11), low hypodiploidy/near-triploidy, or complex karyotype had a significantly inferior outcome. These population-based results demonstrate the cytogenetic heterogeneity of adult acute lymphoblastic leukemia. These data will inform the delivery of routine clinical services and the design of new age-focused clinical trials.

Immunophenotyping of diffuse large B-cell lymphoma (DLBCL) defines multiple sub-groups of germinal centre-like tumours displaying different survival characteristics.

Diffuse large B-cell lymphoma (DLBCL) forms a heterogeneous collection of aggressive non-Hodgkin's Lymphoma in which three principle classes of neoplasia have been defined according to gene expression and immunophenotyping studies. The present investigation sought to examine the immunophenotype of proposed subgroups and relate these to patient survival. A series of 155 DLBCL treated uniformly with anthracycline therapy in clinical trials, were stratified upon the basis of common biomarker expression with combination immunophenotype being related to patient overall survival. Stratification of tumours with respect to combined expression profiles of the three biological markers (CD10, Bcl-6 and MUM-1) revealed six groups showing significant differences in survival (p=0.014). The greatest difference resided between distinct populations of germinal centre (GC) cell tumours; the first being CD10-, Bcl-6+, MUM-1- and the second CD10+ Bcl-6+ MUM-1+ (p=0.002). The former group displayed median survival time of 143 months, the latter only 11 months. A third population of GC tumours (CD10+ Bcl-6+ and MUM-1-) also displayed a relative short median survival (32 months). Of the three groups presenting a non-GC or activated B cell (NGC/ABC) phenotype, only one (CD10-, Bcl-6+ and MUM-1+) presented short-term median survival (27 months) comparable with poor prognosis GC sub-populations. Within the remaining ABC tumour groups (CD10- Bcl-6- MUM-1- and CD10- Bcl-6- MUM-1+) patients presented intermediate median survival times of 54 and 58 months, respectively. Thus, the GC phenotype did not act as a universal indicator of good clinical prognosis, but rather multiple groups of GC tumours were associated with distinct overall survival profiles. Ultimately, the data allowed definition of a predictive algorithm defining three groups predicting poor, intermediate and good clinical prognosis. The first of these comprised two patient sub-populations with GC-like tumours together with one sub-population of NGC/ABC, the second two sub-populations of ABC-like tumours, and the final a single group of GC-like tumours associated with optimal long-term survival.

Epidemiology of leukaemia and lymphoma in children and young adults from the north of England, 1990-2002.

AIM: We aimed to describe and contrast the epidemiology of haematological malignancies among 0-14 and 15-24-year-olds in northern England from 1990 to 2002 and compare clinical trial entry by age group. PATIENTS AND METHODS: Incidence rates were examined by age, sex and period of diagnosis and differences were tested using Poisson regression. Differences and trends in survival were assessed using Cox regression. RESULTS: 1680 subjects were included comprising 948 leukaemias and 732 lymphomas. Incidence rates for acute lymphoblastic leukaemia were significantly higher for 0-14 compared to 15-24-year-olds, whilst Hodgkin lymphoma showed the reverse. No significant changes in incidence were observed. 60% of leukaemia patients aged 15-24 years entered trials compared to 92% of 0-14-year-olds. Survival rates were significantly lower and improved less markedly over time for 15-24 compared to 0-14-year-olds, particularly for leukaemia. CONCLUSIONS: Trial accrual rates need to be improved amongst 15-24-year-olds and a more structured follow-up approach adopted for this unique population.

Micro-vessel density and the expression of vascular endothelial growth factor (VEGF) and platelet-derived endothelial cell growth factor (PdEGF) in classical Hodgkin lymphoma (HL).

There is little information to date regarding the role of angiogenesis in Hodgkin lymphoma (HL). The present study examines micro-vessel density and the expression of vascular endothelial growth factor (VEGF) and platelet-derived endothelial growth factor (PdEGF) in lymph node biopsies of patients with HL at presentation and relapse. Using immunohistochemistry, the degree of new blood vessel formation and the expression of VEGF and PdEGF was assessed in Hodgkin-rich tissue. The micro-vessel density (MVD) increased with disease progression in seven out of 11 cases. Expression of VEGF was observed in endothelial cells (EC) of some micro-vessels and also in follicular dendritic cells. The Hodgkin/Reed-Sternberg (H-RS) cells as well as the inflammatory lymphocytes were negative for VEGF. Cytoplasmic or cytoplasmic and nuclear expression of PdEGF by the H-RS cells was observed in five of the 11 presentation cases. The expression of PdEGF increased with disease progression in seven cases. In conclusion, Hodgkin tissue shows prominent vascularization. The increased MVD and PdEGF expression with disease progression merits further investigation.

Cost-effectiveness analysis of rituximab combined with chop for treatment of diffuse large B-cell lymphoma.

PURPOSE: To estimate the cost-effectiveness from a French payer perspective of CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) alone compared with CHOP plus rituximab (R-CHOP) for treatment of patients with diffuse large B-cell lymphoma. METHODS: Mean patient survival, days of hospitalization, and chemotherapy costs during treatment were estimated from a Phase III trial in France, Belgium, and Switzerland. Survival during the trial was estimated using the Kaplan-Meier method; survival beyond the trial period was projected based on mortality rates from the Scottish and Newcastle Lymphoma Group database. French diagnosis-related group (DRG) payment schedules were applied to trial data to estimate cost of adverse events and drug administration. We estimated survival and cost-effectiveness [the incremental cost per quality-adjusted life-year (QALY) gained] from 4 years (median clinical trial follow-up period) to 15 years, discounted at a fixed annual rate of 3%. We used published patient preferences. We converted currency to euros, based on 2003 exchange rates. RESULTS: R-CHOP resulted in a 20.6% relative increase in complete response rate (absolute increase from 63% to 76%), and a 31% decrease in risk of death at 4 years (95% CI 8-49%). Over a 15-year time horizon, mean overall survival (OS) duration was estimated to be 6.90 years for R-CHOP and 5.74 years for CHOP, a mean increase in OS of 1.16 years (or 1.07 QALYs). Total direct medical costs were 13,170 euro higher with R-CHOP, with an incremental cost-effectiveness ratio of 12,259 euro per QALY gained. CONCLUSION: R-CHOP significantly increases mean OS up to 4 years compared with CHOP, and its cost-effectiveness ratio compares favorably with other oncology treatments in widespread use.

An international approach to the treatment of Hodgkin's disease in the elderly: launch of the SHIELD study programme.

Utilising the Scotland and Newcastle Lymphoma Group population data for Hodgkin's disease (HD), collected over a 20-year period, it is evident that 20% of patients are over the age of 60 yr at diagnosis. Data from 674 patients are available. This group comprised 346 men and 328 women. Median follow-up was 9.5 yr. In total 361 patients had stage I/II disease. In this cohort overall response and complete response (CR) rates were 88% and 79%, respectively, for treated patients. Overall 308 patients had stage III/IV disease. Among treated patients in this cohort, overall and CR rates were 78% and 59%, respectively. Response data were missing for 26 patients with stage I/II disease and 43 patients with stage III/IV disease. The chlorambucil, vinblastine, procarbazine and prednisolone, mechlorethamine, vincristine, probarbazine and prednisolone and doxorubicin, bleomycin, vinblastine and decarbazine were the commonest chemotherapy regimens, in descending order of frequency, used to treat this cohort of patients. Outcome did not vary with these regimens. Thirty-four other chemotherapy combinations were used, some curative others palliative. These data and all other published studies confirm the need for a prospective, age-defined approach to HD in the elderly. Such an approach needs to be closely linked to issues of comorbidity, an assessment of frailness and the tailoring of specific protocols for the elderly to allow full dose delivery. The Study of Hodgkin Lymphoma In the Elderly/Lymphoma Database programme has now been launched and attempts to address these issues (http://www.shieldstudy.co.uk).

Survival in young patients (less than 40 years) with follicular lymphoma: a population based study by the Scotland and Newcastle Lymphoma Group.

We have examined in a population-based observational study the survival of young patients (less than 40 years) with follicular lymphoma (FL) treated conventionally and followed for up to 17 years (minimum 10, median 13 years). Data were derived from the Scotland and Newcastle Lymphoma Group (SNLG) database from 1986. Histology of all available cases was reviewed to ensure that patients met the modern criteria for diagnosis of FL. Of 55 patients identified from the database, 46 were confirmed to have follicular lymphoma. There were 25 males and 21 females, median age 34 years (range 16-39). Thirty-four patients presented with advanced stage disease (Stages III and IV). The majority of patients received initial treatment with chemotherapy, though 7 had surgery (biopsy or splenectomy) alone and 7 radiotherapy alone. All 12 patients with early stage disease showed a complete response (CR) with initial therapy; 6 relapsed and 2 have died (1 of transformation to high grade non-Hodgkin's lymphoma). Overall survival of patients presenting with stage IIIA disease was 68% at 10 years, and 69% for patients in stages IIIB and IV. The SNLG prognostic index for low grade non-Hodgkin's lymphoma was predictive for overall survival. The 71% overall survival in this patient cohort at 10 years provides a baseline for comparison with the results of a more aggressive approach to treatment.

Quantification of CD38 expression in B-cell chronic lymphocytic leukemia (B-CLL): a comparison between antibody binding capacity (ABC) and relative median fluorescence (RMF).

We have previously shown that quantification of CD38 expression using microbeads of specific antibody binding capacity (ABC) improves the prognostic value of CD38 expression in B-cell chronic lymphocytic leukemia, particularly for Binet Stage A patients. Quantification of CD38 expression using beads is expensive, time consuming and could be difficult to implement in a routine clinical laboratory. The calculation of relative median fluorescence (RMF) using the median fluorescence intensities of the test and control samples, is even more simply and cheaply obtained by flow cytometry and could be used as an alternative way of quantifying antigen expression. The present study demonstrates that RMF is an effective prognostic indicator in B-CLL that correlates closely with ABC in predicting disease-specific survival and time to progression for all patients. RMF predicted overall survival and time to progression in all patients (P < 0.0001 for both), in Binet Stage A patients (P < 0.0001 for both) and in Stage A patients under 60 years (P = 0.0299 and P = 0.0143, respectively). ABC predicted overall survival and time to progression in all patients (P < 0.0001 for both) in Stage A patients (P = 0.0024 and P < 0.0001, respectively) and in Stage A patients under 60 (P = 0.0379 and P = 0.0032, respectively). RMF is more effective than percentage CD38 positivity > 30% or > 20% in predicting disease-specific survival in Stage A patients of all ages (CD38 < > 30%: P = 0.0853, CD38 < > 20%: P = 0.0894) and in those under 60 years old (CD38 < > 30%: P = 0.5438, CD38 < > 20%: P = 0.2872). Also, RMF is more effective in predicting time to progression of Binet Stage A patients less than 60 years (P = 0.0143), while percentage CD38 positivity of 30%, 20% or 7% did not achieve statistical significance (P = 0.1103, = 0.0547, = 0.3399, respectively). We suggest that CD38 RMF could be used clinically as an alternative to ABC to identify patients with B-CLL that are likely to progress and require early treatment.

Follicular lymphoma international prognostic index.

The prognosis of follicular lymphomas (FL) is heterogeneous and numerous treatments may be proposed. A validated prognostic index (PI) would help in evaluating and choosing these treatments. Characteristics at diagnosis were collected from 4167 patients with FL diagnosed between 1985 and 1992. Univariate and multivariate analyses were used to propose a PI. This index was then tested on 919 patients. Five adverse prognostic factors were selected: age (> 60 years vs < or = 60 years), Ann Arbor stage (III-IV vs I-II), hemoglobin level (< 120 g/L vs > or = 120 g/L), number of nodal areas (> 4 vs < or = 4), and serum LDH level (above normal vs normal or below). Three risk groups were defined: low risk (0-1 adverse factor, 36% of patients), intermediate risk (2 factors, 37% of patients, hazard ratio [HR] of 2.3), and poor risk (> or = 3 adverse factors, 27% of patients, HR = 4.3). This Follicular Lymphoma International Prognostic Index (FLIPI) appeared more discriminant than the International Prognostic Index proposed for aggressive non-Hodgkin lymphomas. Results were very similar in the confirmation group. The FLIPI may be used for improving treatment choices, comparing clinical trials, and designing studies to evaluate new treatments.

The prognostic value of CD38 expression and its quantification in B cell chronic lymphocytic leukemia (B-CLL).

A large number of prognostic factors are available to help predict the outcome of patients who present with B-cell chronic lymphocytic leukemia (B-CLL). These include clinical stage, leukemic cell morphology, lymphocyte doubling time, the pattern of infiltration in bone marrow trephine biopsies, cytogenetic abnormalities, p53 function and serum factors such as beta-2 microglobulin. Two recently described major prognostic factors are immunoglobulin heavy chain variable region (IgVH) mutation status and cell membrane expression of CD38. These are both highly significant independent prognostic factors, but are not closely correlated. Whereas IgVH mutational status is a time consuming and demanding technique, only available in a limited number of centres, CD38 expression by flow cytometry is relatively simple and rapidly obtained in most diagnostic laboratories. The predictive value of CD38 expression is enhanced by measurement of antigen density in terms of antibody binding capacity (ABC) rather than as the percentage of cells expressing the antigen. ABC correlates closely with relative median fluorescence (RMF), a parameter which is even more simply and cheaply obtained by flow cytometry. One of these methods of determining CD38 expression should be employed routinely. Recent work suggests that membrane ZAP-70 expression determined by flow cytometry will prove to be an accurate proxy for IgVH mutational status and this assay will be within the reach of any laboratory skilled in flow cytometry. The combination of ZAP-70 expression, CD38 antigen density, p53 function and the concentration of serum factors such as soluble CD23, is likely to provide extremely accurate prognostic information in future studies. This will assist in identifying Stage A patients who may benfit from early and/or more intensive treatment, as well as Stage B and C patients who may require alternative treatment strategies at the outset.

High dose chlorambucil in the treatment of lymphoid malignancies.

High dose chlorambucil has been shown to be an effective single-agent treatment in chronic lymphocytic leukemia (CLL), and to be useful as part of combination chemotherapy in low-grade non-Hodgkin's (NHL) and Hodgkin's disease (HD). In general, it is well tolerated and can be used in an outpatient setting. The optimum dose of chlorambucil has not been defined and there are numerous different dosing schedules available. Pharmacokinetic studies suggest decreased bioavailability with successive cycles, probably due to accelerated metabolism. There is good evidence that regimens which use higher doses of chlorambucil have a better outcome than standard dose therapy. Most of the trials which have compared chlorambucil with fludarabine have not used a higher dose regimen of chlorambucil and cannot truly be described as comparative. There is an increase in the incidence of grade 3 and 4 neutropenia and also of sepsis with fludarabine treatment, compared to chlorambucil. Fludarabine produces a higher initial response rate in CLL but no statistical difference has been shown in long term survival between fludarabine and high dose chlorambucil. In the treatment of lymphoma, single agent chlorambucil does not confer a durable remission. There have been good results with combination chemotherapy regimens such as CID and PECC. The oral route of administration of these combinations makes them particularly useful as part of palliative chemotherapy. A further point to consider is that chlorambucil is very much cheaper than fludarabine and other newer agents. Chlorambucil should not automatically be overlooked in favor of more recently developed drugs such as fludarabine. There is good evidence that the drug is an effective treatment at a suitable dose, and there is a need for randomized trials to compare it fully with other current treatments.

Tumour necrosis factor receptor type II 196M/R genotype correlates with circulating soluble receptor levels in normal subjects and with graft-versus-host disease after sibling allogeneic bone marrow transplantation.

BACKGROUND: A single nucleotide polymorphism in the tumor necrosis factor type II receptor (TNFRII) gene, codon 196, results in the substitution of arginine (R allele) for methionine (M allele). The 196R allele is reportedly associated with an increased susceptibility to autoimmune disease, and donor 196R allele carriage correlates with increased severity of acute graft-versus-host disease (GVHD) after matched unrelated bone marrow transplantation (BMT). METHODS: We investigated the impact of donor and recipient TNFRII genotype on GVHD incidence and severity among 104 adult recipients of myeloablative sibling BMTs. RESULTS: 196R allele frequency was 0.28 among recipients, donors, and controls. There was an increased incidence of acute GVHD among 196R-positive recipients (odds ratio [OR] 3.6, P=0.05). This association was confirmed in multivariate analysis (relative risk 4, P=0.04), correcting for previously established clinical and genetic risk factors. Donor 196R homozygosity was associated with an increased incidence of extensive chronic GVHD (OR 18.5, P=0.02). This association was also confirmed in multivariate analysis (OR 11, P=0.02). To investigate the functional impact of the TNFRII 196 M/R polymorphism, 79 volunteer blood donors were genotyped at this locus, by polymerase chain reaction and single-strand conformational polymorphism analysis, and plasma soluble TNFRII (sTNFRII) levels were measured by ELISA. Mean plasma sTNFRII levels (pg/mL: +/-SEM) were 1224 (+/-26) and 1063 (+/-65) for 196M-postive (196 M homozygous or heterozygous) individuals and 196R homozygotes, respectively (P=0.02). CONCLUSIONS: Because sTNFRIIs can act as TNF antagonists, the association between recipient and donor TNFRII 196R allele status and acute or extensive chronic GVHD incidence, respectively, may reflect reduced circulating sTNFRII.

Clinically significant newly presenting autoimmune thrombocytopenic purpura in adults: a prospective study of a population-based cohort of 245 patients.

The true incidence and prognosis of autoimmune thrombocytopenic purpura (ITP) in adults is unknown. We present the results of a prospective study in a population-based cohort of newly presenting adults (> or = 16 years) with ITP and platelet count of < 50 x 109/l, which took place between 1 January 1993 and 31 December 1999 in the former Northern Health Region in the UK (population 3.08 million). A total of 245 cases were confirmed by bone marrow examination with a median follow-up of 60 months (range 6-78 months). There were 134 females/111 males (1.2:1). Overall incidence was 1.6 per 105 per annum. Absolute incidence was similar for both sexes, with highest age-specific incidence in those aged > 60 years. Thirty patients (12%) presented with frank bleeding, and 28% were asymptomatic. Forty-five patients (18%) received no treatment, and 135 (55%) received first-line treatment only. Thirty patients (12%) underwent splenectomy. There were four deaths (1.6%) from bleeding and/or the complications of therapy in this cohort, but only one was in the acute phase of the illness. The majority of patients (155 out of 245) achieved remission (platelet count > 100 x 109/l), with a further 59 (24%) in partial remission with no symptoms (platelet count 30-100 x 109/l). This population-based study suggests that the traditional view of adult ITP as being a predominantly chronic disease that preferentially affects females needs to be modified.

Intracellular cytokine profiles by peripheral blood CD3+ T-cells in patients with classical Hodgkin lymphoma.

The intracellular profiles of T helper type 1 (Th1) and T helper type 2 (Th2) T-cell cytokines by peripheral blood (PB) CD3+ T-cells in patients with classical Hodgkin lymphoma (HL) has not been investigated before. The present study examines the cytoplasmic production of interleukin (IL) 2, 4, 10, tumour necrosis factor alpha (TNFalpha), and interferon gamma (IFNgamma) by activated PB CD3+ T-cells and compares them with the profiles observed with normal individuals. We report a significantly lower mean level of intracellular IL2, TNFalpha and IFNgamma at any time post-cell activation in cells isolated from patients with HL compared with the normal control group. In contrast, the mean level of cytoplasmic IL4 was significantly higher in the HL compared with the control group. No significant difference between the two groups was observed with IL10. In the HL patient group, there was a significantly higher percentage of CD3+CD8+ T-cells that synthesised IL4 compared with the CD3+CD4+ subpopulation, no such difference was observed in normal controls. The intensity of IL4 (expressed as relative median fluorescence) was significantly higher in the CD3+CD8+ cells of the patients with HL compared with the CD3+CD4+ sub-population, or with normal CD3+CD8+ cells. In conclusion, there is reduced intracellular IL2, TNFalpha and IFNgamma and increased cytoplasmic IL4 production by activated PB T-cells in patients with HL. The CD3+CD8+ sub-population is responsible for the increased levels of IL4.

Hodgkin's disease in the elderly: a population-based study.

This study evaluated the incidence and outcome of Hodgkin's disease (HD) in older patients using a population-based approach. In total, 102 patients (52 men, 50 women) aged >or= 60 years presented in the Northern Health Region of England (population of 3.09 million) between 1 January 1991 and 31 December 1998 and were studied prospectively. The age-specific incidence was 1.97/100,000 for those aged 60-69 years, and 2.18/100,000 for those aged 70 years or over. The median age of the cohort was 70 years (range 60-91) and the median follow up was 63 months (range 20-113). Out of 95 treated patients, 70 (74%) obtained complete or good partial (> 90% response) remissions. In the 60 to 69-year-old group, the disease-specific survival at 5 years was 100% for those presenting with early stage disease and 52% for those with advanced stage disease. In patients aged >70 years the 5 year disease-specific survival was 36% in patients with early stage and 14% for patients with advanced stage disease. The survival of patients with Epstein-Barr virus (EBV)-positive tumours was significantly poorer than that of patients with EBV-negative tumours (P = 0.007); median survival in the former group was 20 months versus undefined in the latter group. In total, 43 deaths were due to progressive HD and five were treatment-related. This study defined the incidence of HD in our population and demonstrated that the prognosis of elderly patients, particularly those with advanced stage disease, has not improved concurrently with that of patients aged < 60 years old. Novel approaches to assessment and treatment are necessary.