Non-Hodgkin’s Lymphoma: Approaches to Current Therapy

This is the beginning of an exceedingly exciting era for the study of the non-Hodgkin’s lymphomas. A new pathologic classification system has been developed to incorporate the biology that has been developed since the introduction of the Working Formulation more than 15 years ago. Large enough numbers of patients have been uniformly treated and followed so as to enable the development of new and accurate prognostic indices. These will allow us to adapt our treatment strategies to the patients’ individual risk of failure. Finally after years of similar treatment strategies that have yielded at best marginal improvement, new therapeutic modalities are now available and offer the promise of improved survival and even lessened toxicity for our patients.

In this supplement to ONCOLOGY, several leaders in the field of lymphoma biology and treatment present their views as to the current status and future opportunities for the diagnosis, staging, and treatment of patients with non-Hodgkin’s lymphomas.

Dr. Randy Gascoyne from the British Columbia Cancer Agency reviews the critical elements in obtaining an accurate diagnosis of lymphoma in “Establishing the Diagnosis of Lymphoma: From Initial Biopsy to Clinical Staging.” He stresses the need for an excisional biopsy and carefully details the circumstances in which needle biopsies currently can and cannot be used. Immunophenotype and molecular analyses are now critical elements in certain lymphoma diagnoses. Dr. Gascoyne reviews where and when they should be obtained.

Coauthors Dr. Dennis Moore from the Cancer Center of Kansas and Dr. Fernando Cabanillas of The University of Texas-M. D. Anderson Cancer Center review the International Prognostic Factor Index and the M. D. Anderson Tumor Score in their article “Overview of Prognostic Factors in Non-Hodgkin’s Lymphoma.” They emphasize the patient and tumor characteristics that are being reflected by the individual prognostic factors. They also describe some of the new biologic factors that may replace clinical factors in future prognostic indices.

The management sections of this supplement follow the Working Formulation and divide patients into low, intermediate, and high grades. Dr. Bruce Cheson from the National Cancer Institute reviews the exciting new opportunities presented by the purine analogs in his article “Current Approaches to Therapy for Indolent Non-Hodgkin’s Lymphoma.” He also reviews the data for interferon treatment of these patients as well as introducing the monoclonal antibodies. Dr. Tom Miller from the Arizona Cancer Center describes the “Management of Intermediate-Grade Lymphomas.” He presents interesting long-term data regarding the treatment of follicular large-cell lymphoma with combination chemotherapy. Dr. Miller also reviews his recently published definitive data on the treatment of early stage, aggressive lymphomas. Finally in this section, Dr. Ian Magrath from the National Cancer Institute reviews the complicated problem of “Management of High-Grade Lymphomas.” Treatment of pediatric patients with high-grade lymphomas has been a major success story. Treatment of adults with the same diagnoses has been much less favorable. Dr. Magrath discusses the possibility of improved survival in the adults using treatment strategies developed for pediatric patients.

Among the newly recognized categories of lymphoma are the mantle cell lymphomas. Dr. James Armitage from the University of Nebraska reviews this exceedingly poor prognosis group of patients stressing current and possible future therapeutics in his article “Management of Mantle Cell Lymphoma.”

Relapsed patients with non-Hodgkin’s lymphomas frequently have been treated with high-dose therapy and stem-cell rescue. Dr. Pat Stiff from Loyola University Medical Center reviews the compelling data for treatment of patients with aggressive lymphoma as well as the more controversial data about the indolent lymphomas. In his article “Blood and Marrow Transplantation in Relapsed or Refractory Non-Hodgkin’s Lymphoma,” he also discusses the controversial topics of timing of the transplant, marrow purging, and post-transplant immunotherapy.

Finally, Dr. David Maloney from Fred Hutchinson Cancer Research Center and Dr. Oliver Press from the University of Washington discuss the background, current data, and future prospects for treatment with monoclonal antibodies in their article “Newer Treatments for Non-Hodgkin’s Lymphoma: Monoclonal Antibodies.” The authors review both the unconjugated and the conjugated monoclonal antibodies.

It is our hope that this supplement will prove to be useful to the practicing physician faced with a patient newly diagnosed with non-Hodgkin’s lymphoma as well as for the experienced lymphoma investigator.