The clinical characteristics of B-cell lymphoma (BCL) were studied through the combined analysis of six clinical trials conducted by the Japan Clinical Oncology Group - Lymphoma Study Group (JCOG-LSG) for aggressive lymphoma in the 1990s, before the introduction of rituximab. Through a central pathological review, 829 patients were diagnosed with BCL according to the World Health Organization classification and treated with doxorubicin-containing combination chemotherapies. Of these patients, 642, 104, 30, and 24 patients were diagnosed with diffuse large B-cell lymphoma (DLBCL), follicular lymphoma (FL), mantle cell lymphoma (MCL), and marginal zone lymphoma (MZL), respectively. The overall survival (OS) of FL and MZL patients was higher than that of patients with DLBCL and MCL. The OS of the MCL patients was higher than that of DLBCL patients in the first 5 years, but MCL had the lowest survival after 5 years. The OS of DLBCL patients was clearly stratified by the international prognostic index and showed data compatible with that of aggressive lymphoma in the pre-rituximab era. These results established the clinical aspects of BCL in a large number of patients treated in prospective studies during the pre-rituximab era in Japan.

Peripheral T‐cell lymphomas (PTCL) are a heterogeneous group of non‐Hodgkin lymphomas with poor prognosis. Their molecular pathogenesis has not been entirely elucidated. We previously showed that 6q24 is one of the most frequently deleted regions in primary thyroid T‐cell lymphoma. In this study, we extended the analysis to other subtypes of PTCL and performed functional assays to identify the causative genes of PTCL that are located on 6q24. Genomic loss of 6q24 was observed in 14 of 232 (6%) PTCL cases. The genomic loss regions identified at 6q24 always involved only two known genes, STX11 and UTRN. The expression of STX11, but not UTRN, was substantially lower in PTCL than in normal T‐cells. STX11 sequence analysis revealed mutations in two cases (one clinical sample and one T‐cell line). We further analyzed the function of STX11 in 14 cell lines belonging to different lineages. STX11 expression only suppressed the proliferation of T‐cell lines bearing genomic alterations at the STX11 locus. Interestingly, expression of a novel STX11 mutant (p.Arg78Cys) did not exert suppressive effects on the induced cell lines, suggesting that this mutant is a loss‐of‐function mutation. In addition, STX11‐altered PTCL not otherwise specified cases were characterized by the presence of hemophagocytic syndrome (67% vs 8%, P = 0.04). They also tended to have a poor prognosis compared with those without STX11 alteration. These results suggest that STX11 plays an important role in the pathogenesis of PTCL and they may contribute to the future development of new drugs for the treatment of PTCL.

Aim The purpose of this multicenter cooperative study was to elucidate the clinical features of hepatitis B virus (HBV) reactivation by chemotherapeutic agents and the patient outcomes after HBV reactivation by a retrospective review of accumulated patients’ medical records. Methods Records of a total of 27 patients (hematological malignancy, 14 patients; solid tumor, 13 patients) from 11 institutions who were diagnosed between June 2005 and October 2010 as having HBV reactivation following chemotherapy were reviewed. Results Of the 27 patients with reactivation, 16 patients were hepatitis B surface antigen (HBsAg) positive and 11 were HBsAg negative prior to the commencement of chemotherapy. Of the 11 patients who were HBsAg negative prior to the chemotherapy, 10 had hematological malignancies and one had a solid tumor. Of the 14 patients with hematological malignancies with HBV reactivation enrolled in the study, the reactivation occurred more than 12 months after the completion of chemotherapy in five patients (36%); on the other hand, none of the patients (0%) with solid tumors developed HBV reactivation more than 12 months after the completion of chemotherapy. Of the 24 patients who had acute liver dysfunction at the diagnosis of HBV reactivation, nine (38%) had severe hepatitis and seven (29%) died of liver failure. Conclusion Most of the patients with HBV reactivation who were HBsAg negative prior to the chemotherapy had underlying hematological malignancies. Furthermore, patients with hematological malignancies often developed late‐onset HBV reactivation. The prognosis of patients who develop acute liver dysfunction as a complication of HBV reactivation is extremely dismal.

This study evaluated the clinical features of 276 patients with aggressive adult T-cell leukaemia-lymphoma (ATL) in 3 Japan Clinical Oncology Group (JCOG) trials. We assessed the long-term survivors who survived >5 years and constructed a prognostic index (PI), named the JCOG-PI, based on covariates obtained by Cox regression analysis. The median survival time (MST) of the entire cohort was 11 months. In 37 patients who survived >5 years, no disease-related deaths in 10 patients with lymphoma-type were observed in contrast to the 10 ATL-related deaths in other types. In multivariate analysis of 193 patients, the JCOG-PI based on corrected calcium levels and performance status identified moderate and high risk groups with an MST of 14 and 8 months respectively (hazard ratio, 1·926). The JCOG-PI was reproducible in an external validation. Patients with lymphoma-type who survived >5 years might have been cured. The JCOG-PI is valuable for identifying patients with extremely poor prognosis and will be useful for the design of future trials combining new drugs or investigational treatment strategies.

Based on the advances in research on the clinicopathophysiology of adult T-cell leukemia-lymphoma (ATL), Japanese researchers collected and evaluated cases of smoldering ATL exhibiting primary cutaneous manifestation but showing poor prognosis. Macroscopic findings of skin eruptions were categorized into the patch, plaque, multipapular, nodulotumoral, erythrodermic and purpuric types, as previously reported. Pathological findings were divided into low or high grade based on epidermotropism, tumor cell size and perivascular infiltration. Eight eligible cases were evaluated among 14 collected cases. Macroscopic findings were nodulotumoral in six cases, a subcutaneous tumor in one case and plaque in one case, and the number and size were heterogeneous in each case. Pathological findings of all eight cases were T-cell lymphoma, high-grade type (pleomorphic, medium or large size), with prominent perivascular infiltration and scant epidermotropism. To diagnose such cases as the lymphoma type of ATL, extranodal primary cutaneous variant, it is essential to examine each case carefully, including cutaneous lesions at onset, lymph nodes and other organ involvement using computed tomography (CT) and/or positron emission tomography/CT, as well as the percentage of abnormal lymphocytes in peripheral blood. Based on the results of an ongoing nationwide survey on ATL, ATL with cutaneous lesions will be analyzed to investigate the incidence and prognosis of the so-called lymphoma type of ATL, extranodal primary cutaneous variant.

Primary peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS) of the thyroid is an extremely rare neoplasm. Six cases of primary PTCL-NOS of the thyroid were analysed for clinicopathological features and genomic alteration patterns using oligo-array comparative genomic hybridization. All patients had a diffusely enlarged thyroid and three cases showed leukaemic manifestation. Five of the six cases had anti-thyroid antibodies and the remaining case showed hypothyroidism, suggesting that all cases had autoimmune thyroiditis. Except for one early relapsed case, the remaining five patients are alive and three of these five individuals have survived for 70 months or more. Interestingly, two cases showed spontaneous regressions after partial thyroid biopsy without any therapy. Leukaemic manifestation disappeared after irradiation of the thyroid mass in another two cases. The tumour cells were positive for CD3, CD4 and CXCR3 in all cases, suggesting that the tumour cells are of a type 1 helper T-cell origin. All six cases showed genomic alterations that were different from those previously reported for PTCL-NOS. The loss of 6q24·2 was characteristic and was detected in four of the six cases. These results suggest that primary PTCL-NOS of the thyroid arising from autoimmune thyroiditis is a distinct disease entity among heterogeneous PTCL-NOS.

The role of dacarbazine in ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) therapy in Hodgkin lymphoma (HL) remains unclear. This phase II study assessed the efficacy and safety of ABV therapy with an increased doxorubicin dose (30 mg/m(2)) in advanced-stage HL. The primary endpoint was complete response rate (%CR). Patients received six or eight cycles of ABV every 4 weeks followed by involved-field radiation therapy (IFRT) in residual disease and initial bulky mass. Seventy-two patients were enrolled. An interim analysis in 46 assessable patients showed that %CR had exceeded the stopping criteria. However, the 2-year progression-free survival (%PFS) rate of 49.4% (95% confidence interval [CI] 32.2-66.6) was markedly lower than the 79.2% PFS (95% CI 70.6-87.7) seen in our previously reported study (JCOG9305) of ABVd with two-thirds the dose of dacarbazine of the original ABVD. Therefore, the study was closed early. The %CR in the 70 eligible patients after ABV was 31.4% (95% CI 20.9-43.6) and was increased to 70.0% (95% CI 57.9-80.4) after the addition of IFRT. ABV was inferior to ABVd for PFS in patients with advanced HL, suggesting that dacarbazine is indispensable in ABVD/ABVd.

OBJECTIVETo evaluate the efficacy and safety of intensive post-remission chemotherapy for untreated patients aged 15-69 years with adult acute lymphoblastic leukemia and lymphoblastic lymphoma in a multicenter Phase II study.METHODSThe chemotherapy regimen consisted of induction, post-remission and maintenance for 2 years. The primary endpoint was 5-year progression-free survival, and secondary endpoints included complete remission rate, overall survival and adverse events. Among 115 patients enrolled, 108 eligible patients [median age, 33.5 years (range, 15-69)] including 96 acute lymphoblastic leukemia and 12 lymphoblastic lymphoma were assessed. Other major characteristics were male 50%, T-cell phenotype 21%, Philadelphia chromosome 22%, B-symptom+ 35% and performance status 2/3 22%.RESULTSEighty-seven patients achieved complete remission (81%; 95% confidence interval 72-88%), while five (5%) died during the chemotherapy protocol. The median overall survival and progression-free survival were 1.8 years (95% confidence interval, 1.5-2.6) and 1.2 years (95% confidence interval, 0.8-1.6), respectively. Their 5-year overall survival and progression-free survival were 29 and 28%, respectively. The 5-year overall survival of 31 patients who underwent allogeneic (n = 19) or autologous (n = 12) stem cell transplantation during first complete response was 51%. Major non-hematologic toxicities of Grade 3 or greater were infections (21%) and pulmonary complications (6%). When compared with the investigators' previous Phase II trials, JCOG9402 improved progression-free survival and overall survival when compared with JCOG8702; however, it did not show improvement when compared with JCOG9004.CONCLUSIONSAlthough the intensified induction and post-remission chemotherapy was feasible and 28% of the patients with adult acute lymphoblastic leukemia or lymphoblastic lymphoma achieved long-term progression-free survival, JCOG9402 did not show improvement.

The regimen of cyclophosphamide, doxorubicin, vincristine, and prednisolone, known as CHOP therapy, has been established as the standard treatment for aggressive non-Hodgkin’s lymphoma (NHL). Although patients categorized as low (L) and low–intermediate (L–I) risk using the International Prognostic Index have favorable prognoses in Western countries, the efficacy and safety of CHOP therapy has not been prospectively evaluated in Japan. We conducted a phase II study of CHOP in L and L–I risk Japanese patients, evaluating overall survival (OS) as the primary endpoint. A total of 213 patients were enrolled and treated with eight courses of CHOP. Efficacy was evaluated in 168 eligible patients (L risk, 87; L–I risk, 81). Five-year OS rates in all eligible, L, and L–I risk patients were 68 % [95 % confidence interval (CI): 61–76 %], 73 % (95 % CI: 63–82 %), and 64 % (95 % CI: 53–74 %), respectively. The major toxicity observed was grade 4 neutropenia (64 %). Grade 4 non-hematological toxicities were observed as follows: one case each of paralytic ileus, convulsions, hypoxemia due to interstitial pneumonia, and reactivated fulminant hepatitis B. These results show reasonable efficacy and safety of the CHOP regimen in Japanese patients with lower risk aggressive NHL (UMIN-CTR Number C000000053).

National Cancer Center Hospital, Tokyo, JCOG Data Center, National Cancer Center, Tokyo, Kumamoto Medical Center, Kumamoto, Hokkaido Cancer Center, Sapporo, Sapporo Hokuyu Hospital, Sapporo, Niigata Cancer Center, Niigata, Saga University, Saga, Tokyo Medical University, Tokyo, Nagasaki University, Nagasaki and Nagoya Medical Center, Nagoya, Japan Present address: Tenri Hospital, Tenri, Japan. Present address: Bristol-Myers Squibb, Tokyo, Japan. Present address: Saiseikai Central Hospital, Tokyo, Japan.

The Lymphoma Study Group (LSG) of the Japan Clinical Oncology Group (JCOG) was initiated in 1978 by five institutions and now has 47 members. JCOG-LSG has focused on combined modalities, dose intensification and the incorporation of new agents for major disease entities of lymphoid malignancies. More than 30 trials including 10 randomized trials have been conducted for aggressive non-Hodgkin's lymphoma (NHL), adult T-cell leukemia-lymphoma (ATL), lymphoblastic lymphoma/acute lymphoblastic leukemia, Hodgkin's lymphoma (HL), multiple myeloma, NK/T-NHL and indolent B-NHL, and correlative epidemiological and pathological studies have been performed on human T-lymphotropic virus type-I and T/B cell phenotypes. The first trials for aggressive NHL revealed significant differences in the prognosis of ATL, non-ATL T-NHLs and B-NHLs, establishing a subclassification of ATL, and leading to the establishment of standard therapies for ATL and localized nasal natural killer/T-NHL. Recently, for B-NHLs including diffuse large B-cell lymphoma, mantle cell lymphoma, and indolent B-NHLs, regimens incorporating rituximab have been evaluated. The JCOG-LSG trials for HL led to the approval of dacarbazine for the National Health Insurance in Japan. The multicenter trials by the JCOG-LSG combining new modalities such as molecular-targeting agents will contribute to further improvements in the treatment of lymphoid malignancies.

Abstract Abstract 881 Background. The Japan Clinical Oncology Group (JCOG)-Lymphoma Study Group (LSG) conducted 3 clinical trials in the 1990s for aggressive ATL, i.e. acute, lymphoma, and unfavorable chronic types, associated with human T-lymphotropic virus type-I. The prognosis of aggressive ATL patients (pts) is still poor, but the 5-year survival rate was improved from 5% in the 1980s to 15% in a JCOG study in late 1990s. To characterize long-term survivors and to develop a new predictive model for aggressive ATL, we performed a combined analysis of enrolled pts in the 3 JCOG studies. Methods. A total 276 pts with aggressive ATL were registered in 3 consecutive JCOG-LSG trials exclusively against aggressive ATL, i.e. JCOG9109, a phase II (pII) study of LSG11 consisting of pentostatin, VCR, ETP, PSL and DOX; JCOG9303, a pII study of LSG15 consisting of VCAP-AMP-VECP; and JCOG9801, a pIII study comparing modified (m) LSG15 with CHOP-14. The pts were analyzed for their prognosis, the effects of central nervous system (CNS) prophylaxis in the protocol treatment and allogeneic hematopoietic cell transplantation (allo-HCT) after the protocol treatment, and the outcome of long-term survivors with a follow-up survey. To build a predictive index, multivariate analyses with a Cox proportional hazard model were conducted using the test sample of 193 pts without missing covariate data from the entire cohort of 276 pts. Validation was carried out using external data for 136 pts, who were independent from those included in the JCOG studies. Results. The MST, 5- and 8-yesr OS rates of the entire cohort of 276 pts were 10.9 months, 13.6% and 10.0%, respectively. The median and longest follow-up periods were 10.9 months and 17.5 years, respectively. The differences of CNS prophylaxis by each regimen did not significantly affect the CNS relapse rate. We analyzed 269 eligible pts (acute 170, lymphoma 78, chronic 21). In 67 pts who survived for more than 2 years, there were 38 (22%) pts with acute type, 21 (28%) with lymphoma type and 5 (24%) with chronic type. The major proportion of relapse in pts with acute type occurred within 2 years after initiating chemotherapy, and occurred earlier than in pts with other types. In 37 pts who survived for more than 5 years (acute 22 (13%), lymphoma 8 (10%), chronic 7 (33%)), there were no disease-related deaths among lymphoma type pts, which was in contrast to the 10 disease-related deaths that occurred in pts with acute or chronic type during the follow-up period. The numbers of pts achieving CR and the other response category at the end of the protocol treatment were 24 and 13 in the 37 pts who survived for more than 5 years, respectively, and 11 and 1 in the 12 who survived for more than 10 years, respectively. Six of the 37 pts who survived for more than 5 years and 2 of 12 who survived for more than 10 years had received allo-HCT. In a test sample of 193 pts, two unfavorable factors associated with OS, high calcium (Ca) level and ECOG performance status (PS) of 2 to 4, were identified. The hazard ratio (HR) [95% confidence interval (CI)] of Ca and PS were 1.574 [1.09–2.28] and 1.554 [1.12–2.16], respectively. Considering the potential for clinical usage, four categories using these two factors were combined into a predictive index with 2 strata, thus resulting in pts with both Ca<5.5 mEq/l and PS 0, 1, and 7.9 months, 3.7% and 2.5% in those with Ca>=5.5 mEq/l and/or PS 2 to 4, respectively (Fig 1). The HR [95% CI] was 1.926 [1.42–2.61]. The predictive model was reproducible in the validation set. Conclusion. There were no disease-related deaths in 8 lymphoma type pts who survived for more than 5 years, suggesting that about 10% of pts with lymphoma type may be curable. We developed a predictive model for aggressive ATL based on Ca and PS, however, the MST was only 14.3 months even in the better prognostic group. To further improve the outcome, a pII trial of VCAP-AMP-VECP followed by allo-HCT (JCOG0907) and a randomized pII study of VCAP-AMP-VECP with or without anti-CCR4 antibody are underway. Disclosures: No relevant conflicts of interest to declare.

The Japan Clinical Oncology Group conducted two multicenter phase II trials in 200 patients with advanced Hodgkin lymphoma (HL) in the 1990s. Among 181 patients whose histopathological specimens were available and reviewed by 6 hematopathologists, 167 (92.3%) were diagnosed with HL. Five-year overall survival (OS) among these 167 patients was 88.3%, including 89.2% among nodular sclerosis and 82.2% among mixed cellularity cases. International prognostic score was not closely associated with OS. Seven unfavorable prognostic factors for OS on univariate analysis were male, B symptoms, clinical stage of III or IV, elevated serum LDH, elevated alkaline phosphatase, elevated beta2-microglobulin, and pathological subtype (mixed cellularity and lymphocyte depletion). On multivariate analysis, male [HR 3.30 (95% CI 1.15-9.52, p = 0.027)] and elevated serum LDH [HR 2.41 (95% CI 1.07-5.43, p = 0.034)] were independent factors for OS. Based on these prognostic factors, the 5-year OS was 95.7% in the low-risk group (no adverse factor), 87.9% in the intermediate-risk group (1 adverse factor) and 73.3% in the high-risk group (2 adverse factors). This simple prognostic model for HL warrants further validation studies.

Although ABVD (doxorubicin, bleomycin, vinblastine and dacarbazine) therapy has been regarded as a standard of care for advanced-stage Hodgkin lymphoma (HL) since 1992, there has been no prospective data of ABVD therapy in Japan. To investigate the efficacy and safety of ABVd therapy with the lower dose of dacarbazine (250 mg/m(2)) in patients with newly diagnosed stage II-IV HL, Lymphoma Study Group of Japan Clinical Oncology Group conducted a phase II study. The primary endpoints were complete response rate (%CR) and progression-free survival (PFS). A total of 128 patients with age less than 70 years were enrolled and received 6-8 cycles of ABVd followed by radiation to initial bulky mass. The %CR in 118 eligible patients was 81.4% [95% confidence interval (CI) 73.1-87.9%]. Major toxicity was grade 4 neutropenia (45.3%). Grade 3 nausea/vomiting was the most frequent non-hematological toxicity (10.9%). Transient grade 4 constipation, infection (abscess), hypoxemia and hyperbilirubinemia were observed in 4 patients. No treatment-related death was observed. PFS and overall survival at 5 years were 78.4% (95% CI 70.9-85.9%) and 91.3% (95% CI 86.1-96.5%), respectively. In conclusion, ABVd is effective in Japanese patients with stage II-IV HL with acceptable toxicities (UMIN-CTR Number: C000000092).

Peripheral T- and NK-cell lymphomas (PT/NKCLs) are relatively rare, and few studies have validated the International Prognostic Index (IPI) for PT/NKCLs in prospective clinical trials. Histopathological specimens from 136 patients, enrolled in six prospective multicenter trials of doxorubicin-containing regimens, with PT/NKCLs were reviewed by six hematopathologists following the WHO classification. This combined analysis demonstrated that the IPI was not predictive of prognosis for patients with PT/NKCLs as previously shown by GELA. In a univariate analysis, low total serum protein (TP) and albumin levels, gastrointestinal tract involvement, and histologic subtype (extranodal NK/T-cell lymphoma, nasal type, and peripheral T-cell lymphoma, unspecified) were significantly associated with reduced survival. In a multivariate analysis, TP (p = 0.004) and histologic subtype (p = 0.024) remained significant. We discuss the need to establish the importance and meaning of TP and to develop new strategies for patients with PT/NKCLs allowing for TP, especially with worse histologic subtypes.