Large cell non-Hodgkin lymphoma of childhood: clinical characteristics and outcome

Less is known about the clinical features and treatment outcome in pediatric large cell non-Hodgkin lymphoma (NHL) than the lymphoblastic and small noncleaved cell subtypes of NHL. To characterize presenting features and assess possible risk factors associated with this diagnosis, we analyzed data for 91 patients treated on a succession of multiagent regimens from 1975 to 1990. Five-year event-free survival (EFS) (+/- SE) was related to disease extent (St Jude system): stage I (n = 24), 95% +/- 5%; stage II (n = 20), 84% +/- 9%; stage III (n = 38), 50% +/- 10%; and stage IV (n = 9), 22% +/- 11%. Advanced stage disease, age < or = 5 years and serum LDH > 500 U/l were associated with poorer EFS in the univariate model (p < 0.001, 0.005, and 0.002, respectively). In the multivariate model, advanced stage and age retained prognostic significance (p = 0.001 and 0.02, respectively), but LDH did not. Among limited stage cases, age < or = 5 years was the only adverse risk feature (p = 0.016); treatment era (pre- vs. post-1979) was the only significant feature in patients with advanced disease (p = 0.004). Intrathoracic primaries were associated with a better outcome than other sites among the 38 stage III patients (p = 0.005). Only one of eight patients with bone marrow disease remains failure-free. The excellent results for limited stage pediatric large cell NHL permit consideration of treatment modifications to decrease toxicity; for cases with advanced disease, especially those with bone marrow involvement, novel therapeutic approaches are clearly needed.

Thyroid lymphoma. The case for combined modality therapy

BACKGROUND

Radiation therapy with or without surgery is generally considered standard treatment for lymphoma of the thyroid. Because of the small number of cases, the role of chemotherapy or combined modality treatment is difficult to determine.

METHODS

The published literature was analyzed, supplemented by a series from Yale, for the incidence of local and distant relapse after radiation therapy, chemotherapy, or combined modality treatment for Stage I-II thyroid lymphoma. Patients with advanced disease or in whom radiation was probably inadequate were excluded. Only patients receiving an anthracyline-based regimen were considered in the group with chemotherapy. Patients receiving single agents or non-anthracycline-based regimens were excluded from analysis or, if they also received radiation, were included in the group that received radiation only.

RESULTS

Including a series from Yale, a total of 211 patients with Stage IE and IIE thyroid lymphoma were identified. Distant and overall relapse rate were significantly lower in the group that received combined modality treatment. Local relapse was also less, but the difference was not statistically significant. In a small number of patients with disease confined to the neck, the results with radiation were similar to combined modality treatment if the mediastinum was included in the treatment port.

CONCLUSION

Although mucosa-associated lymphoma tissue lymphomas are thought to have a low distant recurrence rate and are therefore often treated with local therapy alone, a review of the published literature suggests that 30% of thyroid lymphomas with clinically localized disease will have a distant relapse. The addition of chemotherapy to radiation significantly lowered distant and overall recurrence.

Paraneoplastic pemphigus appearing as bullous pemphigoid-like eruption after palliative radiation therapy

Paraneoplastic pemphigus is a recently described disease in which patients have polymorphous skin lesions suggestive of both erythema multiforme major and pemphigus vulgaris in association with internal neoplasms, especially non-Hodgkin's lymphoma. These patients have characteristic autoantibodies that bind specific epidermal proteins. A Nikolsky-negative bullous pemphigoid-like eruption developed within the radiation therapy field in a 72-year-old man receiving palliative treatment for recurrent large cell lymphoma. The eruption rapidly progressed to a Nikolsky-positive bullous process more typical of pemphigus vulgaris with extensive involvement of respiratory epithelia. Despite aggressive treatment with high-dose corticosteroids and antibiotics, the patient rapidly succumbed. Results of immunofluorescence studies and autopsy findings confirmed the diagnosis of paraneoplastic pemphigus.

Oral T-cell lymphoma associated with celiac sprue. A case report

Celiac sprue, also called nontropical sprue, is a malabsorption syndrome with symptoms that are triggered mainly by gluten ingestion. Non-Hodgkin's lymphoma of the gastrointestinal tract has been reported in patients with a long history of celiac sprue. This case report describes the occurrence of primary oral lymphoma in such a patient. This case is unusual because lymphomas associated with celiac sprue usually develop in the small intestine or in the stomach, and primary lymphoma in the mouth is itself uncommon.

MACOP-B +/- radiation therapy for diffuse large cell lymphoma. Analysis of the Stanford results according to prognostic indices

BACKGROUND

The efficacy and toxicity of the MA-COP-B regimen were assessed after outstanding results were reported in diffuse large cell lymphoma (DLCL) by the Vancouver group. The results are reported according to several proposed prognostic indices, including the recent International Prognostic Factors (IPF) Project.

METHODS

Forty-seven patients with untreated DLCL received MACOP-B chemotherapy. Thirty patients, most of whom had bulky disease, also received consolidative radiation therapy (RT). Patient characteristics include median age of 42 years, Stage III/IV (57%), bulky or symptomatic Stage II disease (43%), elevated lactic dehydrogenase (81%) and at least one extranodal site (72%).

RESULTS

At a median follow-up of 3.3 years, overall survival was 57% and freedom from progression (FFP) was 52%. The 3-year FFP data were related to tumor extent: 74% for limited stage versus 38% for extensive disease. These data correlated well with four prognostic indices reported in the literature. The IPF index accurately identified low-, intermediate-, and high-risk subgroups.

CONCLUSIONS

Patients with limited or low-risk DLCL have an excellent prognosis with MACOP-B +/- RT. These results do not support the use of consolidative high-dose therapy and bone marrow transplantation in patients with limited disease, even if bulky or accompanied by an elevated lactic dehydrogenase. Compared to historical CHOP data, MACOP-B +/- RT does not appear to improve outcome for those patients with poor prognostic features, most of whom will fail. The IPF index is a simple, accurate method of distinguishing high-risk patients who require new therapeutic initiatives.

Gallium-67 radiotoxicity in human U937 lymphoma cells

Promising clinical results have been obtained with radiolabeled antibodies in lymphoma patients. The higher uptake by lymphomas of 67Gallium (67Ga) compared with monoclonal antibodies makes selective radiotherapy by the widely available 67Ga appealing. However, the gamma radiation of 67Ga used in scintigraphy is considered to be almost non-toxic to lymphoma cells. However, in addition to photon radiation 67Ga emits low energy Auger electrons and 80-90 keV conversion electrons which could be cytotoxic. The objective of the present study was the assessment of radiotoxicity of 67Ga on a lymphoid cell line: U937. Proliferation (MTT-assay) and clonogenic capacity (CFU-assay) were measured after 3 and 6 days incubation with 10, 20 and 40 microCi ml-1 67Ga. Growth inhibition was 36% after 3 days incubation and 63% after 6 days incubation with 40 microCi 67Ga ml-1. Clonogenic capacity was reduced by 51% after 3 days and 72% after 6 days incubation with 40 microCi ml-1 67Ga. A survival curve showed an initial shoulder and became steeper beyond 200-250 pCi cell-1 (low linear energy transfer type). Iso-effect doses of 67Ga and 90Yttrium (90Y) were determined. The iso-effect dose of 40 microCi 67Ga ml-1 (cumulative dose of conversion electrons 306 cGy) was 2.5 microCi 90Y ml-1 (cumulative dose 494 cGy) and the iso-effect dose of 80 microCi 67Ga ml-1 was 5.0 microCi 90Y/ml. The main cytotoxic effect of 67Ga seems to be induced by the 80 keV conversion electrons. We conclude that the conversion electrons of 67Ga have a cytotoxic effect on U937 cells and that in our experiments a 16-fold higher microCi-dose of 67Ga than of 90Y was needed for the same cytotoxic effect. We believe that 67Ga holds promise for therapeutic use.

Successful treatment of non-Hodgkin's lymphoma in a patient with common variable immunodeficiency

A case of common variable immunodeficiency (CVID) who developed non-Hodgkin's lymphoma (NHL) of the rectum is reported. A 22-year-old male student in whom CVID was diagnosed at 7 years of age was referred to our department for the treatment of rectal NHL. The patient had stage IE disease confined to the rectum after clinical diagnostic procedures. He was initially treated with radiation therapy alone, but a relapse soon occurred in the paraaortic lymph nodes. He was successfully treated with CHOP-Bleo chemotherapy and supplementation with immunoglobulin preparations. He has since remained free of NHL and infectious complications for over 30 months despite his persistent immunodeficiency.

Multiagent chemotherapy in the salvage cure of ocular lymphoma relapsing after radiotherapy

The eye has traditionally been regarded as a sanctuary site for drugs, but recent publications have shown evidence of penetration by drugs and subsequent clinical response of intraocular lymphomas. In this report, a chemotherapy regimen, including high dose methotrexate and cytosine arabinoside, was used to re-induce remission in a patient with intraocular lymphoma relapsing locally after prior radiotherapy. She remains disease free 18 months later.

Brief chemotherapy, involved field radiation therapy, and central nervous system prophylaxis for paranasal sinus lymphoma

Lymphoma of the paranasal sinus is a rare tumor characterized by bulky local disease, early systemic dissemination, and a propensity for central nervous system (CNS) spread. Treatment with radiation alone generally has been disappointing. Based on previous encouraging reports of initial brief chemotherapy followed by involved field radiation therapy (IFRT) for localized large cell lymphoma, four consecutive patients with paranasal sinus lymphoma were treated with 6 weeks of chemotherapy followed by IFRT and CNS prophylaxis. All patients had bulky localized disease and diffuse large cell lymphoma. Complete response was seen in all patients, and none have had a relapse (minimum follow-up, 25 months; range, 25 to 32 months). Chemotherapy and radiation therapy were well tolerated. One patient developed an osteogenic sarcoma in the radiation field 32 months after completion of therapy. Administration of early frequent chemotherapy followed by IFRT and CNS prophylaxis appears to be an effective treatment strategy for patients with localized large cell lymphoma of the paranasal sinuses.

Effects of radiotherapy determined by 11C-methyl-L-methionine positron emission tomography in patients with primary cerebral malignant lymphoma

Two cases of histologically proven primary cerebral malignant lymphoma were examined serially with positron emission tomography (PET) using 11C-methyl-L-methionine (11C Met). Lesions delineated by 11C Met accumulation extended beyond enhancing areas on either X-ray computed tomography (CT) or magnetic resonance imaging. High uptake of 11C Met accurately showed biologically active and residual tumours, at a time when disappearance of a contrast-enhancing lesion on CT seemed to indicate involution. PET provides valuable information on the extent of tumour and assessment of radiotherapy in malignant lymphoma.

Stage IE primary malignant lymphomas of the uterine cervix

The experience of the authors with primary non-Hodgkin's lymphoma of the uterine cervix from 1980 to 1986 included five Ann Arbor Stage IE cases successfully managed by meticulous staging and radiation therapy. The clinicopathologic features of the patients are described and compared with 38 previously reported Stage IE cases. When all 43 patients were evaluated, the median age was 40 years of age (range, 20 to 80 years of age) and 77% were premenopausal. Most patients (74%) reported abnormal vaginal bleeding, although approximately 20% were asymptomatic. The primary cervical tumors were typically of large size, with half exceeding 4 cm in diameter. Using the International Federation of Gynecology and Obstetrics (FIGO) system for staging cervical cancer, stage distribution was 44% Stage I, 42% Stage II, 12% Stage III, and 2% Stage IV. Histologically, approximately 70% were of the diffuse, large cell type (Working Formulation). External beam radiation therapy supplemented by brachytherapy or hysterectomy was used for 76% of the patients reviewed. There was only one treatment failure among the 28 patients whose treatment included radiation and whose cases were followed for at least 2 years. This experience and a review of the literature indicate that most cases of primary lymphoma of the uterine cervix are Ann Arbor Stage IE, and can be cured with traditional combinations of surgery and radiation therapy after careful evaluation.

[Large-cell mediastinal lymphoma]

The authors report a case of large-cell mediastinal lymphoma, a recently defined, fairly infrequent, highly aggressive tumor which responds scarcely to conventional chemotherapy. On the basis of its histopathology, the tumor must be classified as a highly malignant non-Hodgkin lymphoma. The latest data in the literature give cause for a little more optimism thanks to the introduction of the most recent schemes of chemotherapy combined with large-dose radiation for consolidation. Our patient was treated with chemotherapy CHOP high-dose radiation which resulted in complete disappearance of the mediastinal mass and rapid remission of the severe symptoms of mediastinal compression. After about 30 months, instrumental and laboratory findings confirm the persistence of the complete remission.

Primary central nervous system lymphoma in acquired immune deficiency syndrome. A clinical and pathologic study with results of treatment with radiation

Primary central nervous system (CNS) lymphoma occurs frequently in patients with the acquired immune deficiency syndrome (AIDS). Seventeen patients with AIDS and biopsy-proven CNS lymphoma were treated with whole-brain radiation. At presentation, most patients were severely debilitated from previous AIDS-related illnesses. Patients generally had focal neurologic symptoms such as seizures and paralysis. Headaches and mental status changes, often noticed after hospital admission, seldom brought our patients to seek medical attention. Computed tomography (CT) scan showed low-density, contrast-enhancing, mass lesions with variable amounts of peritumor edema. Size, location, and pattern of contrast enhancement of the lesions varied. No specific pattern was seen that could be used to distinguish between CNS lymphoma, toxoplasmosis, or other CNS diseases that occur in patients with AIDS. Biopsy results showed angiocentric, high-grade, large cell tumors with frequent necrosis. Immunohistochemical analysis showed B-cell phenotype with small amounts of T-cells, presumably reactive. All patients received irradiation to the whole brain with parallel opposed fields. A variety of doses and treatment regimens were used. Mean survival was only 72 days. Survival was longer in patients with higher pretreatment Karnofsky scores. The correlation between dose and survival was not significant. At completion of therapy, most patients showed improvement in Karnofsky score and had partial improvement in neurologic symptoms. CNS lymphomas in patients with AIDS are responsive to radiation. Posttreatment CT scans showed regression of tumors. Autopsy examinations showed regression of tumors, but also showed concurrent CNS infections, AIDS encephalopathy, and radiation-induced changes within the normal CNS tissue. Opportunistic infections rather than cerebral herniation or uncontrolled lymphoma was the most common cause of death.

Ring-enhanced primary intracranial malignant lymphoma--report of two cases

Two nonimmunosuppressed patients with primary intracranial malignant lymphoma demonstrated ring-enhanced lesion on postcontrast CT scans. One patient underwent total removal of the tumor and the other patient biopsy, both followed by whole brain irradiation. Histological examination revealed the tumors contained diffuse large cells and necrosis in the central region. The possible mechanisms of ring enhancement may represent central necrosis of the rapidly growing tumor, but is probably not related to the prognosis.

Stages I and II diffuse large cell lymphomas: prognostic factors and long-term results with CHOP-bleo and radiotherapy

One hundred forty-seven patients with Ann Arbor stages I and II diffuse large cell lymphoma (DLCL) were treated with combination chemotherapy consisting of cyclophosphamide, doxyrubicin, prednisone, and low-dose bleomycin (CHOP-Bleo) and involved-field radiation (IF XRT) between 1974 and 1984. A complete remission (CR) was attained by 54 of 57 patients with stage I disease and by 78 of 90 patients with stage II disease. Thirty-five patients had relapsing disease that occurred within 3 years in 31. The overall 10-year survival rate, counting all deaths, for patients with stage I was 72% as compared with 43% for patients with stage II (P less than .01). Determinate survival rates, censoring eight unrelated deaths, were similar to the overall survival rates: 77% and 51%, respectively. A multivariate analysis identified three independent prognostic factors: age, tumor extent, and serum lactic dehydrogenase (LDH) level. When the combined effect of tumor extent and LDH level were taken into consideration in the analysis, three risk groups for survival were identified. The best group, which consists of patients with minimum tumor and normal LDH levels, had a 10-year determinate survival of 79%. Patients with extensive tumors and elevated LDH levels had the poorest survival rate of 44%. An intermediate-risk group with a determinant survival of 62% was composed of patients with either extensive tumors or elevated LDH levels. These differences demonstrate the need to develop different treatment strategies based on risk factors for survival for patients with apparently localized Ann Arbor stages I/II DLCL.

Recurring giant-cell granuloma at the site of previous radiation therapy

A 15-year-old girl presented with an aggressive giant-cell granuloma (GCG) of the maxilla with local invasiveness and bony destruction. The tumor recurred twice and attained a diameter of 6 cm. Previously, this patient had had two hematologic malignancies for which she had received therapeutic doses of radiation to the site where the GCG occurred. It is therefore possible that this tumor was radiation induced.

The patterns of failure in patients with pathological stage I and II diffuse histiocytic lymphoma treated with radiation therapy alone

Radiation therapy was used to treat 36 patients with pathological Stage I and II diffuse histiocytic lymphoma at The University of Chicago Hospitals from 1970 to 1986. Twenty-two patients had pathological Stage I and 14 had pathological Stage II diffuse histiocytic lymphoma. The patients were treated with a median tumor dose of 50 Gy (range of 40-60 Gy). Therapy consisted of extended field radiation therapy in 27 patients (extended mantle or total nodal irradiation) and involved field irradiation in nine patients. The 10-year actuarial relapse-free survival for pathological Stage I and pathological Stage II patients was 91% and 35%, respectively (median follow-up of 7 years). None of the 22 pathological Stage I patients had bulky mediastinal or abdominal disease. Of the 22 pathological Stage I patients, one failed in an unirradiated contiguous lymph node and one relapsed with disseminated disease. Of the 14 pathological Stage II patients, two patients with bulky disease failed in field, one patient failed in a contiguous node, three patients failed within the abdomen, and three patients failed with disseminated disease. To better evaluate the efficacy of staging laparotomy, we analyzed the patterns of failure of 17 clinical Stage I and II diffuse histiocytic lymphoma patients. Four of these patients failed in field (three in sites of bulky disease), and five patients relapsed in the abdomen (three with disseminated disease). Salvage treatment with multiagent chemotherapy resulted in second complete responses in seven of ten patients; however, all but one have recurred and are dead of disease. Radiation therapy may be used as the sole treatment in patients with pathological Stage I diffuse histiocytic lymphoma without bulky disease. Patients with pathological Stage II diffuse histiocytic lymphoma and clinically staged patients have a higher incidence of dissemination and relapse within the abdomen. A benefit resulting from the administration of extended field irradiation was not revealed by this study.

Stage I and II non-Hodgkin's lymphomas: long-term results of radiation therapy

One hundred and sixteen patients with Stages I and II non-Hodgkin's lymphomas were treated with curative radiotherapy between 1964 and 1977. The initial biopsy material was classified according to the criteria of Rappaport et al. All the patients except six were followed for a minimum of 8 years or until death with ninety-two patients having been followed for 10 or more years. Histological pattern was found to be an important prognostic factor with better survival in patients with nodular histology. There were forty-three patients with an initial involvement of an extra-nodal site forming 37% of the total group. Stage I extra-nodal lymphomas had a survival and recurrence-free survival rates of 80% and 74% respectively, similar to those of nodal lymphomas. Stage II patients in both groups did worse than those with Stage I. Survival rates and disease-free survival rates for different histologic types and their pattern of recurrence are presented.

Primary central nervous system lymphoma: long-term survival following treatment with radiation and methotrexate

Primary lymphoma of the central nervous system is a rare disease with poor response to therapy. A 37-year-old man presented with primary cerebral lymphoma diagnosed by stereotactic brain biopsy. He was initially treated with whole brain irradiation but subsequently developed recurrent disease in the spinal cord manifested by paraplegia. Combined modality treatment with spinal cord irradiation, intrathecal methotrexate and 19 courses of high-dose systemic methotrexate with urinary alkalinization, resulted in stabilization of his neurologic status. No further disease progression has been observed and the patient remains free of disease 62 months after beginning chemotherapy. Methotrexate therapy may offer an effective means of treating recurrent primary central nervous system lymphomas.

The myth regarding bone or cartilage involvement by cancer and the likelihood of cure by radiotherapy

A myth persists that tumor involvement of bone and/or cartilage represents a clinical situation in which cure by radiotherapy would be considered unusual. There are sufficient data to the contrary. This essay reviews the radiotherapy results for (1) primary tumors of bone (benign and malignant), (2) primary malignant tumors of cartilage, and (3) benign and malignant tumors that secondarily involve bone and/or cartilage. It is hoped that the myth concerning radiocurability and bone and/or cartilage involvement will be replaced by an appreciation of the relative rates of cure depending on the clinical situation.

Primary orbital lymphomas

Between 1950 and 1982, seventeen patients with primary orbital lymphoma were treated at the University of Kansas Medical Center. There were 10 males and 7 females with a median age of 61 years. Four patients had bilateral disease, seven patients had disease involving the conjunctiva, and in ten patients, the disease involved paraocular structures. Fourteen patients received radiation with a median dose of 3500 cGy (range 2250 cGy to 4250 cGy) given in about 3 1/2 to 5 weeks. Median follow-up was 10 years (range 5 to 31 years). Local control was 100% and 5-year survival was 76%. Three patients are living with no evidence of lymphoma; three patients died from progression of the disease, and others died from unrelated causes. Radiation treatment for localized primary orbital lymphomas appears to be the primary treatment of choice.

Improved survival of poor prognosis diffuse histiocytic (large cell) lymphoma managed with sequential induction chemotherapy, "boost" radiation therapy, and autologous bone marrow transplantation

From 1981 to 1985, 33 patients with the diagnosis of diffuse histiocytic (large cell) lymphoma (DHL) with a poor prognosis received induction multi-drug chemotherapy followed by autologous marrow cryopreservation. Thirty patients who had residual disease after chemotherapy were given "boost" irradiation to these sites, followed immediately by hyperfractionated total body irradiation, 1320 to 1375 cGy in 11 fractions over 4 days, then cyclophosphamide (60 mg/kg/d) for 2 days. All patients received an autologous bone marrow transplant (ABMT), with 15 patients receiving marrow purged with 4-hydroperoxycyclophosphamide. Patients were transplanted either as part of a planned induction-transplant approach (Group I), or as salvage after relapse on the same induction regimen (Group II), or other conventional chemotherapy regimens (Group III). In the entire group, 16 of 33 patients (48%) are alive free of lymphoma with a median follow-up of 32 months (11 to 53 mo). Actuarial (Kaplan-Meier) survival is 51% at 2 years and 46% at 3 years, with only 1 patient dying after 2 years out of 11 at risk. Eight patients (24%) succumbed to early treatment related complications. Nine patients (27%) died from relapse. Patients receiving ABMT as planned sequential therapy post-induction (Group I) did significantly better than patients given ABMT as salvage therapy after relapse on prior chemotherapy (Groups II and III) and better than the historical group of patients treated with chemotherapy alone. At 2 years, the survival in Group I is 79% versus 0% for Group II versus 48% for Group III. Historically, this group of high risk patients had a 2-year disease-free survival of 20% or less with chemotherapy alone.

Primary non-Hodgkin's lymphoma of the liver

A patient with irresectable primary non-Hodgkin's lymphoma of the liver (histiocytic type, Rappaport classification) is presented. Systemic chemotherapy combined with local irradiation were successful in achieving a disease-free interval in a follow-up of 36 months. Review of the literature disclosed 19 other patients previously reported, with considerable variations in extent of disease at presentation. Criteria for the diagnosis of primary non-Hodgkin's lymphoma are proposed, and 11 patients met these criteria. Hepatic resection is advocated for localized tumour, while systemic chemotherapy and local irradiation in patients with irresectable tumours were found effective in achieving local and systemic control in a mean follow-up of 37 months.