Non-Hodgkin's lymphomas. I. Bone marrow involvement

Involvement of the Bone Marrow by Non-Hodgkin's Lymphomas: Incidence, Histology and Pathologic Correlations

The Lukes and Collins system of classification was applied to 151 cases of non-Hodgkin's lymphoma who had bone marrow biopsies taken immediately after histologic diagnosis. Incidence and histologic pattern of bone marrow involvement at the time of initial diagnosis were determined for each subtype of lymphoma. Thirty-three patients (21.8 %) had bone marrow involvement. The frequency of bone marrow involvement was high for undefined and convoluted lymphocyte lymphomas (66.6 %) and low to intermediate for follicular centre cell (20.3 %) and small lymphocyte lymphomas (20.0 %). Within the FCC lymphomas the non-cleaved cell type had a higher incidence of marrow involvement than the cleaved cell type (41.6 % vs 8.9 %). The follicular and diffuse histologic patterns in the diagnostic node did influence the incidence of marrow invasion in the non-cleaved cell type (75 % vs 25 %). A low incidence of marrow involvement was observed for the immunoblastic lymphomas (14.2 %); evidence of marrow infiltration was never observed in patients with true histiocytic lymphoma.

Lymphopenia in histiocytic medullary reticulosis

A survey of the Western literature of histiocytic medullary reticulosis (malignant histiocytosis) provided 104 case reports with sufficient data from which the presence or absence of an absolute lymphopenia could be ascertained. Of these, 46 (44%) were lymphopenic at presentation or within the subsequent 10 days. A survey of a series of publications containing detailed peripheral leucocyte counts recorded in patients with diseases that, like HMR, may present with, or develop, pancytopenia showed that the incidence of lymphopenia ranged from 14% (Hodgkin's: stages I & II) to 46% (acute myelofibrosis; systemic lupus erythematosus; angio-immunoblastic lymphadenopathy). It was concluded a that HMR should be added to the list of accepted causes of lymphopenia, b that lymphopenia, as an aid to the diagnosis of HMR, will be of limited value, c that when the peripheral leucocyte count of a patient is recorded in a case report, it should be accompanied by a full differential count.

Follicular pattern of bone marrow involvement by follicular lymphoma

Five patterns of bone marrow infiltration by non-Hodgkin lymphoma or Hodgkin lymphoma are currently recognized, but a true follicular pattern of bone marrow involvement by follicular lymphoma has not been described. In 260 bone marrow trephine biopsy specimens involved by follicular lymphoma, we identified 12 cases with a follicular pattern of bone marrow involvement. The paratrabecular pattern was not present at all in 9, and it accounted for less than 10% of tumor burden in 3 cases. Malignant follicles in the bone marrow were similar to malignant follicles in the respective lymph nodes. Follicular dendritic cells were identified by immunohistochemical analysis. The true follicular pattern of bone marrow involvement by follicular lymphoma seems to be more frequent in women than in men. It is important to recognize this pattern of follicular lymphoma in the bone marrow because it is possible to misinterpret interstitial lymphoid aggregates as benign in the absence of the more characteristic paratrabecular pattern.

Clinical, immunologic, and pathologic correlates of bone marrow involvement in 291 patients with acquired immunodeficiency syndrome-related lymphoma

Bone marrow involvement is reported in approximately 25% of patients with newly diagnosed acquired immunodeficiency syndrome-related lymphoma (ARL). Studied were 291 patients with ARL, diagnosed and treated at one medical center between 1984 and 1998. Clinical, immunologic, and pathologic characteristics of patients with bone marrow involvement were compared with those of patients without marrow involvement. Bone marrow involvement was present in 55 patients (19%). Small noncleaved lymphoma was diagnosed in 38% of the entire group and was the most common pathologic subtype in patients with bone marrow involvement (55% versus 34%; P =.008). Analysis of complete blood counts revealed a median hemoglobin level of 10.6 g/dL in both marrow-positive and marrow-negative groups. In contrast, a platelet count lower than 100 000/microL was more common in patients with bone marrow involvement (27% versus 11%; P =.02). Patients with marrow involvement were more likely to have leptomeningeal (cerebrospinal fluid [CSF]) lymphoma than patients whose marrows were uninvolved (24% versus 7%; P <.001) and were also more likely to have high lactate dehydrogenase (LDH) (P =.002), bone involvement (P <.001), and/or systemic B symptoms including fever, night sweats, and/or weight loss (P =.05). Median survival did not differ between marrow-positive and marrow-negative groups. On multivariate analysis, factors associated with decreased survival of marrow-positive patients included greater than 50% involvement (P =.002), systemic B symptoms (P =.008), and high-grade histologic type (P =.035). Marrow involvement in ARL correlates with small noncleaved pathology, thrombocytopenia lower than 100 000 mm(3), high LDH, and lymphomatous involvement of the CSF. Survival is statistically shorter in patients with greater than 50% marrow involvement, high-grade pathology, and/or systemic B symptoms.

Bone marrow involvement in lymphoma: the importance of marrow magnetic resonance imaging

Detection of bone marrow involvement is important for staging and treatment decisions in patients with lymphoma. Although routine bone marrow evaluation is based on aspirates and bone marrow biopsies, new diagnostic tools are required to improve diagnostic accuracy. Visual and quantitative assessment of the bone marrow by magnetic resonance (MR) imaging is useful for the detection of occult lymphomatous marrow involvement. MRI is also suitable for the evaluation of disease extent in the bone marrow. Furthermore, abnormal images on marrow MRI may be associated with a significantly poorer survival in patients with lymphoma, regardless of histologic findings in the marrow. Evaluation of the bone marrow by MRI is essential to assess disease status in patients with lymphoma.

Bone marrow metastases. A review

Although bone marrow examination is a common procedure in the evaluation of patients with cancer, its role and contribution have been questioned in recent years. This review deals with the clinical and biologic aspects of metastasis to the bone marrow. The discussion is focused on the common tumor types that involve marrow and the application of newer techniques for tumor detection in the marrow. Therapeutic and prognostic implications of bone marrow metastasis are significant in several clinical settings. The mechanisms by which tumor cells affect marrow function have not been completely defined.

Bone marrow involvement in non-Hodgkin's lymphoma: increased diagnostic sensitivity by combination of immunocytology, cytomorphology and trephine histology

Diagnostic results from cytomorphology and immunocytology of aspirated bone marrow (BM) were compared with the findings from standard trephine histology of 100 adult patients with non-leukaemic non-Hodgkin's lymphomas (NHL) in a retrospective study. Immunocytological investigations were performed by the immunoenzymatic APAAP-technique on BM smears monoclonal antibodies against CD19, Cd3, CD10 or TdT antigens and determination of positive cells in relation to total BM leucocytes. Corresponding results were obtained for trephine histology and for the combination of cytomorphology and immunocytology in 93/100 cases. Four cases with BM involvement by trephine histology were missed by the combination of immunocytology and cytomorphology. In turn, three cases negative by trephine histology, were found to be positive by the combination of immunocytology and cytomorphology. Immunocytochemistry considerably increased the number of true positive detected BM-infiltrations by cytomorphology in low grade B-cell lymphoma from 58% to 97%. For the diagnosis of BM involvement in high-grade NHL cytomorphology of the aspirate was of equal sensitivity to the biopsy and was always confirmed by immunocytology. The high diagnostic sensitivity of immunocytology was mainly due to high B-cell counts in BM involved by B-cell lymphoma (means = 38%, s = 23) in contrast to low B-cell counts in BM not involved by NHL (means = 4.5%, s = 3.8). We conclude from our data that immunocytology in addition to standard cytomorphology improves diagnostic sensitivity in the detection of BM involvement by NHL.

Clinical significance of hematologic parameters in non-Hodgkin's lymphoma at diagnosis

Three hundred seventeen patients with non-Hodgkin's lymphoma (NHL) (54 low grade, 180 intermediate grade, 76 high grade, and seven unclassified) treated with chemotherapy were evaluated for the presence of hematologic abnormalities at diagnostic staging. Anemia was present in 42%, leukopenia in 6%, thrombocytopenia in 13%, leukocytosis in 26%, and thrombocytosis in 14% at presentation. The presence of bone marrow involvement by lymphoma was more likely to be associated with leukopenia and thrombocytopenia than the absence of bone marrow involvement. Although anemia was slightly more common in patients with bone marrow lymphoma than in those without marrow lymphoma, the difference was not statistically significant. Hematologic parameters were similar for patients with B-cell or T-cell lymphoma. Evidence of bone marrow failure with multiple cytopenias was present in 26 patients (8%). Leukoerythroblastosis was present in 2%. Circulating lymphoma was present in 9.5%. Anemic patients had a shorter survival time than nonanemic patients, whether bone marrow was involved by lymphoma or not. Survival was not affected by the presence of leukopenia or mild leukocytosis, but, in patients without marrow lymphoma, leukocytosis with a leukocyte count greater than 20 x 10(9)/l was associated with short survival length. Thrombocytopenia was associated with short survival time only in patients with bone marrow involvement by lymphoma. Patients with multiple cytopenias or leukoerythroblastosis had short survival times, but the presence of circulating lymphoma did not alter survival when compared with other patients with bone marrow involvement by lymphoma. These data suggest that hematologic evaluation at the time of diagnostic staging of NHL provides useful prognostic information that may have therapeutic implications.

Bone marrow and blood involvement by non-Hodgkin's lymphoma: a study of clinicopathologic correlations and prognostic significance in relationship to the Working Formulation

In a series of 172 patients with non-Hodgkin's lymphoma (NHL) classified according to the Working Formulation (WF) the overall incidence of bone marrow infiltration (BM+) at diagnosis was 39%: 59% for low-grade (LGML), 30% for intermediate-grade (IGML), and 25% for high-grade malignant lymphomas (HGML). The features most significantly correlated with the presence of BM+ were a low grade of histological malignancy, the degree of splenomegaly and high values of LDH, while those correlated with the extent of BM+ were a non-focal pattern of BM disease, the presence of blood involvement at diagnosis, and the degree of BM fibrosis. Blood involvement was detected at diagnosis in 13% of patients, and a further 16% developed a leukemic phase during the course of the disease. Blood involvement correlated significantly with splenomegaly, bulky disease, advanced clinical stage, and extent of BM+. The presence of BM infiltration 'per se' at diagnosis did not significantly affect prognosis. However, the extent of BM disease was correlated with a poorer outcome in IGML and HGML patients. Regarding peripheral blood involvement, in LGML patients only late leukemic conversions were significantly associated with a worse prognosis. In patients with IGML and HGML, either initial or subsequent blood involvement was correlated with significantly poorer outcome.

Pancreatic lymphoma. Is surgery mandatory for diagnosis or treatment?

From 1982 to 1986, nine patients with non-Hodgkin's lymphoma primarily involving the pancreas were managed at the Johns Hopkins Medical Institutions. This group of nine patients represents 2.2% of patients with non-Hodgkin's lymphoma (nine of 402) and 4.9% of all patients presenting with pancreatic malignancies (nine of 182) at the Johns Hopkins Medical Institutions during this period. Computed tomography (CT) scan findings of a large pancreatic mass (6 cm) with extrapancreatic extension and significant retroperitoneal lymph node enlargement suggested lymphoma. Diagnosis was established by radiographically-guided needle biopsy in four patients, by laparotomy in four, and by peripheral lymph node biopsy in one. In five jaundiced patients, initial chemotherapy with the nonhepatotoxic agents cyclophosphamide and prednisone resulted in marked tumor regression, allowing for early resolution of jaundice and subsequent addition of more aggressive adriamycin containing combination chemotherapy. Overall, complete remission has occurred in six of nine patients, with a median survival of 24 months (range 4-69 months). It is concluded from this experience that the majority of patients with pancreatic lymphoma can be managed without surgery. Excellent control of symptoms, including jaundice, as well as long-term remission, can be obtained with chemotherapy alone. The only role for surgery in this setting may be to aid in establishing the diagnosis when percutaneous biopsy is nondiagnostic.

Low field strength magnetic resonance imaging of bone marrow in patients with malignant lymphoma

Detection of bone marrow infiltration by lymphoma with low field strength magnetic resonance imaging (MRI) has been assessed. Measurements of spin lattice relaxation time (T1) were made in 31 patients with lymphoma and compared with the results of bone marrow biopsy and with T1 measurements made on 90 healthy volunteers. The sensitivity of MRI was excellent in patients for whom the microscopic pattern of marrow infiltration was diffuse, but poor in those with microscopically focal infiltration.

The value of bone marrow biopsy in breast cancer at the time of first relapse. A prospective study

The value of bone marrow biopsy (BMB) in advanced breast cancer at the time of first relapse was studied in a prospective manner. Bone marrow biopsy was performed in 142 consecutive unselected metastatic patients: 129 at the time of first recurrence, and 13 in patients with metastases at the time of first diagnosis. Overall, BMB was positive in 32 patients (23%). In the group with negative bone x-ray, it was positive in two patients of 84 (2%); both of them had doubtful scan. In the group with positive x-ray, BMB resulted positive in 30 of 58 (52%). There was a significant correlation between number of bone segments radiologically involved and BMB positivity rate, ranging from 15% in the patients with only one, to 68% in those with more than three sites involved (P = 0.02). Patients with x-ray evidence of metastases in the pelvis had significantly higher rate of BMB positivity (67% versus 32%; P = 0.02). The median survival time from the first relapse was 153 weeks in BMB-negative cases and 149 in positive ones. Considering only the patients with demonstration of bone invasion obtained with either or both x-ray and BMB, 34/62 patients had positive BMB (55%). In these cases BMB was found more often positive in patients 50 years or younger than in patients older than 50 years (80% versus 47%; P = 0.05); the median survival time was longer, but not significantly, in BMB-positive patients than in negative ones (149 weeks versus 119; P = 0.3). The authors conclude that BMB is not required in common restaging procedure when both bone survey and scan are negative. Bone marrow biopsy results are more often positive in younger patients and survival is not negatively affected by bone marrow invasion as diagnosed by BMB.

The value of bone marrow biopsy in breast cancer at time of diagnosis. A prospective study

Bone marrow biopsies (BMB) were performed in 173 consecutive unselected breast cancer patients at the time of diagnosis to define the value of this diagnostic tool in the initial staging of mammary carcinoma. In a group of 160 patients with a negative standard staging work-up, BMB was positive in two (1%). Both of them had negative x-ray but bone scan was positive in one and doubtful in the other. Bone marrow biopsy was positive in 31% of 13 additional patients with metastatic disease and in 44% of the nine among them with radiologically involved skeleton. These results exclude that BMB is able to discover micrometastatic foci of neoplastic disease. Its positivity appears strictly correlated with that of bone x-ray and scan. Based on the results of this prospective study, BMB is not required when both bone survey and scan are negative, but could be useful in clarifying diagnostic doubts of skeletal involvement.

Primary lymphoma of the thyroid: clinical features, prognostic factors, and results of treatment

This study analyzes the results of 46 cases of biopsy-proven primary lymphoma of the thyroid, localized at diagnosis and treated at the Royal Marsden Hospital between 1948-1980. In all cases, disease was limited to the thyroid and cervical lymph nodes. There were 43 females and 3 males, with a mean age of 64.4 years (median 66 years; range 17-86). A short history (less than 3 months) of a neck mass and local compressive symptoms was the typical presentation. The majority of patients (91%) had adverse histologies, with diffuse histiocytic lymphomas being most common (78%). The overall crude 5-year survival rate was 40%, with 30% of patients surviving beyond 10 years. Disease-free and overall survival were virtually identical, indicating the ineffectiveness of salvage therapy. The important prognostic factors were: size of tumor, fixation, extra-capsular extension, and retrosternal involvement. Survival was not correlated with age, sex, histology, thyroid status, or stage of disease, as defined by the Ann Arbor classification. Patients who had total macroscopic removal of tumor had the highest rate of local control and long survival (p less than 0.005). No significant difference was seen between lobectomy, subtotal or total thyroidectomy, but 7 of 9 long-term survivors (58-129 months) have had total thyroidectomy. A radiotherapy dose to the tumor, of at least 40 Gy, was required to produce consistent local control in patients with unresected disease. The majority of patients who died had generalized disease. Only 52% of these patients were free of local recurrence. In view of the frequency of occult disseminated disease, adjuvant chemotherapy is one recommendation for patients with poor prognostic factors. For optimal local control, complete surgical eradication is recommended followed by high-dose local radiotherapy. The use of aggressive cytoreductive chemotherapy prior to radiotherapy is a possible alternative option which needs to be explored.

Abnormal chromosomes in histocytic lymphoma

Five of six diffuse histocytic lymphoma patients had chromosomal abnormalities. Four had abnormal clones; three, a large acrocentric chromosome (LAC); and one, an abnormal large submetacentric chromosome (LSC). The LAC was a 14q+ and the LSC, a 4q+. Although no cytogenetic abnormality was found in a normal lymph node of a patient whose diseased lymph node had an LAC, abnormal chromosomes were seen in three patients with normal morphological bone marrow and in two peripheral blood specimens with a normal differential count. Since staging is important in aiding the clinician to select the type of treatment in this disease, it is recommended that cytogenetic studies in all biopsied tissues should be done as part of an overall diagnostic procedure in patients suspected of this disease.

Lymphoproliferations in the bone marrow: identification and evolution, classification and staging

Bone marrow biopsies from 3229 patients with lymphoproliferative disorders and 1156 patients with benign or reactive lymphoproliferations were investigated and criteria for distinguishing between them are given. Bone marrow involvement was found in 89% of multiple myeloma, 64% of non-Hodgkin's lymphomas and 8% of Hodgkin's disease. According to the predominant proliferative cell type there were five major entities in multiple myeloma and non-Hodgkin's lymphomas: (1) plasmacytic; (2) lymphocytic; (3) hairy cell; (4) immunocytic; (5) centrocytic. These were further classified into distinct subtypes each of which had independent prognostic significance. The mode of spread of the lymphoproliferative disorders in the bone marrow showed one of six architectural patterns, which together with the quantity of infiltration in the biopsy (reflecting the tumour cell burden) had significant predictive value. These results demonstrate the value of bone marrow biopsies in the identification, classification and staging of lymphoproliferative disorders, as well as in monitoring the course of disease and the response to therapy.

An appraisal of the value of the bone marrow biopsy in the assessment of proliferative lesions of the bone marrow

The diagnostic value of the bone marrow needle biopsy has proved impressive in a variety of disorders. As a complementary procedure to the aspiration smear it adds an invaluable dimension to the examination of haematopoietic tissue. The procedure is easily learned and safe and should be utilized routinely in haematological practice. The usefulness of the bone marrow biopsy is examined in assessing proliferative lesions of the bone marrow.

The non-Hodgkin's lymphomas. I. A retrospective clinical and pathologic analysis of 499 cases diagnosed between 1958 and 1969

A retrospective clinical and histopathological review was made of 499 previously untreated cases of non-Hodgkin's lymphoma with adequate initial biopsy material diagnosed at Memorial Hospital between 1958 and 1969. Three hundred-eighty-four cases (77%) had diffuse, 104 (21%) nodular, nine (2%) nodular and diffuse, and two (less than 1%) unclassifiable histologic types. Overall median survival was 16 months, and 79% of the patients died with lymphoma. For all treatments, survival of responding patients was the same as that of nonresponders, a reflection of the palliative approach. Significant differences in survival were found between patients in the various Ann Arbor stages. Median survival was 42 months for the nodular group and 11.5 months for the diffuse (P less than 0.001). The ten-year survival was 12% for the diffuse and 22% for the nodular patients. The overall difference in survival was due to early deaths in the diffuse group. Long-term follow-up is necessary to appreciate the usual fatal course of patients with all types of non-Hodgkin's lymphomas treated conservatively.

Assessment of bone marrow histology in the malignant lymphomas (non-Hodgkin's): correlation with clinical factors for diagnosis, prognosis, classification and staging

Bone marrow biopsies of 678 untreated patients with established malignant non-Hodgkin's lymphomas (ML) were investigated. The bone marrow was involved in 468 cases, an overall frequency of 69%. The Kiel classification of the ML (based on lymph node histology) was applied and the biopsies were classified: ML lymphocytic 36%, ML 'hairy cell' 24%, ML lymphoplasmacytic/cytoid 24%, ML centrocytic 6%, ML centroblastic/centrocytic 4%, ML lymphoblastic (without ALL) 3%, ML centroblastic 2% and ML immunoblastic 1%. The life tables of the patients were similar whether classified according to the histology of the lymph node or the bone marrow. A multivariate computer based analysis of both clinical and histological data was performed to test their prognostic relevance. The cell type, the proliferation pattern and the extent of infiltration in the bone marrow all proved to be factors of prognostic significance. The results indicate that classification of the ML based on lymph node histology is applicable to the bone marrow, is reproducible and has prognostic significance. Consequently, a bone marrow biopsy is a useful clinical tool for staging and for histological classification of patients with ML.

Bone marrow and blood involvement by lymphoma in relationship to the Lukes--Collins classification

The incidence, pattern, extent, and morphology of bone marrow involvement in 176 cases of non-Hodgkin's lymphoma (NHL) were studied in relationship to the Lukes--Collins classification. Ninety percent of the cases were B-cell lymphomas; 10% were T-cell lymphomas. In 53% of cases there was bone marrow involvement by lymphoma at diagnosis. Marrow involvement was most frequently found in the small lymphocyte (B), small cleaved follicular center cell (FCC), and convoluted lymphocyte lymphomas. Frequently, the extent of bone marrow biopsy replacement by lymphoma was less than 30%; the pattern of infiltration was predominantly focal (70%). Cytologic agreement between lymph node and bone marrow specimens was always present in small lymphocyte (B), small noncleaved FCC, convoluted lymphocyte, and lymphoepithelioid cell lymphomas. Cytologic diversity between lymph node and marrow was noted in 20% of small cleaved FCC, 40% (2/5) of large cleaved FCC, and 38% (3/8) of large noncleaved FCC lymphomas. In 79% of all involved cases, both bone marrow biopsy sections and aspirate smears were diagnostic of NHL; only biopsy sections were positive in 18%, and only smears were positive in 3%. The Lukes--Collins classification predicts a high incidence of bone marrow involvement for small lymphocyte (B), small cleaved FCC, and convoluted lymphocyte lymphomas.

Follicular (nodular) lymphoma during the first two decades of life: a clinicopathologic study of 12 patients

Twelve patients who developed non-Hodgkin's lymphoma with a follicular pattern during the first two decades of life were studied. Eight had the poorly differentiated lymphocytic type; the remaining four had the "histiocytic" type. Eleven of the 12 patients were male. Nine were asymptomatic, and eight had lymphadenopathy in the head and neck region. Comparison of ages revealed the extent of disease tended to be localized (Stages I and II) in the pediatric (less than 16 years old) patients (83%) and generalized in the adolescent-young adult (16-19 years old) patients (83%). Of ten patients treated with chemotherapy and/or radiotherapy, eight achieved complete remissions that lasted 3-58 months (median, 17.5 months). Five are still in remission; three have relapsed. Seven are alive 12-120 months from diagnosis (median, 48 months); six have no clinical evidence of disease. The remaining five patients died two to 164 months after diagnosis (median, 13 months). Three of the four patients who died with lymphoma had diffuse "histiocytic" lymphoma demonstrated at autopsy examination. Poor prognostic factors included 1) failure to achieve a complete remission following initial therapy; 2) extranodal disease (with the exception of the poorly differentiated lymphocytic type involving the spleen and liver); 3) development of diffuse "histiocytic" lymphoma. Follicular lymphoma occurring in the second decade of life has a biologic behavior similar to follicular lymphoma in adults.

Clinico-pathologic correlation in non-Hodgkin's lymphoma. IV. Analysis of patients with clinically localized disease

A retrospective analysis of 140 patients with non-Hodgkin's lymphoma in clinical stage I or II classified according to a modified LUKES & COLLINS scheme was performed. Three major groups were found according to cell type, with different clinical features: (1) Small cell lymphomas with a relatively favourable survival in spite of high relapse rates. (2) Large cell lymphomas with lower relapse rates, but short time between relapse and death, and unfavourable survival. (3) Mixed small/large cleaved follicular centre cell lymphoma which was most favourable with respect to relapse and survival. Nodular lymphoma had the same overall relapse rate as diffuse lymphoma, but had a significantly longer survival. Tumours stage I were associated with significantly longer relapse-free survival and survival than stage II. The importance of separating the majority of non-Hodgkin's lymphomas into three main groups according to cell type is emphasized. These major groups require different clinical approaches in terms of staging and treatment.

Isolated marrow lymphoma: an entity of possible T-cell derivation

Seven adults had a distinct clinicopathologic type of lymphoproliferative disorder of the bone marrow. All patients presented with weakness and pancytopenia; no evidence of gross extramedullary involvement was found. In 5 cases severe and prolonged bone marrow hypoplasia was associated with combination chemotherapy; 1 patient died of infection during initial therapy. In 6 of the 7 cases, clinical improvement occurred following therapy. As a terminal event, 2 patients developed a leukemic phase. Tumor cell from 4 patients were studied immunologically, and in 2 patients surface marker characteristics suggestive of T-cell tumor origin were found. In 2 cases, ultrastructural studies of lymphoid cells were compatible with a T-cell neoplasm. The above data suggest that these cases represent a distinct type of chemotherapy-sensitive lymphoma in which conservative initial treatment may induce a response without prolonged bone marrow hypoplasia.

Differences in age and sex distributions among patients with non-Hodgkin's lymphoma

The records of a group of 337 adult patients with non-Hodgkin's lymphoma seen at the Stanford University Medical Center, Division of Oncology were examined for relationships between stage and histopathological classification and simple demographic characteristics. Patients with Stages I and II of disease and diffuse varieties of lymphoma were found to be younger than patients in other categories. An excess of male patients was noted particularly in younger patients with diffuse lymphoma and Stages I and II of disease. Male patients with Stages I and II disease were noted to be bimodally distributed with respect to age, with peak number of patients in the fourth and sixth decades. This was particularly apparent among patients with diffuse histiocytic lymphoma. The implications of these findings are discussed.

Bone marrow biopsy in children: a study of 111 patients

Closed trephine needle biopsy of the bone marrow has become an established procedure in the evaluation of many malignant and benign diseases in adults; however, its role in pediatric pathology has not yet been defined. In the period from February 1974 to April 1978 we have performed 164 such biopsies in 111 children under 15 years of age. A representative specimen has been obtained in over 80% of cases. This series included, in order of frequency, non-Hodgkin lymphomas, Hodgkin lymphomas, aplastic anemias, rhabdomyosarcomas, neuroblastomas, miscellaneous solid tumors, and single cases of histiocytosis X, malignant histiocytosis, sarcoidosis, malignant histiocytoma, and Castleman lymphoma of the hyaline-vascular type. Histology has been found superior to cytology in the detection of neuroblastoma invasion; the evaluation of the true cellularity in aplastic anemia, and the detection of granulomatous tissue in the only case of sarcoidosis. In other diseases histology and cytology gave similar information, except for the few cases of acute leukemia in partial relapse, which has been better defined in the aspirate smears than in the core specimen. Further evaluation of this technique in other patient series appears advisable.

Bilateral trephine bone marrow biopsies in Hodgkin's and non-Hodgkin's lymphoma

This study was undertaken to investigate the usefulness of bilateral rather than unilateral iliac trephine biopsies in demonstrating Hodgkin's disease and non-Hodgkin's lymphoma in the bone marrow. One hundred and seventy adequate bilateral biopsies were obtained from 145 patients. Among 76 bilateral trephine biopsies from 65 patients with Hodgkin's disease, tumour was found bilaterally in 3 cases and on only one side in 2 cases. Among 94 bilateral biopsies from 80 patients with non-Hodgkin's lymphoma, tumour was found bilaterally in 17 cases and on only one side in 12. Considering all of the cases in the series, the performance of bilateral biopsy increased the yield of positive marrows from an estimate of 27 to 34, an increase of 26%. We conclude that bilateral trephine biopsy is superior to unilateral biopsy for the demonstration of bone marrow involvement by Hodgkin's disease or non-Hodgkin's lymphoma and recommend that bilateral trephine biopsies be performed when a knowledge of the state of the bone marrow is important for clinical decision making.

Morphology of lymphatic cells and of their derived tumours

Images

Lymphoma of the head and neck

The natural history of 88 cases of non-Hodgkin's lymphoma of the head and neck were reviewed. An analysis is presented of the histopathologic, clinical, and prognostic features of these patients which presented to the Washington University Affiliated Hospitals between 1955-1975. All biopsies were histologically classified according to the criteria of Rappaport and staged accordingly to the Ann Arbor Classification. There were 38 histiocytic lymphomas, 29 poorly differentiated lymphocytic lymphomas, 16 well differentiated lymphocytic lymphomas, and 5 mixed lymphomas. The lesions were equally divided between Waldeyer's ring and other head and neck sites. Most of the lymphomas were extranodal in presentation. Sixty-one percent of all cases presented with disease localized to the site of origin; 17% had extension to regional nodes and 21% had generalized disease (Stage III and IV). In terms of treatment, localized well differentiated lymphocytic lymphoma was treated with radiation therapy. Generalized well differentiated lymphocytic lymphomas were treated with radiation and chemotherapy. Most patients with histiocytic and poorly differentiated lymphocytic lymphoma limited to the site of origin were treated with radiation and all others with combined therapy. Over 90% of patients with Stage I disease were considered cured at the end of three years while the overall survival was 72%.

Computed tomographic scanning in patients with lymphoma

Computed tomography (CT) of the chest and abdomen was performed in 40 patients with lymphoma and the results compared to conventional diagnostic techniques. Overall 34 (85%) of 40 CT scans correctly reflected the presence or absence of lymphoma. Close agreement between the findings of lymphography and CT was noted in 26 of 27 cases. CT has particular utility for assessment of lymphomatous involvement of mesenteric lymph nodes, high retroperitoneal lymph nodes, and extranodal abdominal sites other than the spleen or liver (e.g., pancreas, kidney). Abdominal CT is a useful noninvasive diagnostic technique for the initial staging and subsequent evaluation of selected patients with lymphoma.

The bone marrow examination in breast cancer: diagnostic considerations and clinical usefulness

Bone marrow examinations were performed on 116 women with primary and metastatic breast cancer and were correlated with the clinical status of the patient and other specific diagnostic modalities. The relative diagnostic efficacy of the marrow biopsy, aspirate smear and clot section was examined, as was the value of serial marrow examinations. A marrow positive for tumor was found in 40% of those with metastatic disease, 55% with positive x-rays, 56% with positive bone scans, but only 4% (1/24) with both scan and x-ray normal. Routine hematologic parameters were of limited usefulness in predicting the finding of a positive marrow. The biopsy was superior to the smear and clot section but aspirated material also had to be analyzed to maximize diagnostic yield. When analyzed qualitatively, i.e., positive or negative for tumor, serial marrow examinations were not useful in assessing the efficacy of antitumor treatment. The potential usefulness of bone marrow examination in patients with breast cancer is discussed.

Staging in childhood non-Hodgkin's lymphoma. What are its benefits? How extensive should it be?

A review of published reports of the management of childhood non-Hodgkin's lymphoma was undertaken to determine the extent to which a staging procedure should be implemented and the benefits which could be derived. A variety of clinical, radiographic, surgical, and laboratory investigations were performed by different investigators. Overall, similar results were obtained for the different stages. The utility of the individual studies was not defined in any single review. However, it appeared that bone marrow biopsy was superior to bone marrow aspirates, staging laparotomy was generally not required, and lymphangiography did not constitute a routine staging procedure. Staging permitted identification of patients with primary sites at high risk for the development of central nervous system disease or failure. The reviews did not specify the minimum number of procedures to be performed. It is concluded that each patient should receive individual consideration, and diagnostic evaluation should consist of a series of tests sequentially performed and interrupted whenever sufficient information has been assembled for institution of therapy.

The place of radiation therapy in the treatment of non-Hodgkin's lymphomas

The use of Hodgkin's disease as a model for the evaluation and management of the non-Hodgkin's lymphomas may not be appropriate. This latter group of different syndromes and diseases differs significantly in their clinical presentation from each other as well as from Hodgkin's disease. Survival must be separated from relapse-free survival since the latter is a measure of the effectiveness of any individual therapy being applied. Localized nodal lymphoma is uncommon, but important to identify since it is potentially curable by irradiation. Stage I nodular, non-histiocytic lymphomas treated by radiation results in significant, extended, relapse-free survival. All other localized nodal lymphoma is associated with a high proportion of patients relapsing outside the treatment portal. Whole body irradiation is a useful systemic agent causing regression for an extended period of time in stage III or stage IV nodular lymphoma. Chemotherapy seems to have a limited value in nodular lymphomas, with no clear evidence that combination chemotherapy is more effective than single agents. In diffuse lymphomas, aggressive chemotherapy shows more promise, with diffuse histiocytic lymphoma having extended relapse-free survival.

Stainable iron in aspirated and needle-biopsy specimens of marrow: a source of error

Marrow iron was assessed in needle biopsy sections and in simultaneously obtained aspirated smears and aspirated clot sections from 251 patients. Significantly different amounts of stainable iron were observed in needle biopsy sections and aspirated smears in 15% of the specimens. The usual difference consisted of significantly less stainable iron in needle biopsy sections as compared to the aspirated smears (13%). Of clinical importance was the finding of absent stainable iron in 8% of the needle biopsy sections, in contrast to the definite deposits observed in the corresponding aspirated smear. Of similar interest was the observation that 6% of the needle biopsy sections had significantly less stainable iron than corresponding hemosiderotic smears. The amounts of stainable iron in needle biopsy sections were similar to the amounts observed in the corresponding aspirated clot sections. Evaluation of marrow iron using needle biopsy sections as well as aspirated clot sections differs from results observed in aspirated smears and could be a source of significant error in the assessment of iron stores.

Involvement of the central nervous system in malignant lymphomas

A retrospective histologic study of 145 consecutive autopsy cases of systemic malignant lymphomas (including lymphatic leukemias) was performed. The classification followed the Kiel Classification (Gérard-Marchant et al., 1974). There was an overall secondary CNS involvement in 26.2% of the total or in 30.4% of the non-Hodgkin's lymphomas including ALL, with intracranial lesions in 21.4 and 26.1%, respectively, and spinal epidural spread in 5.5 (5.1%). Peripheral nerve involvement was seen in almost 40% of the examined cases. Ten further cases were isolated ("primary") intracranial lymphomas without evidence of extraneural deposits or systemic lymphatic disease. The CNS complications in non-Hodgkin's lymphomas were diffuse meningeal and/or perivascular infiltration with or without invasion of the nervous parenchyma, and did not differ from those in CNS leukemia. Isolated solid mass lesions in the brain were only present in 7% of the secondary CNS lymphomas, but were seen in all instances of "primary" cerebral lymphomas. The incidence of CNS complications was highest in lymphoblastic lymphomas including ALL (39%), CLL (31%), immunocytic lymphoma (29%), less frequent in immunoblastic (18.7%), and centrocytic lymphomas (16.6%). No intracranial lesion was observed in centroblastic-centrocytic and centroblastic lymphomas which only produced epidural spread. Bone marrow involvement was present in 92.8% of the cases with secondary CNS lesions, and in 83.2% of the epidural lymphomas. Leukemic conversion, present in 44% of the total (52% with ALL), was demonstrated in 83.3% of the cases with secondary brain lesions, but was hardly combined with epidural spread. The histologic pattern of CNS lesions in non-Hodgkin's lymphomas and their frequent association with leukemic conversion suggest the importance of hematogenous dissemination rather than of direct spread from bone marrow or local manifestation in multisystem disease. Isolated ("primary") lymphomas of the CNS which are morphologically identical with the extraneural lymphomas may represent a primary, often lethal manifestation of a multisystem disease with or without secondary generalization.