Non-Hodgkin's lymphomas: a clinicopathologic study of 293 cases

The outcome of combined-modality treatments for stage I and II primary large B-cell lymphoma of the mediastinum

PURPOSE

Primary mediastinal large B-cell lymphoma (PML) has clinicopathologic features distinct from those of other diffuse large-cell lymphomas. However, the optimal treatment for this tumor is evolving, and in particular, the role of radiation therapy remains undefined. We conducted a retrospective review to evaluate the role of radiation therapy in this disease.

METHODS AND MATERIALS

The medical records of 40 consecutive patients with Ann Arbor Stage I or II PML treated at our institution from January 1980 to December 1995 were reviewed. There were 18 patients with Stage I disease and 22 patients with Stage II disease; 62.5% were women and 37.5% were men. The median age was 32.4 years (range, 17-74 years). The tumor scores were 0 in 1 patient, I in 5 patients, II in 13 patients, III in 7 patients, IV in 4 patients, and unknown in 10 patients. The International Prognostic Index (IPI) was 0 in 10 patients, I in 26 patients, II in 2 patients, and unknown in 2 patients. All patients were treated with doxorubicin-based chemotherapy, and 35 patients received radiation therapy. For most patients who received radiation therapy, an involved field or a modified-mantle field was used, and a dose of 40 Gy in 20 fractions or 39.6 Gy in 22 fractions was administered. Univariate analysis was performed to identify prognostic factors.

RESULTS

The median follow-up in surviving patients was 56 months (range, 19-194 months). The actuarial 5-year relapse-free survival (RFS) rate and overall survival (OS) rate for all patients were 67% and 72%, respectively. Thirty-five patients achieved a complete response; 32 of these patients received radiation therapy. The patterns of failure for the complete responders were as follows: locoregional failure alone for 1 patient (at the margin of the radiation field); distant failure alone for 5 patients; and both locoregional (in-field) and distant failure for 1 patient. There were no failures after 2.5 years. None of the 5 patients who never achieved a complete response had local control, and all died with disease. Only 2 of the 5 completed the planned course of radiation therapy; both had massive mediastinal disease. There was no treatment-related death from the initial chemotherapy or radiation therapy. One patient developed a second malignancy (sarcoma) within the radiation field after 13 years. The tumor score was a significant predictor of RFS (p = 0.016) and OS (p = 0.006), but the IPI did not prove to be a significant predictor.

CONCLUSION

We recommend consolidative radiation therapy in view of the excellent local control and the lack of significant toxicity. Modified mantle or involved field appears to be an adequate volume, and 39.6-40 Gy appears to be an adequate dose. The tumor score is a significant prognostic factor.

Radiation therapy of the older patient

Radiotherapy has a major role in the multidisciplinary approach to cancer therapy. It is widely used for curative and palliative treatment of cancer involving various sites. Radiotherapy is of particular benefit to older and frail cancer patients as an alternative to surgery and to systemic therapy. The available data on the sensitivity of normal tissues to radiotherapy in elderly patients strongly suggest that older patients with good functional status tolerate radiotherapy as well as younger patients and have comparable tumor response and survival rates. Aggressive radiotherapy should not be withheld from older patients because of chronological age alone.

Outcome of advanced stage low grade follicular lymphomas in a population-based retrospective cohort

BACKGROUND

To the authors' knowledge previous reports of patient outcome for advanced stage low grade follicular lymphomas (LGFL) have not been population-based. This is the first report describing the outcome of these patients based on a population-based cohort.

METHODS

A retrospective chart review was performed for all patients diagnosed with advanced stage LGFL between 1987-1995 for the adult population of central and northern Alberta, Canada.

RESULTS

One hundred and fifty-seven patients were diagnosed with advanced stage LGFL. Approximately 45% of patients had died at last follow-up. Treatment was initiated at the time of diagnosis in 87 patients (55%), with alkylating agents used in 66% of them. Of the 70 patients not treated at the initial diagnosis, 69% had been treated at a median of 16.3 months. The overall median survival was 5.9 years. On univariate analysis, significant variables (P < 0.20) included age, B symptoms, symptomatic lymphadenopathy, symptomatic splenomegaly, splenomegaly, Eastern Cooperative Oncology Group performance status, baseline lactate dehydrogenase (LDH), diffuse component on histology, and treatment at the time of diagnosis. By multivariate analysis, the only factors that influenced survival significantly and independently were baseline LDH and B symptoms. An elevated baseline LDH had a hazard ratio of 2.80 (95% confidence interval [CI], 1.65, 4.74) and a median survival of 8.0 years versus 3.6 years (P < 0.0001). B symptoms had a hazard ratio of 2.30 (95% CI, 1.23, 4.30) and a median survival of 6.5 years versus 3.1 years (P < 0.0067).

CONCLUSIONS

Although some patients with advanced stage LGFL enjoy a prolonged survival, 80% of deaths in this cohort were attributable to lymphoma. The median overall survival of 5.9 years offers a less positive perspective on the outcome of these patients than in previous nonpopulation-based reports. This emphasizes the need for further population-based studies as well as new therapeutic approaches, especially those directed toward patients with poor prognostic features such as elevated baseline LDH and B symptoms.

Conservative management of follicular non-Hodgkin's lymphoma in childhood

Among 447 children with non-Hodgkin's lymphoma (NHL) on the childhood U.K. registry, seven children with follicular (NHL) were identified. Four were male and their age ranged from 4.25 to 13.5 years (median 7.5); all had localized disease, Murphy's stage I (n = 4) and II (n = 3). Sites involved at presentation were cervical lymph nodes and tonsils (n = 5), ileum (n = 1) and parotid gland (n = 1). Three had complete surgical excision only and four had complete (n = 1) or incomplete excision (n= 3) followed by a short multi-agent chemotherapy regimen (UKCCSG 9001 protocol). With a median follow-up of 1.5 years (range 0.25-5 years) from diagnosis, six are alive in complete remission (CR) including three who had no chemotherapy. These results confirm previous reports that follicular lymphomas in children are rare (1.5%) and tend to be localized at presentation. Their rarity makes it difficult to produce guidelines about treatment, but in localized cases a period of non-intervention may be justified.

The role of radiotherapy in the treatment of localised intermediate and high grade non-Hodgkin's lymphoma in elderly patients

BACKGROUND AND PURPOSE

The treatment of elderly patients with high or intermediate grade non-Hodgkin's lymphoma (NHL) remains difficult and controversial. In order to audit our own practice, 270 elderly patients treated between 1988 and 1993 with this diagnosis were retrospectively reviewed.

MATERIAL AND METHODS

81 patients unfit for chemotherapy received fractionated radiotherapy for apparently localised stage I or II disease. The median age of the patients was 78 years (range 70-87 years). Forty stage I and 17 stage II patients had extra-nodal sites of disease. The radiation field included the primary site plus immediate adjacent nodes.

RESULTS

After a median follow-up of 3.9 years the 5-year overall and disease-free survival rates were 33% and 31%, respectively. Age (hazard ratio (HR) 1.22, P = 0.03), stage (HR 5.50, P = 0.02) and lactate dehydrogenase level (HR 1.003, P = 0.004) were identified as independent risk factors for relapse.

CONCLUSION

These factors can define a group in which radiotherapy can produce acceptable survival rates (age < or = 80 years, stage I and lactate dehydrogenase < or = 500). This group represented 34% of those patients where all these variables were recorded and had 5-year disease-free and overall survival rates of 56% and 62%, respectively.

Pathological and immunophenotypic features of adult non-Hodgkin's lymphomas by age group

To elucidate age-related differences in non-Hodgkin's lymphoma (NHL), the authors evaluated 950 consecutive, human immunodeficiency virus-negative patients (age range, 15 to 96 years) observed between July 1988 and June 1995 in the same Italian cancer institute. Patients were grouped into six age groups and cross-tabulated by Working Formulation (WF) categories and other newly recognized entities according to the Revised European American Lymphoma (REAL) classification, cell immunophenotype, and nodal or extranodal location. There was a tendency of the low-grade category to increase with increasing age (16.8% in the age group 15 to 34 years to 32.4% in the age group 65 to 74 years), although a subsequent decline was seen at age 75 years or older (23.2%). Also the intermediate-grade category was more frequent in the elderly (46.6% and 49.4% at 65 to 74 years and at 75 years or older, respectively). High-grade category showed compared with low and intermediate grade ones, a significant downward trend with age (X2 for trend = 25.31; P < .001), interrupted in only the oldest age group. The relative excess of low-grade NHL in patients older than 55 years. of age was accounted for by the high proportion of small lymphocytic lymphomas, which, however, somewhat declined at age 75 years or older. Conversely, the relative excess of high-grade NHL below age 35 years chiefly derived from the high percentage (28.4%) of CD30-positive anaplastic large cell lymphomas. B- and T-cell lymphomas accounted for 85.9% and 9.0% of all cases, respectively. B- and T- and non-B, non-T-cell and histiocytic NHL accounted for the remaining 5.1%. A highly significant trend of increase in the proportion of B-cell lymphomas with age increase was noted (X2 for trend = 21.90; P < .001); chiefly attributable to the excess of T-cell (15.1%) and undetermined phenotype (18.6%) in patients younger than 35 years of age. Extranodal location was not significantly related to age groups. Thus, the present study showed some interesting differences in NHL morphology and cell phenotype according to age, avoiding, at the same time, the arbitrariness of patients' dichotomization into elderly and nonelderly.

The follicular non-Hodgkin's lymphomas--II. Prognostic factors: what do they mean?

The Ann Arbor staging classification has long been recognised to have shortcomings when used to stage the follicular lymphomas. To date, the identification of important prognostic variables has not succeeded in producing a superior staging classification that reflects the stages of dissemination of these processes in a way that can be used in the testing of new therapeutic strategies. A fresh look is taken at these factors. Data from 398 patients entered into the British National Lymphoma Investigation trials between 1974 and 1980, were analysed to evaluate the performance of the Ann Arbor staging classification. Multiple regression and proportional hazards techniques were used to determine what factors independently influence response to initial treatment, the durability of that response and ultimate survival, and to isolate factors that relate to disease progression from those that have other mechanisms of action. The Ann Arbor staging classification fared poorly, minimally separating relapse-free and cause-specific survival probabilities in patients with the largest staging groupings, III and IV. Significant prognostic heterogeneity was seen in both of these stage groupings, with 22% of patients with stage IV disease on the basis of marrow involvement having slightly better outcomes than patients with stage III disease. Significant differences in outcome were also observed between patients of different age and sex in each Ann Arbor stage grouping. Increasing number of lymph node regions involved, constitutional symptoms, the presence of splenomegaly and increasing age were observed to have powerfully independent adverse influence on probability of complete response to treatment and cause-specific survival. The evolution of the follicular lymphomas is reflected at the clinical level by an increase in the number of lymph node regions involved and splenomegaly. Simple classifications based on simple counts of lymph node regions involved and splenomegaly are more successful than the Ann Arbor staging classification in subdividing the series into patient subgroups that, regardless of gender or age, experience significantly different probabilities of responding completely to therapy and, as a consequence, relapse-free and cause-specific survival expectations. The definition of poor prognosis in subgroups may be of value in selecting patients for newer and more intensive therapeutic approaches.

Non-Hodgkin's lymphoma in Saskatchewan. A review of 10 years' experience

BACKGROUND

The incidence and treatment of non-Hodgkin's lymphoma (NHL) have changed in recent years. This study was intended to compare current features with a previous study (1966-1975) and assess the impact of these changes in our jurisdiction.

METHODS

Clinical features and treatment of 547 patients with NHL registered at our center from January 1980 through December 1989 were reviewed, including reassessment of histologic type in each patient. Multivariate analysis of potential pretreatment prognostic factors was performed using the Cox proportional hazards model, and survival was analyzed in relation to treatment outcome.

RESULTS

This review includes virtually all incident cases of NHL in a defined geographic area, representing an average annual incidence of 11.3/100,000 population. The male-to-female ratio was 1.1:1, median age was 65 years (range, 4-92 years). Median survival time (MST) of 482 patients with disease diagnosed antemortem was 4.8 years (95% confidence interval [CI], 3.7-6.1 years), 52% of whom have died. Thirty-nine percent of patients with disease classified by the International Working Formulation (IWF) had low-grade disease (MST, 103 months); 27% had intermediate disease (MST, 62 months), and 30% had high-grade disease (MST, 35 months). Sixteen percent of patients had associated neoplasms: 4 acute leukemias, 35 skin cancers, and 37 miscellaneous solid tumors. Results of radiation therapy (RT), chemotherapy (CT), and combined CT/RT were analyzed. Survival correlated strongly with responsiveness to treatment. Considering all patients treated with CT, anthracycline-containing CT was associated with the highest response rate, and survival time (more than 48 months) may have been affected by the addition of this agent. A survival advantage for patients with bulky Stage I and II disease treated with consolidative RT after CT is suggested, but not for more advanced stage disease. The proportional hazards model identified histologic type, disease stage, patient age, hemoglobin level, lactate dehydrogenase (LDH) level, bulky abdominal disease, and systemic "B" symptoms as significant independent prognostic factors influencing survival.

CONCLUSIONS

The incidence of NHL has increased, and the survival of patients with high-grade disease has improved significantly since the previous study. A high incidence of other associated malignancies was demonstrated in this group of patients with NHL. Recognition of prognostic factors should permit a rational application of innovative treatments for patients in unfavorable prognostic categories.

Fine-needle aspiration cytology of primary large-cell lymphoma of the mediastinum: cytomorphologic findings with potential pitfalls in diagnosis

We report the fine-needle aspiration (FNA) cytomorphologic features of six cases of primary mediastinal large-cell lymphoma with sclerosis. The series consisted of three men and three women with a median age of 36 yr. All the patients presented with a large anterior or superior mediastinal mass with no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Two of the cases showed typical findings of lymphoma, characterized by hypercellular specimens with numerous individually scattered markedly atypical lymphoid cells present, demonstrating nuclear irregularity with the presence of nucleoli and surrounding scant to slight amount of cytoplasm. Numerous lymphoglandular bodies were seen in the background. Both cases were correctly diagnosed as representing non-Hodgkin's large-cell lymphomas. Two other cases had slight cellularity with the presence of a few scattered atypical lymphoid cells. Although a definite diagnosis was not rendered in either case, the possibility of malignant lymphoma was considered. Two other cases consisted predominantly of microtissue fragments with some associated scattered individual atypical cells. Within the microtissue fragments, the cells were distorted with a tendency to elongate and spindle in a prominent fibrous matrix. Our experience demonstrates that FNA cytology of primary mediastinal diffuse large cell lymphoma with sclerosis can be challenging, with a potential for a false-negative diagnosis due to limited cellularity secondary to the sclerosis or a misdiagnosis as a spindle cell neoplasm due to distortion of these cells by the fibrous matrix. To the best of our knowledge, we believe this is the first FNA series of primary mediastinal diffuse large cell lymphoma with sclerosis.

A combination of mitoxantrone, etoposide and prednisone in elderly patients with non-Hodgkin's lymphoma

From January 1988 to December 1991, 55 elderly patients (14 pretreated and 41 previously untreated) with non-Hodgkin's lymphoma (NHL) entered a prospective study to evaluate the feasibility of a combination of mitoxantrone (7-9 mg/m2), VP 16-213 (150 mg, 2-hour infusion on day 1, and 200 mg per os on days 3 and 5) and low-dose prednisone (25 mg days 1-5) (MVP regimen), recycling every 21-28 days. The median age was 75 (range 64-93). All but 4 pretreated patients had intermediate- or high-grade lymphomas. Complete remissions were obtained in 22 of 40 (55%) evaluable previously untreated patients, and partial remissions in 10 (2 of these obtained complete remissions after radiotherapy), for an overall response rate of 80%. The median duration of response was 12 months. At 24 months the overall survival was 52% and the relapse-free survival was 31%. Of 14 pretreated patients complete remissions were obtained in 4 (29%) and partial remissions in 3. Granulocytopenia and fever were the most important side effects; two patients contracted bronchopneumonia and one of them died. Other toxicities were mild. We conclude that this combination chemotherapy is effective as first-line and salvage treatment in elderly patients with intermediate- and high-grade NHL, and that it is feasible on an outpatient basis, with manageable toxicity.

A non-Hodgkin's lymphoma in the buccal mucosa. A case report

Non-Hodgkin's lymphomas are tumors of the immune system that uncommonly evolve as primary lesions of the oral cavity. A case of a primary lymphoma in the right cheek that had invaded the surrounding tissues is presented.

A study of 15 cases of primary mediastinal lymphoma of B-cell type

Fifteen cases of pure supradiapragmatic lymphoma with initial prominent antero-superior mediastinal involvement displaying a B-cell pattern of reactivity were studied. These cases occurred in six men and nine women with a median age of 33 years at diagnosis (range, 23 to 75 years). Supradiapragmatic peripheral lymphadenopathies were present in three cases, and intrathoracic extension to the lung, pericardium, or pleura was possible. In five cases a thymic origin was obvious. All cases exhibited a B-cell pattern of differentiation, with a great variety of histopathologic aspects associated with a high frequency of fibrosis and/or necrosis. Hodgkin's disease was initially misdiagnosed in four cases. The evolution was purely local, with extrathoracic extension in five cases, at the ultimate phase of the disease. The prognosis appeared to be poor with only five patients still alive at a median survival time of 16 months. A complete chemoresistance and radio-resistance was observed in seven cases; only two complete remissions were achieved with aggressive chemotherapy. Prolonged remission could be achieved after surgical reduction of the mass. Primary B-cell mediastinal lymphoma appears to be a distinct clinical entity with local evolution and resistance to therapy. A new therapeutic regimen, which could include surgery in some cases, should be found for this disease.

Non-Hodgkin's lymphoma in the elderly. A study of 602 patients aged 70 or older from a Danish population-based registry. The Danish LYEO-Study Group

Within a 7-year period 1,597 newly diagnosed cases of non-Hodgkin's lymphoma (NHL) were included in a Danish population-based NHL registry. Of these, 602 (38%) were aged 70 years or older (age range 70-94, median: 76.8). They represent the population defined as 'elderly' patients in the present study. The average annual incidence rate for this elderly patient population was 35.7/10(5), as compared with 6.6/10(5) for patients aged less than 70 (overall annual incidence: 9.5/10(5)). Localised cases (stage I and II) and extranodal manifestations were found more frequently among elderly patients. The most common sites of extranodal involvement were the stomach (21% of all extranodal cases) and the bone marrow (16%). Histologically, follicular centroblastic/centrocytic cases were found to be less frequent (p less than 0.01) in elderly patients as compared to their younger counterparts (less than 70 years), who in contrast had a lower occurrence of diffuse centroblastic cases (p less than 0.01). Overall 7-year survival for the elderly patient population was 35% (median 1.7 years), and for patients aged less than 70 it was 57%. This difference persisted after correction for apparently NHL-unrelated deaths (52% vs. 66%, respectively, p less than 0.0001). Elderly patients with poor prognosis were characterised by the following features identified in a Cox-regression model: hepatic involvement, presence of B-symptoms, high-grade histology and elevated s-LDH. The corresponding relative risk values were in the order 2.4, 2.2, 1.9 and 1.6.

Non-Hodgkin's lymphoma in the elderly. I. Pathologic features at presentation

The pathologic findings of 118 patients aged 70 years or older with non-Hodgkin's lymphoma (NHL) are reported. These patients formed 27.2% of 433 consecutive cases of NHL seen in a single institution over a 5-year period. Thirty-one of 433 NHL cases were histologically not classified, whereas the remaining 402 could be classified according to the International Working Formulation (WF) of NHL for clinical usage. Immunophenotypic analyses were carried out in 112 NHL cases; of this group 28 were NHL in elderly patients. Of the 95 elderly NHL that could be classified in the histologic categories of the WF 28 cases were in the low-grade, 41 in the intermediate-grade, and 26 in the high-grade categories. Eighty-one cases had diffuse histologic types and 14 had follicular/nodular histologic types. Thirty-five cases were of the G (diffuse large cell) + H (large cell, immunoblastic) categories. No significant differences in the prevalence of the different subtypes were observed among patients younger or older than 70 years. Immunohistologically, most NHL cases in the elderly expressed B-cell phenotype. Sixty-two NHL in the elderly were extranodal at presentation. The results of this study indicate that elderly patients form a relevant proportion of patients developing NHL and thereby present a very difficult management problem. The pathologic features of NHL in the elderly does not differ significantly from those of their younger counterparts, although an increase in diffuse versus follicular histologic patterns, and in extranodal versus nodal disease was observed with advancing age.

Combination chemotherapy specifically devised for elderly patients with unfavorable non-Hodgkin's lymphoma

The results of a prospective trial with a specifically devised chemotherapy regimen in elderly patients with unfavorable non-Hodgkin's lymphoma (NHL) are reported. Between April 1983 and April 1986, 37 consecutive patients 70 years old or more (median age 80) received etoposide and prednimustine (E + P) 100 mg/m2 p.o. for 5 days every 21 days. Thirteen patients were previously treated. Objective response rate in the 35 evaluable patients is 66% with 46% complete response. The objective response rate in the 22 previously untreated patients is nearly 70% with 50% complete response. Median survival is 14 months. The overall toxicity was reasonably acceptable. There were 5% (2 patients) treatment-related deaths, but in an unselected elderly population. We experienced the usefulness of a properly oriented clinical approach to elderly patients with NHL. We suggest that a combination regimen E + P, suitable for oral administration, may be safely employed in elderly patients with unfavorable NHL.

Management of malignant lymphoma in the elderly. An EORTC retrospective evaluation

A retrospective EORTC study was carried out in order to evaluate the incidence, clinico-pathological findings and outcome of non-Hodgkin lymphoma and Hodgkin's disease in patients 70 years of age or older. A significant proportion of non-Hodgkin lymphoma, mostly with high-intermediate grade of malignancy occurs in these patients. Aggressive treatment, in particular chemotherapy with 3 drugs or more administered to elderly patients 70 years or older, median age 77 years, is associated with significant lethal and severe toxicity. Prospective randomized studies are clearly needed in order to evaluate the activity and the toxicity of intensive chemotherapy regimens specifically devised for patients aged 70 years or older with unfavourable non-Hodgkin lymphoma. Hodgkin's disease is infrequently (5%) seen in patients 70 years of age or older. Mixed cellularity, B symptoms and stage III and IV account for 50, 47 and 47% of the cases respectively. Aggressive treatment is not associated with an increased lethal and severe toxicity compared with conservative treatment although 1 patient died of bone marrow toxicity after MOPP. Survival of patients 70 years or more with Hodgkin's disease seen in 1984 seems shorter than that in younger patients, especially due to high incidence of unfavourable prognostic factors, such as B symptoms and advanced stages.

Non-Hodgkin's lymphomas in Turkey

Between 1982 and 1986, 185 adult patients with non-Hodgkin's lymphoma (NHL) were studied at Cukurova University Hospital (CUH), Adana, Turkey. This constituted 13% of all malignant neoplasms diagnosed in the oncology clinic. The mean age for men was 45.5 years and 41 years for women. Fifty-four percent of the cases were nodal lymphoma and the remaining 46% were extranodal lymphoma. Sixty-six percent of the extranodal lymphoma cases were gastrointestinal lymphoma. The stomach was the most common localization (43%), followed by intestinal involvement (30%) and abdominal mass (27%). The mean age of the patients with gastric lymphoma was 49 years, and 36 years for patients with abdominal mass. The following conclusions were reached: (1) the relative frequency rate of NHL in South Turkey is higher than Turkey averages, but similar to other Middle East countries; (2) extranodal lymphomas account for more than 40% of all lymphomas; (3) gastric lymphoma is more prevalent than intestinal lymphoma in our region; and (4) compared with western gastric lymphomas, our patients were 10 years younger and had a higher incidence of small lymphocytic and immunoblastic lymphoma.

Non-Hodgkin's lymphomas in the elderly: prospective studies with specifically devised chemotherapy regimens in 66 patients

The results of 2 consecutive and prospective trials with specifically devised chemotherapy regimens in elderly patients (pts) with non-Hodgkin's lymphoma (NHL) are reported. Between August 1979 and September 1984, 66 pts aged 70 or older (median 75 years) with NHL entered 2 consecutive trials, the former with single agent teniposide 100 mg/m2 i.v. weekly (41 pts), the latter with etoposide and prednimustine (E + P), 100 mg/m p.o. for 5 days every 21 days (25 pts). Forty-five pts were previously untreated, 21 previously treated. Forty-seven pts were of the intermediate and high grade groups according to the Working Formulation; 19 pts were of the low grade; 57 pts were stages III and IV, 9 pts were stages I and II. The median performance status was 70 (range 30-100). The objective response rate in the 66 evaluable pts is 53% with 38% CR; the 3-year overall, disease-free and CR survivals are 21, 12 and 40% respectively. The objective response rate in the 45 previously untreated pts is 58% with 42% CR; the 3-year overall, disease-free and CR survivals are 24, 16 and 58% respectively. The overall toxicity was mild. Severe toxicity (grade III and IV according to WHO criteria) was observed only in 16/498 courses (3.2%), with 1 toxic death (grade IV leucopenia). We experienced the usefulness of a properly orientated clinical approach to elderly pts with NHL. We suggest that a combination regimen like E + P, suitable for oral administration, may be safely employed in a large fraction of pts with NHL.

Clinical and pathologic features of follicular large cell (nodular histiocytic) lymphoma

Clinicopathologic correlations were made in 50 patients with follicular large cell (FLC) lymphoma to better define the influence of a variety of clinical and pathologic features on survival and the potential for continuous freedom from disease. The 5- and 10-year actuarial survivals for the entire group of patients are 77% and 63%, respectively, but disease-free survival is only 46% at 5 years and 22% at 10 years. No significant survival differences were found with various treatment approaches, although a single relapse occurred after 3 years among patients treated with modern combination chemotherapy containing doxorubicin. Median survivals of approximately 10 years despite recurrent disease are characteristic of the majority of follicular lymphomas. Furthermore, the reproducibility of cytologic diagnosis among follicular lymphomas is known to be variable. At this time, it is unclear whether intensive chemotherapy will cure a significant number of FLC patients or novel approaches are necessary as for the other follicular lymphomas.

A morphologic study of childhood lymphoma of the diffuse "histiocytic" type. The Pediatric Oncology Group experience

Of 227 cases of pediatric non-Hodgkin's lymphoma with adequate histopathologic material for review, 72 (32%) were classified as diffuse "histiocytic" lymphoma (DHL). These cases were further divided into different morphologic subtypes according to the Lukes-Collins classification, and the National Cancer Institute Working Formulation, to ascertain whether there were any significant prognostic differences among the different subtypes. The results of our study showed that 40 patients were classified as immunoblastic lymphomas, and 32 were called large follicular center cell (FCC) tumors. Of the 40 patients with immunoblastic histology, 19 had morphologic features of the clear cell type and were interpreted as consistent with T-immunoblastic lymphomas; an additional two had polymorphous features also consistent with T-cell type: 17 had plasmacytoid features, and were morphologically classified as B-immunoblastic lymphomas; two could not be subtyped. Of the 32 patients with morphologic features of FCC lymphomas, 29 were classified as large noncleaved type, and three as large cleaved type. A clinicopathologic analysis showed that 90% of the patients obtained complete remission, and there were no significant differences in complete remission rate among the different morphologic subtypes of DHL. The estimated five year disease-free survival for all patients was over 70%, with no failure after the second year; and there were no significant differences in the disease-free survival among the different subtypes. The only clinical differences that we found, were that patients with lymphomas of FCC (large noncleaved) type were younger (P = 0.01); had less nodal involvement (P = 0.03); and had more organ involvement (P less than 0.01). We conclude that the morphologic subclassification of DHL in children currently has limited clinical prognostic significance.

Non-Hodgkin's lymphomas in the Middle East. A study of 417 patients with emphasis on special features

A total of 417 evaluable patients with non-Hodgkin's lymphomas were diagnosed between January 1974 and December 1983 at the American University of Beirut Medical Center in Beirut, Lebanon. Of these, 179 (43%) patients had nodal lymphomas, and 183 (44%) had extranodal lymphomas. The commonest lymphoma was diffuse large cell (27%), followed by large cell immunoblastic (21%). The histopathologic pattern was follicular in 18% of the nodal lymphomas and in 5.3% of the extranodal forms. The most common site of extranodal lymphoma was the gastrointestinal tract (46.5%), followed by Waldeyer's ring (19%). Small intestinal lymphomas were three times more common than gastric lymphomas. Immunoproliferative small intestinal disease (IPSID) was diagnosed in 20 of 59 patients who had primary small intestinal lymphoma. Of the 34 patients who had Waldeyer's ring lymphoma, 7 had gastrointestinal involvement at some time during the course of the disease. Nodal lymphomas were associated with poor prognostic factors: 82% were diffuse; 77% had advanced disease at presentation; 77% had intermediate- or high-grade malignancy lymphoma; 40% had marrow involvement; and 46% had B symptoms. In children, the most common lymphoma was Burkitt's, and 80% of pediatric lymphomas were high-grade malignancy. In conclusion, this study delineates the special features of non-Hodgkin's lymphomas in the Middle East: The presence of IPSID; the high incidence of extranodal forms, in particular the intestinal ones; and the rarity of follicular lymphomas.

Evaluation of malignant lymphomas using three classifications and the working formulation. 482 cases with median follow-up of 11.9 years

Three classifications and the Working Formulation for non-Hodgkin's lymphomas have been studied in 482 patients with a median follow-up of 11.9 years. Each classification was evaluated independently, and their similar and discrepant aspects were analyzed by comparing subgroups in the different schemes. Clinical staging was essential in the evaluation of some categories. There are several differences between the classifications that are not readily reconcilable. The Rappaport classification's principal groups are heterogeneous. Separation of follicular lymphomas into small and large cleaved cell types (Lukes-Collins) is significant. The addition of a follicular mixed cell type (Rappaport, Working Formulation) detracts from this significance. Centrocytic and lymphoplasmacytic tumors (Kiel) are well-defined categories and important in understanding some deficiencies in the other classifications. The small cleaved cell type, diffuse (Lukes-Collins, Working Formulation) is heterogeneous. Diffuse lymphomas of mixed cell types are poorly defined subgroups. Excluding lymphoblastic types, the presence of plasmacytic differentiation is important in identifying the high-grade lymphomas with the poorest prognosis. These results suggest that adjustments should be made in the classifications and in the Working Formulation.

Non-Hodgkin's lymphoma in the elderly. A retrospective clinicopathologic study of 50 patients

The pathologic and clinical findings of 50 patients aged 65 or older (median, 71.5 years) with non-Hodgkin's lymphomas (NHL) are reported. These patients formed 27% of all cases of NHL seen in a single institution over a 7-year period. Forty patients presented with nodal and 10 with extranodal NHL. According to the Ann Arbor system, 20 were clinical and/or pathologic Stages I and II, and 30 were Stages III and IV; of the 10 patients presenting with extranodal NHL, 8 were Stages I and II. Histologically, 84% of the cases were of the intermediate and high-grade groups according to the Working Formulation; diffuse histiocytic was the most frequent histotype (34%) according to the Rappaport classification. The pattern was diffuse in 94% of the cases. Five patients received no treatment; treatments were conservative (monochemotherapy and/or local radiotherapy) in 19 patients and aggressive (polychemotherapy and/or extended-field radiotherapy) in 26. Four patients of the latter group died of toxicity; 22 patients died of lymphoma and 13 of other causes; the other 11 (22%) patients are still alive. The overall median survival was 2.2 years. A significantly better survival was observed in patients with Stages I and II (P less than 0.025) and in those with intermediate grade (P less than 0.05) when compared with patients having Stages III and IV and high-grade histology, respectively. Apparently, no significant difference both in response and survival was found between the groups of patients which arbitrarily underwent conservative or aggressive treatments on the basis of their general conditions. Randomized clinical trials should be designed in order to draw more significant conclusions on the correct management of elderly patients with NHL.

Nodular lymphomas: current concepts

The past several years have witnessed innovative approaches to clinical management as well as significant insights into the basic biology of the nodular lymphomas. Clinical studies have explored two apparently widely disparate approaches to the treatment of patients with nodular lymphoma. On the one hand, withholding initial therapy (watch and wait) has proved to be a viable option in the management of some patients. This approach has provided information regarding the natural history of disease, such as the relative incidence of spontaneous tumor regression vs. histologic transformation to more aggressive forms of lymphoma. Alternatively, recent data also suggest that the administration of intensive chemotherapy, shown to induce long-term remissions in a high percentage of patients with diffuse aggressive lymphomas, may also produce a significant number of durable remissions in at least certain histologic subtypes of nodular lymphomas. Clinical studies which attempt to achieve a synthesis of the above two approaches are currently in progress. Advances in immunology and molecular biology have also found application in the study of nodular lymphoma. Monoclonal antibodies have been employed diagnostically, as, for example, in detecting small numbers of persistent abnormal lymphoid clones in patients in apparent remission, and therapeutically, as exemplified by the clinical use in vivo of monoclonal antibodies directed against unique idiotypic determinants expressed by surface immunoglobulin on the malignant B lymphocytes. The demonstration of the immunoglobulin gene rearrangements in nodular lymphoma cells has established a more definitive criterion for their phenotypic characterization. Finally, molecular cloning of the breakpoint of the t(14; 18) chromosome translocation frequently found in nodular lymphoma cells has led to the identification of a potential new transforming gene which could be activated as a direct consequence of its rearrangement in proximity to the immunoglobulin in heavy chain gene locus.

Prognostic significance of architectural patterns in non-Hodgkin lymphomas

Clinical data and lymphoma biopsies were analyzed in 651 patients with non-Hodgkin lymphoma in order to describe the prognostic influence of different grades of follicular architecture compared to diffuse architecture. The follicularity was graded qualitatively according to the distinctness of the pattern (intra-follicular, infiltrative follicular and traceably follicular patterns). The partially follicular pattern, with co-existence of follicular and diffuse areas in the same biopsy, was graded quantitatively according to the proportion of these areas. The median survival of patients with diffuse pattern was 1.2 years, while that of patients with follicular patterns ranged from 2.5 to 7.3 yr. The prognosis for those with partially follicular pattern was not affected, whether or not more or less than 50% of the lymphoma was diffuse. For cytologically identical lymphomas, only the intra- and infiltrative follicular patterns influenced the prognosis favourably. This conclusion was further substantiated by means of multivariate analysis.

Non-Hodgkin's lymphoma in northern India. A retrospective analysis of 238 cases

A retrospective analysis was performed of 238 patients, aged 12 years and older, with non-Hodgkin's lymphoma presenting to the All India Institute of Medical Sciences, New Delhi, India, between September 1975 and December 1982. Pathologic material was reviewed and classified according to the modified Rappaport classification. The most common histologic type encountered was diffuse histiocytic lymphoma (39%), followed by diffuse poorly differentiated lymphocytic lymphoma (29%), and diffuse mixed histiocytic and lymphocytic lymphoma (9%). Nodular lymphomas constituted 9% of all non-Hodgkin's lymphomas. A lower frequency of nodular lymphomas, a lower median age of onset (45 years), and a higher male to female ratio (4.5:1) as compared with Western countries was observed. Survival information on 90 patients revealed no effect of age, sex, stage of disease, and "B" symptoms on survival, whereas histologic diagnosis had a significant influence on survival (P less than 0.05). A median survival of 24 months in 58 patients receiving chemotherapy is comparable to that reported by other investigators.

The significance of the number of centroblasts in centroblastic/centrocytic lymphomas. A long term study in a large group of patients

A group of 385 centroblastic/centrocytic lymphomas with long follow-up periods was subdivided on the basis of the relative number of centroblasts in the initial biopsies. Only minor differences in overall survival were found although a different survival pattern was observed between the groups. The transition into a high-grade malignant secondary centroblastic lymphoma correlated, at a statistically significant level, with the relative number of centroblasts in the initial biopsy.

Treatment of diffuse poorly differentiated lymphocytic lymphoma. An analysis of prognostic variables

Forty patients with diffuse poorly differentiated lymphocytic lymphoma (DPDL) Stages II-IV were treated with three different and successive combination chemotherapy protocols. Seventeen patients were treated with the cyclophosphamide (CTX) L2 protocol which included maintenance chemotherapy for 3 years. Only three patients were treated with the NHL-3 (non-Hodgkin's lymphoma) protocol, and 20 patients received the NHL-5 program. All protocols included radiotherapy (1500-4800 rad) to areas of initial bulky disease or persistent tumor, as well as central nervous system (CNS) prophylaxis with intrathecal methotrexate in patients with bone marrow involvement. Seventy-eight percent of local recurrences occurred in previously irradiated areas. Two-year survival rates were 55% and 70% for the CTX-L2 and NHL-5 protocols, respectively. Median disease-free survival for 24 complete response (CR) patients was 16.5 months. Of the 40 patients, 37 were evaluable for response to therapy. The CTX-L2 produced an 80% total response (TR) rate, a 60% CR, and a 20% partial response (PR). The patients on the NHL-5 achieved a TR rate of 95%, 74% CR, and 21% PR. Differences in TR and CR between the two protocols were not significant. Only 1 of 3 patients on the NHL-3 protocol achieved a CR. There was a trend for age greater than 50 years to lessen the chances of CR (P = 0.091); however, sex, symptoms, stage of disease, and LDH level were not significantly related to CR rate. Response to treatment (CR versus PR versus failure) was the most important factor influencing survival (P less than 0.001); age (greater than 50 years) was also significant (P = 0.008). Lactate dehydrogenase (LDH) was of borderline significance (P = 0.06). Cox regression model showed age (greater than 50 versus less than 50 years, P = 0.001), LDH (greater than 500 versus less than or equal to 500 U/L, P = 0.019) and symptoms (A or B) to be the best predictors of survival.

Histological, epidemiological and clinical aspects of centroblastic-centrocytic lymphomas subdivided according to the "working formulation"

A group of 424 lymphomas diagnosed as centroblastic-centrocytic lymphomas at the Lymph Node Registry in Kiel was subdivided into small (S), mixed (M) and large (L) cell groups, according to the "working formulation" proposed in a National Cancer Institute sponsored study. Histological epidemiological and clinical parameters were studied. It was found that in group S a follicular growth pattern was most frequent and in group L a follicular and diffuse growth, while group M took an intermediate position. No statistically significant differences were found in respect to epidemiological factors or overall survival. However, in the first 6 years after the diagnosis the survival in group S was better than in group M, but thereafter a reversal occurred. Group L appeared to have the worst survival throughout. Growth pattern and sclerosis were found to be of limited influence on survival within the cytological groups.

The heterogeneity of follicular follicle center cell tumors. II. Clinical follow-up of 30 patients

The Kiel classification for the histology of malignant lymphomas distinguishes the group of follicular lymphomas as low-grade malignancies. Clinically, this proves to be a heterogeneous group. With the aim of establishing parameters giving indications for the prognosis of the patient, a retrospective analysis was made of 30 patients with a histologic diagnosis of follicular follicle center cell tumor (FCC). Neither the immunologic markers of the cells nor the stage of dissemination have prognostic significance for survival. On the basis of the predominating neoplastic cell type, a cytologic subdivision of the lymphomas was made, characterizing the following subgroups: SCC (small centrocytes with occasional centroblasts), CBCC/A (centrocytes with several centroblasts), and CBCC/B (centrocytes with many centroblasts), SLCC (small and large centrocytes), SLCB (small and large centroblasts). The actuarial survival of the total group of 30 patients was 66% after 5 years, but the survival in the cytologic subgroups ranged from 100% in group SCC to 0% in group SLCB. Comparing the groups SCC and CBCC/A with CBCC/B and SLCB gave a significantly worse prognosis for the groups with an increased number of centroblasts (i.e., CBCC/B and SLCB). Therefore it seems justified to treat patients with a predominance of centroblasts aggressively with the aim of reaching a complete remission.

The heterogeneity of follicular center cell lymphomas. I. Cytohistologic, immunologic, and enzymehistochemical aspects

Histologic material from 44 patients with follicular center cell lymphomas with a follicular growth pattern was divided into five groups on the basis of the predominating neoplastic cell type(s), i.e., small centrocytes with occasional centroblasts (SCC), centrocytes and few (CBCC/A) or many (CBCC/B) centroblasts, small and large centrocytes (SLCC), and small and large centroblasts (SLCB). Histologic, immunologic, and enzymehistochemical parameters as observed in these groups were compared, and follow-up material and material obtained during staging procedures were studied. Immunologic and enzymehistochemical findings confirmed both the B-cell origin and the neoplastic nature of the lymphomas, but did not yield relevant differences between the various groups. The groups with a predominance of small centrocytes or of small centrocytes and centroblasts showed the most prominent follicular growth and early dissemination to bone marrow and spleen. Histologic transformation in these groups was characterized by an increase in the number of centroblasts and a more diffuse growth pattern. The groups composed of small and large centrocytes or centroblasts tended to a more diffuse growth and had later dissemination and no histological transformation.

A new working formulation of non-Hodgkin's lymphomas. A retrospective study of the new NCI classification proposal in comparison to the Rappaport and Kiel classifications

Two hundred thirty cases of malignant non-Hodgkin's lymphomas were reclassified in a retrospective study according to the New Working Formulation for Clinical Usage of the NCI as compared to the Rappaport and Kiel classifications. The reproducibility for the individual schemes this study was 81% (Rappaport), 79% (Kiel), and 85% (New Working Formulation). In keeping with the results of the NCI international study, all lymphomas were subdivided into 3 prognostic groups: (1) low-grade malignancy (6.0 years median survival); (2) intermediate-grade malignancy (3.5 years median survival); and (3) high-grade malignancy (1.4 years median survival). The NCI-proposed New Working Formulation for Clinical Usage is thus recommended as practical and unprejudicing classification scheme for general application; however, its usefulness as tool for translating one classification scheme into another appears limited.

An autopsy study of histologic progression in non-Hodgkin's lymphomas. 192 cases from the National Cancer Institute

Histologic slides were reviewed from 192 autopsies of patients with non-Hodgkin's lymphomas admitted to the National Cancer Institute (NCI) from 1953 to 1975. Each autopsy was classified according to the systems of Rappaport and Lukes-Collins. Comparisons with the initial diagnosis were made. The initial histologic diagnoses of the autopsied population were similar in distribution to other published series of non-Hodgkin's lymphomas. Of the 56 cases which initially demonstrated nodular patterns of growth, the following distribution was found at autopsy: 25%, no lymphoma; 6%, nodular lymphoma; 32%, diffuse histiocytic (large cell) lymphoma (DHL); 21%, diffuse undifferentiated (non-Burkitt's) lymphoma (DUL); and 16%, the remaining diffuse morphologies. Of the 136 patients with initial diagnosis of diffuse lymphoma, the following distributions were observed at autopsy: 20%, no lymphoma; 0%, nodular lymphoma; 31%, diffuse histiocytic (large cell) lymphoma; 12%, diffuse undifferentiated (non-Burkitt's) lymphoma; 9%, Burkitt's tumor; 14%, diffuse poorly differentiated lymphocytic lymphoma; and 14%, the remaining diffuse morphologic types. One hundred and thirty-four cases which were initially diagnosed as follicular center cell type within the Lukes-Collins classification gave the following distribution at autopsy: 21%, no lymphoma; 25%, small noncleaved type; 17%, large noncleaved type; 23%, non-follicular center cell lymphomas (17% immunoblastic B); and the remaining 13% were distributed among the other follicular center cell types. This autopsy review demonstrates the rarity of nodular (follicular) lymphomas at autopsy, and the predominance of the diffuse histiocytic or "transformed" type. This study provides a comparison of the rate of histologic progression of lymphomas in the same patient population at autopsy with a previously published study of progression during life.

Stage III nodular lymphomas. Preliminary results of a combined chemotherapy/radiotherapy program

Since 1975, all histologic subtypes of Stage III and IIIE nodular lymphoma patients were treated with a combination of radiotherapy and multiple-agent chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine, prednisone, and bleomycin (CHOP-Bleo). Fifty-eight patients were treated through 1979. Treatment consisted of two cycles of CHOP-Bleo alternating with sequential radiotherapy to clinically involved regions, and further CHOP-Bleo to a total of ten cycles. Radiotherapy doses ranged between 3000 and 4000 rad delivered in three to four weeks. Forty-six patients completed treatment. In the other 12 patients, treatment was interrupted because of progressive disease in seven, and myelosuppression in five. Overall five-year survival and disease-free survival results were 82% and 47%, respectively. Survival for those patients who completed therapy was 93%. By histopathology, survivals for all patients were: poorly differentiated lymphocytic, 100%; mixed cell, 80%; and histiocytic, 39%. Disease-free figures for all 58 patients were: poorly differentiated lymphocytic, 44%; mixed cell, 65%; and histiocytic, 35%. The extent of abdominal disease influenced five-year survival as follows: 100% for those who had only occult disease at staging laparotomy; 88% for those who were Stage III on the basis of a positive lymphangiogram; and 50% for those who had a palpable mass or required an exploratory laparotomy for symptoms. Five of seven patients with progression during protocol therapy have died. No patients died as a result of myelosuppression. A number of patients developed complications during treatment, none of which were fatal. Eight patients developed herpes zoster, four patients developed transient radiation hepatitis, and four patients had miscellaneous complications.

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.

Primary non-Hodgkin's lymphoma of the mediastinum

Non-Hodgkin's lymphoma localized to the mediastinum and adjacent structures occurred in 12 of 215 (6+) non-Hodgkin's lymphoma patients seen at the Massachusetts General Hospital between 1975 and 1979. Lymphangiography, radionuclide scanning and whole body computerized tomography were used to exclude patients with extrathoracic disease at presentation. Eleven of the 12 patients presented with extensive contiguous extranodal disease (Stage IIE) with involvement of either the pericardium, sternum, chest wall, pulmonary parenchyma or, in four cases, with superior venacaval obstruction. Diffuse large cell lymphoma (eight cases) and diffuse poorly differentiated lymphocytic lymphoma (four cases) were the prevalent histologic subtypes; no instances of lymphoblastic lymphoma without extrathoracic spread were encountered. None of four lymphomas studied could be characterized as either B- or T-cell tumors utilizing conventional surface marker techniques. Ten of the 12 patients achieved complete remissions, either after treatment with combination chemotherapy alone (three patients) or after both chemotherapy and mediastinal irradiation (seven patients). Two of these ten have subsequently relapsed, but median survival has not been reached after a mean period of observation of 28 months. Primary nonlymphoblastic non-Hodgkin's lymphoma of the mediastinum is more common than previously realized, displays aggressive contiguous spread within the chest and responds well to combination chemotherapy with or without adjuvant mediastinal irradiation.

Diffuse large cell and undifferentiated lymphomas with prominent mediastinal involvement

This report describes 11 adults with non-Hodgkin's lymphoma who presented with symptoms caused by large mediastinal masses. Patients with lymphoblastic lymphoma were excluded from this analysis. Most of the patients were young women with localized disease at presentation. Ten tumors were diffuse large cell ("histiocytic") lymphomas and one was a diffuse, undifferentiated lymphoma, non-Burkitt's type. According to the Lukes' and Collins' classification scheme, seven were large cleaved cell type, three were large noncleaved and one was small noncleaved cell type. Sclerosis was present in four cases. Despite aggressive therapy nine patients died within 26 months of diagnosis and only two remain disease-free. Median survival of these patients was 16 months. Patients with symptomatic mediastinal masses and non-Hodgkin's lymphomas composed predominantly of large cell appear to share certain clinico-pathologic features and to present a poor prognosis subset of patients with non-Hodgkin's lymphoma.

The impact of growth pattern on survival in non-Hodgkin's lymphomas classified according to Lukes and Collins

203 cases of non-Hodgkin's lymphomas assigned as follicle centre cell (FCC) type according to the classification of Lukes and Collins (1975) were analyzed according to growth pattern. Nodular cases had a better prognosis than diffuse ones even within a certain cell type. The abundance of parafollicular lymphocytes was a better criterium of nodularity than prominence of venules. Degrees of nodularity was best scored according to distribution of diffuse and nodular areas. Prognosis was better with a higher degree of nodular growth even within a certain cytological cell type. Therefore it is proposed that scoring according to different degrees of nodularity has a high prognostic impact and could be an alternative to scoring according to cell type within the group of follicle centre cell lymphomas.

Nodular histiocytic lymphoma: factors influencing prognosis and implications for aggressive chemotherapy

Twenty-five patients with Stage III and IV nodular histiocytic lymphoma (NH), entered on three different Eastern Cooperative Oncology Group protocols from 1972-78, were analyzed for response and survival. A complete response (CR) rate of 44% was observed, with 40% partial responders (PR). Four of the 11 CRs are continuing in their original remission. Median survival for CRs was 52 months; for PRs it was 30 months. The six patients treated with cyclophosphamide-prednisone had a median survival of 18 months versus 51 months for the 19 patients treated with more aggressive combination chemotherapy programs. No significant difference in survival was noted between those patients with both nodular and diffuse histology and those with a pure nodular pattern. The median survival of the 25 NH patients was 47 months and is similar to a group of 101 patients with nodular mixed lymphoma (NM) entered on the same ECOG protocols during this time. This survival is intermediate between the nodular lymphocytic poorly differentiated subtype and diffuse histiocytic lymphoma. It suggests that patients with NH histologies be treated with aggressive combination chemotherapy programs designed to achieve complete remission and prolonged disease-free survival.

Morphologic classification of non-Hodgkin's lymphoma. I. Retrospective analysis using the Kiel classification

In a retrospective analysis of 334 cases of non-Hodgkin's lymphoma observed between 1969 and 1978, 250 cases could be classified according to the Kiel classification. Clinicopathologic correlation was analysed for these latter cases. Irrespective of the morphologic appearance, all cases initially in stage I showed an excellent prognosis after radiation therapy alone, whereas the prognosis for stage II was similar to stages III and IV. For stages II-IV, 3 major prognostic groups with significantly differing survival curves were identified. The median survival times were one, 3 and more than 7 years, respectively. The pathologic and clinical significance of the Kiel classification is discussed.

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.

The influence of histologic type on survival in non-Hodgkin's lymphoma

Histologic groups in 231 cases of malignant lymphoma were correlated with survival data at 100 months from the time of initiation of the study. Patients in the first two decades of life fared comparably with adults, but those over 60 years of age showed a poorer survival trend. Seven favorable and four unfavorable histopathologic groups were found with collective median survivals of 83 and 16 months, respectively (P less than 0.001). The favorable group included three follicular classes (cleaved, mixed, and large noncleaved) and four diffuse classes (small lymphocytic, cleaved, Burkitt non-cleaved, and convoluted lymphocytic). The unfavorable group consisted of four diffuse classes (plasmacytoid lymphocytic, mixed, and small and large non-cleaved). The group of 88 patients with follicular lymphoma had significantly longer overall survival than the group of 143 patients with diffuse lymphomas. No significant differences in survival were noted within three grades of follicular involvement. The favorable and unfavorable diffuse lymphomas had collective median survivals of 82 and 16 months, respectively (P = 0.01). Significant survival differences due to pattern of nodal involvement (P = 0.01) were found in patients with mixed and large non-cleaved cell lymphomas, but not in those with cleaved cell lymphomas. The group with large cleaved cells had significantly longer survival than those with large non-cleaved cells. Patients with mixed and large non-cleaved cell lymphomas of the same nodal pattern had similar survival data.

Natural history of malignant lymphomas with divergent histologies at staging evaluation

The pathology and medical records of 515 patients with malignant lymphomas treated at the National Cancer Institute have been reviewed to determine the frequency and natural history of patients who have different histologic diagnoses in various tissue sites at their initial staging evaluation. Of the 101 patients who had multiple tissue sites biopsied, 33 patients had different histologic diagnoses. Eighteen patients had a nodular pattern in one site and a diffuse pattern in another. The final stage and treatment of these 18 patients were similar to that of the 27 patients with multiple identical nodular biopsies and 41 patients with multiple identical diffuse biopsies. However, the 56% complete response rate for patients with both a nodular pattern and a diffuse pattern was intermediate between that achieved in patients with identical nodular biopsies (70%) and identical diffuse biopsies (30%). Median survival for these three groups was as follows: identical nodular biopsies, 53 months; both a nodular and a diffuse pattern, 37 months; and identical diffuse biopsies, 12 months. These results demonstrate that patients with different histologic diagnoses in various sites at staging evaluation are not uncommon and have a unique natural history that should be considered in planning treatment.

Diffuse histiocytic lymphoma with sclerosis: a clinicopathologic entity frequently causing superior venacaval obstruction

Of 107 patients with diffuse histiocytic lymphoma (DHL) seen at the University of Chicago, 14 (13%) were classified as having moderate to marked sclerosis. Three of the 14 (21%) had predominantly retroperitoneal masses. Fifty percent of our group, however, had bulky disease seen predominantly or exclusively in the mediastinum, and all of these individuals had superior venacaval (SVC) obstruction. Of the seven patients with SVC syndrome, three were in Pathologic Stage IIA, three were in Clinical Stage II, and only one was in Clinical Stage IIIA. No other patients with DHL displayed SVC obstruction or predominantly mediastinal disease. Five of seven patients with SVC syndrome had large cleaved cell histology. In spite of an apparently favorable histopathologic subtype and a tendency to localized involvement, patients with DHL and sclerosis who have bulky or disseminated disease appear to be resistant to megavoltage radiotherapy alone and relatively resistant to combination chemotherapy.

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.

Nodular lymphoma: clinicopathologic correlations of parafollicular small lymphocytes and degree of nodularity

One hundred thirty-four cases of Stages III and IV nodular non-Hodgkin's lymphoma, subclassified according to the criteria of Rappaport, were assessed for parafollicular small lymphocytes and vascular prominence and degree of nodularity. Statistically significant correlations with survival were found for the groups in the Rappaport classification but not for groups based on the amount of parafollicular small lymphocytes or vascular prominence (PSL grading). In the subgroup of patients with nodular poorly differentiated lymphocytic lymphoma, a significant difference in survival time was found between those with pure nodular patterns and those with 25--60% diffuse areas.