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Yohannan B, Rios A. Primary Diffuse Large B-Cell Lymphoma of the Bone. J Hematol 2023; 12:75-81. [PMID: 37187495 PMCID: PMC10181325 DOI: 10.14740/jh1087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 02/27/2023] [Indexed: 05/17/2023] Open
Abstract
Primary lymphoma of the bone (PLB) is a rare lymphoproliferative neoplasm that can present either as solitary or multiple bone lesions. We report four patients with PLB who were successfully treated with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) followed by consolidative radiotherapy. All patients achieved a complete remission and had excellent long-term outcomes. PLB has a favorable response to combined modality treatment with chemoimmunotherapy and radiation. Long-term outcomes of PLB tend to be better than those of non-osseous diffuse large B-cell lymphoma.
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Affiliation(s)
- Binoy Yohannan
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Adan Rios
- Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
- Corresponding Author: Adan Rios, Division of Hematology/Oncology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
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2
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Vijayasekharan K, Kc A, Prasad M, Dhamne C, Roy Moulik N, Shet T, Sridhar E, Laskar S, Kembhavi S, Shah S, Gujral S, Narula G, Banavali SD. Clinical outcomes and prognostic factors in children with B-cell lymphoblastic lymphoma (LBL) treated according to on modified BFM-90 protocol: Experience from a Tertiary cancer care center in India. Pediatr Hematol Oncol 2022; 39:427-440. [PMID: 35179438 DOI: 10.1080/08880018.2021.2005725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Pediatric B-cell lymphoblastic lymphoma (LBL) is a rare entity, and appropriate treatment for pediatric B-cell LBL is not well defined. While intensive ALL type regimens achieve long term survival of 90% across Western co-operative group trials, published data from Asian studies on long term outcomes are scarce. We retrospectively analyzed the data of pediatric B-cell LBL patients treated between January 2010 and December 2017 on a uniform protocol (modified BFM 90). Kaplan-Meier method was used to estimate the survival and Cox regression models to identify prognostic factors. Of 21 patients who received treatment on the modified BFM-90 protocol, 17(81%) were alive in remission, 3(14%) had relapse, and 1(4%) had treatment-related mortality (TRM) while in remission. Two of 3 relapsed patients subsequently expired. With a median follow-up of 66 months (range 6-114), 5-year event free survival (EFS) and overall survival (OS) were 80% (95% CI:71-89%) and 91% (95% CI:85-97%), respectively. While delayed presentation from symptom onset (p=0.030), and partial response at early (D35) interim assessment (p=0.025) had inferior EFS, patients with elevated baseline LDH had a worse OS (p=0.037). Outcomes of pediatric B-cell LBL patients treated on a modified BFM-90 protocol at a single center in India were excellent. In our study, higher disease burden manifested by elevated baseline LDH and delayed presentation (≥3months) and partial interim response portend poorer survival.Supplemental data for this article is available online at https://doi.org/10.1080/08880018.2021.2005725.
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Affiliation(s)
- Kalasekhar Vijayasekharan
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India.,Department of Pediatric Oncology, Regional Cancer Centre, Trivandrum, Kerala, India
| | - Anand Kc
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Maya Prasad
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Chetan Dhamne
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Nirmalya Roy Moulik
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Tanuja Shet
- Department of Pathology, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Epari Sridhar
- Department of Pathology, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Siddhartha Laskar
- Department of Radiation Oncology, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Seema Kembhavi
- Department of Radiodiagnosis, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sneha Shah
- Department of Nuclear Medicine, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Sumeet Gujral
- Department of Pathology, Tata Memorial Center, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Gaurav Narula
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
| | - Shripad D Banavali
- Department of Medical Oncology, Tata Memorial Center, Pediatric Hematolymphoid Disease Management Group, Mumbai, Maharashtra, India.,Homi Bhabha National Institute, Mumbai, Maharashtra, India
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3
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Jain A, Alam K, Maheshwari V, Khan R, Nobin H, Narula V. Primary bone lymphomas-Clinical cases and review of literature. J Bone Oncol 2013; 2:132-6. [PMID: 26909283 PMCID: PMC4723388 DOI: 10.1016/j.jbo.2013.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Revised: 07/19/2013] [Accepted: 07/24/2013] [Indexed: 11/05/2022] Open
Abstract
Primary bone lymphoma (PBL) is an uncommon clinical entity and a rare presentation of non-Hodgkin's lymphoma. PBL accounts for less than 5% of malignant bone tumors, 4–5% of extra nodal lymphoma and less than 1% of all non-Hodgkin's lymphoma. Diffuse large-B-cell lymphoma (DLBCL) accounts for the majority of cases of PBL. The incidence of PBL is so rare that many of its aspects remain unknown. A number of studies have been reported from western countries but only a few reports are available from Asia. Out of 20,000 bone lesions received in our department over 5 years, only 5 cases were primary bone lymphoma; all of which were DLBCL. We report our experience on PBLs with main emphasis on two unusual presentations of this rare tumor.
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Affiliation(s)
- Anshu Jain
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
| | - Kiran Alam
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
| | - Veena Maheshwari
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
| | - Roobina Khan
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
| | - Hage Nobin
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
| | - Varsha Narula
- Department of Pathology, Jawahar Lal Nehru Medical College, AMU, Aligarh, Uttar Pradesh 202002, India
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4
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Christie D, Dear K, Le T, Barton M, Wirth A, Porter D, Roos D, Pratt G. Limited Chemotherapy and Shrinking Field Radiotherapy for Osteolymphoma (Primary Bone Lymphoma): Results From the Trans-Tasman Radiation Oncology Group 99.04 and Australasian Leukaemia and Lymphoma Group LY02 Prospective Trial. Int J Radiat Oncol Biol Phys 2011; 80:1164-70. [PMID: 20638196 DOI: 10.1016/j.ijrobp.2010.03.036] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 03/19/2010] [Accepted: 03/26/2010] [Indexed: 11/16/2022]
Affiliation(s)
- David Christie
- Premion and Bond University, Gold Coast, Queensland, Australia.
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5
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Abstract
BACKGROUND Primary lymphoma of bone is a rare disease. There is yet no systematical evaluation of primary lymphoma of bone in Korea. Here we report our experience of sixteen cases with primary lymphoma of bone focusing on the survival. METHODS Sixteen cases, collected for 13 years, were evaluated on the clinical presentation, histologic subtype, stage and treatment outcomes of the primary bone lymphoma. RESULTS The most common presenting complaint was bone pain. Malignant lymphoma of bone involved a wide variety of sites, the most prevalent site of which in this study was the spine. Most of the cases were in the diffuse large B-cell category. The clinical stage of lymphoma was IEA in two cases, IIEA in three cases, IVEA in five cases and IVEB in three cases. All treated cases received systemic chemotherapy and ten cases among them were treated with combined modality therapy. Median overall survival was not reached after median follow-up period of 28 months and five-year overall survival rate was 54%. CONCLUSION More promising therapeutic strategies are needed for survival improvement on more accumulated cases.
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Affiliation(s)
| | - Jee Sook Hahn
- Address reprint requests to : J.S. Hahn, M.D., Department of Internal Medicine, Yonsei University College of Medicine, CPO Box 8044, Seoul 120-752, Korea. E-mail:
| | - Chang Ok Suh
- Radiation Oncology, Yonsei University College of Medicine, Seoul, Korea
| | - Woo Ick Yang
- Pathology, Yonsei University College of Medicine, Seoul, Korea
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Huebner-Chan D, Fernandes B, Yang G, Lim MS. An immunophenotypic and molecular study of primary large B-cell lymphoma of bone. Mod Pathol 2001; 14:1000-7. [PMID: 11598170 DOI: 10.1038/modpathol.3880425] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Primary non-Hodgkin's lymphomas of bone (PNHLB) is a rare form of extranodal lymphoma. Many studies have reported the clinical, radiologic, and histopathologic characteristics of PNHLB; however, their molecular features have not been well studied. In this report, we present the immunophenotypic and molecular characteristics of 20 primary large B-cell lymphoma (PLBCL) of bone from 20 adults. Most demonstrated centroblastic morphology, with the majority exhibiting nuclear multilobation. One case (5%) demonstrated anaplastic features with strong CD30 expression but was ALK-1 negative. BCL-6 expression was seen in 6 of 20 cases, and strong p53 protein expression was seen in 11 of 20 (55%) cases. The majority of cases analyzed (13/18 = 72%) demonstrated a clonal B-cell process by IgH gene rearrangement studies. Of the five cases that did not demonstrate a clonal population, two expressed BCL-6 protein. No cases demonstrated a bcl-2/JH rearrangement, but BCL-2 protein expression was seen in 11 of 20 (55%) cases. In summary, primary lymphoma of bone is largely a non-Hodgkin's lymphoma of large B-cell type. Our studies demonstrate that p53 and BCL-2 expression may play a role in the pathogenesis of PLCBL of bone. In addition, a subset of the cases are of putative germinal center B-cell origin based on the expression of BCL-6 protein and may be genetically distinct from follicle center lymphomas. The results provide evidence for molecular heterogeneity within primary large B-cell lymphomas of bone.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Antigens, CD20/analysis
- Bone Neoplasms/genetics
- Bone Neoplasms/metabolism
- Bone Neoplasms/pathology
- DNA, Neoplasm/genetics
- DNA-Binding Proteins/analysis
- Female
- Gene Rearrangement
- Humans
- Immunoglobulin Heavy Chains/genetics
- Immunohistochemistry
- Ki-1 Antigen/analysis
- Ki-67 Antigen/analysis
- Lymphoma, B-Cell/genetics
- Lymphoma, B-Cell/metabolism
- Lymphoma, B-Cell/pathology
- Lymphoma, Large B-Cell, Diffuse/genetics
- Lymphoma, Large B-Cell, Diffuse/metabolism
- Lymphoma, Large B-Cell, Diffuse/pathology
- Male
- Middle Aged
- Polymerase Chain Reaction
- Proto-Oncogene Proteins/analysis
- Proto-Oncogene Proteins c-bcl-2/analysis
- Proto-Oncogene Proteins c-bcl-2/genetics
- Proto-Oncogene Proteins c-bcl-6
- Transcription Factors/analysis
- Tumor Suppressor Protein p53/analysis
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Affiliation(s)
- D Huebner-Chan
- Department of Pathology, Kaiser Permanente Medical Center, Anaheim, California, USA
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7
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Robak T, Kasznicki M, Bartkowiak J, Kordek R, Wawrzyniak E, Błonski JZ. Richter's syndrome following cladribine therapy for chronic lymphocytic leukemia first manifested as pathologic fracture of the femur. Leuk Lymphoma 2001; 42:789-96. [PMID: 11697509 DOI: 10.3109/10428190109099341] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Richter's syndrome (RS) refers to the development of aggressive non-Hodgkin's lymphoma (NHL) during the course of chronic lymphocytic leukaemia (CCL). It occurs in approximately 3% of patients with CLL. The isolated form of this complication in bone is extremely rare and, so far, has not been described in a patient treated with cladribine (2-CdA). We report a case of CLL treated successfully with 2-CdA, where isolated diffuse large B-cell lymphoma (LBCL) developed 2 years after the diagnosis of CLL Rai II and one year after the completion of 2-CdA treatment. RS was first manifested as a pathologic fracture of the left femur. The LBCL was clonally distinct from the original CLL cells. The patient was successfully treated with CHOP and radiotherapy and obtained complete response of the LBCL.
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MESH Headings
- Aged
- Bone Marrow/pathology
- Cell Transformation, Neoplastic/chemically induced
- Cladribine/administration & dosage
- Cladribine/adverse effects
- Femoral Fractures/diagnostic imaging
- Femoral Fractures/etiology
- Humans
- Karyotyping
- Leukemia, Lymphocytic, Chronic, B-Cell/pathology
- Lymph Nodes/pathology
- Lymphoma, B-Cell/pathology
- Lymphoma, Non-Hodgkin/chemically induced
- Lymphoma, Non-Hodgkin/etiology
- Lymphoma, Non-Hodgkin/pathology
- Male
- Neoplasms, Second Primary/chemically induced
- Neoplasms, Second Primary/etiology
- Neoplasms, Second Primary/pathology
- Radionuclide Imaging
- Syndrome
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Affiliation(s)
- T Robak
- Department of Hematology, Medical University of Lódź, Poland.
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8
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Christie DR, Barton MB, Bryant G, Cheuk R, Gebski V, Hornsey J, Lonergan D, MacLeod C, Pratt G, Roos D, Shannon J, Thornton D, Wirth A. Osteolymphoma (primary bone lymphoma): an Australian review of 70 cases. Australasian Radiation Oncology Lymphoma Group (AROLG). AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1999; 29:214-9. [PMID: 10342020 DOI: 10.1111/j.1445-5994.1999.tb00686.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND To examine prognostic factors, treatment outcomes and design future studies for Osteolymphoma (OL)--also known as primary bone lymphoma. METHODS Between 1979 and 1993, 70 patients with OL were treated in nine Australian centres. The effect of patient-, tumour-, and treatment-related factors on local control, distant disease-free survival and overall survival were assessed by multivariate analysis. RESULTS Most patients (94%) received radiotherapy (RT) (median dose 40 Gy) and 56% received chemotherapy. Multifocal disease was present in 20% of patients. The five year rates of overall survival and local control were 59% and 82%. Although there was a trend towards better results with the addition of chemotherapy, on multivariate analysis, there were no factors identified which appeared to impact upon overall and disease-free survival. Among the distant recurrences, there was a high proportion in bone (33%). Six patients suffered pathological fractures after treatment. CONCLUSION High rates of local control were achieved by RT, but the overall survival remains relatively poor, worse than nodal lymphoma. The natural history of the disease suggests that OL may be a distinct entity, different to nodal lymphomas, so the results of clinical trials in nodal lymphoma may not be relevant to OL. Prospective studies could define the outcome of combined modality therapy and set a benchmark for testing further proposals, as well as improving our knowledge of the clinical features of OL.
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Affiliation(s)
- D R Christie
- East Coast Cancer Centre, John Flynn Hospital, Tugun, Qld
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10
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Ferreri AJ, Reni M, Ceresoli GL, Villa E. Therapeutic management with adriamycin-containing chemotherapy and radiotherapy of monostotic and polyostotic primary non-Hodgkin's lymphoma of bone in adults. Cancer Invest 1998; 16:554-61. [PMID: 9844615 DOI: 10.3109/07357909809032885] [Citation(s) in RCA: 23] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The best treatment of primary lymphoma of bone (PLB) remains undefined. We reviewed 15 patients with monostotic PLB and 8 with polyostotic PLB. Twenty of the patients were suitable for analysis. All patients but 1 received adriamycin-containing chemotherapy in association with radiation therapy. Radiotherapy for monostotic cases consisted of 40 Gy to long bones, followed by a boost to 45 Gy to bulky lesions or 40-45 Gy to whole flat bones. In cases of polyostotic PLB, bulky sites, fractured lesions, or sites with a high risk of fracture were irradiated with a median dose of 38 Gy. All patients with monostotic disease achieved complete remission (CR): 10 patients were alive and relapse-free at the time of this writing, 1 other patient was alive following a relapse, and 1 patient died while relapse-free. The survival rate for the patients in the study at the time of this writing was 92% at 50 months. Four patients with polyostotic disease achieved CR. Three of them had only two adjacent sites of disease and were treated as cases of monostotic PLB. Two of these 3 patients are alive and relapse-free. Four patients with polyostotic disease achieved PR, relapsed rapidly, and died of progressive disease. The relapse site was invariably the skeleton. The survival rate for patients with polyostotic PLB at the time of writing was 25% at 40 months. No severe late treatment-related toxicity was observed. The treatment of patients with monostotic PLB with adriamycin-containing chemotherapy and whole-bone irradiation with 40 Gy, followed by a boost to 45 Gy to bulky sites, prevented local relapse and produced a more favorable outcome than the use of radiotherapy (RT) alone. Patients with multiple adjacent lesions that can be included within a single radiation field with acceptable toxicity should be treated as cases of monostotic PLB.
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Affiliation(s)
- A J Ferreri
- Department of Radiochemotherapy, San Raffaele H Scientific Institute, Milan, Italy.
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Shannon JA, Bell DR, Levi JA, Wheeler HR, Boyle FM. Bone presentation of non-Hodgkin's lymphoma: experience at the Royal North Shore Hospital, Sydney; highlighting primary bone lymphoma. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 1994; 24:701-4. [PMID: 7717923 DOI: 10.1111/j.1445-5994.1994.tb01787.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Primary lymphoma of bone (PLB) is a rare form of extranodal lymphoma. Between 1975 and 1992 39 patients with lymphoma presenting in bone were seen at the Royal North Shore Hospital (RNSH), Sydney. Of these, 12 (31%) had truly localised disease (Stage IE). AIMS Patients were studied retrospectively to determine the prognostic significance of bony involvement per se versus involvement of a single bony site, and to determine the impact of treatment modality on outcome. METHODS The 39 patients were divided into three groups according to extent of disease; single osseous site (Stage IE), multifocal bone, and bone plus visceral and/or nodal disease. Kaplan-Meier survival curves were constructed, and five year actuarial survival stated. Cox regression analysis was used to determine hazard ratios. Overall survival was used as the end-point. RESULTS A trend for better survival was noted with Stage IE disease. Multifocal and disseminated disease appeared to have a poorer outcome when assessed by hazard ratio, with a value of 3 (95% CI 0.87-10.4; p = 0.08), compared to unifocal disease. Radiotherapy alone was as effective as combined modality treatment although patient numbers were too small for statistical confirmation. CONCLUSIONS The stage of lymphoma, rather than bony involvement per se, seems to have more prognostic importance. Radiotherapy alone offered equivalent results to combined modality treatment in this series.
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12
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Rathmell AJ, Gospodarowicz MK, Sutcliffe SB, Clark RM. Localised lymphoma of bone: prognostic factors and treatment recommendations. The Princess Margaret Hospital Lymphoma Group. Br J Cancer 1992; 66:603-6. [PMID: 1520599 PMCID: PMC1977956 DOI: 10.1038/bjc.1992.322] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Twenty seven adult patients with newly diagnosed non-Hodgkin's lymphoma localised to either bone (Stage IE) or bone and regional lymph nodes (Stage IIE) were treated between 1967 and 1988. Median age was 53 years and the commonest histology (21 patients) was diffuse histiocytic lymphoma. Twenty-four patients were treated radically: 15 with radiation therapy (XRT) alone and nine with chemotherapy plus radiation therapy (CMT). The cause specific survival for these patients was 56% at 5 years and 40% at 10 years. Survival was significantly better for patients treated by CMT (88% at 5 years) as compared to XRT alone (40% at 5 years, P = 0.03) and for age less than 60 (72% at 5 years) compared to greater than or equal to 60 (30% at 5 years, P = 0.018). Relapse-free rate was 27% at 5 years with XRT alone and 89% with CMT (P = 0.01). Risk factors for loco-regional relapse (seven cases) included: large tumour bulk, treatment by XRT alone and use of 'limited' radiation fields. No radiation dose-response relationship could be identified in this study. Long term local control and survival for localised lymphoma of bone were excellent after treatment by CMT but XRT alone was associated with unacceptably high local and distant failure rates.
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Affiliation(s)
- A J Rathmell
- Princess Margaret Hospital, Department of Radiation Oncology, Toronto, Ontario, Canada
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