Non-Hodgkin's lymphoma

Neuroradiology of Pediatric Hemolymphoproliferative Disease

Hemolymphoproliferative diseases (HLD) are among the most common causes of morbidity and mortality in children. In the past few years, the increased effectiveness of treatment modalities has significantly increased overall survival, but has also disclosed new aspects of the natural history of these disorders, among which central nervous system (CNS) involvement. CNS complications of HLD can basically be categorized into direct localization of primary disease, indirect effects of malignancy such as cerebrovascular or infectious complications, and iatrogenic side effects. Magnetic resonance imaging plays an important, often crucial role in the diagnosis of several of these disorders. Close interdisciplinary collaboration between hemato-oncologists and neuroradiologists is of paramount importance to provide affected children with an early diagnosis and proper treatment.

Clinicopathologic and survival characteristics of childhood and adolescent non Hodgkin's lymphoma in Yazd, Iran

BACKGROUND

Data regarding childhood and adolescent non Hodgkin lymphomas in Iran are limited. The aim of this study was to assess the epidemiological and histomorphological features and survival of affected patients in our center.

MATERIALS AND METHODS

The clinicopathologic features and outcome of 44 children and adolescents with non Hodgkin lymphoma diagnosed during 2004-2012, were investigated retrospectively. The influence of potential prognostic parameters in overall survival was investigated by log-rank test and Cox regression analysis.

RESULTS

The mean age at presentation was 13.8 ± 6.16 years with a male predilection (M: F=3:1). Malignant lymphoma, not otherwise specified, diffuse large cell lymphoma and Burkitt lymphoma were the three most common histological types observed. The tumors were 36.4% intermediate grade, 27.3% high grade and 34.1% belonged to the malignant lymphoma not otherwise specified group. Immunohistochemistry findings were available in 39 cases. Out of these cases 33 (84.6%) had B cell lineage, 4 (10.25%) T cell lineage and 2 (5.12%) of the cases belonged to miscellaneous group. 3 year and 5 year survivals were 48% and 30% respectively and median survival was 36 months (95%CI=21.7-50.3 months). Overall survival in patients with high grade tumors was 19.5 months, in the intermediate group,79 months , and for malignant lymphomas not otherwise specified it was 33.6 months (p value=0.000).

CONCLUSIONS

The survival rate for children and adolescents with non Hodgkin lymphomas at our center during 2004-2012 was at a low level.

Tonsillar follicular lymphoma in a child

Follicular lymphomas (FL) are among the most common non-Hodgkin's lymphoma (NHL) in adults. However, they are rare in children making up less than 3% of paediatric NHL cases. They occur most commonly in the head and neck region, lymph nodes or tonsils, with occasional extra-nodal occurrences. Distinction of FL from potentially clonal but, reactive follicular hyperplasia is important. We report a case of a 6-year-old male child presenting with night stridor since 6 months. Clinical examination revealed asymmetrical enlargement of the left tonsil. Routine left tonsillectomy was performed and the specimen was sent for histopathological examination. Diagnosis of follicular lymphoma was made on histopathological examination and further confirmed by immunohistochemistry.

[Bilateral primary renal Burkitt lymphoma presenting with acute renal failure]

We report the case of a 12 year-old girl who presented with acute renal failure with massive infiltration in both kidneys due to a Burkitt lymphoma that was diagnosed by percutaneous renal biopsy. This case fulfilled all the diagnostic criteria of Malbrain et al. to be considered as primary renal non-Hodgkin lymphoma. We discuss the differential diagnosis with other processes that present with acute renal failure and bilateral nephromegaly, and the mechanism by which renal failure occurs. It should be emphasised that this patient showed clinical symptoms compatible with rheumatic disease at diagnosis. The possibility of joint and muscle problems should be considered as a sign of onset of hematopoietic disease.

Rapid onset proptosis and vision loss as the initial presentation of Burkitt lymphoma

Burkitt lymphoma is a rapidly growing, high-grade non-Hodgkin lymphoma occurring in three distinct clinical subtypes: endemic, sporadic, and human immunodeficiency associated. The sporadic subtype typically presents as an abdominal mass. Orbital involvement has rarely been reported. The authors report a case of Burkitt lymphoma presenting as rapidly progressive proptosis and loss of vision. Given the tumor's rapid growth rate, potential for vision loss, and good response to chemotherapy, clinicians should be aware of this rare presentation.

Neck lumps and head and neck tumours in children

This article discusses the presentation, investigation and treatment of both benign and malignant lumps encountered in the head and neck region in children.

Primary cutaneous B-cell lymphoma in a child

Primary cutaneous B-cell lymphoma is a B-cell lymphoma of the skin with no evidence of extracutaneous involvement at the time of diagnosis. In this report, we describe an 8-year-old boy who presented with a firm, alopecic, skin-colored, smooth nodule over the right frontal scalp. Histological examination revealed a mid-to deep-dermal mononuclear lesion. Immunohistochemical staining revealed a B-cell population that was CD10(+), CD5(-), CD21(+), and bcl2(-). This pattern of reactivity is characteristic of primary cutaneous B-cell lymphoma of follicle-center subtype. To the best of our knowledge, this is the first report of this type of cutaneous lymphoma in a child.

Intestinal complications in children undergoing chemotherapy for mediastinal non-Hodgkin's lymphoma

Toxicities involving gastrointestinal tract are common in patients undergoing aggressive chemotherapy for cancer. However, it is uncommon to develop severe ulceration or perforation of the small intestine in absence of direct involvement of the bowel with the malignancy. The authors describe two children who developed severe gastrointestinal complications requiring surgical intervention following initial chemotherapy for non-Hodgkin's lymphoma. Both patients had no evidence of small bowel involvement by lymphoma on clinical staging.

Childhood cancer among Alaska Natives

OBJECTIVE

The primary purpose of this study was to examine the occurrence of cancer in Alaska Native (AN) children (under age 20). Although several studies have compared differences in cancer incidence between white and black children, few have examined cancer among Alaska Natives/American Indians. We know of no published article describing cancer incidence in AN children. We compared our findings with those of American Indian children of New Mexico and of Alaska white children. Data on mortality, survival, and prevalence are also included. Alaska Native is the term used collectively for the inhabitants whose ancestors occupied the area before European contact of what is now the state of Alaska. Alaska Natives include Eskimo, Indian, and Aleut groups. Although the 3 major groups differ in culture, language, and probably genetics, there are similarities in numerous social and economic indicators. The Northern Eskimo of Alaska (Inupiat) are related to Canadian and Greenland Inuit. Indians in Alaska include Athabaskan (in the interior of the state), who share commonalities with Canadian Athabaskan as well as with Navajo and Apache in the southwestern United States. Tlingit, Haida, and Tsimshian groups reside primarily in the southeast panhandle of the state. The panhandle Indian groups are similar to those of British Columbia.

METHODS

Data on cancer incidence are from the Alaska Native Tumor Registry, 1969-1996. We studied children under age 20 to make our results comparable to national data as presented in the National Cancer Institute's Surveillance, Epidemiology and End Results (SEER) Pediatric Monograph. Population data for AN are based on census data and Indian Health Service intercensal estimates. Data for US whites and New Mexico Indians are from the National Cancer Institute's SEER program. Calculations were made using SEERStat software. Data for Alaska whites are for the years 1996-2000. (The Alaska Cancer Registry has collected data for all Alaskans only since 1996). Odds ratios (ORs) of rates with 95% confidence intervals (CIs) were calculated.

RESULTS

The rate among all AN children (both sexes) for all cancers combined is similar to that of US whites (OR: 1.0; 95% CI: 0.8-1.1). Examination of childhood cancer rates by ethnicity, however, reveal that rates are significantly lower for Indian (OR: 0.6; 95% CI: 0.4-0.8) but not significantly different for Eskimo or Aleut children. For most International Classification of Childhood Cancers groups, incidence rates for AN children are also similar to those of US whites. However, AN children are at significantly higher risk for hepatic tumors (OR: 13.1; 95% CI: 7.9-20.5), particularly hepatocellular carcinoma (OR: 43.8; 95% CI:24.4-75.1) and retinoblastoma (OR: 2.8; 95% CI: 1.3-5.3). By ethnic group, rates for hepatocellular carcinoma are significantly high only for Eskimo. Rates for all AN children are lower for neuroblastoma (OR: 0.1; 95% CI: 0.1-0.6) and lymphoma (OR: 0.5; 95% CI: 0.3-0.9), particularly Hodgkin's disease (OR: 0.2; 95% CI: 0.0-0.5). On the basis of 5 years of data, rates for Alaska white children do not seem to differ from those of US white children. Because of our findings of differences between AN and US whites, we reviewed data of other relevant populations, specifically American Indian data from the New Mexico SEER registry. Using SEER data and SEER software, we calculated rates for New Mexican American Indians (NMAI) and compared them with US white rates. Rates for all cancers combined among NMAI are significantly lower than for US white (OR: 0.8). However, similar to AN children, the rate among NMAI for retinoblastoma is higher compared with US whites (OR: 2.5; 95% CI:1.4-4.5). Similar to AN, NMAI also seem to be at low risk for neuroblastoma (OR: 0.2; 95% CI: 0.1-0.7), lymphoma as a group (OR: 0.1; 95% CI: 0.0-0.3), and, specifically, Hodgkin's disease (OR: 0.1; 95% CI: 0.0-0.4). Rates among NMAI children are low for central nervous system tumors (OR: 0.5; 95% CI: 0.3-0.7). The average annual age-adjusted cancer mortality rate among AN children is lower but not significantly lower than that of US white children (28.6 vs 37.3 per million).

CONCLUSIONS

Comparison of AN rates for all cancers combined are similar to those of US and Alaska white children but seem higher than those of NMAI. Differences between AN and US whites exist for select International Classification of Childhood Cancers groups. The most striking rate differences are found in hepatic tumors, largely because of elevated rates of hepatitis B-associated hepatocellular carcinoma. All children in our study with hepatocellular carcinoma were hepatitis B antigen positive. A statewide hepatitis B virus immunization program was begun in late 1982. Although 16 children who were born before 1983 developed hepatocellular carcinoma, no children who were born in the 20 years since hepatitis B immunization was instituted among infants have received a diagnosis of hepatocellular carcinoma, a significant difference. Comparing AN and US white childhood cancer rates after removing hepatocellular carcinoma cases from both populations results in an OR of 0.8 (95% CI: 0.7-1.0). Thus, if no increase in other childhood cancers occurs in the coming generations, then rates for childhood cancer may soon be significantly lower than those in US white children. Rates are low for all lymphomas, largely because of very low rates of Hodgkin's disease. Rates are also low for neuroblastoma. It is reassuring that rates for AN children are not in excess and do not seem to be increasing. There is concern among the population regarding environmental exposure, including ionizing radiation. Our data do not show excess childhood leukemia or thyroid cancers, malignancies for which radiation is known to increase risk.

Assessment of minimal residual disease in childhood non-hodgkin lymphoma by polymerase chain reaction using patient-specific primers

A feasibility study was undertaken to identify patient-specific primers (PSPs) from childhood non-Hodgkin lymphoma (NHL) specimens to detect minimal residual disease (MRD). Eleven tumor specimens were amplified using immunoglobulin heavy chain and T-cell receptor primers to identify PSPs, which were then used to evaluate staging/follow-up specimens. Disease was detected in 19 of 21 staging and 16 of 17 follow-up specimens. Among seven patients in remission by 1 month, PSPs identified MRD in follow-up specimens. This study demonstrated the feasibility of PSPs to identify disease in staging and follow-up specimens, which could be used to develop strategies for MRD analysis in a larger setting.

Role of flow cytometry in the diagnosis of lymphadenopathy in children

To evaluate the combination of fine-needle aspiration (FNA) and flow cytometric immunophenotyping (FCI) in the diagnosis of lymphadenopathy in children, we reviewed a total of 71 FNA specimens from pediatric patients with persistent lymphadenopathy. Two cases were deemed inadequate. In the remaining 69 cases, 54 (78%) were diagnosed as benign lesions, 9 (13%) as Hodgkin's lymphoma, 4 (6%) as non-Hodgkin's lymphoma or leukemic infiltrate, and 2 as metastatic tumors. Of the 69 cases, 25 cases (38%) were diagnosed based on cytomorphology alone, 30 (43%) by combined cytomorphology and FCI, and 19 (28%) by surgical biopsy. In conclusion, FNA is an easy, safe, and reliable procedure in the diagnosis of lymphadenopathy in children. In difficult cases, FCI can be used to exclude non-Hodgkin's lymphomas.

Survival trends of childhood cancer diagnosed during 1970-1994 in Piedmont, Italy: a report from the Childhood Cancer Registry

BACKGROUND

The Childhood Cancer Registry of Piedmont (CCRP) started its activity in 1967. It is population based and covers the Piedmont Region (population 4,500,000; NW Italy). This article reports on time trends in survival after a childhood cancer diagnosed during 1970-1994.

PROCEDURE

During 1970-1994, 2,329 incident cases were registered at CCRP on the basis of histological and/or clinical information, excluding 30 cases reported only by death certificate. Histological or hematological diagnosis was available for 2,067 cases. Vital status was assessed through the offices of the town of residence. At the end of follow-up, 1,202 cases were alive, 1,084 dead and 43 were not traceable. Survival was measured for the major diagnostic groups using both univariate and multivariate statistics.

RESULTS

The 5-yr survival rate for acute lymphoblastic leukemia (ALL) improved regularly from 24.7% in 1970-1974 to 81.1% in 1990-1994, for acute nonlymphoblastic leukemia (ANLL) from 0% to 38.1%, for non-Hodgkin lymphoma (NHL) from 25.2% to 67.7%, for tumors of the central nervous system (CNS) (all types) from 33.4% to 75.9% and for Ewing tumor from 0% to 90%. Focusing on survival by period of diagnosis, the highest 5-year survival rate was observed for children diagnosed during 1985-1989 for medulloblastoma, neuroblastoma (NB), retinoblastoma, Wilms tumor, osteosarcoma, and rhabdomyosarcoma and for children diagnosed in 1990-1994 for the remaining sites. The trend over time was statistically significant for ALL, ANLL, NHL, CNS tumors, NB, and osteosarcoma as well as for all malignancies together.

CONCLUSIONS

Population-based survival studies are useful complements to clinical studies. Survival results in the present study are similar to those presented for other European countries and the United States. For most types of neoplasm (except CNS) survival probability appears to stabilize 5-10 years after diagnosis.

Allogeneic stem cell transplantation for the non-Hodgkin's lymphomas and Hodgkin's disease

Certain poor-prognosis patients with non-Hodgkin's lymphoma and Hodgkin's disease, usually with recurrent and/or refractory disease, are rarely curable with standard chemoradiotherapy. Autologous hematopoietic stem cell transplantation has been shown to result in improved long-term disease-free survival in some of these patients. Unfortunately, a number of patients are not suitable for autologous transplantation due to a damaged stem cell pool involvement or other disease processes of the marrow. These patients may benefit from allogeneic stem cell transplantation. In addition to the therapeutic effect of high-dose chemotherapy with or without total body irradiation, an immunologic [i.e. graft-versus-lymphoma (GVLym)] effect may be present in some patients undergoing allogeneic transplantation, resulting in a lower relapse rate than autotransplants. However, allografts are almost always associated with a higher non-relapse mortality due primarily to graft-versus-host disease (GVHD); unfortunately, GVHD and GVLym are difficult to separate. Thus, full exploitation of this GVLym effect may require the modification of commonly used conditioning regimens; if successful, these modifications may allow an additional decrement in the incidence of relapse without additional morbidity. Also, when combined with lesser intensity conditioning, such may permit patients who otherwise would not be candidates for standard transplant regimens to be allografted.

Lymphomas of the anterior mediastinum

Lymphomas are the most common cause of masses in the pediatric mediastinum. More than 50% of children with lymphoblastic lymphoma present with an anterior mediastinal mass, and more than one third of all patients with non-Hodgkin's lymphoma have their primary sites in the mediastinum. Hodgkin's disease also frequently involves this anatomic compartment with approximately two thirds of all pediatric cases manifesting mediastinal adenopathy. Although surgical resection generally is not involved in the primary treatment of these diseases, surgeons often play a key role in obtaining adequate tissue for proper diagnostic analysis. Surgical access to the mediastinum often is required in the acquisition of a specimen.

Non-Hodgkin lymphoma in children: a 20-year population-based epidemiologic study in western Sweden

PURPOSE

The aim of this study was to investigate incidence, clinicopathologic features, prognostic risk factors, and long-term survival in non-Hodgkin lymphoma (NHL) in a 20-year population-based study of children using Swedish health care organizations and their central registry for childhood malignancies.

PATIENTS AND METHODS

The hospital registry, the Cause of Death Registry, and the two established Swedish registries for malignancy (the Swedish Cancer Registry and the National Registry for Solid Tumours in Childhood) were searched for children in western Sweden with NHL diagnosed from 1975 to 1994. The clinical files of all children with NHL were collected and abstracted for information regarding age at diagnosis, gender, disease characteristics, treatment, and outcome of treatment. All sections from paraffin-embedded blocks of tumors with a diagnosis of malignant lymphoma were collected and reexamined histopathologically and immunohistochemically. To guarantee that no patients with NHL were misdiagnosed, a reexamination of other childhood malignancies collected from these registries was also performed. Median follow-up duration of surviving patients is 10 years.

RESULTS

The annual incidence of NHL in children younger than 15 years of age was 9/million children, representing 6% of all childhood malignancies during the investigation time. The male-female ratio was 4.1:1.0. Immunologic marker studies were available for 64 of the 77 NHLs: 41 patients had B-cell, 17 had T-cell, and 6 had Ki-1-positive anaplastic large cell lymphoma (ALCL). Two patients with Ki-1-positive ALCL were originally thought to have malignant histiocytosis and Langerhans cell histiocytosis (LCH), respectively. Treatment was the most significant prognostic factor; event-free survival (EFS) was 19% in the preprotocol era (1975 to 1979) and 74% from 1980 to 1994. Other than treatment, stage was the most significant prognostic factor; EFS was 86% for patients (1980 to 1994) with stage I or II disease and 64% for patients with stage III or IV disease, with a dismal prognosis for children with initial involvement of the bone marrow or central nervous system (EFS was 38% and 20%, respectively). Bulky disease and performance state at diagnosis were independent prognostic factors. The patterns of relapse, including early recurrence of the B-cell lymphomas, are in accordance with previous experience.

CONCLUSION

The incidence of NHL was found to be somewhat higher than reported in our previous Nordic study. The higher incidence found in this study might be the result of the thorough data collection (based on hospital registry and cross-checked with all registries for malignant diseases in Sweden) or because reexamination of the tissue material was performed. A more pronounced male predominance than found in previous investigations was observed. The immunophenotypic distribution and the stage distribution is in accordance with earlier investigations. Treatment was the most important factor affecting outcome. A dramatic improvement of survival was seen with the introduction of intensive therapy; treatment success can be expected in 86% of children with localized disease and 64% of children with extensive disease. The absence of improvement in survival despite further treatment stratification with the introduction of the BFM protocol for B-cell-NHL is surprising. LSA2L2-like protocols seem to be as effective. Future studies on treatment of NHL must also concentrate on reducing the intensity of therapy in patients with lower risk disease to minimize late toxic effects.

Lymphoma at the extremes of age

OBJECTIVES

To provide a review of the unique features of both Hodgkin's and non-Hodgkin's lymphoma in pediatric and geriatric patient populations. Treatment approaches and nursing care interventions at the extremes of age will be discussed.

DATA SOURCES

Review articles, research studies, and book chapters.

CONCLUSIONS

Lymphoma is a highly heterogeneous malignancy whose classification and management have undergone significant evolution. Of particular concern has been lymphoma's prevalence and treatment at the extremes of age. Appropriate treatment by age and subtype remains controversial.

IMPLICATIONS FOR NURSING PRACTICE

The nursing care of pediatric and geriatric patients with lymphoma presents numerous challenges in education, symptom management, and supportive care.