[Combined therapy of advanced tonsillar squamous cell carcinoma and one-stage repair of the defect]

OBJECTIVE

To evaluate the treatment of advanced squamous cell carcinoma of the tonsil.

METHODS

Eight patients with advanced tonsillar carcinoma underwent resections combining mandibular ramus and oral cavity approaches, neck dissection and one-stage repair of the defect with pectoralis major myocutaneous flap (PM). The managements were supplemented with preoperative chemotherapy and postoperative radiotherapy.

RESULTS

Following up 3 to 9 years, 6 of 8 cases(75%) survived for more than 3 years. Two of 8 cases (25%) died of different causes postoperatively. One case died of serious hemorrhage resulted from radio-mandibulomyelitis 3 months after operation, and the other case died of esophageal carcinoma 2 years after operation. Two cases complicated radio-mandibulomyelitis. Two cases suffered from temporary regurgitation of food to the nasal chamber.

CONCLUSIONS

Through this combined approach, the advanced tonsillar carcinoma could be resected en bloc under direct visual field and keeping 1-1.5 cm safe margin to the tumor. Neck dissection, preoperative chemotherapy and postoperative radiotherapy were supplemental measures. Combined therapy was of great significance in reducing recurrence of the tumor. PM was usually survived and easily obtained, hence, suitable for repairing the pharyngeal defect.

Tonsillar metastasis from large cell carcinoma of the lung

A 52-year-old female was referred to our department for treatment of a left lung tumor, 80 mm in diameter, arising in the left S1 + 2. The patient's chief complaint was persistent dry cough and spiking fever. Left upper lobectomy with hilar and mediastinal lymph node dissection (ND2a) was performed, and the pathological diagnosis was primary large cell carcinoma of the lung, p-T3N0M0. At one week after being discharged, the patient visited our outpatient clinic complaining of a sore throat. A tumor in the right tonsil was discovered, and excisional biopsy revealed it to be metastasis from the large cell carcinoma of the lung. Right cervical lymph node metastasis was also detected, and the patient was treated by combined chemo-radiotherapy, resulting in a complete remission.

Transfusion-associated graft vs. host disease in a patient with high-grade B-cell lymphoma. Should cellular products for patients with non-Hodgkin's lymphoma be irradiated?

We present the case of a 64-year-old man who died from transfusion-associated graft vs. host disease (TA-GVHD) having been treated 2 years earlier for a high-grade, non-Hodgkin's lymphoma (NHL). We suggest that he was at increased risk of developing TA-GVHD as a result of the NHL and its subsequent treatment, and propose that patients with NHL should be added to those 'at risk' groups who receive irradiated cellular blood components.

Prognostic factors and therapeutic efficacy of combined radio-chemotherapy in Waldeyer's ring non-Hodgkin lymphoma

OBJECTIVE

To improve the prognosis and therapeutic efficacy of Waldeyer's ring non-Hodgkin lymphoma (NHL-WR), combined radio-chemotherapy was used to treat the patients with NHL-WR and prognostic factors were analyzed.

METHODS

Ninety patients with stage I-IV NHL-WR were treated with combined radio-chemotherapy. 4000 cGy to 6000 cGy were given to Waldeyer's ring structure and involved cervical nodes. Uninvolved low cervical nodes received 3000 cGy to 4000 cGy. The combination chemotherapy consisted of COPP (cyclophosphamide [CTX], vincristine [VCR], procarbazine [PCZ], prednisone [PDN]) or CHOP (CTX, ADM, VCR and PDN). Univariate analysis was performed to determine the prognostic unfavorable factors.

RESULTS

Five-year overall survival rate was 69.7% for the whole group, and 83.2% for patients with stage I, II. In univariate analyses, over survival (OS) rates of the patients with low and intermediate grade (76.1%), with stage I, II (83.2%), without fever (75.2%) and with performance status (PS) 0, 1 (85.7%) were significantly better than those of the patients with high grade (53.0%), with stage III, IV (24.7%) with fever (38.5%), with PS2 (41.7%), PS3, 4 (0.0%), respectively (P < 0.05).

CONCLUSIONS

Combined radio-chemotherapy can improve the 5-year survival rate for the patients with NHL-WR, especially for stage I, II patients. PS > or = 2, stage III, IV, fever and high grade histology were associated with unfavorable prognosis.

[Burkitt lymphoma of a palatine tonsil]

Non-Hodgkin lymphoma (NHL) comprise 7-10% of all malignant tumors in childhood. Early systems of classification (Rappaport, Luke-Collins) have been improved with the Working Formulation. NHL are classified into low, intermediate and high-grade disease. Head and neck manifestations of Burkitt's lymphoma are encountered in less than a quarter of the reported cases and usually present as cervical adenopathy. Parapharyngeal space and extranodal disease are unusual sites of involvement. We present a case of tonsillar lymphoma diagnosed with fine-needle biopsy and confirmed with excisional biopsy. Accurate staging (stage IV) and chemotherapy regimen was promptly begun. We review the clinical aspects, pathologic features and treatment of this disease.

[Results of a prospective randomized trial with induction chemotherapy for cancer of the oral cavity and tonsils]

Although induction chemotherapy administered prior to local therapy produces encouraging initial response rates in head and neck cancer, randomized studies have failed to demonstrate an improvement in survival rates. All randomized studies included only patients with advanced stage III and IV disease. In our opinion, this is the main reason for the low rate of complete responses demonstrated in the randomized trials (maximum 18%). Frei et al. estimate that a 40%-50% complete response rate is necessary before improved survival rates are seen. To date, such complete response rates with induction chemotherapy have only been attainable in resectable T2-T3, N0-N2 disease. Therefore, we initiated a prospective randomized trial including only patients with the mentioned disease stages. Patients (pts) were randomized to receive either induction chemotherapy with three cycles of carboplatin/5-FU prior to surgery and radiotherapy (arm A, 70 pts) or standard treatment with surgery and radiotherapy (arm B, 74 pts). Patients were classified according to primary tumour site and neck disease. The observed remission rate after chemotherapy confirmed the primary estimated rate for this subgroup of patients with head and neck cancer (CR: 43%, PR: 37%, NR: 15%, PD: 5%). After a follow-up of 12-96 months overall survival was 58% in arm A and 45% in arm B (n.s.). Disease-free survival in arm A (61%) is statistically significantly better than in arm B (43%, P=0. 03). Therefore, we recommend further controlled trials to investigate the role of induction chemotherapy in patients with primary resectable carcinomas of the oral cavity and tonsils and stage T2-T3 and N0-N2 disease prior to surgery.

Clinical management of six cases of low-risk primary tonsillar non-Hodgkin's lymphoma

CONTEXT

There have been many reports that favor aggressive systemic treatment with chemotherapy and radiotherapy, even for well-localized lymphomas, avoiding the need for tonsillectomy of the normal tonsil.

CASE REPORT

We report six cases of primary tonsillar lymphoma with a median patient age of 42 years. There were two lymphoma cases with diffuse large cells, two cases with mixed small and large cells, one with small cells and one indeterminate. They were treated with six cycles of chemotherapy and cervical radiotherapy. All patients achieved durable complete remission. Our data agree with previous reports that suggested that primary tonsillar high-grade B-cell NHL has a good prognosis if aggressively treated.

Multilobated large B-cell lymphoma diagnosed cytologically. A case report

BACKGROUND

Fine needle aspiration (FNA) biopsy can be used to reliably classify most conditions involving lymph nodes or, at least, significantly reduce the differential diagnosis.

CASE

A 70-year-old male presented with an ulcerated mass arising from the left tonsillar fossa and involving the anterior and posterior pillars. A biopsy of the tonsillar mass performed at an outside hospital was interpreted as a large cell undifferentiated carcinoma. Subsequently the patient developed systemic lymphadenopathy. A bone scan showed intense uptake within the medial tibial plateau of the left knee. FNA biopsy of the right axillary mass was interpreted at University of Cincinnati Medical College as a large cell lymphoma, multilobated type. Histologic and immunohistochemical studies of the lymph node confirmed the presence of multilobated B-cell lymphoma. Lymphoma chemotherapy was initially successful but was discontinued due to toxicity. The patient died two months after the initial cytologic diagnosis of lymphoma.

CONCLUSION

Multilobated lymphomas are an unusual variant of non-Hodgkin's lymphomas (mostly B-cell type). Cytology and immunocytochemistry are useful diagnostic procedures that can help to diagnose this relatively uncommon type of lymphoma and significantly reduce the possibility of misdiagnosis.

The blastic variant of mantle cell lymphoma arising in Waldeyer's tonsillar ring

We present three cases of blastic mantle cell lymphoma with an unusual initial manifestation in Waldeyer's ring with methods for differentiating it from other blastic neoplasms of the head and neck. All cases presented with a feeling of fullness in the area of the mass. Morphologically, the tumours were blastic with a high mitotic rate (three to nine per high power field). All were B-cell phenotype with coexpression of CD43. In all cases cyclin D1 and bcl-2 were positive and CD23 negative. Blastic mantle cell lymphoma occurring in Waldeyer's tonsillar ring may be mistaken for other high grade haematopoietic neoplasms. Immunohistochemistry and awareness of this type of lymphoma are helpful in differentiating it from other neoplasms.

Prognostic factors and treatment outcome in non-Hodgkin's lymphoma of Waldeyer's ring

Prognostic factors and treatment outcome of 71 patients with non-Hodgkin's lymphoma of Waldeyer's ring were analyzed retrospectively. In univariate analyses, unfavorable prognosis was associated with primary disease in the base of the tongue, stage III-IV diseases, B-symptoms, high-grade histology, T-cell phenotype, elevated serum LDH levels, decreased peripheral blood lymphocyte counts, and negative response on delayed type hypersensitivity skin reactions. Multivariate analysis showed that stage III-IV and T-cell phenotype were significant independent risk factors for death. In stage I-II lymphomas, patients with unilateral large or bilateral cervical lymph node involvement had a poorer prognosis. In stage I-II lymphomas with intermediate or high-grade histology, patients who had received radiotherapy with MTCOP-P chemotherapy (pirarubicin, cyclophosphamide, vincristine, methotrexate with leucovorin rescue, peplomycin, and predonisolone) showed significantly better 5-year disease-free survival rate compared with patients treated with radiotherapy alone.

Chronic lymphocytic leukaemia with upper airway obstruction

We report a case of B-cell chronic lymphocytic leukemia in a 58 year old female in whom the clinical course was dominated by upper airway obstruction due to massive enlargement of the palatine and later the lingual tonsils. The peripheral blood morphology and immunophenotype were typical of chronic lymphocytic leukaemia with expression of CDl9+, CD20+, CD5+, CD23+ and HLA-DR+ together with weak, surface immunoglobulin with monoclonal lambda light chain. Therapy included surgical removal of the palatine tonsils and later chemotherapy, both of which provided temporary relief of obstruction before recurrence of obstruction at the site of the lingual tonsils. Lasting relief from mass effect and obstruction only occurred following localised radiotherapy to Waldeyer's ring.

[Acute cerebellar syndrome after treatment with 5-fluorouracil]

We report on a case of 5-fluorouracil induced neurotoxicity during 5-fluorouracil cisplatin combination chemotherapy for advanced head and neck squamous cell carcinoma. The initial manifestations included an acute cerebellar syndrome and peripheral neuropathy. Computed tomography of the brain was normal. The results of nerve-conduction studies were compatible with the diagnosis of distal sensory neuropathy. The patient experienced improvement, without treatment, four weeks after cessation of chemotherapy. The role of cisplatin and alcohol abuse in this neurotoxic episode, can not yet completely be excluded.

Treatment of non-Hodgkin's lymphoma of Waldeyer's ring: radiotherapy versus chemotherapy versus combined therapy

Treatment of stage IA non-Hodgkin's lymphoma (NHL) of Waldeyer's ring remains controversial, probably because of the small number of patients and the scarcity of controlled studies. Between 1981 and 1991, 316 patients with stage I NHL of Waldeyer's ring were randomised for treatment with radiotherapy alone (extended fields), 101 patients; combined chemotherapy with a regimen of CHOP (cyclophosphamide, vincristine, doxorubicin, and prednisone) or CHOP-like (epirubicin instead of doxorubicin), 106 patients; and combined therapy (radiotherapy followed by the same combination chemotherapy), 109 patients. Median follow-up was 6.8 years. Complete response was achieved in 93, 87 and 97%, respectively. Relapses were least frequent in patients treated with combination therapy. The 5-year rate for failure-free survival was 48% for radiation therapy, 45% for the patients who were treated with chemotherapy, which was statistically significantly less than the 83% for patients treated with combined therapy (P < 0.001). Overall survival was also better in the combined therapy arm: 90%, statistically different to 58% for the patients treated with chemotherapy alone and 56% for patients treated with radiation therapy (P < 0.001). Toxicity was mild and late side-effects were not observed in any patients. From these results combined therapy should be considered as the best therapeutic approach in patients with localised NHL of Waldeyer's ring.

Clinical analysis of malignant lymphomas of tonsils

Data of 38 patients with primary tonsil lymphoma, treated during the past 14 years was analysed. All cases were non-Hodgkin lymphomas. There were 11 patients with Stage 1, 14 with Stage II, 8 with Stage III, and 4 with Stage IV tonsillar lymphomas. The applied chemotherapies were CHOP or MACOP-B regimen. The overall 5-year survival rate was 64.4%. Further analysis of the intermediate grade group showed that 5-year survival rates were 72.7%) for patients younger than 60 years old, in contrast to 35.0% for patients aged 60 or older (p 0.0049). Five-year survival rates were 100%) for Stage I, 32.4% for Stage II, 55.6% for Stage III, and 100%) for Stage IV patients (p = 0.0878). In patients with Stage II tonsillar lymphomas, 5-year survival rates were below 100% for CHOP regimen, 100% for MACOP-B regimen, 66.7% for radiation alone, and 0% for radiation followed by chemotherapy (p = 0.1966). In patients with Stage III tonsillar lymphomas, 5-year survival rates were below 100% for MACOP-B regimen, and 0% for initial radiation followed by chemotherapy (p = 0.2568). The factors influencing survival were age, stage, and treatment modality. For Stage I patients without bulky mass, radiation therapy is sufficient. For Stage II patients or Stage I patients with a bulky mass, CHOP regimen (followed by radiation) is the choice of treatment. For Stage III or IV patients,, MACOP-B regimen is promising.

Capillary leak syndrome likely the result of granulocyte colony-stimulating factor after high-dose chemotherapy

Two cases of malignant lymphoma complicated with capillary leak syndrome following super high-dose chemotherapy and administration of granulocyte colony-stimulating factor (G-CSF) are presented. Subsequent to the nadir of granulocytes, and at the stage of rapid increase of granulocytes, the symptoms of fever, hypotension, dyspnea, pleural effusion and edema appeared, and laboratory data revealed hypoxia, hypocapnia and hypoalbuminemia. In addition, an abscess-like lesion was observed in the liver in one patient. After the administration of G-CSF was ceased or decreased, and pulse therapy with methylprednisolone was initiated, these symptoms disappeared quickly.

Myocardial ischemia after 5-fluorouracil chemotherapy

A 40-year-old male patient with carcinoma of the tonsil was put on a 5-fluorouracil and cisplatinum regimen. On day 2 during 5-fluorouracil infusion, he had features of myocardial ischemia manifesting as angina and ST-elevation in ECG. These vasospastic ischemic changes subsided after nitroglycerine plus nifedipine therapy. Such vasospastic toxicity of 5-fluorouracil is rare and few such cases have been reported.

[Initial anthracycline-based chemotherapy without radiotherapy in patients older than 70 years with localized lymphoma arising from Waldeyer's ring]

Between July 1982 and November 1992 twenty-six patients older than 70 years with localized stage of non-Hodgkin's lymphoma (NHL) arising from Waldeyer's ring were treated with initial chemotherapy consisting of anthracycline-based combination chemotherapies without regional radiotherapy in Saitama Cancer Center and Chiba Cancer Center. Patients with stage I-II were eligible for this study. There were 9 men and 17 women, ranging in age from 70 to 86 years with a median age of 77. Eight patients were aged over 80. The initial chemotherapy consisted of 400 mg/m2 of cyclophosphamide iv on day 1, either 40 mg/m2 of adriamycin or 40 mg/m2 of epirubicin iv on day 1, 2.0 mg/m2 of vindesine iv on day 1 and 40 mg/m2 of prednisolone po for 5 days. This combination chemotherapy was repeated every 4 weeks and given 6-10 cycles. There were 4 cass of stage I disease and 22 cases of stage II disease. Histologic subtypes were follicular large (1 case), diffuse large (16 cases), diffuse mixed (4 cases), and diffuse medium (4 cases). A complete response was obtained in 23 (88%) of the 26 patients. The median courses of chemotherapies in complete responders were 6 (range, 2-10). There were 7 recurrences among the 23 responders. The complete response was well sustained with an actuarial relapse-free survival of 59% at 5 years. To date 9 patients expired, four after a recurrence, four under complete remission and the remaining one without attaining CR. The survival curve of all patients became flat at 56 months and was well sustained with an actuarial survival of 34%.

Adult T-cell leukaemia-lymphoma in Waldeyer's ring: a report of three cases

Adult T-cell leukaemia-lymphoma (ATLL) is a new type of T-cell malignancy which has an adult onset, a rapidly progressive terminal course and a clustering at patients' birthplaces in southeast Japan and the Caribbean. We report the clinical features of three cases of ATLL in Waldeyer's ring, which has been rarely reported in the literature. The patients complained of throat pain and lump in the neck. They received combination chemotherapy, but all died within a year of first noticing the symptoms.

Early-onset leukopenia and severe thrombocytopenia following doxorubicin chemotherapy for tonsillar squamous cell carcinoma in a dog

Doxorubicin is reported to cause myelosuppression, with a white blood cell count nadir occurring between day 7 and day 10. Thrombocytopenia is less severe and occurs between days 3 and 8. This report presents an early onset of leukopenia (day 5) and a severe thrombocytopenia (4000 platelets/microliter) (day 6) associated with doxorubicin administration for treatment of recurrent tonsillar squamous cell carcinoma in a dog.

[Adjuvant treatment of patients with neoplastic lesions using the combination of a vitamin complex and an amino acid. Apropos of a series of 17 cases of epidermoid carcinoma of the upper aerodigestive tract]

The aim of the work reported here was to evaluate the effects of an adjuvant treatment composed of an association of vitamins with an amino acid: beta-alanine, in cancer patients. This adjuvant therapy has been given to 17 subjects with a squamous cell carcinoma of upper aerodigestive tract treated by radiotherapy most cases were T3 (according to the TNM-UICC). After a 63 months follow-up, 7 patients are alive and sterilized, 4 are alive but no sterilized, 2 died, 4 were excluded from the study. Besides a physical comfort improved in all our patients, we note a restoration of the immune defenses, both humoral and cellular, disturbed by radiotherapy. At last, we note an increase of survival in the patients treated by the adjuvant therapy, compared to a reference population of patients with squamous cell carcinoma of upper aerodigestive tract. Despite the limits of the study, it was interesting to report the positive effects of the therapeutical association, vitamins and beta-alanine, after a combined radio-surgical treatment of patients with squamous cell carcinoma of upper aerodigestive tract.