Lymphomas of the head and neck. 1: Nasofacial T-cell lymphoma

Multidisciplinary acute care research organization (MACRO): if you build it, they will come

BACKGROUND

Clinical research will increasingly play a core role in the evolution and growth of acute care surgery program development across the country. What constitutes an efficient and effective clinical research infrastructure in the current fiscal and academic environment remains obscure. We sought to characterize the effects of implementation of a multidisciplinary acute care research organization (MACRO) at a busy tertiary referral university setting.

METHODS

In 2008, to minimize redundancy and cost as well as to maximize existing resources promoting acute care research, MACRO was created, unifying clinical research infrastructure among the Departments of Critical Care Medicine, Emergency Medicine, and Surgery. During the periods 2008 to 2012, we performed a retrospective analysis and determined volume of clinical studies, patient enrollment for both observational and interventional trials, and staff growth since MACRO's origination and characterized changes over time.

RESULTS

From 2008 to 2011, the volume of patients enrolled in clinical studies, which MACRO facilitates has significantly increased more than 300%. The percentage of interventional/observational trials has remained stable during the same period (50-60%). Staff has increased from 6 coordinators to 10, with an additional 15 research associates allowing 24/7 service. With this significant growth, MACRO has become financially self-sufficient, and additional outside departments now seek MACRO's services.

CONCLUSION

Appropriate organization of acute care clinical research infrastructure minimizes redundancy and can promote sustainable, efficient growth in the current academic environment. Further studies are required to determine if similar models can be successful at other acute care surgery programs.

Angiocentric T-cell and NK/T-cell lymphomas: radiotherapeutic viewpoints

PURPOSE

To investigate the patterns of local failure and the risk factors predictive of local failure and to establish the dose-response relationships influencing the probability of local control in patients with Stage I and II angiocentric T-cell or natural killer (NK)/T-cell lymphoma who were treated with radiotherapy (RT) alone.

METHODS AND MATERIALS

We retrospectively reviewed the data from 102 patients with Ann Arbor Stage I and II angiocentric T-cell or NK/T-cell lymphoma who underwent RT alone to a median dose of 45 Gy (range, 20-70 Gy) between 1976 and 1998. The patterns of local failure, risk factors predictive of local failure, dose-response relationships, and survival data were analyzed. Because of the protean feature of local recurrences, the sites of local failure were allocated to one of three categories: true recurrence (TR), marginal recurrence (MR), and elsewhere recurrence (ER).

RESULTS

Despite a higher complete remission rate (72%) after RT, 60 patients experienced treatment failure, including local failure in 48 (47%), regional failure in 3 (3%), and systemic failure in 28 (27%). The patterns of local failure were TR in 42, MR in 3, and ER in 5 patients. The median time to recurrence for TR/MR was shorter than that for ER (1 month for TR/MR vs. 12 months for ER). Patients with TR/MR had a more unfavorable prognosis than those experiencing ER (2-year survival rate after salvage treatment: 6% for TR/MR vs. 80% for ER; p <0.01). The dose-response curve was sigmoid in shape within the range of 20-54 Gy, which followed the plateau at doses in excess of about 54 Gy. A positive correlation was observed in the dose-response curve for the probability of local control (p = 0.017, logistic regression analysis). The overall 5-year actuarial survival and local recurrence-free survival rate for all patients was 42% and 53%, respectively. Achievement of complete remission was the most statistically significant risk factor predictive of TR/MR and the most important prognostic factor.

CONCLUSION

Our data confirm that local failure remains the major obstacle for patients who receive RT alone and that achievement of complete remission is a particularly important determinant of treatment success. Although dose escalation up to >54 Gy cannot entirely reduce the incidence of TR/MR, we believe it is important to identify an appropriate subset of patients for whom an additional boost dose may be beneficial. Given the high rate of local failure, an investigational approach should be conducted to supplement RT using radiosensitizers or more effective chemotherapeutic agents in future trials.

Mantle cell lymphoma of the hard palate: a case report and review of the differential diagnosis based on the histomorphology and immunophenotyping pattern

To our knowledge, mantle cell lymphoma (MCL) has never been reported in the hard palate, but it is commonly observed in the nasopharynx and Waldeyer's tonsillar ring. MCL is characterized by a diffuse infiltrate of small lymphocytes with the expression of CD5, CD20, and cyclin D1 (Bcl-1), but not CD10. MCL presenting in the hard palate must be accurately distinguished from other forms of so-called small B-cell lymphomas-such as small lymphocytic lymphoma, follicular lymphoma, and extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue-because MCL possesses a worse prognosis. Awareness of MCL of the hard palate will prompt pathologists to perform adequate immunohistochemical analysis to aid in confirming the diagnosis.

Combined chemotherapy and radiation versus radiation alone in the management of localized angiocentric lymphoma of the head and neck

BACKGROUND AND PURPOSE

To clarify the clinical benefit derived from the combined modality therapy (CMT) comprised of chemotherapy and involved-field radiotherapy (XRT) for stage I and II angiocentric lymphomas of the head and neck.

MATERIAL AND METHODS

Of 143 patients with angiocentric lymphoma of the head and neck treated at the Yonsei Cancer Center between 1976 and 1995, 104 patients (XRT group) received involved-field XRT alone with a median dose of 50.4 Gy (range: 20-70 Gy), while 39 patients (CMT group) received a median three cycles (range: 1-6 cycles) of chemotherapy before starting involved-field XRT. The response rate, patterns of failure, complications, and survival data of the XRT group were compared with those of the CMT group.

RESULTS

Despite a higher response rate, local failure was the most common pattern of failure in patients of the both groups. The patterns of failure, including the systemic relapse rate were not influenced by the addition of combination chemotherapy. Although both modalities were well tolerated by the majority of patients, aberrant immunologic disorders or medical illnesses, such as a hemophagocytic syndrome, sepsis, intractable hemorrhage, or the evolution of second primary malignancies were more frequently observed in patients of the CMT group. The prognosis of patients in the XRT group was relatively poor, with a 5-year overall actuarial survival rate of 38% and disease-free survival rate of 32%, respectively. However, their clinical outcome was not altered by the addition of systemic chemotherapy. Achieving complete remission was the most important prognostic factor on univariate and multivariate analyses, but treatment modality was not found to be a prognostic variable influencing survival.

CONCLUSIONS

Involved-field XRT alone for angiocentric lymphoma of the head and neck was insufficient to achieve an improved survival rate, but the combination of chemotherapy and involved-field XRT failed to demonstrate any therapeutic advantage over involved-field XRT alone.

Oral mucosal non-Hodgkin's lymphoma--a dangerous mimic

Reports of T-cell lymphomas in the oral cavity are rare. Most have presented as a persisting ulcerated swelling. This paper reports two men, one of whom presented with a short history of increasing facial swelling and pain apparently related to a lower premolar tooth, and the other who had recurrent oral ulceration in several sites over a period of years. These types of cases are likely to present initially to general dental practitioners.

Primary nasal and nasopharyngeal lymphomas: a comparative study of clinical presentation and treatment outcome

Primary nasal lymphoma (NSL) and nasopharyngeal lymphoma (NPL) are uncommon extranodal lymphomas that have often been grouped together in studies published in the literature. It is unclear whether or not NSL and NPL are biologically different entities. We reviewed the records of 25 NSL and 19 NPL patients who were managed between 1985 and 1995, to evaluate and compare their clinical characteristics and treatment outcome. Clinical variables, including age, sex, stage, tumour bulk and treatment modality, were assessed for their prognostic influence on survival. Nasal obstruction (80%), nasal discharge (64%) and epistaxis (60%) were the predominant symptoms in NSL patients; neck swelling/mass (42%), nasal obstruction (37%) and hearing impairment (32%) were common findings in NPL patients. Limited stage disease (I/II) was present in all NSL and in 80% of the NPL patients. Thirty-six per cent of the NSL and 32% of the NPL patients had bulky disease. The majority of the immunophenotyped NSLs were of T-cell lineage (75%, 12/16) and most immunophenotyped NPLs were of B-cell lineage (69%, 11/16). The patients were treated with radiotherapy alone (14%), chemotherapy alone (23%) or chemotherapy plus radiotherapy (64%). NSL patients showed a lower complete remission rate and higher relapse rate than NPL patients, although the difference did not reach statistical significance. Both the 5-year disease-free survival (36% versus 76%; P = 0.007) and overall survival (33% versus 82%; P = 0.003) were significantly worse in NSL compared with NPL patients. Advanced age (>60 years; P = 0.03) and bulky disease (P = 0.04) were also associated with inferior survival times. The analysis of sex, stage and type of therapy showed no evidence of significant impact on the survival. Despite the close anatomical relationship in origin, NSL and NPL were noted to behave as biologically distinct entities, in which the NSLs demonstrated a higher frequency of T-cell tumours and a much worse prognosis than NPL. In addition to the primary site, advanced age and bulky disease were also associated with reduced survival.

Midline granuloma presenting as orbital cellulitis

BACKGROUND

Lethal midline granuloma usually presents with rhinorrhoea and redness of the skin above the nose. Early ocular symptoms are very rare. We here describe a patient who presented with acute orbital cellulitis.

PATIENT

A 73-year-old woman had a 24-h history of severe pain around her left eye. We saw the typical clinical picture of orbital cellulitis. A CT scan revealed a diffuse infiltration of the left upper and lower lid, the anterior orbit and the ethmoidal sinuses.

RESULT

On surgical exploration we found a granular, partly necrotic tumour. Histological examination revealed an angiocentric nasal T-cell lymphoma (midline granuloma).

CONCLUSION

Midline granuloma should be included in the differential diagnosis of acute orbital cellulitis.

Sinonasal lymphomas

Advances in immunocytochemical phenotyping and molecular genetics have nearly resolved the histopathologic and therapeutic quandaries brought about by a diagnostic nomenclature that provided little guidance in the management of midfacial necrotizing lesions. Gone are terms like midline granuloma syndrome, lethal midline granuloma, polymorphic reticulosis, lymphomatoid granulomatosis, midline destructive granuloma, and idiopathic midline destructive disease. They have been replaced by the appreciation that the majority of the lesions are lymphomas of the sinonasal tract. The lymphomas are of B- or T-cell lineage and have a broad biologic spectrum from low to high grade. Still to be addressed are apparent geographic differences in biologic behavior, the epidemiologic significance of a preponderance of T-cell nasal lymphomas in the Orient, and optimum therapeutic regimens.