Extranodal lymphoma: surgical and other therapeutic alternatives

Hematological Evaluation of Primary Extra Nodal Versus Nodal NHL: A Study from North India

Primary extra nodal lymphomas (EN-NHL) are different from primary nodal non-Hodgkin's lymphoma (N-NHL) and are comparatively less common. Hemogram findings and bone marrow involvement is less studied and very few reports are available in the literature. The present study is a retrospective analysis of bone marrow samples evaluated for staging of non-Hodgkin's lymphoma. The age, sex distribution, clinical features, and site of presentation, hemogram findings, pattern of bone marrow involvement and grade of reticulin fibrosis was noted. These findings were compared with the type of non-Hodgkin's lymphoma and prognostic information was determined. A total of 647 cases of NHL, which underwent bone marrow examination for staging, over a seven year period, were retrieved and analyzed for all hematological parameters. Prevalence of EN-NHL was 23.5% (152/647), while nodal NHL comprised 76.5% (495/647) of all NHL cases. 90.1% (137/152) cases of EN-NHL were adult patients, out of which 15.3% (21/137) cases showed bone marrow infiltration as compared to 89% (441/495) adult primary nodal NHL cases, of which 39% (175/441) showed bone marrow infiltration. 9.9% (15/152) cases of EN-NHL were pediatric patients, out of which 40% (6/15) showed bone marrow infiltration, while 10.9% (54/495) of nodal NHL cases were pediatric, of which 20.3% (11/54) showed bone marrow infiltration. Hemogram findings were not found useful in predicting bone marrow infiltration in both nodal as well as EN-NHL. 100% (6/6) of pediatric patients had high grade lymphoma as compared to 48% (9/21) of adult patients, showing bone marrow infiltration in EN-NHL group. Reticulin fibrosis also did not reveal relation with grading of NHL. Prognostically EN-NHL of stomach and central nervous system were found to be better than EN-NHL of other sites, as none of these cases showed bone marrow infiltration. EN-NHL can involve various sites and the prognosis depends upon the sites of disease as well as the type of NHL. Moreover, pediatric EN-NHL cases are likely to have poorer prognosis, due to increased risk of bone marrow involvement as compared to their counterparts having primary nodal NHL. Bone marrow infiltration at times cannot be assessed reliably from hemogram findings only and a bone marrow biopsy for staging is mandatory.

Localised extranodal lymphoma of the head and neck: the Sheffield Lymphoma Group experience (1971-2000)

AIMS

Over the 30-year period from 1971-2000, 3750 cases of lymphoma were referred to the Sheffield Lymphoma Group for investigation and treatment. Of these, 580 were extranodal presentations and, of these, 190 (33%) were localised to the head and neck region. The aim of this lymphoma database review was to evaluate the patient characteristics and survival rates for these patients.

MATERIALS AND METHODS

The sample included 98 women and 92 men, with a median age at presentation of 65 years.

RESULTS

The most common site affected was tonsil (34%), followed by salivary glands (16%). Other common sites were the thyroid, orbit and nasopharynx. The most frequent presenting feature was a swelling or mass, with pain, dysphagia and nasal obstruction also comprising large groups. All cases were non-Hodgkin's lymphoma. Fifty-five cases were histological grade 1; 132 were grade 2. Diffuse large B cell was the most common histological subtype. The overall 5- and 10-year survival rates were 55% (95% CI 47-62) and 44%, (95% CI 36-53), respectively, with a median survival of 92 months (95% CI 56-128). Stage and grade were both found to influence survival.

CONCLUSION

This data concords with and extends information available from previous studies. More detail is now required on specific head and neck sites.

[Initial diagnosis of malignant lymphomas with manifestations in the mouth cavity and adjacent tissues]

The present study investigates a series of 89 lymphomas of the head and neck seen over a 40-year period. The lymphomas were classified according to the Kielclassifikation and staged using the Ann Arbor system. A total of 78 patients had a non-Hodgkin's lymphoma, 50 high grade and 28 low grade. Eleven patients had Hodgkin's disease. Fifty-seven cases were extra-nodal and 52 nodal; 20 were combined. The 5-year survival with Hodgkin's disease was 52.2%, with non-Hodgkin's disease, 66.5%. Low- and high-grade lymphomas had the same 5-year survival (P = NS). Stages I and II had a better prognosis than stages III and IV (P = 0.3).

Extranodal non-Hodgkin's lymphoma of the head and neck: presentation in the facial bones

1. The most common site of ENL is the head and neck, with Waldeyer's ring and specifically, the tonsil, standing as the most frequent area of involvement. Most patients have intermediate or high-grade histologies. 2. Patients present with identical signs and symptoms as squamous cell carcinoma of the head and neck, underscoring the importance of a thorough otolaryngological examination. 3. Biopsy samples should be submitted as fresh and permanent samples specifically labeled for lymphoma evaluation. 4. A thorough and timely staging work-up should be conducted once a positive biopsy diagnosis is obtained. 5. Treatment consists of radiation and/or chemotherapy. Prognosis depends on histology, stage, and site of lesion. Newer treatment strategies may lead to improved survival for patients with head and neck NHL.

Malignant lymphoma of the rectum treated preoperatively with hyperthermia and radiation

A 58-year-old Japanese woman with primary malignant lymphoma of the rectum was treated preoperatively with radiation and intraluminal hyperthermia, after which abdominoperineal rectal amputation (Miles' operation) was done. The rectal tumor disappeared and there were no lymphoma cells in the resected specimens. The postoperative course was smooth and she is being followed in the outpatient department. At this writing, five years after the surgery, she remains well.

The significance of spinal cord compression as the initial manifestation of lymphoma

Eighteen patients with spinal cord compression caused by previously undiagnosed lymphoma were treated at our institution between 1976 and 1991. There were 14 male and 4 female patients (mean age, 58.2 years). The absence of bony involvement on radiographic images was a feature in 16 of the cases. All patients underwent laminectomy for decompression and tissue diagnosis, after which 5 underwent radiotherapy, 3 underwent chemotherapy, and 10 underwent combined-modality treatment. The functional outcome was improvement in 8 patients and no change in 10; no patient worsened after surgery. Eleven had advanced disease at diagnosis, while seven had limited disease, including three patients with localized extradural lymphoma. There were 16 cases of non-Hodgkin's lymphoma and 2 of Hodgkin's disease. Two patients had T-cell lymphoma and were among the longest survivors. DNA flow cytometry identified the low-grade tumors as diploid with very low proliferative indices, while the high-grade tumors all had high indices. At a mean observation time of 41.7 months, five patients have died of their disease, and seven remain in complete remission. Survival is markedly better than that reported for other malignant extradural tumors; however, even limited stage lymphoma can behave aggressively. Similarities in age, sex distribution, histological features, and the results of flow cytometry suggest behavior similar to extranodal lymphoma at other sites. Surgery to provide a tissue diagnosis, followed by combined radiotherapy and chemotherapy, is indicated for all cases.

Lymphoma presenting as a salivary gland mass

A retrospective review of 36 cases of lymphoma presenting as a salivary gland mass was conducted over a 34-year period. A significant increase in the occurrence of lymphoma was noted in proportion to other salivary gland tumors (P less than 0.01, chi 2 analysis: 1954-1972, 11 of 714 (1.5%); 1973-1979, 9 of 201 (4.5%); 1980-1987, 16 of 265 (6.0%). The mean age was 61 years, sex distribution was equal, and 75% occurred in the parotid. Only 42% presented with signs or symptoms other than a painless mass. Glandular excision was done in early stages of the disease while biopsy was done at later stages. Frozen section analysis was accurate in all but one case and was useful in determining if biopsy were adequate. All patients were definitively treated with chemotherapy and/or radiotherapy. Several instructive points are apparent. Any patient presenting with an isolated salivary gland mass can have a lymphoma. There has, in fact, been a significantly increasing proportion of salivary gland lymphoma among the various salivary gland tumors in our patient population. In contrast to other salivary gland tumors, surgery is reserved for diagnosis and not for treatment. A lymph node biopsy may be sufficient to establish a diagnosis, in which case, glandular excision is unnecessary. Most of the patients presented with an asymptomatic isolated salivary gland mass. The presence of adjacent adenopathy, a rubbery feel to the mass, and the intraoperative appearance were the most suggestive signs of lymphoma. Frozen section analysis is helpful in determining the appropriate extent of surgery and is recommended.