Clinical relevance of the histopathological subclassification of diffuse "histiocytic" lymphoma

A retrospective clinico-pathologic study of non-Hodgkin's lymphomas classified according to the nomenclatures of Lennert and of Rappaport

The survival of 88 patients treated for non-Hodgkin's lymphoma 1972-73 have been reviewed. In 49 patients it was possible to do a re-classification of the lymphomas according to Rappaport's and Lennert's classifications. The main obstacle to the classification according to Lennert was inadequacy of the cyto-pathological material. The correlation between survival and pathology was studied and a comparison between the two classifications was made. Lennert's classification was found to have a good reproducibility and to be more accurate than Rappaport's in separating lymphomas with favourable prognosis from those with unfavourable.

Classification of lymphoid neoplasms: the microscope as a tool for disease discovery

In the past 50 years, we have witnessed explosive growth in the understanding of normal and neoplastic lymphoid cells. B-cell, T-cell, and natural killer (NK)-cell neoplasms in many respects recapitulate normal stages of lymphoid cell differentiation and function, so that they can be to some extent classified according to the corresponding normal stage. Likewise, the molecular mechanisms involved the pathogenesis of lymphomas and lymphoid leukemias are often based on the physiology of the lymphoid cells, capitalizing on deregulated normal physiology by harnessing the promoters of genes essential for lymphocyte function. The clinical manifestations of lymphomas likewise reflect the normal function of lymphoid cells in vivo. The multiparameter approach to classification adopted by the World Health Organization (WHO) classification has been validated in international studies as being highly reproducible, and enhancing the interpretation of clinical and translational studies. In addition, accurate and precise classification of disease entities facilitates the discovery of the molecular basis of lymphoid neoplasms in the basic science laboratory.

Molecular profiling provides evidence of primary mediastinal large B-cell lymphoma as a distinct entity related to classic Hodgkin lymphoma: implications for mediastinal gray zone lymphomas as an intermediate form of B-cell lymphoma

Expanding on prior studies that have used molecular profiling to elucidate the heterogeneity of diffuse large B-cell lymphomas (DLBCLs), two recent studies (Rosenwald et al and Savage et al) have characterized a third molecularly distinct subtype of DLBCL, primary mediastinal (thymic) large B-cell lymphoma (PMLBCL). Both groups found distinct gene expression patterns that were able to reliably diagnose PMLBCL and distinguish it from other DLBCLs. Notably, the signature gene expression profile of PMLBCL was more closely related to classic Hodgkin lymphoma (CHL) than other DLBCL subtypes. These studies provide further evidence that PMLBCL and nodular sclerosis CHL may represent related tumors on either ends of a continuum, whose interface includes an intermediate form of disease, mediastinal gray zone (MGZL) lymphoma. MGZLs are tumors that have a transitional morphology and phenotype, combining features of both PMLBCL and nodular sclerosis CHL, and provide a diagnostic challenge to pathologists. These studies provide insights into the biology of PMLBCL and CHL and demonstrate the utility of genomic technologies in defining and diagnosing hematopoietic tumors. The ability to map specific pathologic signal transduction pathways regulating hematopoietic differentiation, proliferation, and apoptosis through genomic or proteomic technologies promises to provide the basis for the development of individualized molecularly targeted therapies for specific tumors.

Immunophenotypic and molecular studies in the diagnosis and classification of malignant lymphoma

Immunophenotypic and molecular studies play an increasingly important role in the diagnosis and classification of lymphoid neoplasms. These studies are not yet a substitute for expert histopathologic evaluation, but are a valuable adjunct to the examination of the hematoxylin and eosin-stained slide. Major applications include determination of lineage, determination of B and T cell monoclonality, detection of oncoprotein expression, and detection of oncogene rearrangements and chromosomal translocations. The recognition of the lymphomas as distinct biologic entities with specific immunophenotypic and genotypic features, as embodied in the Revised European-American Lymphoma (REAL) and World Health Organization (WHO) classifications, is a key to the future development and application of targeted biologic and molecular therapies. In the future, application of gene expression array analysis to the lymphoid neoplasms will permit classification of the lymphomas at a molecular level.

Among diffuse large B-cell lymphomas, T-cell-rich/histiocyte-rich BCL and CD30+ anaplastic B-cell subtypes exhibit distinct clinical features

BACKGROUND

The EORTC clinical trial 20901, activated in 1990, was designed to treat non-Hodgkin's lymphomas (NHL) of intermediate/high-grade malignancy according to the Working Formulation. Established in 1994, the R.E.A.L. Classification on NHL has now replaced all former classifications.

PATIENTS AND METHODS

We reanalysed all cases (n = 273) documented by material available for review according to the R.E.A.L. Classification. In addition, we subdivided cases recognised as diffuse large B-cell lymphoma (DLBCL) into three morphologically distinct categories, namely, large cleaved DLBCL (LC-DLBCL), T-cell-rich/histiocyte-rich B-cell lymphoma (T-cell-rich/histiocyte-rich BCL) and CD30+ DLBCL with anaplastic cell features (CD30+ DLBCL). Finally, T/NULL anaplastic large-cell lymphoma (ALCL) cases were subdivided into ALK+ and ALK- lymphomas. Review was performed independently by two pathologists from two different centres.

RESULTS

DLBCL (61%), T/NULL ALCL (15%) and mantle-cell lymphoma (MCL, 50%) were the main NHL categories represented in the study. Fifty-seven of one hundred sixty DLBCL cases were further subclassified as LC-DLBCL (33 cases), T-cell-rich/histiocyte-rich BCL (13 cases) or CD30+ DLBCL (11 cases). The remaining cases were indicated as unspecified DLBCL. A clinico-pathological correlation confirmed the findings of previous studies suggesting that MCL, DLBCL and ALCL represent distinct entities with MCL being characterised by a short survival, in contrast with the longer survival and less frequent progression typical of ALK+ compared to ALK- ALCL. Within DLBCL, T-cell-rich/histiocyte-rich BCL showed distinctive features at presentation whereas CD30+ DLBCL showed a trend towards a more favourable prognosis, that might be comparable to that of ALK+ ALCL.

CONCLUSIONS

Our data further support the usefulness of the R.E.A.L. Classification and illustrate the feasibility of DLBCL subtyping. Moreover, our results demonstrate the distinct clinical characteristics of T-cell-rich/histiocyte-rich BCL and CD30+ DLBCL with anaplastic cell features suggesting that they may represent clinico-pathologic entities.

Primary non-Hodgkin's lymphoma of the jaws: immunohistochemical and genetic review of 10 cases

PURPOSE

Non-Hodgkin's lymphoma (NHL) comprises a group of malignant lymphoproliferative diseases characterized by clonal expansion of lymphocytes at various levels of ontogenetic development. The aim of this study was to review the immunohistochemical and cytogenetic features of 10 cases of NLH of the jaws to determine their respective derivation.

PATIENTS AND METHODS

Histopathologic and immunohistochemical review of 10 cases of large-cell lymphomas of the jaws, together with Southern blot analysis of 2 of the cases, was performed and results compared with the findings in the literature.

RESULTS

In the 10 cases studied, the average age of onset of the NHL was 51 years, with a male-to-female ratio of 3:2. Tumefaction was the first clinical sign of disease. Eight of 10 cases were high-grade, large-cell NHLs, centroblastic type. Two cases were high-grade, large-cell NHL, immunoblastic type.

CONCLUSION

The immunohistochemical and Southern blot data remain the principal laboratory aids in the diagnosis and characterization of NHL, and they provide critical information for guiding clinicians to the appropriate treatment protocol for these malignancies.

Diffuse large B-cell lymphoma: is morphologic subdivision useful in clinical management?

The diffuse large B-cell lymphoma category of the REAL classification encompasses different morphologic lymphoma subtypes in a single entity. The aim of this study is to determine the influence of the morphologic subdivision within this category with respect to clinical features and response to treatment. From January 1993 to October 1996, 132 patients were diagnosed de novo with diffuse large B-cell lymphoma in our institution. All cases were classified according to the REAL and the Updated Kiel classifications, and immunohistochemical study was performed in all of them. Sixty-three per cent of patients received chemotherapy with a curative approach. Of the 105 assessable patients, 80 cases (74%) were classified as centroblastic (CB) and 25 cases (26%) as immunoblastic (IB), according to the updated Kiel classification. These 2 subsets of lymphomas did not differ with respect to major clinical features and laboratory parameters. Both groups had a similar complete response rate with a uniform therapeutic approach and the overall 2-yr survival did not show statistical differences (49% in CB vs. 45% in IB). In conclusion, for clinicians, morphologic subdivision of the diffuse large B-cell lymphoma category into CB and IB subtypes has little clinical and prognostic significance.

A cutaneous multilobated B-cell lymphoma

A patient with multilobated B-cell malignant lymphoma with lesions limited to the skin is described. The light, electron microscopic, and immunohistochemical features of this unusual morphologic variant of non-Hodgkin's lymphoma are described. The nosologic position of this histologic subtype is discussed. The clinical course, with lesions confined to the skin, and the response to treatment suggest a favorable prognosis.

Clinical significance of morphologic subdivision in diffuse large cell lymphoma

Although diffuse large cell lymphomas can be morphologically divided into large cell (DLC) and immunoblastic (IBL) subtypes, the clinical significance of this subdivision remains controversial. The initial diagnostic materials from 85 patients with recorded diagnoses of diffuse large cell lymphoma who were treated at Stanford between 1975 and 1986 with cyclophosphamide, doxorubicin (Adriamycin; Adria Laboratories, Columbus, OH), vincristine, and prednisone (CHOP); methotrexate, bleomycin, doxorubicin, cyclophosphamide, vincristine, and dexamethasone (M-BACOD); or methotrexate, doxorubicin, cyclophosphamide, vincristine, prednisone, and bleomycin (MACOP-B) chemotherapy were retrospectively reviewed by a panel of hematopathologists and classified according to morphologic criteria of the Working Formulation. Based on the criterion of agreement of two of three observers, 60 patients were classified as having DLC, 19 as having IBL, and the lymphomas in 6 patients could not be additionally classified. No significant differences in complete response (CR) rate, freedom from disease progression (FFP), or overall survival were found between the DLC and IBL groups. There was also no significant difference in prognosis between DLC cases additionally subclassified as large cleaved cell (16 patients) and those with large non-cleaved cell (36 patients). Although IBL is considered to be a high-grade lymphoma, the authors concluded that it does not differ significantly in prognosis from DLC lymphoma and, therefore, does not justify a modified treatment selection based on IBL morphologic type alone. Definitive evaluation of the prognostic significance of morphologic subdivision may require a larger cohort of uniformly treated patients.

Imprint cytology of non-Hodgkin's lymphomas based on a study of 212 immunologically characterized cases: correlation of touch imprints with tissue sections

The classification of non-Hodgkin's lymphomas (NHLs) has been traditionally based on analysis of histologic sections and has been supplemented more recently by immunologic marker studies. It was the purpose of the present study to illustrate, side-by-side, sections and Romanowsky-stained imprints from the same surgical specimen from practically all categories of immunophenotyped NHLs, including rare and atypical variants that were difficult to classify from the histologic sections alone. Our results indicate that imprint cytology may reveal nuclear and cytoplasmic details not discernible in even the best tissue sections and that it may be selectively helpful in contributing to the classification of NHLs. Our results also show that the relative value of imprint cytology in the classification of malignant lymphomas varies greatly among categories. Specifically, we have found that imprints assist in three ways: the recognition of plasmacytoid features in small cell lymphocytic lymphomas, the recognition of plasmacytoid immunoblastic lymphoma, and the differentiation between NHLs which may be difficult to distinguish histologically. These include (1) small lymphocytic lymphoma versus lymphocytic lymphoma of intermediate differentiation, (2) true histiocytic malignancies versus large cell malignant lymphomas with abundant cytoplasm and/or phagocytosis, (3) anaplastic myeloma versus plasmacytoid immunoblastic lymphoma, (4) large noncleaved versus plasmacytoid immunoblastic lymphoma, (5) lymphoblastic lymphoma versus diffuse small cleaved cell lymphoma, and (6) lymphoblastic lymphoma versus small noncleaved cell lymphoma. Lymph node imprints are easy to prepare and readily interpretable by those experienced in the study of abnormal blood and bone marrow films. Their value as an ancillary methodology aimed at optimal accuracy in the classification of NHLs should be recognized.

Non-Hodgkin's lymphoma in bone. Pathologic and radiologic features with clinical correlates

Thirty-seven lymphomas of bone were studied, including 33 diffuse large cell lymphomas, three undifferentiated (small noncleaved cell) lymphomas, and one well-differentiated (small) lymphocytic lymphoma. The large cell lymphomas were subclassified as large cleaved, large noncleaved, multilobated cell, and immunoblastic sarcoma (large cell lymphoma, immunoblastic type). Eleven of 26 large cell lymphoma patients with adequate follow-up were long-term survivors (free of disease for more than 5 years). Nineteen of the 33 large cell lymphomas were localized to one bone. The stage and histologic pattern significantly correlated with long-term survival among large cell lymphomas. Seventy-three percent of patients with localized lymphoma were long-term survivors, in contrast to 9% of those with disseminated disease. Sixty-seven percent of patients with large cleaved and multilobated cell lymphoma were long-term survivors, but only 21% of those with large noncleaved cell and immunoblastic sarcoma were. The tumors had a blastic, lytic, or mixed radiographic appearance and had either sclerotic, lytic, or permeative borders; none of the radiologic findings were diagnostically useful.

The non-Hodgkin's lymphomas: pathology, staging, treatment

The non-Hodgkin's lymphomas include a broad range of neoplasms derived from the T cells and B cells and their precursors in the lymphoid system. Although they are not among the most common cancers, the lymphomas have engendered a great deal of interest among researchers because of their interesting biology and responsiveness to therapy. The non-Hodgkin's lymphomas include at least ten major subtypes of diseases with different morphologic characteristics and clinical behavior. Based upon survival characteristics, it is convenient to divide the lymphomas into three broad categories, low grade, intermediate grade, and high grade. The low grade lymphomas usually arise in middle age or older individuals (median age, 55 years). They are derived from B cells and often have a follicular architectural pattern. They usually present with advanced stages of disease, often by virtue of bone marrow involvement. Nevertheless, patients are usually asymptomatic and may even have spontaneous regressions of disease. These lymphomas are responsive to a broad range of therapies including irradiation, single agent or multi-agent chemotherapy, or combined modality therapy. They are also affected by treatment with biologicals such as alpha interferon and monoclonal antibodies. Unfortunately, response to any of these therapies is often transient and relapse is common. The intermediate grade lymphomas include the common large cell lymphomas (follicular or diffuse) and diffuse mixed cell lymphoma. The lymphomas, together with the high grade immunoblastic lymphoma, are often grouped together for the development of management strategies. These lymphomas may be derived from B cells or T cells. They occur over a broader age range than the low grade lymphomas and they are much more aggressive in their natural behavior. Effective treatment programs have been developed for both limited and advanced clinical stages of disease. In limited disease, moderately intensive chemotherapy is often combined with involved field irradiation. In advanced stage disease, more aggressive combination chemotherapy programs are usually employed. From 40% to 80% of patients may be cured with these approaches, depending upon the initial extent of disease. Two types of high grade lymphoma-lymphoblastic and small noncleaved cell are particularly aggressive in their behavior. Lymphoblastic lymphoma is a T cell lymphoma that often arises in adolescent males and presents with a large mediastinal mass, marrow, and CNS involvement. It closely resembles acute lymphoblastic leukemia (ALL) and similarly intensive chemotherapy programs as are utilized in ALL may be successful in its management.(ABSTRACT TRUNCATED AT 400 WORDS)

Malignant lymphoma of the testis

Malignant lymphomas of the testis account for approximately 5 percent of testicular neoplasms, and they are the most common testicular malignancy between the ages of 60 and 80. Testicular lymphoma has a propensity to be associated with involvement of the skin, the central nervous system, Waldeyer's ring and adjacent structures, and the contralateral testicle. In general, essentially all patients with testicular lymphoma have been categorized as having "poor-risk" non-Hodgkin's lymphoma, with diffuse histiocytic lymphoma being the most common histologic subtype. All patients with testicular lymphoma should be treated with aggressive combination chemotherapy, with or without radiotherapy.

Prognostic indicators in diffuse large-cell (histiocytic) lymphoma

Identification of prognostic groups among patients with diffuse large-cell (histiocytic) lymphoma (DHL) would help to select specific therapy for individual patients and allow comparisons among combination chemotherapy clinical trials. The Ann Arbor staging system is of limited value in predicting outcome in diffuse histiocytic lymphoma. Prognostic factors have been examined by various groups without a consensus of reliable prognostic indicators. This study was undertaken to examine the validity of a predictive model for response to treatment and survival in DHL. Eighty-six patients with the diagnosis of DHL treated with combination chemotherapy between the years 1976 and 1982 were examined for prognostic variables influencing response to treatment and survival. The variables examined included: age, sex, presence or absence of systemic symptoms, serum lactic dehydrogenase (LDH), sites of disease involvement, bulk of disease, prior therapy, stage of disease, according to the Ann Arbor classification, and pathological criteria, according to the Lukes Collins classification. Factors achieving a p-value in the 0 to 0.05 range with univariate analysis for predicting response were age and systemic symptoms. Factors significant for overall survival were age and bone marrow involvement. These factors have been found to influence survival in previous studies, but there has not been a consistency regarding the importance of these factors. Large numbers of patients must be examined for various factors in order to allow identification of prognostic groups among patients with DHL.

Large noncleaved follicular center cell lymphoma. Clinical features in 53 patients

To clarify the clinical characteristics of large noncleaved lymphoma (LNC-FCC; intermediate grade, large cell, noncleaved, Working formulation), 53 patients were studied. Thirty-one were male and 22 female. Median age was 54 years. Initial symptoms included lymphadenopathy (40%), pain (34%), and B symptoms (21%). Stage I disease was present in 6, Stage II in 9, Stage III in 14, and Stage IV in 24 (72% Stage III or IV). Gastrointestinal (GI) tract involvement was present in 13. Central nervous system (CNS) disease was present at diagnosis in two patients, occurred during therapy in two, and was the sole site of relapse in two. Bone marrow involvement was found in 7 of 50 patients (14%). Complete remission was attained in 60% of all patients. Twenty-nine Stage III and IV patients received intensive multiagent chemotherapy; complete remission (CR) was attained in 69%. In contrast, zero of nine patients with Stage III or IV disease who did not receive an anthracycline-containing regimen, attained CR. Median survival for the entire group was 25 months. It was concluded that, in our patients with LNC-FCC, GI involvement was prominent (25%) and CNS disease was not uncommon (11%). Long-term disease-free survival may be achieved in patients with more advanced disease after the administration of anthracycline-containing combination chemotherapy.

VP-16-213 in the treatment of stage III and IV diffuse large cell lymphoma

Between 1975 and 1979, 81 consecutive patients with clinical Stage III or IV diffuse large cell lymphoma were randomized to prospectively receive the epipodophyllotoxin VP-16-213 as a single agent (Group 1: n = 25), or an equivalent quantity of the same drug combined with either cyclophosphamide (Group 2: n = 24), or doxorubicin (Group 3: n = 32). In previously untreated patients complete remission rates were 55% for Group 1, 29% for Group 2, and 62% for Group 3, with further partial remission in 22%, 12%, and 13%, and overall median survival for the three groups being 19 months, 5 months, and 19 months, respectively. There was no difference between Group 1 and Group 3, whereas the cyclophosphamide-containing regimen (Group 2) was clearly inferior (P less than 0.01). Survival was adversely affected by failure to achieve complete remission, prior chemotherapy, and the presence of high bulk disease. No statistically significant correlation could be demonstrated between survival and histologic subtype, differences between Stage III and IV disease, and invasion of either the bone marrow or gastrointestinal tract. The epipodophyllotoxin VP-16-213 is an active agent in patients with advanced stages of diffuse large cell lymphoma. The inferior results obtained when combined with cyclophosphamide remain unexplained. The inclusion of previously treated patients in the series suggested a superiority for combining the epipodophyllotoxin VP-16-213 with doxorubicin, since a higher percentage achieved complete remission, median duration of survival was longer, and a great number of individuals remain disease-free. When re-analysed excluding previously treated patients, these differences are no longer evident and the combination is not statistically superior to the epipodophyllotoxin alone.

Immunoblastic sarcoma of T- and B-cell types: morphologic description and comparison

Immunoblastic sarcoma (IBS) is a large cell lymphoma conceptually related to transformed T and B lymphocytes of the extrafollicular compartment of the immune system (immunoblasts). This light microscopic study of a series of 47 immunologically defined cases of IBS was undertaken in an attempt to define more precisely the morphologic features of the T- and B-cell subtypes. A remarkable morphologic spectrum characterized T-IBS (31 cases), which could be divided into two main groups: 1) tumors composed of varying mixtures of small, medium-sized, and large transformed cells; and 2) tumors with more homogeneous populations of medium-sized or large transformed cells. These cells, in all sizes, generally had abundant pale-staining cytoplasm, delicate nuclear membranes, finely dispersed chromatin, and one to several, small or medium-sized, prominent nucleoli. A distinctive background of small, irregular lymphocytes was frequently present. Plasmacytoid differentiation, seen most consistently as amphophilic staining of the cytoplasm, generally characterized B-IBS (16 cases). B-IBS similarly showed a morphologic spectrum that occurred in two main forms: 1) tumors consisting of a spectrum of transformed cells, with the smaller cells often showing the most striking plasmacytoid differentiation; and 2) tumors consisting predominantly of medium-sized to large transformed cells with varying degrees of plasmacytoid differentiation. With this constellation of features, all but two cases of T-IBS and one case of B-IBS were morphologically distinguishable.

Comparison of the working formulation of non-Hodgkin's lymphoma with the Rappaport, Kiel, and Lukes & Collins classifications. Translational value and prognostic significance based on review of 658 patients treated at a single institution

Six hundred fifty-eight cases of previously untreated non-Hodgkin's lymphoma seen between 1970 and 1979 at the Medical Department, the Finsen Institute, were the basis for a comparative study of the prognostic value of the Rappaport, Kiel, and Lukes & Collins classifications and the new translation system, the Working Formulation of Non-Hodgkin's Lymphoma. Each histopathologic system proved equally effective in separating patients into subgroups with a spectrum of prognoses ranging from a median survival of less than 1 year to greater than 7 years. The established classifications were compared with the Working Formulation in order to evaluate its translational value. The Working Formulation was more similar to the Rappaport and the Lukes & Collins systems than to the Kiel system, since 82%, 89%, and 75% of the cases, respectively, were translatable following the guidelines outlined in the National Cancer Institute (NCI)-sponsored study. Similarities among the four systems were demonstrated in lymphomas with follicular growth pattern, and in diffuse lymphomas composed of small mature appearing lymphocytes or small cleaved lymphocytes. Incongruity among the systems was more marked in lymphomas composed of large lymphoid cells or in lymphomas of mixed cellular composition. A comparison was performed for each classification against the Working Formulation. All such subdivided subsets were tested for prognostic heterogeneity and the following conclusions were reached: the diffuse poorly differentiated lymphocytic category of Rappaport was separated into two subgroups (malignant lymphoma [ML] small cleaved cell and ML lymphoblastic) with different prognoses (P = 0.01); the diffuse "histiocytic" lymphomas were prognostically homogeneous, since none of the newer systems were able to identify subpopulations with significantly different prognoses; the subtypes of the Kiel classification were prognostically homogeneous; the only weakness of the Lukes & Collins classification was the undefined cell subtype, encompassing two populations with different prognoses; and (5) the importance of follicular growth pattern was confirmed for small cleaved cell and mixed cell cytology, whereas large cell cytology implied a poor prognosis regardless of pattern. By the use of the Cox regression model it could be demonstrated that the Working Formulation can substitute any of the established classifications in terms of prognostic value.

CHOP-firstline treatment in NHL with unfavorable prognosis--evaluation of therapeutic response and factors influencing prognosis

58 NHL-patients (9 large cell centrocytic, 18 centroblastic, 16 immunoblastic, 15 lymphoblastic lymphomas) were treated immediately after diagnosis with CHOP-chemotherapy regardless of the extent of disease. Because of the advanced age of the majority of patients (median age 61 years, range 22-85 years) a reduced dose in the first two cycles was administered. Statistically significant prognostic variables influencing survival were the following: histologic subtypes according to the Kiel-classification (p less than 0,05), B-symptoms (p less than 0,001), blood sedimentation rate (p less than 0,02) and LDH (p less than 0,0005). With regard to prognosis there was no difference between patients over 60 years of age and younger ones (p less than 0,4). Patients achieving complete remission survived significantly longer (p less than 0,0001). Ann Arbor stages were of limited value, since patients with CS II disease and accumulation of risk factors (B-symptoms, abdominal disease, bulky tumor masses) showed a poorer outcome than patients with CS III who did not have these risk factors. A risk factor score summarizing features influencing prognosis is described and might be a useful tool in stratifying the heterogeneous group of NHL with unfavorable prognosis.

Large cell lymphoma. II. Differential diagnosis of centroblastic and B-immunoblastic subtypes by morphometry on cytologic preparations

Measurements were made, using semiautomatic electronic planimetry, of nuclear and nucleolar parameters of cytologic preparations from 18 cases of centroblastic and 9 cases of B-immunoblastic Non-Hodgkin's lymphomas, in order to determine whether these two subgroups of large cell lymphoma could be differentiated objectively by morphologic criteria. Statistically significant differences between centroblastic and B-immunoblastic lymphoma occurred in the mean and standard deviation of nucleolar area, the mean nuclear area, and the number of nucleoli per nucleus. The most useful discriminatory parameter was mean nucleolar area. The mean percentage of immunoblasts, defined as cells with nuclear area greater than 35 micron 2 and mean nucleolar area greater than 3 micron 2, was significantly different between the two groups of patients. The results suggest that although the groups of centroblastic and of immunoblastic lymphomas can be differentiated by measurable morphologic criteria, the individual cases form a spectrum from nodular centroblastic through diffuse centroblastic to immunoblastic, with polymorphic forms in between. A comparison with the results of a similar study on histologic sections from the same patients demonstrated that morphologic measurements on these two types of material are not interchangeable but, in general, the same conclusions were reached by morphometric study on histologic and cytologic specimens.

Nuclear morphologic and morphometric analyses of large noncleaved cell and immunoblastic non-Hodgkin's lymphomas

Both morphologically and immunologically, non-Hodgkin's lymphoma (NHL) of the large cell type has been shown to be a heterogeneous category. However, the homogeneity of the nuclear parameters, particularly size and condensed chromatin organization, used to classify this subtype of NHL has not been investigated. In fact, objective morphologic techniques have not been systematically applied to verify the segregation of NHL on the basis of nuclear parameters, a concept common to all current classification systems. In this study morphometric image analysis was used to compare the nuclei in 20 specimens from NHLs of the large cell type with those in mantle zone and germinal center lymphocytes from lymph nodes with reactive hyperplasia. Results of the assessment of mean nuclear area in large cell lymphomas revealed that this class is also heterogeneous, with some of the specimens having a nuclear size in the upper range of that for normal small lymphocytes. In addition, in only a few of these specimens was the mean nuclear area within the range of that for fully transformed germinal center lymphocytes. The majority of large cell lymphomas have a nuclear size more characteristic of partially transformed lymphocytes in germinal centers. In addition to indicating inconsistencies in the current diagnostic criteria used in NHL classifications, the results indicate reasons for interobserver variations in clinicopathologic trials; the validity of nuclear size as a prognostic indicator and the biologic basis for classifying NHL as a reflection of normal lymphocyte transformation are also questioned. In terms of patient management, the classifications of NHL currently used require objective reappraisal.

A multivariate analysis of factors affecting survival in patients with high-grade histology non-Hodgkin's lymphoma

One hundred and eleven patients with advanced-stage, high-grade histology non-Hodgkin's lymphoma were studied over a 7-yr period and were treated with one form of chemotherapy and radiotherapy. Multivariate analyses were carried out to identify factors which could predict a favourable prognosis. A complete response, low serum LDH and absence of clinical evidence of liver involvement were associated with long-term survival. The presence of 'B' symptoms, bone marrow involvement, low serum albumin and male sex predicted a reduced chance of achieving a complete remission. For those patients who achieved a complete response, the subdivision of histologies, particularly according to the Kiel classification, was the only significant factor predictive of prolonged relapse-free and overall survival. This confirms the importance of identifying different histological subgroups of lymphoma when considering treatment planning.

Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas results of a prospective multicenter study by the Kiel Lymphoma Study Group

Clinical and prognostic relevance of the Kiel classification of non-Hodgkin lymphomas (NHL) was investigated in 1127 patients entering a prospective multicenter observation study. Survival of the 782 (69.4 per cent) patients with low-grade malignant NHL (lymphocytic lymphomas, predominantly B-CLL, LP immunocytoma, centrocytic lymphoma, centroblastic-centrocytic lymphoma) exceeded that of the 341 patients (30.2 per cent) with high-grade malignant NHL (centroblastic, immunoblastic, lymphoblastic lymphomas). Prognosis was best in centroblastic-centrocytic lymphoma and in B-CLL and least favorable in immunoblastic and lymphoblastic lymphomas. Survival of LP immunocytoma and centrocytic lymphoma patients was intermediate after 2 to 2.5 years of follow-up. Corresponding to histopathology, pattern of survival curves of low-grade malignant NHL (slow decline, no plateauing) differed from that of high-grade malignant NHL (rapid decline, subsequent plateauing). Prognosis of B-CLL was superior to that of LP immunocytoma. Stages I and II were more frequent in centroblastic-centrocytic lymphoma (21 per cent) than in LP immunocytoma (2.5 per cent) and centrocytic lymphoma (11 per cent). Ability of radiotherapy to induce stable complete remissions in stage III of centroblastic-centrocytic lymphoma indicates prolonged restriction of lymphoma to the lymphatic system. In immunoblastic and centroblastic lymphomas, stages I and II were diagnosed in 34 and 38 per cent of cases, respectively, but only in stage I/IE of centroblastic lymphoma prolonged remissions were achieved by radiotherapy. In advanced high-grade malignant NHL marked improvement of prognosis was solely possible by induction of complete remissions whereas in corresponding low-grade malignant lymphomas also partial remissions were prognostically relevant.

A clinicopathologic study in advanced non-Hodgkin's lymphomas treated with sequential non-cross-resistant regimens: comparison of the working formulation with the Rappaport and Kiel classifications

One-hundred and ninety-four adult patients with histologically proven stage III and IV non-Hodgkin's lymphomas, treated with CVP (cyclophosphamide, vincristine and prednisone) alternated with ABP (adriamycin, bleomycin and prednisone), were analyzed to test the validity of the clinicoprognostic correlation offered by the working formulation in comparison with the Rappaport and Kiel classifications. Actuarial overall survival at 5 yr showed a significant difference among the three prognostic subgroups of the working formulation (low grade, 53.3%; intermediate grade, 47.5%; high grade, 27.7%). Overall survival of favorable subgroups of the Rappaport and Kiel classifications was superior to that of unfavorable prognostic groups. The percentage of systemic symptoms and bulky disease increased in patients with low-grade compared to those with intermediate-grade and intermediate-to-high-grade malignancy. The achievement of complete remission was not related to any of the prognostic groups of the Working Formulation, and no difference could be detected within the various prognostic groups of the Rappaport and Kiel classifications. Within the diffuse histiocytic lymphomas of the Rappaport classification, two groups with a different prognostic outcome were evidenced by the working formulation (G, with an overall survival of 50%, and H, with an overall survival of 26.7% at 5 yr) and by the Kiel classification. The possibility of reporting results in the three different groups of the working formulation instead of two can be considered a step forward. Within the diffuse histiocytic histology, the working formulation allows separation, as does the Kiel classification, into two main different prognostic subgroups.

Prognostic factors for non-cleaved follicular center-cell lymphomas and immunoblastic sarcoma. A Bayesian approach

The Bayesian multivariate statistical method was applied to determine the relative strength and optimal combination of 17 variables in predicting survival of 151 patients with non-Hodgkin's lymphomas assigned as non-cleaved follicular center-cell and immunoblastic sarcoma types according to the classification of Lukes & Collins. Considering all the factors simultaneously, the analysis showed that the combination of stage, Hb level and location of the lymphoma was included in the best predictive model at each survival time studied. Additional factors were erythrocyte sedimentation rate, thrombocyte count and leucocyte count. Of the histological variables, only growth pattern and mitotic ratio in the biopsy specimen remained significant. At manually controlled computer simulation with these best indicators, this model would have given a correct classification for 69-78% of the patients at the 4 survival times studied. One can thus expect about 70% correct prognoses using this model.

Studies on the pathology of non-Hodgkin's lymphoma of childhood. I. The role of routine histopathology as a prognostic factor. A report from the Children's Cancer Study Group

Between April 1977, and August 1980, the Children's Cancer Study Group (CCSG) conducted a clinical trial of childhood non-Hodgkin's lymphoma (NHL), randomizing 256 patients to one of two treatment regimens. A 4-drug regimen (regimen 1, modified cyclophosphamide, Oncorin [vincristine], methotrexate, prednisone [COMP] ) was compared with a 10-drug regimen (regimen 2, modified LSA2-L2). Using the Rappaport classification, the review pathologist diagnosed the 213 evaluable tissue specimens as follows: lymphoblastic (LC), 73; Burkitt's tumor (BT), 40; "undifferentiated" non-Burkitt's type (NB), 67; large cell or "histiocytic" lymphoma (HI), 29; and other types (OT), 4. Concurrence in classification between the review and institutional pathologists was poor when using the above four categories; however, concurrence was 88% between the review pathologist and other hematopathologists, and 99% when classifying the specimens as lymphoblastic or nonlymphoblastic. For patients with nonlocalized disease, this randomized controlled study demonstrated a new important correlation of histopathology with the effectiveness of treatment. When analyzed without stratification into lymphoblastic and nonlymphoblastic types, the two regimens showed identical relapse free survival (RFS) curves for patients with nonlocalized involvement. However, when patients were stratified according to histologic classification, regimen 2 was superior to regimen 1 for patients with lymphoblastic lymphoma, achieving 74% RFS at 30 months compared to 31% for regimen 1 (P = 0.001). Conversely, those with nonlymphoblastic types (BT, NB, HI) treated with regimen 1 had a 58% RFS at 30 months compared to 32% for those treated on regimen 2 (P = 0.01). This study demonstrates that proper, routine histopathologic classification of NHL is the best criterion for choice of therapy in children with nonlocalized involvement. As a result of this study, all patients with nonlocalized disease, diagnosed after August 1980, were no longer randomized but were assigned to the appropriate treatment regimen based on prospective review of histopathology.

Skin involvement of malignant B-cell lymphomas

In 1186 patients with systemic malignant B-cell lymphomas, the skin was involved in 6.17% of low-grade malignant, 9.7% of medium-grade malignant, and 7.4% of high-grade malignant lymphomas. Skin involvement is associated with an impaired prognosis in malignant B-cell lymphomas, with the exception of medium-grade malignant lymphomas.

Identification of large cell undifferentiated tumours in lymph nodes using leucocyte common and keratin antibodies

A total of 43 cases undifferentiated large cell tumours presenting in lymph nodes were stained by immunoperoxidase techniques using antibodies against keratin and a leucocyte-associated glycoprotein. In 26 cases diagnosed histologically as metastatic carcinoma, staining with the keratin antibody suggested a squamous cell origin in 11 cases. This was supported by microscopic observation of intracellular filaments in seven cases. In 15 patients in whom the original diagnosis was uncertain, a definite diagnosis was possible in all cases following immunoperoxidase staining with the two antibodies and most of these proved to be large cell lymphomas. In two cases a potentially major diagnostic error was detected. It is suggested that the staining of undifferentiated human neoplasms using combinations of antibodies reactive with epithelial and lymphoid cells should result in much greater diagnostic accuracy in the field of large cell tumours presenting in lymph nodes.

Deoxycytidylate deaminase activity in lymphoproliferative disorders

The activity of dCMPase has been measured in cell extracts from human lymphoproliferative disorders. The highest levels occurred in T helper-CLL and Thy-ALL, but high levels were also found in C-ALL, NPDLL transforming to DHL, DPDLL and DHL. A range of enzyme activities was found in the majority of types examined, with the widest range encountered in ALL, NPDLL and DHL. In DWDLL, a narrow range of dCMPase activities was found, with enzyme levels in the control range or moderately increased. Similarly, B-CLL exhibited a narrow range of enzyme activities, within that of the controls. The highest enzyme activity in HD was found in the highly malignant type - lymphocyte depleted HD. Statistically significant differences were found between the distribution of dCMPase activities in ALL and the chronic leukemias; and between favorable histologic types of non Hodgkin's lymphomas and the unfavorable DHL type. These data suggest that dCMPase activity is a marker of the clinical aggression of human lymphoid malignancies. Moreover, the marked variation in enzyme activity in each type of lymphoid malignancy suggests that this also applies to individual tumors as well. In view of the important role of dCMPase in pyrimidine metabolism and the profile of enzyme activities in leukemia and lymphoma, it is suggested that an inhibitor of dCMPase could be of clinical value in lymphoid malignancy.

Histiocytic sarcoma (true histiocytic lymphoma): a clinicopathological study of 20 cases

Large-cell non-Hodgkin's lymphomas (T- and B-immunoblastic, centroblastic and true histiocytic lymphomas) have a heterogeneous clinical course. In the present study the clinical and morphological data of 20 cases of histiocytic sarcoma (true histiocytic lymphoma) are presented. Diagnosis was supported by immunohistochemistry, cytochemistry, rosette assays and/or electron microscopy. Although the follow-up was relatively short (up to 144 months, mean 26 months), the clinical data differed clearly from the series of large-cell non-Hodgkin lymphomas, recorded in the literature. Differences were found in age distribution with a peak in the third decade, in organ involvement showing a preference for skin, gastrointestinal tract and bone, and in response to therapy. In general, histiocytic sarcoma appears to have a more favourable response to therapy and clinical course than the other large-cell lymphomas (T- and B-immunoblastic and centroblastic lymphomas). Moreover, preliminary observations in the group of histiocytic sarcomas suggested that the presence of lysozyme and/or 5-nucleotidase and the absence of alpha 1-antitrypsin in the cytoplasm is associated with a better response to therapy and favourable clinical course.

Characterization of malignant and non-neoplastic cell phenotypes in highly malignant non-Hodgkin lymphomas

Malignant and non-neoplastic cells in 38 cases of highly malignant non-Hodgkin lymphomas: 3 centrocytic anaplastic, 18 centroblastic, 13 immunoblastic and 4 lymphoblastic (according to the Kiel classification) were immunophenotyped in cryosections and cell suspensions by means of monoclonal antibodies. Additionally, cell cycle analysis on cell suspensions was performed by DNA flow cytofluorometry. In 33 (87%) lymphomas the malignant cells expressed monoclonal surface immunoglobulin (Ig), which indicated B-cell origin of tumors. In 7 of the 19 B-cell lymphomas tested by the peroxidase-antiperoxidase method, cytoplasmic Ig was found. Four lymphomas were of T-cell and one of non-B/non-T-cell origin. In II B-cell and 2 lymphoblastic non-B-cell tumors, common acute lymphoblastic leukemia antigen (CALLA) was found. In 25 of 30 studied NHL the malignant cells expressed receptor for transferrin and in 19 of 28 cases a high percentage of cells in S-phase (greater than 10.85%) was found. Number and distribution as well as type of non-B-cells infiltrating B-cell-derived lymphomas varied considerably from case to case. Among these cells Leu 3+ (T helper/inducer) cells predominated. Leu 2+ (T suppressor/cytotoxic) and Leu 7+ (natural killer and killer) cells constituted less numerous groups. Correlation of cytodiagnostic analyses with clinical observations indicates that high content of infiltrating T cells may be a favorable prognostic feature in highly malignant B-cell lymphomas.

Adult non-Hodgkin's lymphoma. Correlation of cell surface marker phenotype with prognosis, the new working formulation, and the Rappaport and Lukes-Collins histomorphologic schemes

The interrelationships between histomorphologic classification, cell surface marker phenotype and prognosis were prospectively studied in 130 adults with non-Hodgkin's lymphomas. Within each of the classification schemes used there were certain histologic variants that exhibited heterogeneity of cell lineage as well as those that were extremely uniform. Diffuse lymphomas with cell populations consisting of large cells, or mixtures of large and small cells were the most heterogeneous phenotypically and were most resistant to precise definition of immunologic cell lineage. The new Working Formulation for Clinical Usage likewise exhibited considerable heterogeneity of phenotype even within well defined histomorphologic categories. Two immunologic phenotypic variables that conferred a significant favorable prognosis were the expression of surface membrane immunoglobulin (B derivation) and the simultaneous expression of a membrane mu and delta immunoglobulin heavy chain. The results of this study suggest that cell surface marker phenotypic determinations have well defined and potentially useful correlations with histomorphologic classification schemes, and are useful in predicting biologic behavior and prognosis. It is suggested that a knowledge of both immunologic phenotype and histomorphologic characteristics is necessary in formulating therapeutic decisions.

Lectin binding patterns in diffuse large cell lymphoma

The staining reaction of a panel of lectins in paraffin embedded lymph node specimens of diffuse large cell lymphoma was studied in relation to survival. In 47 of 49 patients, varying degrees of lectin binding were observed with Ricinus communis agglutinin (RCA), crude extract of Arachis hypogaea (c-PNA), Concanavalin ensiformis A (Con A), Triticum vulgaris A (WGA) and Phaseolus vulgaris A (PHA). Binding was either absent or only minimal with Pisum sativum A (PSA) and Lens culinaris A (LCA). Two categories of binding were observed: cell surface and cytoplasmic. Cell surface binding was seen in tumor cells, while cytoplasmic binding was observed in macrophage-histiocytes. Varying numbers of tumor cells were stained with RCA, WGA, c-PNA or PHA; but with Con A virtually no tumor cells were stained. Stromal macrophage-histiocytes were stained with RCA, WGA, or Con A in all but one case, frequently with all three lectins; c-PNA binding macrophage-histiocytes were absent in one third of the cases. With PHA the staining of stromal macrophage-histiocytes was extremely rare. Tumor cells that stained with RCA but not with c-PNA were observed in 9 of 15 patients who survived more than 2 years after diagnosis. In all 15 long-term survivors, stromal macrophage-histiocytes were positive for c-PNA. Tumor cells that reacted with c-PNA but not with RCA were seen in five patients who survived less than two years. All 16 patients whose tumors lacked c-PNA binding stromal macrophage-histiocytes in the presence of RCA binding macrophage-histiocytes were short-term survivors. These observations suggest the heterogeneity of stromal macrophage-histiocytes as well as that of tumor cells. Furthermore, the variation of lectin binding might be useful in assessing prognosis.

Correlation of immunophenotype to morphology in unfavourable non-Hodgkin lymphoma

The relationship between immunological markers and histology according to the Kiel classification was studied in 40 adult non-Hodgkin lymphoma patients of Rappaport unfavourable histology. The membrane-associated and cytoplasmic Ig as well as receptors for sheep erythrocytes, Fc gamma and C3d receptors were analyzed on cryostate sections and in suspension. In some cases, a more precise immunophenotype was achieved by the use of monoclonal antibodies detecting different T and B cell antigens. Eighty-eight per cent of the lymphomas had B-cell, five per cent T cell and 7 per cent non-B/non-T cell phenotypes. All CBCC and CC lymphomas expressed monotypic Ig, but only 66 per cent of the CB lymphomas. Thus, morphology alone did not consistently predict immunophenotype in large-cell lymphomas. A simultaneous expression of multiple heavy chains and cytoplasmic Ig was found in some lymphomas, suggesting an intratumoral differentiation. The nodular or irregular tissue distribution patterns for Ig and C3d receptors found in histologically diffuse follicle derived lymphomas also suggest intratumoral variations in the marker expression, probably related to differentiation. The results suggest that lymphoma immunophenotype is important in obtaining a definite diagnosis in large-cell lymphomas and that it may lead to a better understanding of the differentiation of lymphomas of low-grade malignancy.

A clinico-pathological and immunological study of unfavourable non-Hodgkin lymphomas. Comparison of the Rappaport and Kiel classifications

To evaluate the prognostic information of the Kiel classification a homogeneous material of 63 non-Hodgkin lymphomas of unfavourable Rappaport histology were re-evaluated according to the definitions of the Kiel classification. The patients were selected from a prospective lymphoma study including 775 patients. Only ambiguous histological diagnoses analysed independently by two hematopathologists were accepted. Immunological markers of the tumours studied both in suspensions and on cryostate sections were in addition analysed in 40 of the patients. Forty-one per cent (26/63) were of high grade malignancy according to the Kiel classification, 59% (36/63) were of low-grade malignancy. The DLPD group was most heterogeneous while a better concordance was found between DM and CB/CC and between DH and CB cases. However, prognostic subgroups of the two classifications were only partly equivalent. A good correlation was found between the Kiel high-grade malignant group and patients of Rappaport poorest prognosis (DU, DH). Eighty-eight per cent of the lymphomas were of B cell, 5% of T cell and 7% of non-B-non-T phenotypes. Both the Kiel and Rappaport morphologic classifications predicted survival in this selected material. Patients with B phenotypes survived longer than patients with lymphomas of non-B type. Among patients with diffuse lymphomas, those with a nodular and irregular distribution of immunoglobulin and C3d receptors tended to respond better and survived longer. No prognostic information was obtained from immunoglobulin isotypes, C3d or Fc-gamma receptors. It is concluded that the Kiel classification is equally reliable for clinical judgement as the Rappaport system and that immunological marker studies may add prognostic information.

A new working formulation of non-Hodgkin's lymphomas. A retrospective study of the new NCI classification proposal in comparison to the Rappaport and Kiel classifications

Two hundred thirty cases of malignant non-Hodgkin's lymphomas were reclassified in a retrospective study according to the New Working Formulation for Clinical Usage of the NCI as compared to the Rappaport and Kiel classifications. The reproducibility for the individual schemes this study was 81% (Rappaport), 79% (Kiel), and 85% (New Working Formulation). In keeping with the results of the NCI international study, all lymphomas were subdivided into 3 prognostic groups: (1) low-grade malignancy (6.0 years median survival); (2) intermediate-grade malignancy (3.5 years median survival); and (3) high-grade malignancy (1.4 years median survival). The NCI-proposed New Working Formulation for Clinical Usage is thus recommended as practical and unprejudicing classification scheme for general application; however, its usefulness as tool for translating one classification scheme into another appears limited.

Primary lymphoma of the heart. A case report

The necropsy findings of a large cell lymphoma involving only the pericardium and myocardium in a 62-year-old woman are reported. The initial presenting symptoms were heart failure followed by rapidly progressive heart block. The diagnosis of cardiac lymphoma was suggested by gallium and blood pool isotope studies, and was subsequently confirmed by operative myocardial biopsy. The clinical course was abrupt, and the patient died before therapy was instituted. While primary cardiac lymphoma is an extremely rare condition, experience in this case suggests that noninvasive isotope studies, particularly gallium and blood pool, are helpful in the diagnosis of atypical cardiomyopathy.

Non-Hodgkin's lymphoma in children

Non-Hodgkin's lymphomas (NHLS) in children can conveniently be divided into four major types: lymphoblastic lymphoma, Burkitt's lymphoma, non-Burkitt's lymphoma, and large-cell lymphoma. This article reviews the clinical and histopathologic features of the different types. Recent studies have demonstrated that accurate diagnosis and histopathologic classification of NHL in children provide the optimal basis for selection of therapy.

The cellular content of non Hodgkin lymphomas: a comprehensive analysis using monoclonal antibodies and other surface marker techniques

Five samples of tonsil, 10 reactive lymph nodes and 65 consecutive cases of non-Hodgkin lymphoma (NHL) were evaluated in suspension phenotyping with the monoclonal antibodies alpha Leu-I, alpha Leu-2a, alpha Leu-3a, OKT1, OKT3, OKT4, OKT6, OKT8, W6/32, 26/114, DA-2, 2DI, J5, AN51 and OKT9 together with conventional surface marking by rosetting (E, Fc gamma, Fc mu, C3b, C3d) and staining for surface and cytoplasmic immunoglobulin (SIg, CyIg) heavy and light chain classes. The results confirm the reproductability and specificity of staining with monoclonal antibodies against T cells and T cells subsets. Evidence is presented for reactivity of alpha Leu-I antibody with SIg positive and Ia positive cells in some lymphomas (centroblastic centrocytic, lymphocytic and immunoblastic), and 2 cases showed evidence of marking with OKT3 on SIg positive cells in T cell predominant immunoblastic lymphoma. Lymphoblastic lymphomas of T cell type expressed the marker OKT6. On the basis of these results criteria for the diagnosis of T cell lymphoma are suggested. The monoclonal antibody J5, reactive with C-ALL antigen, showed variable positivity, occasionally strong in B cells in cases of centroblastic and centrocytic follicular lymphoma. Proportions of cells staining with the monoclonal antibody OKT9 showed a correlation between levels of cellular expression of transferrin (trf) receptor and the histological grade of malignancy, OKT9+ cells being elevated in high grade lymphomas, and in some cases of transforming lymphoma of low grade histological class. These results are discussed and indicate the advantage of employing a wide range of defined monoclonal reagents in the phenotypic evaluation of NHL.

Primary gastric lymphomas. A clinicopathologic study of 58 cases with long-term follow-up and literature review

A large series of primary gastric lymphomas with long-term follow-up (average, 12.8 years) is reported. A number of factors known to affect nodal lymphoma were examined. Five- and ten-year survival rates were 57 and 46%, respectively. Statistically significant favorable prognostic variables were smaller tumor size (less than or equal to 7 cm), superficial mural invasion (submucosal only), and pathologic Stage I disease; these variables were intimately interrelated. A favorable influence on survival was discerned concerning histologic type and nodular histology, although still below statistical significance. No significant relation to survival was observed concerning clinical weight loss or palpable mass, vascular invasion, mode of therapy, or histologic subtypes of "histocytic" lymphoma. Of patients who succumbed to disease, 75% did so within two years (average, 1.8 years); however, later recurrence and death may occur. An argument for resection of localized disease is presented. Mitotic index and nuclear diameter were of diagnostic importance, and associated lesions such as pseudolymphomas are discussed in relation to pathogenesis. Histologic variation within tumors suggested visualization of clonal development in non-Hodgkin's lymphomas.

Malignant lymphoma. 1. The histology and staging of 473 patients at the National Cancer Institute

A retrospective review was performed of 473 consecutive patients with malignant lymphoma referred to the National Cancer Institute. All patients had their clinical and pathologic material reviewed and where necessary reclassified. Using a modification of the Rappaport system, 180 (38.1%) patients had a nodular lymphoma, 293 (61.9%) had a diffuse lymphoma. Nodular lymphoma patients usually presented with lymphadenopathy; diffuse lymphoma patients often presented with extranodal disease, particularly those patients with poorly differentiated lymphocytic, "histiocytic", and Burkitt's lymphoma. Median age for all patients was 46 years, but was lower for diffuse poorly differentiated lymphocytic, diffuse undifferentiated, and Burkitt's lymphoma patients. Women were more likely to have a nodular rather than diffuse lymphoma. P less than 0.05. Analyzed by clinical staging, most nodular lymphoma patients had CS III (66.1%) disease, while most diffuse lymphoma patients had either CS III (31.1%) or CS IV (38.9%) disease. Analyzed by pathologic staging, most nodular lymphoma patients had PS III (34.8%) or PS IV (49.4%) disease, most diffuse lymphoma patients had PS IV (56.3%) disease. Only 7% of all lymphoma patients had PS I disease, only 14.9% were PS II. Systemic symptoms were more likely to be found in diffuse lymphoma and/or advanced stage patients.

Malignant lymphoma. II Prognostic factors and response to treatment of 473 patients at the National Cancer Institute

Treatment results were reviewed in 473 consecutively staged and treated patients at the National Cancer Institute over a 22-year period from 1953 to 1975. Responses correlated with histologic pattern and stage of disease. Complete responses to radiotherapy were frequent in CS I (86%) or PS I (91%). CS II (70%) or PS II (69%) nodular lymphoma patients. Similar treatment regimens were less effective in diffuse lymphoma patients, CS I (53%) or PS I (57%) and CS II (50%) or PS II (51%). Using chemotherapy or combined modality approaches, complete responses were obtained in a high proportion of advanced nodular disease patients, CS III (51%) or PS (59%), CS IV (44%), or PS IV (46%). With the introduction of combination chemotherapy and/or modern radiotherapeutic techniques, 52% CS III and 63% PS III, and 47% CS IV and 46% PS IV patients achieved a complete response. Patients with nodular lymphoma tend to have higher complete response rates and longer survivals than their counterparts with diffuse histologic types (P less than 0.05). Patients with nodular lymphocytic lymphoma had a better survival than those with mixed or "histiocytic" histologic types (P less than 0.03). Patients with diffuse well differentiated lymphocytic lymphoma survived significantly longer than patients with other diffuse histologic types (P less than 0.05). Percentage and prominence of nodularity were not of prognostic significance in those patients with combined nodular and diffuse patterns of disease. When compared by histologic type, patient sex did not appear to be an important prognostic factor. The presence of B-symptoms was associated with a poorer survival in patients with nodular disease (P less than 0.05) and in patients with diffuse disease (P less than 0.001). Over the years of this study, survival appears to have improved in each histologic subtype except DPDL.

Clinical relevance of markers of cell proliferation in human lymphoid malignancies: a concise review

The major advances being made in the understanding of the biology of human lymphoid malignancies have shown these to be a heterogenous group of tumours with respect to a variety of biological markers. The cell proliferative rate, an important determinant of tumor aggressiveness and response to therapy, is one of the biological phenomena currently being investigated in the lymphoid malignancies, particularly in the non-Hodgkin's lymphomas. In this paper we describe the techniques used in the analysis of cell proliferation in the lymphoid malignancies, and review the patterns of cell proliferation found in the various types of these tumours and the clinical relevance of these findings. We indicate that differences in cell proliferative rate are an important determinant of the response of non-Hodgkin's lymphomas to current therapeutic modalities and may explain the paradox that a significant number of reputed unfavorable tumors are now curable. Finally, we suggest that inherent differences in the proliferative rate of the neoplastic cell(s) of the so-called favorable histological types of non-Hodgkin's lymphomas may determine histologic progression as well as therapeutic responsiveness.

Predicting therapeutic outcome in patients with diffuse histiocytic lymphoma treated with cyclophosphamide, adriamycin, vincristine and prednisone (CHOP)

Seventy-five patients with diffuse histiocytic lymphoma (DHL) ranging in age from 33 to 94 years were treated with cyclophosphamide, Adriamycin, vincristine and prednisone (CHOP). Thirty-eight patients (51%) achieved complete remission, but nine of these patients relapsed after remission lasting one to 23 months (median time to relapse, four months). We used multivariate analysis to identify those characteristics that significantly affected treatment outcome. The chances for complete remission were adversely affected by DHL appearing after histologic conversion from another lymphoma (P = 0.006), the presence of systemic symptoms (P = 0.24), and not having the large noncleaved (LNC) histologic subtype (P = 0.40). The chance for relapse from complete remission was increased only by the presence of systemic symptoms (P = 0.042). Overall survival was adversely affected by the presence of bone marrow involvement (P = 0.002), having other than LNC histologic subtype (P = .010), and the presence of systemic symptoms (P = 0.043). It appears that patients whose DHL appears de novo and who also are symptom status A (70% long-term disease-free survival) or have the LNC histologic subtype (67% long-term disease-free survival) have an excellent outlook when treated with CHOP at the doses used in this study. However, patients with B symptoms (16% long-term disease-free survival), histologic conversion to DHL (8% long-term disease-free survival), previous chemotherapy (8% long-term disease-free survival), and bone marrow involvement (8% long-term disease-free survival) respond poorly and for these patients other treatments need to be identified. In addition, patients with B symptoms who achieve complete remission with CHOP are at high risk to relapse (59% relapse rate) and should be considered for "intensification" therapy after complete remission is documented.

Reticulum cell sarcomas (large cell lymphomas) presenting in the skin. High frequency of true histiocytic lymphoma

The clinical and histologic data from 12 patients with "reticulum cell sarcoma" (large cell lymphoma) presenting in the skin were reviewed. Moreover, when appropriate material was available additional immunological, cytochemical and ultrastructural techniques were used to define the nature of the neoplastic cells. Eight tumors were found to be of true histiocytic origin (histiocytic sarcoma), three of B-cell origin (two B-immunoblastic lymphomas and one centroblastic or large noncleaved follicle center cell lymphoma) and one case could not be classified. Possible explanations for the discrepancy between the current report and other studies as to the frequency of true histiocytic tumors will be discussed. The differentiation into T-cell, B-cell and true histiocytic lymphomas appears to be important, not only because of different clinical behaviour, but possibly also from a therapeutical point of view.