Osteonecrosis of the jaw after radiation followed by bevacizumab

Osteonecrosis of the jaw is a recognized complication associated with bevacizumab. Here, we present a patient with squamous cell carcinoma of the tonsil who experienced minimal skin fibrosis following intensity-modulated radiation therapy. Subsequently, the patient developed rectal adenocarcinoma and encountered osteonecrosis of the jaw after receiving two cycles of bevacizumab. Close monitoring, accompanied by thorough examination to detect early signs of osteonecrosis of the jaw, should be considered for patients who have undergone radiation therapy in the head and neck region and are receiving bevacizumab or other medications known to be associated with osteonecrosis of the jaw.

Hodgkin lymphoma involving the tonsil misdiagnosed as tonsillar carcinoma: A case report and review of the literature

RATIONALE

Primary Hodgkin lymphoma (HL) involving the tonsil is extremely rare. Only about 20 such cases with verification of biopsy and immunohistochemistry have been reported. Because of its rarity and unremarkable clinical presentation, a timely correct diagnosis is very challenging.

PATIENT CONCERNS

A 43-year-old man complained left tonsillar enlargement and painless masses in left neck, with night sweat. The clinical examination found a marked tonsillar asymmetry, with an enlarged left tonsil and ipsilateral cervical lymphadenopathy and a normal right tonsil.

DIAGNOSIS

The patient was initially regarded as tonsillar lymphoepithelial carcinoma.

INTERVENTIONS

The patient received a resection of left tonsil and left cervical masses and then was definitively diagnosed as HL (IIEB). He was managed by 6 cycles of chemotherapy (adriamycin, bleomycin, vinblastine, and dacarbazine) and radiotherapy to the Waldeyer ring.

OUTCOMES

The patient has been disease free for more than 3 years after diagnosis.

LESSONS

As the reason of an extreme rare occurrence of HL involving the tonsil, doctors can easily misdiagnose the disease as tonsillar lymphoepithelial carcinoma. This case serves as a reminder important role of biopsy.

Targeted Intra-Arterial Chemoradiation for Advanced Tonsil Cancer

OBJECTIVES: To determine the effects of combined radiation and targeted, intra-arterial (IA) cisplatin infusions (RADPLAT) in patients with advanced squamous cell carcinoma (SCC) of the tonsil.

STUDY DESIGN AND SETTING: Prospective study of treatment outcomes and toxicity of patients enrolled on the RADPLAT protocol, with specific analysis of patients with advanced SCC of the tonsil.

RESULTS: Thirty patients with advanced tonsil carcinoma (17 T4, 12 T3, 1 T2) were enrolled, and 24 of 30 patients completed at least 3 IA cisplatin infusions and a minimum of 63 Gy or radiation therapy (minimum therapy). Two-year estimated overall and disease-specific survival was 42% and 50%, respectively, for all 30 patients (intent-to-treat group) and 49% and 58%, respectively, for the minimum therapy subgroup. The 2-year estimated local and regional disease control was 87% and 90%, respectively, for the intent-to-treat group, and 100% and 90% for the minimum therapy subgroup. Functional organ preservation was achieved in 92% of patients.

CONCLUSIONS: Locoregional disease control achieved with this regimen appears to be significantly improved over that described in the literature for similarly staged tonsil cancer. Survival, on the other hand, remains comparable.

EBM RATING: C

Primary small cell neuroendocrine carcinoma of the tonsil: a case report and review of the literature

Small cell neuroendocrine carcinoma (NEC) that originates in the tonsil is extremely rare and carries a poor prognosis. Only a few cases of this tumor have been reported so far and the standard treatment protocol remains uncertain. Here we describe a 74-year-old woman presented with throat pain for about 2 months. Computed tomography (CT) scan revealed a 3.4×1.8 cm tumor with moderate enhancement in the left tonsil and a 1.3×1.0 cm neck mass in left level II. A biopsy of the tonsillar mass was performed and histologic examination revealed small round to oval tumor cells were arranged in cords or nests, containing hyperchromatic nuclei and scant cytoplasm. Mitotic figures were readily identified. Immunohistochemical staining showed that tumor cells were strongly positive for CD56, focally positive for PCK and negative for LCA. A diagnosis of primary small cell NEC of the left tonsil was obtained. The patient was treated by six cycles of cisplatin combined with etoposide and the masses showed initial complete response. But recurrence in the left neck was found 9 months after initial diagnosis and the patient refused any further treatment. With a review of the literature, the nomenclature, clinicopathological characteristics and treatment modalities of this rare tumor are discussed.

[A case of pneumatosis cystoides intestinalis receiving chemotherapy for esophageal and tonsillar cancers]

A man in his 50, underwent chemotherapy for esophageal and tonsillar cancers. Diarrhea appeared on the 4th day and worsened daily. On the 12th day, free air was pointed out on abdominal X-ray and he consulted our department. At that time, there was no peritoneal irritation sign. Though CT showed pneumatosis and free air, there were neither perforation nor intestinal necrosis, therefore we diagnosed pneumatosis cystoides intestinalis (PCI). Conservative management was performed. He could ingest orally on the 14th day and was discharged on the 37th day. After that, chemotherapy was performed on several occasions for cancer, but there was no recurrence of PCI.

A rare but severe pulmonary side effect of cetuximab in two patients

Cetuximab is a monoclonal antibody that treats malignant disease by inhibiting epidermal growth factor receptor. Many common adverse events have been reported and include skin rashes, infusion reactions, gastrointestinal complaints and headache. Up to now, cetuximab-associated pulmonary toxicity has been rarely reported in the literature. The present report describes two cases with probable interstitial pneumonitis 5-6 weeks after commencing treatment with chemotherapy combined with cetuximab. One patient recovered and the second patient died due to gastrointestinal bleeding 3 weeks after an initial response to steroids.

Swallowing function after transoral laser microsurgery (TLM) ± adjuvant therapy for advanced-stage oropharyngeal cancer

OBJECTIVES/HYPOTHESIS

To perform a longitudinal description of swallowing function following transoral laser microsurgery (TLM) ± adjuvant therapy for advanced-stage oropharyngeal cancer (OPC) and identify prognostic factors associated with swallowing performance.

STUDY DESIGN

Retrospective analysis and longitudinal descriptive study of swallowing outcomes.

METHODS

Patients treated with TLM for AJCC stage III-IV OPC at Washington University from 1996 to 2008 were included. A search of medical records and direct patient contact were performed to obtain swallowing function at multiple time points. Persistently poor swallowing at 2 year after surgery was the primary outcome measure. Two year swallowing outcomes stratified by tumor site and T stage are presented.

RESULTS

One hundred eighteen patients met criteria for the study (median follow-up 53.9 months). There were 44 T1's, 41 T2's, 23 T3's and 10 T4's. Forty seven percent received radiotherapy and 41% received chemoradiotherapy. Ninety-eight percent underwent neck dissection. Patients tolerated TLM well with 82% enjoying good swallowing at 1 month after surgery. During adjuvant therapy, at 3 months, good swallowing dropped to 55%. At 1 and 2 years after TLM, 89% and 88% of patients had good swallowing function, respectively. At 2 years, 9 patients had persistently poor swallowing function. 93% of patients with T1 through T3 enjoyed good swallowing at 2 years. T4 base of tongue disease was associated with persistently poor swallowing function in multivariate analyses (P = 0.0023), with 40% having good swallowing at 2 years. Preexisting comorbidities and conversion to an open procedure were associated with delayed return of swallowing function, but not with persistently poor swallowing. Seven patients developed late-onset swallowing dysfunction.

CONCLUSIONS

Treatment of advanced stage OPC with TLM ± adjuvant therapy results in excellent swallowing outcomes for patients with either T1 to T3 tonsil or T1 to T3 base of tongue resections. A detailed, longitudinal swallowing profile is presented to assist in preoperative counseling.

Tonsillar metastasis of signet-ring cell adenocarcinoma of the colon

Cases of primary colorectal signet-ring cell carcinoma metastatic to the tonsil are extremely rare. To the best of our knowledge, only 4 such cases have been previously reported in the literature. We report a new case in a 76-year-old white woman. She was treated with chemotherapy, but her disease continued to spread and she was eventually placed on comfort care and palliative radiation therapy. The manner in which tonsillar metastases evolve is still unknown, but some hypotheses have been proposed, and we briefly review these theories.

Non-Hodgkin lymphoma presenting as bilateral tonsillar hypertrophy: case report

We describe the case of a 57-year-old man who was referred to us with persistent sore throat, dysphagia, and enlarged tonsils. He had not responded to earlier treatment with antibiotic therapy and other routine measures. In view of the persistent nature of the patient's symptoms and the tonsillar hypertrophy, we decided to perform a tonsillectomy and to send the excised specimens for pathologic analysis. Histologic evaluation identified non-Hodgkin lymphoma in both tonsils. The patient was treated with postoperative chemo- and radiotherapy, and he was free of symptoms during 18 months of follow-up. To the best of our knowledge, only 4 cases of bilateral non-Hodgkin lymphoma of the tonsils have been reported in the English-language literature. We also discuss the importance of histologic analysis of excised tonsil tissue in selected cases.

Successful treatment of syncope with chemotherapy irresponsive to cardiac pacemaker in head and neck cancer

Recurrent syncope as a complication of recurrent neck malignancy is an uncommon but well documented association. The syncope is presumed to occur when a tumor mass invades the baroreceptor within the carotid sinus or when it disrupts the afferent nerve fibers of the glossopharyngeal nerve. A 59-year-old man presented with recurrent syncope and headache. He had a wide local excision including tonsillectomy and modified left radical neck dissection for tonsilar cancer 4 years ago. A computed tomography scan revealed ill-defined lesions in left parapharyngeal, carotid space and right upper jugular region. After clinical evaluation, cardiac pacemaker was placed, but he still suffered from the syncope. Then, he received the chemotherapy with docetaxel and cisplatin. The last hypotension event occurred on day 10 of the chemotherapy. Six months after 3 cycles of chemotherapy, he remained in complete remission and resolution of syncope. We report a case in which syncope was associated with a recurrence of tonsilar cancer and successfully treated with chemotherapy.

Primary radiotherapy for tonsillar carcinoma: a good alternative to a surgical approach

OBJECTIVES

To review the Notre-Dame hospital experience in the treatment of tonsillar carcinoma with primary radiotherapy and to evaluate the different factors affecting locoregional control (LRC) and survival.

METHODS

We reviewed the records of 164 patients treated consecutively for squamous cell carcinoma of the tonsillar region between January 1990 and June 1999. Our study included 22 T1, 75 T2, 54 T3, and 12 T4 lesions; according to N stage, there were 48 N0, 50 N1, 51 N2, and 15 N3 disease. Overall staging was 6 stage I, 28 stage II, 62 stage III, and 67 stage IV disease. All patients received curative radiotherapy, and 31 patients received chemotherapy either prior to or during treatment with radiotherapy. No patient received surgery as a primary treatment modality.

RESULTS

The median follow-up was 4.2 years for all patients and 5.4 years for alive patients. The overall LRC rate was 72% at 5 years. By T and N stage, local and regional control rates at 5 years were as follows: T1, 82%; T2, 74%; T3, 66%; T4, 65%; N0, 77%; N1, 83%; N2, 65%; and N3, 38%. Significant favourable prognostic factors for LRC on univariate analysis were N stage and global stage. On multivariate analysis, the single favourable prognostic factor was N stage. The overall survival (OS) rate was 57% at 5 years. By T and N stage, OS at 5 years was as follows: T1, 62%; T2, 67%; T3, 45%; T4, 22%; N0, 63%; N1, 70%; N2, 46%; and N3, 32%. Significant prognostic factors for OS on univariate analysis were T stage, N stage, and global stage. Favourable prognostic factors for OS on multivariate analysis were T stage and N stage.

CONCLUSION

Lower N stage was a favourable prognostic factor for LRC and OS, whereas lower T stage was a favourable prognostic factor on OS. Our results compare favourably with other single-institution surgical series and justify the role of radiotherapy as a primary treatment modality in early tonsillar carcinoma. Concurrent chemotherapy and radiation therapy is currently our standard of care in advanced tonsillar carcinoma.

[Clinical features of 89 patients with primary non-Hodgkin's lymphoma of the tonsil]

BACKGROUND & OBJECTIVE

Head and neck lymphoma develops predominantly in the tonsil. This study was to investigate the clinical features of primary non-Hodgkin's lymphoma (NHL) of the tonsil, and to explore possible ways to improve the prognosis and quality of life of the patients after treatment.

METHODS

Clinical data of 89 naive patients with NHL of the tonsil, treated from May 1990 to Jan. 2003, were retrospectively reviewed. All patients were confirmed pathologically and classified according to revised European-American Lymphoid Neoplasms and World Health Organization Classification, and staged according to the Ann Arbor classification. Stage I-II patients received radiochemotherapy-predominant treatment, whereas stage III-IV patients received chemotherapy-predominant treatment.

RESULTS

Of the 89 cases, 60 (67%) were diffuse large B-cell subtype, 11 (12%) were peripheral T-cell subtype, 5 (6%) were indolent lymphoma, 1 was anaplastic large T-cell lymphoma, and 1 was T lymphoblastic lymphoma; 81 (91%) were stage I-II disease. Of the 89 patients, 58 (72%) received radiochemotherapy, 19 (21%) received radiotherapy alone, 3 received chemotherapy alone, and 1 received radiochemotherapy combined with rituximab. The 5-year overall survival rate was 80%, that of stage I-II patients was 84%. Cox regression multivariate analysis showed that the survival rate was correlated to the value of international prognostic index (IPI), and whether the patient had primary refractory or relapsed disease, but was not correlated to sex, age, pathologic subtype, B symptoms, and bulky disease.

CONCLUSIONS

Most patients with NHL of the tonsil are at early stages, with good prognosis. Diffuse large B-cell lymphoma is the most common pathologic subtype. Primary refractory, relapse, and IPI>1 are independent prognostic factors.

Swallowing Function After Chemoradiation for Advanced Stage Oropharyngeal Cancer

OBJECTIVE

Advanced-stage oropharyngeal cancer may be treated either surgically or nonsurgically. We reported previously functional outcomes after surgical resection with free-tissue transfer. In the present study, we evaluated swallowing function after combined chemoradiation for oropharyngeal cancer.

STUDY DESIGN AND SETTING

Retrospective review of 30 patients treated at a tertiary academic center for Stage III/IV oropharyngeal cancer with sequential or concurrent chemoradiation from 1994 to 2003.

RESULTS

Inclusion criteria were met by 27 of 30 (90%) patients. Most patients had base of tongue lesions (67%) and Stage IV disease (93%). Gastrostomy was carried out in 22 (82%) patients either before or during treatment. Three months after chemoradiation, 33% (9/27) were consuming all nutrition orally, 22% (6 of 27) were NPO, and 45% (12 of 27) had some oral intake but still required tube feeds. One year after treatment, 53% (10 of 19) had an exclusively oral diet whereas 47% still required tube feeds including 1 patient (5%) who was NPO. In patients without recurrence and follow-up length >1 year, 69% (9 of 13) were consuming all nutrition orally whereas 31% still required gastrostomy tube (G-tube) support. A higher rate of G-tube dependence was observed in patients treated for base of tongue lesions vs tonsil lesions (67% vs 25%, P = 0.049, chi(2) analysis).

CONCLUSIONS

At this institution, the short-term (3-4 months) rate of G-tube dependence was similar after surgical and non-surgical treatment of oropharyngeal cancer. One year after chemoradiation, 31% of patients without recurrence still required tube feeds.

SIGNIFICANCE

These results suggest that organ-preservation protocols do not reduce the prevalence of chronic dysphagia and G-tube dependence after management of oropharyngeal cancer.

EBM RATING

C-4.

Morphoproteomic and pharmacoproteomic rationale for mTOR effectors as therapeutic targets in head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) has a relatively high mortality rate and poor prognosis. Recently, we showed that overexpression of phosphorylated (p) nuclear factor-kappaB (NF-kappaB) in squamous cell carcinoma of the tonsil (SCCT) and high grade dysplasia is associated with a poor prognosis. Because the mammalian target of the rapamycin (mTOR) pathway contributes to the activation of NF-kappaB through immunophilin/mTOR signaling, we investigated: (a) the immunohistochemical expression and state of activation and potential clinical significance of components of the mTOR signal transduction pathway in SCCT patients (morphoproteomics); and (b) the inhibitory effects of rapamycin on the growth and state of activation of mTOR in 2 HNSCC cell lines (pharmacoproteomics). Archival biopsy materials from 39 patients with SCCT were studied by immunohistochemistry for the expression of p-mTOR (Ser 2448), and p-p70S6K (Thr 389), and/or cyclin D1. Results for SCCT were compared with adjacent non-neoplastic epithelium, when present, and with normal tonsillar epithelium from approximately age-matched controls; clinical outcomes were also assessed. SCCT showed mTOR (Ser 2448) expression in 93% (30/32 cases) with 2+ or 3+ plasmalemmal and/or cytoplasmic intensity in 84% vs 42% in surface epithelium from normal tonsils (p <0.001). The mean combined expression score (signal intensity x percentage of positive cells) for p-p70S6K was significantly greater in the SCCT group vs adjacent non-neoplastic squamous epithelium and normal tonsillar epithelium of the control group (p <0.05). A relationship existed between higher p-p70S6K expression levels in the non-neoplastic squamous epithelium adjacent to the SCCT and increased risk of death from disease (hazard ratio = 7.9; 95% confidence interval (CI) = 2.1 to 29.9; p = 0.002). There was also a relationship between nuclear expression of cyclin D1 in SCCT and shortened recurrence-free survival (p = 0.015). Two human HNSCC cell lines, SCC-15 and FaDu, were incubated with and without rapamycin to assess its impact on growth and on the expression of p-mTOR. Rapamycin in a dose-dependent fashion inhibited growth more in SCC-15, which correlated with a greater reduction in constitutively activated p-mTOR (Ser 2448) as shown by Western blotting. In conclusion, these morphoproteomic and pharmacoproteomic data collectively provide a rationale for selecting mTOR effectors as therapeutic targets in HNSCC.

Advanced-staged tonsillar squamous carcinoma: Organ preservation versus surgical management of the primary site

BACKGROUND

Our aim was to review our experience in the management of advanced tonsillar squamous cell carcinoma (SCC) and to compare treatment outcomes between patients treated with and without surgery to the primary site.

METHODS

The records of 74 patients with advanced-stage tonsillar SCC were reviewed. The median age at diagnosis was 58 years. Thirty-eight patients received definitive surgery to the primary site, and 36 were treated with an organ-preservation approach (OP) using radiotherapy +/- chemotherapy.

RESULTS

No significant difference in overall survival (OS) or freedom from relapse (FFR) by treatment was found. T classification and N status were significant independent predictors on multivariate analysis for OS and FFR. Major late toxicity was noted in 10 patients in the surgical group and nine in the OP group.

CONCLUSION

Patients treated with OP and primary surgery had comparable OS and FFR. T classification and N status were significant independent predictors for tumor relapse and survival. On the basis of these results, we favor organ-preservation therapy for patients with advanced-stage tonsillar SCC.

Positron Emission Tomography Scan to Determine the Need for Neck Dissection after Chemoradiation for Head and Neck Cancer: Timing is Everything

We present a case of a negative positron emission tomography (PET) scan in a patient with pathologic viable cancer at neck dissection.

STUDY DESIGN

Case Report.

METHODS

A 69-year-old man presented with clinical stage T2N2c squamous cell cancer of the left tonsil and was treated with definitive chemoradiation. Left-sided adenopathy decreased but remained palpable after therapy.

RESULTS

PET scan performed 23 days after completion of treatment showed no suspicious uptake in the left neck. Neck dissection performed at 2 months post-therapy revealed viable tumor in left cervical nodes.

CONCLUSIONS

Persistent adenopathy after chemoradiation for head and neck cancer remains a clinical dilemma. A negative PET scan is accurate but only if the scan is performed 3 to 4 months after therapy.

Radiation-induced chondrosarcoma of the maxilla 7-year after combined chemoradiation for tonsillar lymphoma

Radiation-induced sarcoma is a rare complication of radiation therapy. We report a case of radiation-induced chondrosarcoma of the maxilla. An 80-year-old Persian woman developed radiation-induced chondrosarcoma of the left maxilla 7 years after combined chemotherapy and external beam radiation therapy for the Ann Arbor stage IE malignant lymphoma of the right tonsil. She underwent suboptimal tumour resection and died due to extensive locoregional disease 8 months later. An English language literature search of Medline using the terms chondrosarcoma, radiation-induced sarcoma and maxilla revealed only one earlier reported case. We describe the clinical and pathological features of this case and review the literature on radiation-induced sarcomas.

Dermatomyositis and malignancy of the pharynx in Caucasian patients: report of two observations

The association between dermatomyositis and malignancy of the pharynx is rare among whites but not uncommon among Far Eastern and north African populations. We report two cases of Caucasian Italian patients with dermatomyositis associated, respectively, with nasopharyngeal and tonsillar carcinomas. The relationship between dermatomyositis and malignancy is also discussed.

[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.

Stage I malignant lymphoma of Waldeyer's ring: frequent relapse after radiation therapy

The natural history and therapeutic results of 26 patients with stage I malignant lymphoma of Waldeyer's ring (ML-WR) were analyzed retrospectively. Complete response was achieved in all 26. Relapse occurred in 9 of 21 (43%) patients treated with radiation therapy (RT) alone, while no relapse was seen in those treated with a combination chemotherapy consisting of cyclophosphamide, adriamycin, vincristine, and prednisolone (CHOP therapy). Relapse occurred within 1 year in 8 of the 9 patients. Relapse-free survival in the patients treated with RT alone was considered suboptimal.