It was considered timely to review the pathological and staging classifications of GI tract lymphoma. This meeting specifically did not address the question of treatment; the management of GI tract lymphoma could perhaps form the basis for a further workshop. The following recommendations were made: to adopt the Isaacson histological classification, that all patients with GI tract lymphoma be investigated uniformly, to record the prognostic factors described above, to use the staging classification shown above. It is hoped that these recommendations will be taken into account in the design of future clinical trials of therapy for GI tract lymphoma.
Records of 73 patients with medullary thyroid cancer were reviewed to assess prognostic factors and the role of external beam radiation therapy. Patients were treated between 1954 and 1992. The median age was 49 years (range 15-85), M:F ratio 1.6:1, and the median follow-up was 7.9 years. (2.5-34.6). The primary tumor size was < 1 cm in 10%, 1-4 cm in 53%, and > 4 cm in 37%. Multifocality was noted in 32%, and 23% had metastasis at presentation. Eight patients presented with inoperable tumors, 40% had gross, and 37% microscopic residual disease postthyroidectomy. Extraglandular extension was present in 56%, and 74% had pathologically involved lymph nodes. Treatment was by total or near total thyroidectomy in 41 patients; 37 had a lymph node dissection. Forty-six patients were irradiated, the dose of radiation ranging from 20 to 75.5 Gy; median was 40 Gy, treatment time median was 28 days and the median number of fractions was 20. The overall cause specific survival (CSS) was 70% and 57% at 5 and 10 years, respectively. In a univariate analysis, the following factors predicted for lower CSS: age as a continuous variable (p = 0.003), male gender (p = 0.008), presence of distant metastasis (p < 0.0001), lymph node involvement (p = 0.03), gross residual disease (p < 0.0001), tumor size > 4 cm (p = 0.05), extraglandular invasion (p < 0.004), vascular invasion (p = 0.007), diarrhea (p < .0007), and abnormal postoperative calcitonin (p = 0.02). On multivariate analysis only two factors were significant: the presence of extraglandular invasion, and postoperative gross residual disease. There was no difference in local/regional relapse free rate between patients receiving external radiation and those that did not, but in 40 high risk patients (microscopic residual disease, extraglandular invasion, or lymph node involvement), the local/regional relapse free rate was 86% at 10 years with postoperative external beam radiation (25 patients), and 52% for those with no postoperative external radiation (p = 0.049). To optimize local/regional tumor control, we therefore continue to advise external beam radiation in patients at high risk of local/regional relapse.
SummaryTwenty seven adult patients with newly diagnosed non-Hodgkin's lymphoma localised to either bone (Stage IE) or bone and regional lymph nodes (Stage IIE) were treated between 1967 and 1988. Median age was 53 years and the commonest histology (21 patients) was diffuse histiocytic lymphoma. Twenty-four patients were treated radically: 15 with radiation therapy (XRT) alone and nine with chemotherapy plus radiation therapy (CMT). The cause specific survival for these patients was 56% at 5 years and 40% at 10 years. Survival was significantly better for patients treated by CMT (88% at 5 years) as compared to XRT alone (40% at 5 years, P = 0.03) and for age <60 (72% at 5 years) compared to > 60 (30% at 5 years, P = 0.018). Relapse-free rate was 27% at 5 years with XRT alone and 89% with CMT (P = 0.01). Risk factors for loco-regional relapse (seven cases) included: large tumour bulk, treatment by XRT alone and use of 'limited' radiation fields. No radiation dose-response relationship could be identified in this study. Long term local control and survival for localised lymphoma of bone were excellent after treatment by CMT but XRT alone was associated with unacceptably high local and distant failure rates.
Sixteen patients (median age 67 yrs.) with non-Hodgkin lymphoma of the testis were studied. Twelve of these patients had disease that was classified as local (Stages IE and IIE). Eight patients had diffuse histiocytic lymphoma, 6 had diffuse poorly differentiated lymphocytic lymphoma, 1 had both lymphoma and seminoma, and 1 had nodular poorly differentiated lymphocytic lymphoma. The overall median survival was 9.5 months. Para-aortic nodal involvement was the factor that had the strongest prognostic influence with the management methods used. Median survival without para-aortic nodal involvement was 57+ months, but with such involvement it was 6 months (p = 0.002). There is a high probability of generalized disease if lymphoma can be detected in the para-aortic nodes. For patients with Stages IE and IIE disease, radical radiation therapy is the preferred treatment. For those with disseminated disease, chemotherapy, with irradiation reserved for symptomatic and bulky localized deposits, is the recommended method of management.
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