Treatment of non-Hodgkin's
lymphoma of Waldeyer's ring: radiotherapy versus chemotherapy versus combined therapy.
Aviles A, Eur J Cancer B Oral Oncol. 1996 Jan;32B(1):19-23.
Department of Hematology, Oncology Hospital, National Medical Center, Mexico.
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.
Non-Hodgkin's lymphomas of the tonsil: a retrospective analysis of twenty-eight
patients with primary tonsillary lymphoma.
Barista I, Tumori. 1995 Jul-Aug;81(4):234-7.
Department of Medical Oncology, Hacettepe University, Ankara, Turkey.
AIMS: To analyze the clinical and therapeutic aspects of patients with primary tonsillary
non-Hodgkin's lymphoma. METHODS: Twenty-eight patients with primary tonsillary
non-Hodgkin's lymphoma who had been followed in the Hacettepe Oncology Institute between
1974 and 1992 were retrospectively analyzed. Fifteen patients were male, 13 were female.
Median age was 55 years. RESULTS: Constitutional symptoms were present in 10 patients
(35.7%). Stages according to the Ann Arbor classification were I and II in 12 and 16
patients, respectively. According to the Rappaport classification, poorly differentiated
lymphocytic was the most common pathologic subgroup (42.9%). Grades according to the
Working Formulation were low, intermediate and high in 3, 22 and 3 patients, respectively.
Twenty-two patients had received chemotherapy. Cyclophosphamide, vincristine and
prednisone (CVP), and cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP)
were the regimens most commonly employed. Eighteen patients received radiotherapy to
Waldeyer's ring and neck. Eight patients achieved remission with chemotherapy plus
radio-therapy, 7 patients with chemotherapy alone, and 5 patients with radiotherapy alone.
In addition to the 20 patients who achieved complete remission, 3 patients achieved
partial remission; the overall response rate was 82.1%. The response rates and survival
attained with the combined modality, chemotherapy, or radiotherapy alone were not
statistically different (P > 0.05). The median follow-up was 14 months. Overall and disease-free survival at 5 years were 62.6% and 77.6%,
respectively. Pathologic grade was the most important prognostic factor influencing
overall survival in the Cox multivariate model. CONCLUSIONS: Poorly differentiated
lymphocytic lymphomas were the most common pathologic subtype, and pathologic grade was
the most important prognostic factor to influence survival in the present study. Although
combined modality treatment did not appear to be superior to chemotherapy or radiotherapy
alone, a larger number of patients is needed to draw definite conclusions.
Localized
non-Hodgkin's lymphoma of Waldeyer's ring: clinical features, management,
and prognosis of 130 adult patients.
Ezzat AA, Head Neck. 2001
Jul;23(7):547-58.
Department of Oncology, King Faisal Specialist Hospital & Research Centre,
PO Box 3354, Riyadh, 11211, Saudi Arabia.
Waldeyer's ring (WR) is the primary
site of non-Hodgkin's lymphoma (NHL) involvement in approximately 5% to 10%
of all lymphoma patients, and it accounts for more than half of all primary
extranodal lymphomas of the head and neck. Materials and Methods A
retrospective review was performed of 130 adult patients with localized
(stages I and II) WR-NHL seen at a single institution over 18 years.
RESULTS: Patients had a median age of 55 years, and the male-female ratio
was 1:5:1. Seventy five (58%), 46 (35%), and 9 (7%) patients had primary
tonsillar, nasopharyngeal, and base of the tongue lymphoma, respectively. Forty-five
(35%) and 85 (65%) had stage I and stage II disease, respectively.
Most patients (109 patients, 84%)
had diffuse large B-cell NHL (DLC). Chemotherapy (CT) was given to 58
(45%) patients, whereas 26 (20%) received radiation therapy (RTX), and 46
(35%) were managed with a combination of chemotherapy and radiotherapy (CMT).
One hundred nine (84%), 16 (12%), and 5 (4%) patients attained complete
remission (CR), partial remission (PR), and treatment failure, respectively,
with no difference in CR rates between the three therapeutic modalities. Of
those patients with DLC, 90 (83%), 15 (14%), and 4 (3%) demonstrated CR, PR,
and treatment failure, respectively. In a multivariate analysis, the
modified International Prognostic Index (IPI) was found to predict the
attainment of CR. Over a median follow-up of 49 months; 76 (58%) of the
patients were alive and disease-free, 5 (4%) were alive with evidence of
disease, and the remaining 49 (38%) were dead. Most distant relapses were in
nongastrointestinal extranodal sites. The median overall survival (OS) has
not been reached; however, the
projected 5-year OS was 58%. No OS difference was noted between
patients with stage I and stage II. Cox proportional hazards model
identified primary tonsillar site and a low-risk group as defined by the
modified IPI were associated with favorable OS. The
median event-free survival was 82.3 months, with the primary tonsillar site,
and low-risk modified IPI group were associated with favorable EFS in a
multivariate analysis. Probably because of the high frequency of patients
with DLC, the outcome and the prognostic factors in those patients were not
distinctive from those for the whole group.
The CMT was not associated with a
superior OS compared with either of the single modality treatments; however,
it was associated with more favorable EFS. CONCLUSIONS: This series
characterized the clinicopathologic features and outcome of adult patients
with early stage WR-NHLs. No survival difference was noted between stage I
and stage II, and the outcome was favorable. Primary tonsillar site and the
low-risk group of the modified IPI predicted favorable OS and EFS.
CMT is probably superior to single
modality treatment; however, prospective studies are warranted.
Radiochemotherapy for non-Hodgkin's lymphoma in palatine tonsil.
Fujitani T, Cancer. 1984 Oct 1;54(7):1288-92.
From January 1966 to December 1980, 367 cases of non-Hodgkin's lymphoma (NHL) were
autopsied at Kobe University Hospital. The rate of extranodular type was 76.7% and the
most common site of origin was the palatine tonsil. Of 133 patients with NHL in the
palatine tonsil, at the Kobe University Hospital 110 were treated. All of the patients
were treated by irradiation. Sixty-one patients were treated by irradiation alone.
Forty-nine patients were treated in addition with conventional chemotherapy using
vincristine, cyclophosphamide, endoxan a, and prednisolone. In 14 of 49 patients, adjuvant
immunochemotherapy using a Streptococcus pyogenes (OK-432) was added at maintenance dose
in combination with induction radiochemotherapy. The survival curve of the patients
treated by radiochemotherapy is better than that of the patients treated by irradiation
alone. The survival rates at 0 to 1, 1 to 2, and 2 to 3 years for the patients treated by
radiochemotherapy were 81.5, 66.3, and 59.0%, respectively, significantly higher than
those of the radiotherapy group. The 5-year survival rates of the radiotherapy group were
50.2% for Stage I and 26.5% for Stage II patients. The rates
increased to 78% and 41.8% by radiochemotherapy. The extranodal NHL of Stage II
also frequently develops into the advanced stage and adjuvant chemotherapy is necessary
for such patients.
Waldeyer's Ring
Lymphomas: Treatment Results and Prognostic Factors.
Gurkaynak M, .Am J Clin Oncol. 2003 Oct;26(5):437-40.
Departments of Radiation Oncology and dagger Medical Oncology, Hacettepe University,
Faculty of Medicine, Ankara, Turkey.
SUMMARY: ABSTRACT Optimal management of patients with localized Waldeyer's ring (WR)
lymphoma remains controversial due to the lack of randomized studies and heterogenous
grouping of most reported series. In this retrospective study, we have evaluated the
possible prognostic factors and treatment outcome of WR non-Hodgkin's lymphoma. Between
December 1993 and February 2000, 32 patients with WR lymphoma, stage I (11 patients) and
stage II (21 patients) were treated. There were 17 male patients and 15 female patients
with a median age of 47 years. The distribution among different anatomical sites were as
follows: tonsils in 16 (50%), nasopharynx in 10 (31%), base of tongue in 6 (19%).
According to Working Formulation, 10 had high-grade, 17 intermediate grade, 3 low-grade,
and 2 had unclassified lymphomas. Combined chemotherapy and radiotherapy was the primary
modality of therapy for intermediate or high-grade lymphoma. Radiotherapy alone was
employed only in low-grade WR lymphomas. Chemotherapy was median 6 courses of CHOP
(cyclophosphamide, doxorubicin (Adriamycin), vincristine, and prednisolone) in 26 patients
and CEOP (cyclophosphamide, doxorubicin, etoposide, and prednisone). Radiotherapy volume
was involved field and the median dose was 40 Gy. Median follow-up is 40 months (ranged
from 6-82 months). Overall survival and disease-free survival (DFS)
rates at 3 years are 100% and 92%, respectively. Two patients developed recurrence,
both salvaged with further chemotherapy. Only one patient died because of other reasons.
International Prognostic Index score (</=2 vs. >2) is found to be an important
prognostic factor for DFS. The other significant prognostic factors for DFS are
performance status and serum levels of alkaline phosphatase and lactate dehydrogenase. Our
results suggest that combined chemotherapy and involved field radiotherapy is appropriate
treatment for stage I-II WR lymphoma. International Prognostic Index is the strongest
predictor for DFS.
Treatment of early stage primary tonsil
non-Hodgkin's lymphoma
Gao YH, .Zhonghua Xue Ye Xue Za Zhi. 2003 Apr;24(4):190-2.
Department of Radiation Oncology, Cancer Hospital, CAMS, Beijing 100021, China.
OBJECTIVE: To investigate the treatment for patients with early stage primary tonsil
non-Hodgkin's lymphoma (NHL). METHODS: Two hundred and thirteen patients with previously
untreated early stage primary tonsil NHL were reviewed. All patients were pathologically
confirmed. According to Ann Arbor classification, 35 patients were stage I, 178 stage II.
The primary treatment for stage I was radiotherapy alone in 12 and combined modality
therapy (CMT) in 23 patients. The primary treatment for stage II was radiotherapy alone in
57,chemotherapy alone in 2, and CMT in 119 patients. RESULTS: The 5-year overall survival,
cancer specific survival (CSS) AND disease-free survival (DFS) for the early stage primary
tonsil non-Hodgkin's lymphoma were 65%, 70% and 61%, respectively. The 5-year CSS was 63%
for the radiotherapy alone group and 72% for the CMT group (p = 0.064), and the 5-year DFS
were 56% for the radiotherapy alone group and 62% for the CMT group. For
patients with stage I disease, The 5-year CSS were 100% in both radiotherapy alone and CMT
groups, and the 5-year DFS were 100% and 80% in these two groups (p = 0.148),
respectively. There was no significant difference of efficacy between the two
treatment s for the patients with stage I disease. For the patients with stage II disease,
the 5-year CSS was 58% in radiotherapy alone group and 66% in CMT group (p = 0.051).
However, CMT significantly improved DFS in stage II disease, with a
5-year DFS of 46% for radiotherapy alone and 60% for CMT (P = 0.046). CONCLUSION:
Patients with stage I tonsil non-Hodgkin's lymphoma treated with radiotherapy alone or CMT
can achieve an excellent outcome. CMT significantly improve the DFS in stage II patients.
There was a trend that CMT improved the survival rates in the patient with early stage
disease. It was suggested that CMT should be used for the patients with early stage
primary tonsil non-Hodgkin's lymphoma.
Radiotherapy of primary
extranodal non-Hodgkin's lymphoma of the head and neck region. Results of a
prospective multicenter study. Study Group NHL: early studies
Hoederath A,
Strahlenther Onkol. 1996 Jul;172(7):356-66
Strahlenklinik, Universitatsklinikum Essen.
PURPOSE: To evaluate the long-term outcome of patients with limited-stage
primary extranodal lymphoma of head and neck treated with definitive
radiotherapy in low-grade and a combined radio- and chemotherapy in
high-grade lymphoma. PATIENTS AND METHODS: Between January 1986 and August
1993, 63 patients with primary extranodal Non-Hodgkin lymphoma of head and
neck region, stages IE and IIE were treated with radiotherapy. The
histological classification followed the Kiel classification, staging the
Ann Arbor classification. Patient characteristics: 33 male, 30 female; age
18 to 84 years; tumor localisation: tonsils 26, nasopharynx 7, oropharynx 8,
paranasal sinus 11, salivary glands 7, floor of mouth/gingiva 3, larynx 1.
Mean follow-up is 74 months.
Low-grade lymphoma in stages I and II CS were treated with definitive
radiation therapy according to the concepts of epithelial tumors of the same
localisation
(target volume and technique). The adjuvant dose was 30 Gy and in the tumor
volume 40 Gy, 2 Gy daily. 28 patients were registered, 18 in stage I and 10
in stage II. High-grade lymphoma were treated with definitive radiation
therapy according to the concepts of epithelial tumors of the same localisation,
too. The dose was 40 respectively 50 Gy, followed by 4 courses of adjuvant
chemotherapy with CHOP. Thirty-five patients were enrolled, of whom
only 10 received chemotherapy. RESULTS:
The overall 5-year survival rates
were for low-grade 67% and for high grade lymphoma 88%. The corresponding
relapse-free survival rates were 54/68%, respectively. Only 1 patient
failed within the irradiated target volume. Recurrences occurred at sites
distant to the irradiated volume in nodal and extranodal regions. Prognosis
was influenced by histologic grade. Significant trends were not observed for
other potential pretreatment parameters (age, stage, localisation, bulk).
CONCLUSIONS: In stage I or II patients with low malignant non-Hodgkin's
lymphoma of the head and neck, initial management with definitive external
radiotherapy is appropriate and probably curative.
In high-grade lymphoma of clinical
stage IE with nonextensive
tumor size definitive radiotherapy is possible in curative intention.
Primary chemotherapy followed by radiation is probably preferable.
Waldeyer's ring
lymphomas: a clinical study from the Comprehensive Cancer Center West
population based NHL registry.
Krol AD, Leuk Lymphoma. 2001
Sep-Oct;42(5):1005-13.
Department of Clinical Oncology, Leiden University Medical Center, The
Netherlands
It is debated whether non-Hodgkin's lymphomas originating in Waldeyer's ring
(WR NHL) behave as NHL originating in lymph nodes or share common features
with extranodal lymphomas originating in mucosa associated lymphatic tissue
(MALT). We analyzed data from a population based NHL registry on patterns of
dissemination at diagnosis, response to treatment, patterns of failure and
survival of 77 primary Waldeyer's ring Non-Hodgkin's lymphomas (WR NHL)
patents. Data of completely staged patients with diffuse large cell
lymphomas (DLCL) originating in WR (n=44) were compared with those of
patients retrieved from the same registry with DLCL originating in lymph
nodes or stomach (the latter as prototype of a lymphoma originating in
MALT). Primary WR
NHL had favorable risk scores
according to the International
Prognostic Index (IPI), and responded well to therapy: a complete response
(CR) rate of 74% was observed. Disease free survival (DFS) and overall
survival (OS) were poor, however (47% and 31% at 10 years, respectively).
The comparison of DLCL originating in WR, lymph nodes and stomach revealed
that WR and gastric NHL patients shared a restricted pattern of
dissemination at diagnosis, in contrast to patients with DLCL originating in
lymph nodes. Although not all patients were completely restaged at relapse,
analysis of patterns of failure suggested that the gastro-intestinal tract
is a preferential site for recurrences, both for WR and gastric DLCL
patients. CR rates of WR, nodal and gastric DLCL patients were 77%, 55% and
55% respectively (P=0.03), OS of the three patient subgroups did not differ
(33%, 27% and 37% at 10 years). DFS of WR DLCL patients was similar to nodal
DLCL patients but inferior to gastric DLCL patients (47%, 48% and 73% at 10
years respectively, P=0.006). After Cox regression analysis the relative
relapse risk for patients with WR DLCL when compared to patients with DLCL
originating in lymph nodes was 2.01 (C.I. 0.99-4.01, P=0.05), and 3.46 (C.I.
1.32-9.00, P=0.01) when compared to patients with gastric DLCL. The clinical
picture of primary WR NHL emerging from this population based study is in
agreement with data form hospital based studies. In the comparison of WR
DLCL, nodal DLCL and gastric DLCL, the observed patterns of dissemination
suggest similarities between WR DLCL and gastric DLCL.
The frequent relapses after CR
observed for WR DLCL
patients, however, indicate that these lymphomas clinically behave as nodal
DLCL,
and should be treated accordingly.
Treatment of localized non-Hodgkin's lymphomas
of the head and neck.
Ruijs CD, Cancer. 1994 Jul 15;74(2):703-7.
Department of Otorhinolaryngology, University Hospital Utrecht, The Netherlands.
BACKGROUND. Localized non-Hodgkin's lymphomas of the head and neck are generally treated
with radiotherapy with or without chemotherapy, although the results of treatment of
localized non-Hodgkin's lymphomas with of treatment of localized non-Hodgkin's lymphomas
with chemotherapy alone appear to be favorable. It is unclear if and when combined
modality therapy should be used. METHODS: The authors reviewed the records of 53 patients
with Stage I or II non-Hodgkin's lymphoma of the head and neck, who were treated with
radiotherapy alone (13 patients), chemotherapy according to the cyclophosphamide,
doxorubicin, vincristine, prednisone- (CHOP) regimen (27 patients), or a combination of
both treatments (13 patients). RESULTS. A complete remission was achieved in 43 (81%)
patients. The 5-year survival for all patients was 78%. A significant difference (P =
0.03) in 5-year relapse-free survival was observed between Stages I and II disease, of 92
and 60%, respectively. Extensive tumor was a significantly poor prognostic factor (P =
0.04) with a 5-year relapse-free survival of 52 versus 84% for patients with nonextensive
lymphoma. Eight relapses occurred; in five patients, a local relapse was the first
presentation. Although salvage radiotherapy was successful in these five patients, a
distant relapse developed in three. No relapses were observed in previously irradiated
areas. CONCLUSIONS. Our results suggest that radiotherapy alone is the appropriate
treatment for nonextensive Stage I intermediate grade non-Hodgkin's lymphoma of the head
and neck. For extensive Stage I or II non-Hodgkin's lymphomas, chemotherapy is preferable.
The value of combined modality therapy remains unclear.
|
