Primary non-Hodgkin's lymphoma of the female breast masquerading as a breast abscess

We report the case of a primary non-Hodgkin's lymphoma of the breast, masquerading as a breast abscess.     

Primary malignant lymphomas of the breast.

Fourteen cases of primary malignant lymphomas of the breast were found in the pathology files of the M. D. Anderson Hospital and Tumor Institute from 1944 to 1975. The lymphomas represented only 0.12% of 11,277 primary malignant breast tumors seen during the same period. There were no definite clinical features to distinguish the patients with lymphoma from those with breast carcinoma. All of the lymphomas had a diffuse pattern. Eight cases were classified as undifferentiated lymphoma, five as histiocytic, and one as poorly differentiated lymphocytic, convoluted cell type. Four patients had mastectomies and the remainder biopsies as their sole surgical procedure. Eight patients received post-surgical radiotherapy and all eventually had chemotherapy. The five-year survival rate for the 13 patients with follow-up was 49%. Patients with histiocytic lymphoma appeared to have a more favorable prognosis than those with the undifferentiated type. Six of the latter patients are dead with a median survival of seven months, comparable to the reported survival of patients with American Burkitt's lymphoma. The patient with the convoluted cell type has developed acute blastic leukemia and is currently under therapy.     

Primary non-Hodgkin's lymphomas of the major salivary glands

BACKGROUND: The clinical course of primary salivary gland lymphomas has received little attention. METHODS: We retrospectively assessed 20 patients with previously untreated non-Hodgkin's lymphomas (NHLs) and histologically confirmed as having parenchymal involvement of the salivary glands. The clinical presentation, therapy, and outcomes were compared between the 12 patients with mucosa-associated lymphoid tissue (MALT) lymphomas and the 8 patients with other NHLs. RESULTS: At diagnosis, the 12 patients with MALT lymphoma had a greater mean age and longer duration than did the 8 patients with other NHLs (P < 0.05). Eight of the 12 MALT lymphoma patients had recurrent episodes of salivary gland swelling and 5 had myoepithelial sialadenitis, Sj?gren syndrome, or gastric MALT lymphoma; these were not observed in the 8 other NHL patients. Compared with the latter group, the MALT lymphoma group had significantly greater five-year relapse-free (37.5% vs. 91.7%, P < 0.05) and disease-free (35.0% vs. 90.9%, P < 0.05) survival rates. However, two MALT lymphoma patients with high-grade transformation had recurrences beyond the head and neck region. CONCLUSION: Understanding the distinct clinical presentation and course of primary salivary gland lymphomas may help guide the proper diagnosis and management of patients with these tumors.     

Primary non-Hodgkin's lymphoma of the female genital tract

Genital tract lymphoma is a rare disease; information on diagnosis, treatment and outcome are limited. We report on eight patients affected by non-Hodgkin's lymphoma of the genital tract, five from the cervix, two from the vagina and one from the vulva collected between 1987 and 1998. Age at presentation ranged from 36 to 82 (median 67) years. The commonest initial symptom was vaginal bleeding, post coital in 1 patient. Three patients complained of vescical symptoms. Ann Arbor classification was stage IAE for 6 patients. Histology, according to the IWF, was either intermediate grade (4 patients), or high grade (3 patients), not evaluable in one case. Seven patients were treated with chemotherapy (anthracycline based in four) followed by pelvic radiotherapy in five; one patient received irradiation alone. Five patients are currently alive and free of disease with follow-up ranging from 8 to 126 months. Based on our experience in this series, we support a management scheme of combination chemotherapy and radiotherapy for patients with non-Hodgkin's lymphoma of the genital tract.     

Primary gastrointestinal non-Hodgkin's lymphomas. A retrospective clinicopathologic study of 150 cases

The records of 150 primary gastrointestinal (GI) lymphomas in adults collected from 1974 to 1982 at the Department of Pathology, University of Vienna, were reviewed. One hundred thirty-three cases of malignant lymphomas (ML) were analyzed with respect to histologic type, presenting tumor stage, and clinical course, as well as for factors influencing prognosis. The histologic type of ML as assessed by the Working Formulation and the Kiel, the Lukes and Collins, and the Rappaport classifications showed only a minor influence on prognosis. MLs of follicular center cell origin prevailed in the stomach and large cell, immunoblastic MLs prevailed in the bowel. Immunoperoxidase studies indicated a B-cell nature of GI MLs and demonstrated intracytoplasmic IgM kappa or lambda in most of the MLs of the small lymphocytic, plasmacytoid, and immunoblastic type, respectively. The 105 cases of gastric MLs represented 3.6% of all malignancies of the stomach collected during the study period. Clinical symptoms preceded the diagnosis by 4.4 months on average, and endoscopic biopsy specimens indicated malignancy in 78%. Presenting tumor stages of gastric MLs according to the Ann Arbor staging system were Stage I in 20%, Stage II in 76.2%, and Stage IV in 3.8%. The 28 cases of intestinal ML localized in the small and large bowel without any site prevalence presented with Stage I in 14%, Stage II in 82%, and Stage III in 4%. Tumor resection was performed in 90% of all cases and was followed by multiagent therapy in 53%. Radical tumor resection was obtained in 58% of the gastric MLs and only 28.6% of the intestinal MLs and was closely related to tumor stage. Statistical analysis demonstrated a significant influence of the presenting tumor stage on prognosis as expressed by the overall 2-year survival rate of 70% for Stage I versus 39% for Stage II ML. In addition, Stage II1 according to Musshoff et al. run a better course than II2 as shown by the disease-free 2-year survival rate of 49% versus 15%, respectively. Radical tumor resection was a major determinant of survival and cure of disease as exhibited by the disease-free 2-year survival rate of 57% after radical resection versus 8% after nonradical resection of ML. Finally, diffuse tumor growth and tumor penetration of the gastric wall beyond serosa decreased the survival rates.     

Lymphocyte markers in non-Hodgkin's lymphomas.

The lymphocyte marker pattern of non-Hodgkin's lymphoma cells was related to current concepts of lymphoma classification. In a series of 28 lymphomas lymphocyte markers indicated that 2 were of histiocytic origin, 2 were unclassifiable, none were derived from T cells and the remainder were B-cell neoplasms. The immunoglobulin heavy chain associated with the B-cell tumours was gamma in one case, alpha in one case but was mu in the majority of cases, reflecting the predominance of this heavy chain, together with delta chains, on normal lymph node lymphocytes in man. delta chains accompanied mu chains on the tumour cells in 6/17 lymphomas in which anti-delta staining was performed. delta chains were not found on any lymphomas other than well differentiated diffuse lymphocytic types. There was evidence of a reduction in surface immunoglobulin, Fcgamma and C3 receptors on undifferentiated lymphoma cells. T lymphocytes of normal morphology were present in all lymphomas except one, and were more numerous in follicular lymphomas than in diffuse tumours.     

Primary non-Hodgkin's lymphomas of the liver with nodular and diffuse infiltration patterns have different prognoses.

BACKGROUND: Primary liver non-Hodgkin's lymphomas have peculiar clinical and biological patterns. This study correlates these patterns with pathology and outcome. PATIENTS AND METHODS: Clinical records and histology of patients with primary liver non-Hodgkin's lymphoma, treated at our institution over a 20-year period, were reviewed. Lymphoproliferations occurring after liver transplantation were excluded. Survival analyses were performed with patients from the other published series (62 patients). RESULTS: Our series included eight patients. Three patients had a nodular liver infiltration, corresponding to a large B-cell lymphoma. Five patients had a diffuse liver infiltration, of whom three had a T-cell lymphoma with predominant sinusoid infiltration, and two had a large B-cell lymphoma. Patients with diffuse liver infiltration presented with hepatomegaly, and two of these also had acute liver failure. Diffuse infiltration had a worse prognosis than nodular infiltration (P = 0.0033). Among these latter patients, those treated with an anthracycline-based chemotherapy had a better outcome (P < 0.0001). CONCLUSIONS: Patients with primary liver lymphomas can be classified in two groups, depending on the type of infiltration. Those with nodular infiltration may benefit from anthracycline-based chemotherapy. Diffuse infiltration has a bad prognosis, and should be suspected in patients presenting with altered liver functions and hepatomegaly.     

New chemotherapeutic agents for non-Hodgkin's lymphomas.

Combination chemotherapy regimens achieve complete remissions in 60% to 80% of patients with non-Hodgkin's lymphomas; however, the majority of patients will relapse, and resistant disease remains a problem. Attempts to identify new, effective chemotherapy agents have primarily focused on the development of analogues that, unfortunately, have uniformly failed to provide a substantial therapeutic advantage. Drugs with a unique mechanism of action are more likely to be successful; among these are the purine analogues (e.g., fludarabine, 2'-deoxycoformycin, 2-chlorodeoxyadenosine) and agents that can reverse clinical drug resistance. The number of patients who can be cured can be increased only by incorporating new agents into front-line regimens through carefully designed clinical trials.     

Medical history and the risk of non-Hodgkin's lymphomas.

The relationship between selected aspects of medical history and the risk of non-Hodgkin's lymphomas (NHLs) was investigated using data from a hospital-based case-control study conducted in northern Italy on 177 cases of NHL and 561 controls in hospital for acute conditions, other than nonneoplastic or immunological. Among six viral diseases considered, only herpes zoster (shingles) had a relative risk (RR) significantly above unity [RR = 2.7; 95% confidence intervals (CI), 1.5 to 4.7]. The association, however, was restricted to subjects whose diagnosis of herpes zoster dated back to less than 10 years, suggesting that this slow-acting virus could be reactivated by the early development of NHL. Six of eight bacterial diseases considered showed RR above unity, and the estimate was significant for scarlet fever (RR = 1.9; 95% CI, 1.1 to 3.5) and pyelonephritis (RR = 5.3; 95% CI, 1.8 to 16.2). These associations were not restricted to the few years before lymphoma diagnosis. When various classes of infectious or inflammatory diseases were grouped together, no association was evident for viral infections (RR = 0.8; 95% CI, 0.6 to 1.2), acute bacterial diseases (RR = 1.0; 95% CI, 0.7 to 1.5), or allergic conditions (RR = 1.0; 95% CI, 0.6 to 2.1). The risk estimates were nonsignificantly above unity for chronic bacterial diseases (RR = 1.2; 95% CI, 0.7 to 1.2) and autoimmune conditions (RR = 1.4; 95% CI, 0.9 to 2.2), and significantly elevated for chronic inflammatory disease (RR = 1.9; 95% CI, 1.2 to 3.0).(ABSTRACT TRUNCATED AT 250 WORDS)     

Epirubicin in non-Hodgkin's lymphomas

Epirubicin (Epi-DX), a new analog of doxorubicin, was administered I.V. once q 3 weeks at the dose of 90 mg/m2 to 20 evaluable patients with non-Hodgkin's lymphomas (NHL). Eighty-two percent of patients with favorable histology and 67% with unfavorable histology achieved complete or partial remissions, with an overall response rate of 75%. Gastrointestinal and hematologic toxicity was generally mild to moderate. Reversible ST-T changes were observed only in two patients. Epi-DX has high activity in patients with NHL, and further studies in combination with other agents are recommended.     

A critical analysis of the classifications of non-Hodgkin's lymphomas.

The Rappaport classification of non-Hodgkin's lymphomas was proposed almost a quarter century ago, before the advent of modern immunology. This classification, which is based entirely on morphologic features, has proved its clinical usefulness. In light of recent scientific advances, however, its terminology is not appropriate. Five new classifications have been proposed recently, each claiming to have more merit than the others. The purpose of this study is to critically analyze and evaluate these newly proposed classifications to determine which classification is conceptually and scientifically acceptable as well as clinically useful. The results of the study show that there are more similarities than differences among the Rappaport. Lukes and Collins, Dorfman, British, and WHO classifications; the Kiel classification, however, is fundamentally different (Tables 8, 9, 11). None of these classifications can be used in its proposed form. Based on the analysis of these classifications, a compromise working classification is proposed which incorporates the relevant concepts and terminology from the Rappaport, Berard, Dorfman, WHO, and Lukes and Collins classifications (Tables 15, 16). The proposed compromise classification is an attempt to reconcile the various classifications, and to stimulate others to offer modifications which may bring about a final solution to the problem of classification of non-Hodgkin's lymphomas.     

Treatment and prognosis of orbital non-Hodgkin's lymphomas.

Twenty patients with orbital lymphomas were treated and followed over a 14-year period. Ten of these patients had well-differentiated lymphocytic lymphoma (WDL), and all of them were clinical stage IE. Five patients had nodular poorly differentiated lymphocytic lymphomas (NPDL), three patients had diffuse histiocytic lymphomas (DHL), one had nodular mixed-cell lymphoma, and one had diffused mixed-cell lymphoma. The patients with WDL received local radiation therapy, and all of them entered completed remissions. The projected survival at 10 years was 100% for these patients. The patients with low-grade lymphomas with advanced disease were treated with chlorambucil and prednisone or cytoxan and vincristine. The patients with high-grade lymphomas received treatment with methotrexate, cyclophosphamide, doxorubicin, vincristine, bleomycin, dexamethasone (mBACOD) or cyclophosphamide, vincristine, methotrexate, cytosine arabinoside, leucovorin (COMLA). The overall survival estimate for all patients was 63% at 10 years. The disease-free survival was 49% at 10 years. The patients with high-grade lymphomas had a poor prognosis, with no survivors after 4 years. This study suggests that patients with WDL usually present with localized disease to the involved orbit, and have an excellent prognosis with radiation therapy alone. Patients with high-grade orbital non-Hodgkin's lymphomas have a poor outcome despite use of aggressive combination chemotherapy regimens.     

Clinical course of early extranodal non-Hodgkin's lymphomas.

The subsequent sites of relapse following local X-ray therapy treatment of early stage non-Hodgkin's lymphoma were analyzed. The short interval to recurrence, the involvement of noncontiguous sites, and the rapid progression to death all suggest that seemingly early extranodal non-Hodgkin's lymphoma often is disseminated at diagnosis and that local treatment alone is ineffective. The analysis of sites of first relapse suggests that extended field treatment such as total nodal irradiation would benefit only a minority of these patients but would be superior to a radiation technique covering only the adjacent lymph node regions. While immediate contiguity of lymph node involvement was often seen with extranodal presentations, the more common pattern of relapse in bone marrow, liver, lung, stomach, and extranodal sites, indicates the need for an effective systemic therapy.     

Histologic conversion in the non-Hodgkin's lymphomas

Between July 1, 1971 and December 31, 1978, 150 patients with favorable subtypes of non-Hodgkin's lymphoma [nodular poorly differentiated lymphocytic (NLPD), nodular mixed, or diffuse well differentiated lymphocytic] were entered into prospective randomized clinical trials at Stanford University. Treatments included involved field, total lymphoid, or whole body irradiation, single alkylating agent chemotherapy, combination chemotherapy with cyclophosphamide, vincristine and prednisone (CVP) or with cyclophosphamide, vincristine, procarbazine, and prednisone (C-MOPP), or various combinations of chemotherapy and irradiation. The initial complete response rate (CR) was 79%. Among patients who achieved a CR, 31% later relapsed. There were 78 patients who either failed to achieve a CR or achieved a CR and later relapsed. Histologic conversion (change from initially favorable to an unfavorable subtype of non-Hodgkin's lymphoma) was documented in 22/78 patients (28%). However, the actuarial risk for conversion was actually much greater (60% at 8 yr). The median time to documentation of conversion was 51 mo. The most common type of histologic conversion was from NLPD to diffuse histiocytic lymphoma. Documented histologic conversion was often associated with a more aggressive clinical behavior of the lymphoma, and the median survival after conversion was less than 1 yr. However, those patients who achieved a CR after conversion had a more favorable outcome (actuarial survival 75% at 5 yr). No specific risk factors predictive of histologic conversion could be identified.