Alvin M. Panahon

Gastrointestinal involvement in non-Hodgkin's lymphoma

A total of 813 patients admitted to Roswell Park Memorial Institute from 1963–1972 with non‐Hodgkins lymphoma (NHL) were reviewed for gastrointestinal (GI) involvement. Primary involvement was found in 71 and secondary involvement in 31 patients. Occult GI involvement was detected in 46% of the autopsy cases. The median survival time after the diagnosis of secondary GI involvement was nine months. The occurrence of primary GI‐NHL was: 33 in the stomach, 18 in the small intestine, 14 in the ileocecal area including appendix, and 6 in the large intestine. Retrospective staging according to the Ann Arbor staging classification showed 24 to have presented as Stage I, 30 as Stage II, 4 as Stage III, and 13 as Stage IV. The primary diagnostic and therapeutic approach was operative, except in 2 patients with rectal lymphoma. Resection of the principally involved site was carried out in 42 patients. The remainder had palliative procedures or biopsy examinations only. Postoperative radiation therapy was given to 38 patients. Prognostically important features for primary GI‐NHL were: stage; histologic type; site of the primary disease; and whether or not radiotherapy was administered. The age of the patient, size or degree of local extension, and type of operative procedure were prognostically of no importance. The results of this study would indicate that in Stage I and II primary GI‐NHL, elective resection is not necessary prior to radiation therapy and that resection alone cannot be considered adequate treatment. A modified staging classification is proposed. Cancer 46:215–222, 1980.

Long‐term effects of cranial irradiation on endocrine function in children with brain tumors a prospective study

This study prospectively evaluated the endocrine function of 11 children treated with cranial irradiation (CRT) for brain tumors. All tumors were remote from the hypothalamic‐pituitary axis. Children were studied before treatment and at 3, 6, and 12 months after the completion of CRT. T4, thyroid‐stimulating hormone, prolactin, plasma cortisol, and urinary follicle‐stimulating hormone and lueteinizing hormone values were normal before and after treatment in all patients. Growth hormone (GH) deficiency was identified in 0 of 7 patients before treatment, in 2 of 7 patients 3 months post‐CRT, in 9 of 11 patients 6 months post‐CRT, and in 7 of 8 patients 12 months post‐CRT. Growth deceleration was identified in five of seven prepubertal patients. GH deficiency is an extremely common sequelae of CRT, beginning as early as 3 months after the completion of CRT. The deficit is progressive over time.

Spinal cord compression in malignant lymphoma—Treatment and results

The natural history, treatment, and results of 73 spinal cord compressions caused by malignant lymphomas are analyzed. It is found that the spinal cord compression caused by malignant lymphomas is generally a late manifestation of the illness, although primary or early involvements are occasionally seen. In our study, reticulum cell sarcoma is the most frequently variety followed by Hodgkins disease and lymphosarcoma. The dorsal spinal cord is the most frequently involved segment and pain, weakness, and paresthesia are cardinal symptoms. Radiation treatment delivered in the early phase of the compression is commonly successful in reversing the neurologic symptoms and a dose above 2500 rads appears to be optimal for local control of disease. The low incidence of cervical cord compression in Hodgkins disease patients may be related to frequent manifestation and irradiation of the neck nodes in these patients. Early detection of disease in the deep seated areas along the spinal cord and irradiation of these areas may prevent progression of tumor to the epidural space.

Appraisal of aspiration cytology in management of Hodgkin's disease

The value of aspiration cytology in the management of Hodgkins disease is shown in this study of 228 paients and 403 aspirations; 385 from lymph nodes and 18 from extranodal masses. In all patients the initial diagnosis was established on surgical biopsy. Aspirates were helpful in staging, defining extension of unusual radiation fields, and in recognizing residual disease and relapses after therapy. Adequate material was obtained in 80% of aspirations. The diagnosis of Hodgkins disease could not be established in the adequate cytologic sample in 9.9% of cases. In 5.5%, the diagnosis was that of benign reactive hyperplasia and in 4.4%, non‐Hodgkins lymphoma. Unsatisfactory material was usually obtained from nodes less than 1 cm in diameter or from residual lesions following radiation or chemotherapy. Only 14 of 93 such lesions proved to have active disease during follow up. There were no significant complications. Characteristics of the varied aspects of aspirated tumor cells found in Hodgkins disease are described.

Treatment of early--stages I and II--nodular, poorly differentiated lymphocytic lymphoma.

Twenty-nine patients with Stages I and II nodular, poorly differentiated lymphocytic lymphoma were treated with radiation therapy or radiation therapy plus chemotherapy. Twenty-two patients with Stage I received radiation to the involved field, the other seven with Stage II received total lymphoid radiation. Complete remission was achieved in all 29. There were no differences in remission duration or survival according to treatment modality. Five of 29 (17%) patients relapsed. No relapses were observed after 5 years. Ten patients died; one patient died of lymphoma, and nine others died in continuous complete remission of various other causes. Sixty-six percent of the patients were alive at 74–160 months (median 118 months). Involved field radiation with or without chemotherapy was well tolerated, producing acceptable toxicity. Substantially more toxicity was observed after total lymphoid irradiation and although cures were also achieved, less toxic treatment programs should be investigated. The low rate of relapse observed in early stages of this lymphoma in this and in other studies is suggestive that cures might be achieved in nearly one-half of the patients presenting in early stage.

Postoperative respiratory complications in patients with Hodgkin's Disease: Relationship to the size of the mediastinal tumor☆

Postoperative respiratory complications were investigated in patients with Hodgkins disease, stages I-III, presenting with a mediastinal mass. By measuring the ratio between the widest diameter of the mediastinal mass and the width of the thorax at T5-6 (mediastinal thoracic ratio, MTR) in a PA chest X-ray, patients were divided into three groups: I: MTR less than 0.35 (41 patients); II: MTR 0.35-0.49 (33 patients); and III: MTR greater than 0.50 (23 patients). Five patients of group II and eight of group III received preoperative radiation therapy (RT) to the mediastinum due to severe clinical or radiological findings associated with the mediastinal mass. No patient of group I received preoperative RT. Without preoperative RT, group III had a significantly higher incidence of respiratory complications (7/15) compared to groups I (7/41) and II (2/28). Respiratory complications were not significantly different after preoperative RT in group III (1/8) compared to that observed in groups I plus II without preoperative RT (9/69).

Staging Laparotomy and Splenectomy in Early Hodgkin's Disease No Therapeutic Benefit

In a prospective randomized study of treatment for early-stage Hodgkins disease presenting above the diaphragm, 76 patients had staging by laparotomy (Group I) and 28 had staging by closed techniques (Group II). Treatment consisted of involved-field radiotherapy alone (44 patients), involved-field radiotherapy followed by chemotherapy (38 patients), total nodal radiotherapy alone (15 patients), or total nodal radiotherapy followed by chemotherapy (seven patients). On presentation, both groups had similar clinical features and similar treatment distribution. With similar follow-up (87 months), no significant differences in remission or survival were observed between Groups I and II: remission 59 versus 68 percent; survival 74 versus 92 percent; p value 0.27 and 0.09, respectively. Multiple areas of relapse were more frequently observed in Group I (11 of 32 had relapse) as compared with Group II (none of nine had relapse, p less than 0.082). In Group I, relapse in the abdomen was observed as an isolated event or as part of disseminated relapse in 12 percent of patients compared with 3 percent (one patient) in Group II with abdominal relapse alone. Seven patients in Group I and two patients in Group II died with Hodgkins disease. Six other patients in Group I died with complete remission of non-Hodgkins lymphoma (one patient), leukoencephalopathy (one patient), sepsis during chemotherapy (two patients), myocardial infarction (one patient), and cerebrovascular accident (one patient). Three other patients in this group had other secondary malignancies successfully controlled (histiocytic lymphoma, squamous cell carcinoma of the cervix, and malignant schwannoma). No second primary lesions or death with complete remission were observed in Group II. Staging laparotomy with splenectomy in early-stage Hodgkins disease did not improve the duration of remission or survival or decrease the number of abdominal relapses compared with closed staging.

Seminoma at Roswell Park, 1970 to 1979. An analysis of treatment failures.

A retrospective study of all cases of seminoma treated at Roswell Park Memorial Institute from 1970 through 1979 was conducted. Fifty‐six evaluable patients treated initially with radiation therapy were seen during this period, and the overall survival rate at an average follow‐up period of 52 months was 82%. The survival rate in patients with bulky abdominal or supradiaphragmatic metastases was only 33% (4 of 12 patients). Treatment failures were analyzed to determine their apparent causes and the implication of such failures to the future management of seminoma. The use of combination chemotherapy as the initial treatment modality in advanced seminoma is discussed in light of these results.

Second malignant tumors detected by needle aspiration cytology

Between 1967–1980, 14 second primary cancers were detected by needle aspiration cytology in patients treated for malignant tumors. The interval between the first cancer and the occurrence of the second cancer varied from six months to 21 years. In all 14 cases, the cytologic diagnosis of the second cancer was later confirmed by histopathologic examinations. In 13 patients, the second cancer was dissimilar from the first one, and in one patient the two cancers were subtypes of lymphoproliferative tumors. In three patients the cytologic diagnosis falsely defined the subtype of the second cancer. Malignant lymphoma was the predominant tumor either as the first cancer (50%) or as the second cancer (43%). Thyroid cancer occurred as the second cancer in three patients. Needle aspiration cytology of all newly appearing lesions can be performed routinely during follow‐up examinations to discriminate between relapsed disease and new malignant tumors.

Simultaneous low-dose radiation and low-dose chemotherapy in the treatment of advanced Hodgkin's disease

SIMULTANEOUS COMBINATION CHEMOTHERAPY (CT) (BCNU 40 mg/m2, procarbazine 50 mg/m2. prednisone 40 mg/m2, and vincristine 1 4 mg/m2) with low-dose radiation therapy [(RT) 2000 rad] delivered to all areas of tumor involvement aside from the bone marrow was given to 28 patients with advanced Hodgkins disease. Upon completion of RT and CT, the BCNU and procarbazine was increased by 100% until a total of six cycles of CT (with and without RT) were given. Eleven patients had received prior CT and had not achieved complete remission (CR) or had relapse from CT-induced CR within 1 year Seventeen others had not had prior CT (7 had prior RT). Among the previously treated patients, one patient died in autopsy-proven CR during treatment. The other 10 patients achieved CR Eight had relapsed at 4–36 months (median time to relapse, 6 months). Five patients died of Hodgkins disease, three others died of status asthmaticus and pneumonia, radiation pneumonitis, and acute nonlymphocytic leukemia, respectively. Three patients are still alive (2 in continuous CR) at 28, 89, and 90 months. Among the previously untreated patients, four died during treatment, one of acute myocardial infarction, two of liver failure, and one of radiation pneumonitis. Twelve of the other 13 patients achieved CR. One of the CR died of pneumonia and sepsis 3 months after completion of treatment, two other patients relapsed at 10 and 15 months. Nine remain in continuous CR at 42–89 months of follow-up, (median follow-up, 81 months). Of 107 tumor areas treated with RT, in-field relapse occurred in two areas (1.9%). Hematologic tolerance to this treatment was good in both groups of patients. Radiation pneumonitis occurred in 50% of the patients whose lungs were irradiated, and it was fatal in two. By design or for other reasons, the median and mean doses of BCNU and procarbazine given to previously treated patients were 62% and 65.2%, respectively. In untreated patients, the median and mean doses of these two agents were 66.6% and 61.4%, respectively. There were no differences in dosage of these two agents between patients who remain alive in CR and those who relapsed and died. The potential of similar programs of radiation and chemotherapy is discussed.