- Email: [email protected]
Malignant lymphoma of the tonsil
International Congress Series 1257 (2003) 289 – 292
www.ics-elsevier.com
Malignant lymphoma of the tonsil Sohei Endo a,*, Tetsuo Yamazaki b, Yoshimasa Kura b, Umihiko Sawada b, Yuzuru Abiko a, Kenzo Tsuji a, Yoshiaki Tanaka c, Akinori Kida a a
Department of Otorhinolaryngology-Head and Neck Surgery (ORL-HNS), Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi, Tokyo 173-8610, Japan b Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan c Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
Abstract. Thirty patients with lymphoma of the tonsils were treated in the Nihon University Itabashi Hospital between January 1991 and December 2001. Good prognosis was obtained in stage I tonsillar lymphoma with either radiation or chemotherapy. The 5-year survival rate in stage II disease was 76% with either full cycle chemotherapy or induction chemotherapy followed by radiation. In the latter instances, locoregional recurrences increased but did not impair survival. Otolaryngologists should play an important role in improving survival by diagnosing primary tonsillar lymphoma and by detecting early local recurrences. D 2003 Elsevier B.V. All rights reserved. Keywords: Malignant lymphoma; Tonsil; Otolaryngologist; Prognosis; Diagnosis
1. Introduction Most tonsillar lymphoma patients who complain of a throat or neck mass problem are usually examined by otolaryngologists. This study was conducted to investigate the clinical pictures of such patients and to clarify the role of otolaryngologists in diagnosis and follow-up. 2. Material and methods Thirty patients with lymphoma of the tonsils were treated in the Nihon University Itabashi Hospital between January 1991 and December 2001: 22 patients were males, 8 were females; mean and median ages, 62.6 and 60.5 years, respectively. All of those tumors were non-Hodgkin lymphomas (NHL), and except for one case, whose pathology was follicular lymphoma, all were diagnosed as having diffuse lymphomas. Patients were classified according to the Ann Arbor system [1]. Twenty-five patients (83%) were in early stage, I or II. Five out of seven patients with stage I disease were mainly treated with * Corresponding author. Tel.: +81-3-3972-8111; fax: +81-3-3972-1321. E-mail address: [email protected] (S. Endo). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01159-2
290
S. Endo et al. / International Congress Series 1257 (2003) 289–292
Table 1 Presenting symptoms (n = 30) Sore throat Mass or mass sensation in the throat Lateral neck mass Dysphagia Odynophagia Hoarseness Dyspnea a
14 12 8 2 1 1 1
(47%)a (40%) (27%)a (7%) (3%) (3%) (3%)
Peritonsillar abscess caused her to visit the hospital in one case.
radiation. In contrast, none of the patients with stage II disease were treated with radiation alone. Seven of eighteen patients with stage II disease were treated with chemotherapy alone. The remaining 11 patients were treated with chemotherapy mainly followed by radiation. All patients with advanced stage were treated with chemotherapy (Table 2). The chemotherapeutic regimens were CHOP [2], MACOP-B [3], THP-COP (adriamycin was substituted with THP-adriacin) and for an 82-year-old patient oral etoposide. Recently, rituximab [4] was used in combination with CHOP regimen. CHOP was used in 14 patients, MACOP-B in 4, THP-COP in 3 and CHOP with rituximab in 2, respectively. The median duration of follow-up was 192.5 (range 19 – 515) weeks. Kaplan– Meier’s method was used in estimating survival curves, and the log-rank test was also used for statistical analysis. SASk was used for actual calculation. 3. Results The chief complaints of patients were: sore throat in 14 (47%), mass or mass sensation in the throat in 12 (40%), and lateral neck mass in 8 (27%) (Table 1). In one case, peritonsillar abscess had caused her to visit the hospital. Twenty-five patients (83%) were first seen by otolaryngologists. Examination showed that, all except one case had unilaterally enlarged tonsils (97%). Only one case had bilateral tonsillar enlargement (3%). All patients with stage I disease showed complete response (CR) with the initial treatments. In stage II patients, just 1 out of 18 failed to achieve CR despite several kinds of treatment. Among 10 patients with stage II disease who showed CR with chemotherapy and radiation, none developed locoregional recurrence. In contrast, two out of seven patients with stage II disease, who achieved CR with chemotherapy alone, developed Table 2 Treatment RT Stage I A (n = 7) Stage II A (n = 18) Stage III A (n = 2) Stage III B (n = 1) Stage IV A (n = 2) Total (n = 30) CT = chemotherapy, RT = radiation.
CT – >RT
RT – >CT
10 1
1
12
1
5
5
CT 2 7 1 1 2 12
S. Endo et al. / International Congress Series 1257 (2003) 289–292
291
Fig. 1. Survival curves according to stage.
locoregional recurrences in the follow-up period. The disease specific survival rate of all patients at 5-year was 80%. The survival rate for the patients with stages I and II were 100% and 76%, respectively. The survival rate for those with stages III A, III B, and IV A was 50%, less than 100% (not reached at 5-year follow-up period), 100%, respectively (Fig. 1). The survival of the patients with stage II disease was not different between the group treated with chemotherapy alone, and those treated with chemotherapy followed by radiation. 4. Discussion Waldeyer’s ring origin comprises about 30% of all lymphoma in Japan [5]. About 80% of them were tonsillar origin [6]. In this study, it became clear that most of the patients with tonsillar lymphomas were first seen and diagnosed by otolaryngologists. This is to be expected as the complaints which brought patients to the clinic or hospital were pharynx related ones—sore throat, foreign body sensation or mass itself in the throat, etc. This suggests that otolaryngologists play an important role in diagnosing tonsillar lymphoma, especially in detecting early stage lymphoma. Either radiation or chemotherapy is effective and sufficient in treating stage I patients if the staging is correct. For stage II disease, addition of chemotherapy has yielded higher survival rate [7– 9]. And also full cycle chemotherapy can be substituted for induction chemotherapy followed by radiation. It can spear dry mouth syndrome commonly seen after radiation treatment for the patients with lymphoma of Waldeyer’s ring. However, in that situation where radiation was not used, locoregional recurrences were more prevalent. In such instances, otolaryngologists should also play an important role in detecting local recurrence as early as possible in the course of follow-up. This trend where radiation is avoided can be accelerated because of the introduction of rituximab—anti-CD20 monoclonal chimeric antibody [10]. In that situation, it is possible that some local recurrence could occur because of the lack of radiation.
292
S. Endo et al. / International Congress Series 1257 (2003) 289–292
5. Conclusions 1. Good prognosis was obtained in stage I tonsillar lymphoma with either radiation or chemotherapy. 2. Five-year survival rate in stage II tonsillar lymphoma was 76% with either full cycle chemotherapy or induction chemotherapy followed by radiation. In the latter instance, locoregional recurrences increased but did not impair survival. 3. Otolaryngologist should play an important role in improving survival by diagnosing primary tonsillar lymphoma and by detecting early local recurrences. Acknowledgements The authors would like to thank Dr. Gordon Liversidge for his assistance in the preparation of this manuscript. References [1] P.P. Carbone, et al., Report of the committee on Hodgkin’s disease staging, Cancer Res. 31 (1971) 1860 – 1861. [2] E.M. McKelvy, et al., Hydroxydaunorubicin (adriamycin) combination chemotherapy in malignant lymphoma, Cancer 38 (1976) 1484 – 1493. [3] P. Klimo, et al., MACOP-B chemotherapy for the treatment of diffuse large cell lymphoma, Ann. Intern. Med. 102 (1985) 596 – 602. [4] B. Coiffier, et al., Rituximab (antiCD 20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: the LNH 93-5 study, Blood 92 (1998) 1927 – 1932. [5] N. Mohri, B-cell lymphomas of extranodal origin, Jpn. J. Clin. Oncol. 13 (1983) 591 – 606. [6] H. Shibuya, et al., Stage I and II Waldeyer’s ring and oral-sinonasal non-Hodgkin’s lymphoma, Cancer 59 (1987) 940 – 944. [7] T. Fujitani, et al., Radiochemotherapy for non-Hodgkin’s lymphoma in palatine tonsil, Cancer 54 (1984) 1288 – 1292. [8] M. Kondo, et al., Prognostic factors in stage I and II non-Hodgkin’s lymphoma of Waldeyer’s ring, Acta Radiol. Oncol. 24 (1985) 153 – 158. [9] T.P. Miller, et al., Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade non-Hodgkin’s lymphoma, N. Engl. J. Med. 339 (1998) 21 – 26. [10] B. Coiffier, et al., CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large B-cell lymphoma, N. Engl. J. Med. 346 (2002) 235 – 242.
www.ics-elsevier.com
Malignant lymphoma of the tonsil Sohei Endo a,*, Tetsuo Yamazaki b, Yoshimasa Kura b, Umihiko Sawada b, Yuzuru Abiko a, Kenzo Tsuji a, Yoshiaki Tanaka c, Akinori Kida a a
Department of Otorhinolaryngology-Head and Neck Surgery (ORL-HNS), Nihon University School of Medicine, 30-1 Oyaguchi-kamicho, Itabashi, Tokyo 173-8610, Japan b Department of Internal Medicine, Nihon University School of Medicine, Tokyo, Japan c Department of Radiology, Nihon University School of Medicine, Tokyo, Japan
Abstract. Thirty patients with lymphoma of the tonsils were treated in the Nihon University Itabashi Hospital between January 1991 and December 2001. Good prognosis was obtained in stage I tonsillar lymphoma with either radiation or chemotherapy. The 5-year survival rate in stage II disease was 76% with either full cycle chemotherapy or induction chemotherapy followed by radiation. In the latter instances, locoregional recurrences increased but did not impair survival. Otolaryngologists should play an important role in improving survival by diagnosing primary tonsillar lymphoma and by detecting early local recurrences. D 2003 Elsevier B.V. All rights reserved. Keywords: Malignant lymphoma; Tonsil; Otolaryngologist; Prognosis; Diagnosis
1. Introduction Most tonsillar lymphoma patients who complain of a throat or neck mass problem are usually examined by otolaryngologists. This study was conducted to investigate the clinical pictures of such patients and to clarify the role of otolaryngologists in diagnosis and follow-up. 2. Material and methods Thirty patients with lymphoma of the tonsils were treated in the Nihon University Itabashi Hospital between January 1991 and December 2001: 22 patients were males, 8 were females; mean and median ages, 62.6 and 60.5 years, respectively. All of those tumors were non-Hodgkin lymphomas (NHL), and except for one case, whose pathology was follicular lymphoma, all were diagnosed as having diffuse lymphomas. Patients were classified according to the Ann Arbor system [1]. Twenty-five patients (83%) were in early stage, I or II. Five out of seven patients with stage I disease were mainly treated with * Corresponding author. Tel.: +81-3-3972-8111; fax: +81-3-3972-1321. E-mail address: [email protected] (S. Endo). 0531-5131/ D 2003 Elsevier B.V. All rights reserved. doi:10.1016/S0531-5131(03)01159-2
290
S. Endo et al. / International Congress Series 1257 (2003) 289–292
Table 1 Presenting symptoms (n = 30) Sore throat Mass or mass sensation in the throat Lateral neck mass Dysphagia Odynophagia Hoarseness Dyspnea a
14 12 8 2 1 1 1
(47%)a (40%) (27%)a (7%) (3%) (3%) (3%)
Peritonsillar abscess caused her to visit the hospital in one case.
radiation. In contrast, none of the patients with stage II disease were treated with radiation alone. Seven of eighteen patients with stage II disease were treated with chemotherapy alone. The remaining 11 patients were treated with chemotherapy mainly followed by radiation. All patients with advanced stage were treated with chemotherapy (Table 2). The chemotherapeutic regimens were CHOP [2], MACOP-B [3], THP-COP (adriamycin was substituted with THP-adriacin) and for an 82-year-old patient oral etoposide. Recently, rituximab [4] was used in combination with CHOP regimen. CHOP was used in 14 patients, MACOP-B in 4, THP-COP in 3 and CHOP with rituximab in 2, respectively. The median duration of follow-up was 192.5 (range 19 – 515) weeks. Kaplan– Meier’s method was used in estimating survival curves, and the log-rank test was also used for statistical analysis. SASk was used for actual calculation. 3. Results The chief complaints of patients were: sore throat in 14 (47%), mass or mass sensation in the throat in 12 (40%), and lateral neck mass in 8 (27%) (Table 1). In one case, peritonsillar abscess had caused her to visit the hospital. Twenty-five patients (83%) were first seen by otolaryngologists. Examination showed that, all except one case had unilaterally enlarged tonsils (97%). Only one case had bilateral tonsillar enlargement (3%). All patients with stage I disease showed complete response (CR) with the initial treatments. In stage II patients, just 1 out of 18 failed to achieve CR despite several kinds of treatment. Among 10 patients with stage II disease who showed CR with chemotherapy and radiation, none developed locoregional recurrence. In contrast, two out of seven patients with stage II disease, who achieved CR with chemotherapy alone, developed Table 2 Treatment RT Stage I A (n = 7) Stage II A (n = 18) Stage III A (n = 2) Stage III B (n = 1) Stage IV A (n = 2) Total (n = 30) CT = chemotherapy, RT = radiation.
CT – >RT
RT – >CT
10 1
1
12
1
5
5
CT 2 7 1 1 2 12
S. Endo et al. / International Congress Series 1257 (2003) 289–292
291
Fig. 1. Survival curves according to stage.
locoregional recurrences in the follow-up period. The disease specific survival rate of all patients at 5-year was 80%. The survival rate for the patients with stages I and II were 100% and 76%, respectively. The survival rate for those with stages III A, III B, and IV A was 50%, less than 100% (not reached at 5-year follow-up period), 100%, respectively (Fig. 1). The survival of the patients with stage II disease was not different between the group treated with chemotherapy alone, and those treated with chemotherapy followed by radiation. 4. Discussion Waldeyer’s ring origin comprises about 30% of all lymphoma in Japan [5]. About 80% of them were tonsillar origin [6]. In this study, it became clear that most of the patients with tonsillar lymphomas were first seen and diagnosed by otolaryngologists. This is to be expected as the complaints which brought patients to the clinic or hospital were pharynx related ones—sore throat, foreign body sensation or mass itself in the throat, etc. This suggests that otolaryngologists play an important role in diagnosing tonsillar lymphoma, especially in detecting early stage lymphoma. Either radiation or chemotherapy is effective and sufficient in treating stage I patients if the staging is correct. For stage II disease, addition of chemotherapy has yielded higher survival rate [7– 9]. And also full cycle chemotherapy can be substituted for induction chemotherapy followed by radiation. It can spear dry mouth syndrome commonly seen after radiation treatment for the patients with lymphoma of Waldeyer’s ring. However, in that situation where radiation was not used, locoregional recurrences were more prevalent. In such instances, otolaryngologists should also play an important role in detecting local recurrence as early as possible in the course of follow-up. This trend where radiation is avoided can be accelerated because of the introduction of rituximab—anti-CD20 monoclonal chimeric antibody [10]. In that situation, it is possible that some local recurrence could occur because of the lack of radiation.
292
S. Endo et al. / International Congress Series 1257 (2003) 289–292
5. Conclusions 1. Good prognosis was obtained in stage I tonsillar lymphoma with either radiation or chemotherapy. 2. Five-year survival rate in stage II tonsillar lymphoma was 76% with either full cycle chemotherapy or induction chemotherapy followed by radiation. In the latter instance, locoregional recurrences increased but did not impair survival. 3. Otolaryngologist should play an important role in improving survival by diagnosing primary tonsillar lymphoma and by detecting early local recurrences. Acknowledgements The authors would like to thank Dr. Gordon Liversidge for his assistance in the preparation of this manuscript. References [1] P.P. Carbone, et al., Report of the committee on Hodgkin’s disease staging, Cancer Res. 31 (1971) 1860 – 1861. [2] E.M. McKelvy, et al., Hydroxydaunorubicin (adriamycin) combination chemotherapy in malignant lymphoma, Cancer 38 (1976) 1484 – 1493. [3] P. Klimo, et al., MACOP-B chemotherapy for the treatment of diffuse large cell lymphoma, Ann. Intern. Med. 102 (1985) 596 – 602. [4] B. Coiffier, et al., Rituximab (antiCD 20 monoclonal antibody) for the treatment of patients with relapsing or refractory aggressive lymphoma: the LNH 93-5 study, Blood 92 (1998) 1927 – 1932. [5] N. Mohri, B-cell lymphomas of extranodal origin, Jpn. J. Clin. Oncol. 13 (1983) 591 – 606. [6] H. Shibuya, et al., Stage I and II Waldeyer’s ring and oral-sinonasal non-Hodgkin’s lymphoma, Cancer 59 (1987) 940 – 944. [7] T. Fujitani, et al., Radiochemotherapy for non-Hodgkin’s lymphoma in palatine tonsil, Cancer 54 (1984) 1288 – 1292. [8] M. Kondo, et al., Prognostic factors in stage I and II non-Hodgkin’s lymphoma of Waldeyer’s ring, Acta Radiol. Oncol. 24 (1985) 153 – 158. [9] T.P. Miller, et al., Chemotherapy alone compared with chemotherapy plus radiotherapy for localized intermediate- and high-grade non-Hodgkin’s lymphoma, N. Engl. J. Med. 339 (1998) 21 – 26. [10] B. Coiffier, et al., CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large B-cell lymphoma, N. Engl. J. Med. 346 (2002) 235 – 242.