Head and neck extra nodal NHL (HNENL) - Treatment Outcome and Pattern of failure - A Single Institution Experience
Giridhar, Prashanth (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Mallick, Supriya (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Bhasker, Suman (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Pathy, Sushmita (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Mohanti, Bidhu Kalyan (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Biswas, Ahitagni (Department of Radiation Oncology, All India Institute of Medical Sciences) ;
Sharma, Atul (Department of Medical Oncology, All India Institute of Medical Sciences)
Background: Extra nodal lymphoma (ENL) constitutes about 33 % of all non-Hodgkin's lymphoma. 18-28% develops in the head and neck region. A multimodality treatment with multi-agent chemotherapy (CT) and radiotherapy (RT) is considered optimum. Materials and Methods: We retrieved the treatment charts of patients of HNENL treated in our institute from 2001-2012. The charts were reviewed and the demographic, treatment details and outcome of HNENL patients were retrieved using predesigned pro-forma. Results: We retrieved data of 75consecutive patients HNENL. Median age was 47years (Range: 8-76 years). Of the 75 patients 51 were male and 24 were female. 55patients were evaluable. The patient and tumor characteristics are summarized in Table 1. All patients were staged comprehensively with contrast enhanced computed tomography of head, neck, thorax, abdomen, pelvis and bone marrow aspiration and biopsy 66 patients received a combination multi-agent CT with CHOP being the commonest regimen. 42 patients received 4 or lesser number of cycles of chemotherapy whereas 24received more than 4 cycles chemotherapy. Post radiotherapy, 41 out of 42 patients had a complete response at 3 months. Only 21patients had a complete response after chemotherapy. All patients received radiation (mostly involved field radiation) as a part of the treatment. The median radiation dose was 45 Gray (Range: 36 Gray-50 Gray). The radiation was planned by 2D fluoro simulation based technique in 37cases and by 3 Dimensional conformal radiation therapy (3DCRT) in 36 cases. Two patients were planned by the intensity modulated radiation therapy (IMRT) technique. IMRT was planned for one thyroid and one nasal cavity primary. 5 patients experienced relapse after a median follow up of 19 months. The median survival was not reached. The estimated two and three year survival were 92.9% (95%CI- 68.6- 95.35) and 88% (95%CI- 60.82 - 92.66) respectively. Univariate analysis revealed higher stage and poorer baseline performance status to be significantly associated with worse progression free survival. 5 patients progressed (relapse or primary disease progression) after treatment. Of the 5 patients, two patients were primary orbital NHL, two patients had NHL nasal cavity and one was NHL thyroid. Conclusions: Combined modality treatment in HNENL confers excellent disease control with acceptable side effects.
Head and neck;extra nodal;NHL;chemotherapy;radiotherapy;India
Aviles A, Delgado S, Ruiz H, et al (1996). Treatment of non- Hodgkin's lymphoma of Waldeyer's ring: radiotherapy versus chemotherapy versus combined therapy. Eur J Cancer B Oral Oncol, 32, 19-23 https://doi.org/10.1016/0964-1955(95)00058-5
Coiffier B, Lepage E, Briere J, et al (2002). CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-cell lymphoma. N Engl J Med, 346, 235-42 https://doi.org/10.1056/NEJMoa011795
Al Diab AR, Aleem A, Qayum A, et al (2011). Clinicopathological pattern of extranodal non-Hodgkin's lymphoma in Saudi Arabia. Asian Pac J Cancer Prev, 12, 3277-82.
D'Amore F, Christensen BE, Brincker H, et al (1991). Clinicopathological features and prognostic factors in extranodal non-Hodgkin lymphomas. Danish LYFO Study Group. Eur J Cancer, 27, 1201-08. https://doi.org/10.1016/0277-5379(91)90081-N
Delarue R, Tilly H, Mounier N, et al (2013). Dose-dense rituximab-CHOP compared with Standard rituximab-CHOP in elderly patients with diffuse large B-cell lymphoma (the LNH03-6B study): a randomised phase 3 trial. Lancet Oncol. 14, 525-33. https://doi.org/10.1016/S1470-2045(13)70122-0
Gospodarowicz MK, Sutcliffe SB (1995). Theextranodal lymphomas. SeminRadiat Oncol, 5, 281-300.
Globocan (2012) (International Agency for Research on Cancer) data; Cancer Atlas.
Horning SJ, Weller E, Kim K, et al (2004). Chemotherapy with or without radiotherapy in limited stage aggressive non hodgkins lymphoma: Eastern Cooperative Oncology Group study 1484. J Clin Oncol, 22, 3032 https://doi.org/10.1200/JCO.2004.06.088
Lowry L, Smith P, Qian W, et al (2011). Reduced dose radiotherapy for local control in non hodgkins lymphoma; a randomized phase III trial; Radiotherapy Oncology. 100, 86-92 https://doi.org/10.1016/j.radonc.2011.05.013
Lasrado S, Prabhu P, Kakria A, et al (2012). Clinicopathological profile of head and neck cancers in the Western development region, Nepal: a 4-year snapshot. Asian Pac J Cancer Prev, 13, 6059-62. https://doi.org/10.7314/APJCP.2012.13.12.6059
Mertsoylu H, Muallaoglu S, Besen AA, et al (2014). Primary extranodal non-Hodgkin's lymphoma: clinicopathological features, survival and treatment outcome in two cancer centers of southern Turkey. Asian Pac J Cancer Prev, 15, 7207-11. https://doi.org/10.7314/APJCP.2014.15.17.7207
Miller TP, Dahlberg S, Cassady JR, et al (1998). Chemotherapy alone versus chemotherapy plus radiotherapy in intermediate and high grade lymphomas. N Engl J Med, 339, 21 https://doi.org/10.1056/NEJM199807023390104
Moslehi R, Devesa SS, Schairer C, Fraumeni JF Jr (2006). Rapidly increasing incidence of ocular non-hodgkin lymphoma. J Natl Cancer Inst, 13, 936-9.
Nimmagadda RB, Digumarti R, Nair R, et al (2013). Histopathological pattern of lymphomas and clinical presentation and outcomes of diffuse large B cell lymphoma: A multicenter registry based study from India; Ind J Med Ped Oncol, 34, 299-304. https://doi.org/10.4103/0971-5851.125250
Nathu RM, Mendenhall NP, Almasri NM, et al (1999). Non- Hodgkin's lymphoma of the head and neck: a 30-year experience at the University of Florida. Head Neck, 21, 247-54. https://doi.org/10.1002/(SICI)1097-0347(199905)21:3<247::AID-HED10>3.0.CO;2-6
Wotherspoon AC, Diss TC, Pan LX, et al (1993). Primary low-gradeB-cell lymphoma of the conjunctiva; A mucosaassociated lymphoid tissue type lymphoma. Histopathology. 23, 417-22 https://doi.org/10.1111/j.1365-2559.1993.tb00489.x
Zhu Y, Lu J, Wei X, et al (2013). The Predictive value of interim and final (18f) fluorodeoxyglucose positron emission tomography after rituximab-chemotherapy in the treatment of non-hodgkin's lymphoma: a meta-analysis; Biomed Res Int, 275805.
Zucca E, Roggero E, Bertoni F, et al (1999). Primary extra nodal non-Hodgkin's lymphomas. Part 2: Head and neck, central nervous system and other less common sites. Ann Oncol, 10, 1023-33. https://doi.org/10.1023/A:1008313229892