Residual abdominal masses in aggressive non-Hodgkin's lymphoma after combination chemotherapy: significance and management.

Abstract

When patients with aggressive lymphoma present with intraabdominal disease, a stable residual mass is frequently detected radiographically at the time of the clinical complete remission. To discern the optimal management for this clinical problem, we reviewed 241 patients with aggressive lymphoma treated at the National Cancer Institute (NCI) from 1977 to 1986. Seventy-two/241 patients (30%) had an abdominal mass at diagnosis and 29/72 (40%) were left with a radiographically detectable residual mass at clinical complete remission. The likelihood of a residual mass was much higher for patients with bulky disease (P2 less than .0003) (two-tailed test [P2]). Twenty-nine patients had radiologically stable residual masses after therapy, and of 22 (76%) with pathologic evaluations, 21 had negative specimens (95%) and one was positive (5%). None of the patients with negative pathologic evaluation has relapsed in the abdominal site (median follow-up, 31 months). Seven patients were observed clinically without laparotomy: five are alive, without evidence of disease, at 2 to 9 years; two relapsed with disseminated disease within 2 months of chemotherapy. Initial tumor size and size of the residual mass did not correlate with residual disease, since residual masses identified by radiographic examination did not usually harbor viable lymphoma cells. Aspiration cytology was negative for residual tumor in 15/16 cases. One negative result was not confirmed at laparotomy, presumably due to sampling error. The one positive aspiration was followed by a negative laparotomy, possibly due to subsequent tumor necrosis. Restaging laparotomy has a low yield. In most patients with aggressive lymphoma who have otherwise completely responded to carefully administered full-dose combination chemotherapy, stable residual abdominal masses can be closely followed clinically without surgical exploration.

Utility of Positron Emission Tomography (PET) Scanning in Managing Patients with Hodgkin Lymphoma

“…However, data in patients with aggressive NHL, of whom about one-third develop residual masses following treatment, particularly if they have bulky disease at diagnosis, indicate that the likelihood of residual disease at the site of residual mass in patients who are otherwise in clinical CR (i.e., without clinical or biochemical evidence of disease) is only about 10-20% and is similar in patients with bulky and nonbulky disease at diagnosis. 39,40 Overall, these patients also appear to have a similar relapse rate to that in patients with CR by CT. 41 Since the true nature of residual mass in the vast majority of such patients has been identified as necrosis/fibrosis, the nature of such masses also holds true in patients with HL, it is reasonable to assume that the majority of HL patients with bulky disease at baseline who have a residual mass post therapy but are otherwise in clinical CR will do well without RT, analo- • Rebound thymic hyperplasia in young patients (< 40 years)…”

A phase III trial comparing CHOP to PMitCEBO with or without G-CSF in patients aged 60 plus with aggressive non-Hodgkin's lymphoma

“…This trial has demonstrated almost identical FFS and OS with CHOP and PMitCEBO. This equivalence of survival is despite the fact that the CR rate was less with PMitCEBO and presumably reflects that the earlier response assessment carried out with the shorter duration regimen underestimates the true response rate because of residual necrotic or fibrotic tissue (Surbone et al, 1988;Sweetenham et al, 1991). PMitCEBO is thus a valid alternative to CHOP contrasting with several other curtailed or modified regimens, which appear to be inferior (Meyer et al, 1995;Sonneveld et al, 1995;Bastion et al, 1997;Tirelli et al, 1998;Osby et al, 2003).…”

Response Assessment Criteria and Their Applications in Lymphoma: Part 1

“…This phenomenon proved especially problematic for lymphoma, for which the response assessment criteria relied solely on anatomic imaging. Approximately 40% of NHL patients and 20% of HL patients continue to exhibit residual mediastinal or abdominal masses on CT after therapy (17,18). In studies that restaged such patients via laparotomy, between 80% and 95% of residual masses were shown to be nonmalignant on pathology (17,19).…”

“…Approximately 40% of NHL patients and 20% of HL patients continue to exhibit residual mediastinal or abdominal masses on CT after therapy (17,18). In studies that restaged such patients via laparotomy, between 80% and 95% of residual masses were shown to be nonmalignant on pathology (17,19). Moreover, the presence of residual masses on imaging was found not to be associated with time to relapse or survival (18).…”