Tonsillar B-Cell Lymphoma With No B Symptoms?

Avraham Eisbruch, MD

Disclosures

May 13, 2002

Question

What treatment would you recommend for a 16-year-old boy with bilateral tonsillar diffuse large B-cell lymphoma beyond tonsillectomy? He has no B symptoms and only borderline enlarged cervical lymph nodes bilaterally (jugulodigastric). CT of the chest and abdomen were negative except for mild splenomegaly. Endoscopic gastrostomy was negative for upper GI involvement.

Response from Avraham Eisbruch, MD

This is a young patient with intermediate-grade tonsillar lymphoma. Chemotherapy should be part of therapy in this case, just as in similar lymphomas in other sites.[1] The standard treatment of stage I-II intermediate-grade lymphoma is 3 cycles of cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) chemotherapy followed by involved field radiation (40 Gy). Of interest, a large randomized study comparing this therapy regimen with 8 cycles of CHOP alone found better progression-free survival and overall survival, as well as less life-threatening toxic events, following the combined regimen compared with chemotherapy alone.[2]

The main issue in this case is the patient's young age, 16. Assuming he has a good chance of cure regardless of therapy (young age is a good prognostic factor in lymphomas), and that he will continue to live for many years, the main concern in his case is the risk of therapy-induced secondary cancer. Most of the available data relate to young patients with Hodgkin's disease, where therapy consisted of extensive, subtotal nodal irradiation. In these patients, the risk of another cancer developing in the irradiated fields approaches 15%, and rises over the years.[3] Although it is postulated that limiting the irradiated fields to involved fields only should reduce this risk, no relevant long-term data exist.

My personal preference would be to treat this patient with chemotherapy alone due to his young age. If it is decided to proceed with combined-modality therapy, radiation should be limited to the involved sites (ie, Waldeyer ring and jugulodigastric nodes, following 3 cycles of CHOP). In any case, the risk of radiation-related malignancy and the alternative (chemotherapy alone) should be discussed with the patients' guardians.

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