General Strategy of Staging and Therapy of Non-Hodgkin’s Lymphomas

Abstract

The classification of lymphomas proposed by Rappaport et al. [1] in 1966 brought order to the chaos surrounding the non-Hodgkin’s lymphomas. This classification, based on the presence or absence of a nodular pattern of nodal involvement and on the degree of differentiation of the malignant cells, stimulated much of the work presented at this symposium. It served a useful purpose in identifying the nodular pattern as carrying a favorable prognostic import when compared to the diffuse pattern. In addition, it called attention to the differing natural histories and patterns of disease progression associated with the major Rappaport classifications. It was in this context that, in 1971, the National Cancer Insititute (NCI) initiated a study of the patterns of organ involvement and response to therapy of each of the lymphoma subclasses (2). An important aspect of this study was the ordered, sequential nature of the staging procedures used (Table 1). The staging approach used involved an initial battery of procedures including lymphangiogram, bone marrow, and percutaneous liver biopsy which served to identify a significant proportion of those with stage IV disease. Those patients with negative percutaneous liver biopsies were subject to peritoneoscopy with multiple liver biopsies and if still negative with respect to liver disease, then laparotomy. Table 2 illustrates the upstaging which resulted from the procedures used. It also emphasizes that a majority of the patients were staged adequately without laparotomy. Thus, this staging approach gave all of the advantages of aggressive clinical staging while limiting laparotomy to the minority of patients where it is of value. This NCI study and the work of others have served to clarify the natural history of the non-Hodgkin’s lymphomas (Table 3).