The clinical evaluation of patients with myeloma includes a careful physical examination searching for tender bones and masses. Only a small minority of patients has an enlargement of the spleen and lymph nodes, the physiologic sites of antibody production. Chest and bone radiographs may reveal lytic lesions or diffuse osteopenia. MRI offers a sensitive means to document extent of bone marrow infiltration and cord or root compression in patients with pain syndromes. A complete blood count with differential may reveal anemia. Erythrocyte sedimentation rate is elevated.
Table 105-9 International Prognostic Index for NHL
Five clinical risk factors:
Age ≥60 years
Serum lactate dehydrogenase levels elevated
Performance status ≥2 (ECOG) or ≤70 (Karnofsky)
Ann Arbor stage III or IV
1 site of extranodal involvement
Patients are assigned a number for each risk factor they have
Patients are grouped differently based upon the type of lymphoma
For diffuse large B cell lymphoma:
0, 1 factor = low risk: 73%
35% of cases; 5-year survival,
2 factors = low-intermediate risk: 51%
27% of cases; 5-year survival,
3 factors = high-intermediate risk: 43%...
Evaluation of an adequate biopsy by an expert hematopathologist is sufficient to make a diagnosis of follicular lymphoma. The tumor is composed of small cleaved and large cells in varying proportions organized in a follicular pattern of growth (Fig. 105-7). Confirmation of B cell immunophenotype and the existence of the t(14;18) and abnormal expression of BCL-2 protein are confirmatory. The major differential diagnosis is between lymphoma and reactive follicular hyperplasia. The coexistence of diffuse large B cell lymphoma must be considered.
Patients with follicular lymphoma have a high rate of histologic transformation to diffuse large B cell lymphoma (5–7% per year). This is recognized ~40% of the time during the course of the illness by repeat biopsy and is present in almost all patients at autopsy. This transformation is usually heralded by rapid growth of lymph nodes—often localized—and the development of systemic symptoms such as fevers, sweats, and weight loss.
Because a number of patients with diffuse large B cell lymphoma are either initially refractory to therapy or relapse after apparently effective chemotherapy, 30–40% of patients will be candidates for salvage treatment at some point. Alternative combination chemotherapy regimens can induce complete remission in as many as 50% of these patients, but long-term disease-free survival is seen in ≤10%.
Anaplastic Large T/Null Cell Lymphoma: Treatment
Treatment regimens appropriate for other aggressive lymphomas, such as diffuse large B cell lymphoma, should be utilized in patients with anaplastic large T/null cell lymphoma, with the exception that the B cell–specific antibody, rituximab, is omitted. Surprisingly, given the anaplastic appearance, this disorder has the best survival rate of any aggressive lymphoma. The 5-year survival is 75%.
Heterogeneities in tumor blood flow are associated with cyclic changes in
pO2 or cyclic hypoxia. A major difference from O2 diffusion-limited or
chronic hypoxia is that the tumor vasculature itself may be directly influ-enced by the fluctuating hypoxic environment, and the reoxygenation
phases complicate the usual hypoxia-induced phenotypic pattern.
Hydrogenated amorphous silicon, a new form of a common element, is a
semiconductor that has come of age. Its scientific attractions include a
continuously adjustable band gap, a usable camer lifetime and diffusion
length, efficient optical transitions, and the capability of employing either nor
Furthermore, it can be fabricated very easily as a thin film by a technology
that not only inherently escapes the expenst: of crystal perfection but also
requires significantly smaller amounts of raw materials....
Paradoxically, skin is both a primary barrier to systemic absorption of topically
exposed chemicals and a portal to systemic delivery of transdermal medicaments.
Knowledge of the factors that determine both extent and rate of chemical flux across
the skin is an important component of both toxicology and pharmacology studies.
The aim of this book is to provide current approaches and techniques by which
dermal absorption may be quantitated utilizing end points relative to these two
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