Histopathology in Prognosis & Therapy of Lymphocytic Lymphomas 207 



ino- to Diamond,- 1 the length of time the patient lived was not affected by 

 specific therapy. Case 1 was an example of the most benign type of giant 

 follicular lymphoma. The patient's clinical course illustrated that the best 

 response to therapy occured when indications for therapy were at best 

 minimal and that the response to therapy became poorer with a change in 

 cytology toward a more immature cell type. Contrary to Bilger's 7 and 

 I. umb's 37 concept, my data supported the view that a change to a more 

 malignant, treatment-resistant type of disease did indeed occur without loss 

 of follicular pattern. 



Case 2 represents the other extreme in the variegated pattern that is char- 

 acteristic of the group of giant follicular lymphoma. The follicular pattern 

 was well delineated (Fig. 17-2/J). There was no evidence of diffuse sar- 

 comatous change or of loss of follicular pattern that has been alleged to 

 indicate a more malignant course. 7 :;7 59 The follicles were ringed by small 

 lymphocytes, but most of the inner core was composed of a pleomorphic 

 mixture of reticulum cells and large and medium-sized lymphocytes (Fig. 

 \~-2B). This patient did not respond to x-ray therapy or nitrogen mustard 

 and died within a few months of onset of his disease. On the basis of this 

 case, it would appear, in accord with Rappaport and colleagues, 4 "' that 

 cytologic composition was more important than the architectural pattern as 

 a guide to prognosis and response to therapy. 



Case 3 had a fulminating course, characterized by failure of the disease 

 to respond to chemotherapy or to radiophosphorus. The patient's major 

 clinical problems were hepatosplenomegaly, intractable ascites, and pleural 

 effusion. Figure 17-3^4 demonstrates in a liver biopsy the typical follicular 

 pattern, similar to that noted in the biopsy of lymph node and spleen. The 

 dominant cell type (Fig. \7-3B) was larger and more delicate than in the 

 first biopsy of Case 1 (Fig. 1 7-1 S) and was smaller, more heavily stained, and 

 with less conspicuous nucleoli than the large lymphocytes in Case 2 (Fig. 17- 

 2B). This cell is classified as a medium lymphocyte (lymphoblast). In this 

 patient it was difficult to determine whether his malignant course and lack 

 of response to therapy depended upon the massive hepatic and splenic in- 

 volvement (local manifestations of activity of his disease) or upon the cell 

 type characteristic of his lesion. Certainlv a follicular pattern in Cases 2 

 and 3 was not correlated with the relatively favorable prognosis usually 

 associated with giant follicular lymphoma. 



Fig. 17-1. Case 1, giant follicular lymphoma. (A) Lymph node 1943, poorly demarcated 

 follicles (F) separated by less lymphocyte rich interfollicular tissue, (x 80) (B) Small 

 lymphocytes representing dominani cell type in follicles oi ./. (x 650) (C) Lymph node. 

 1950, follicles (F) more cleaih demonstrable 7 years after original biopsy, (x 80) (D) 

 Follicles of C composed primarily of medium-sized lymphocytes. (X 650) 



