HistopatJiology in Prognosis & Therapy of Lymphocytic Lymphomas 251 



niques of physical, x-ray, and laboratory examination. For example, 

 Hodgkin's paragranuloma has been considered to be limited to a single 

 area merely because no other masses were demonstrable. This naive ap- 

 proach to the problem obviously had no validity in excluding the presence 

 of asymptomatic areas of microscopic and even gross involvement by the 

 disease in the more inaccessible parts of the patient's body. One of my pa- 

 tients with Hodgkin's disease was killed in an accident twenty-four hours 

 after posteroanterior and lateral x-ray films of the chest were read as negative 

 for mediastinal involvement. At autopsy walnut-sized nodes were found 

 scattered through the entire mediastinum. 



There were certain anatomic areas of involvement that were inherently 

 associated with a poor prognosis. Under such circumstances a patient with 

 a biologically benign type of disease, on histopathologic grounds, may have 

 a lesion which in itself caused such a serious train of complications that it 

 induced an unfavorable or lethal clinical complex. The most striking ex- 

 ample was a patient referred for treatment with a benign Hodgkin's para- 

 granuloma. He had developed lumbar transverse myelitis due to an unrecog- 

 nized lesion in the dura. Death resulted from renal tract infection, stones, 

 decubital ulcers, and inanition rather than from the Hodgkin's disease itself. 



Extension of the lymphoma from the mediastinum into the lung paren- 

 chyma foreboded a poor prognosis/"- 41 This type of lesion interfered with 

 pulmonary drainage and caused recurrent intractable pulmonary infections. 

 X-ray therapy may give temporary relief, but the resulting fibrosis further 

 decreases pulmonary drainage. The majority of patients died within one 

 year of the time that this complication was clinically apparent. For unknown 

 reasons patients with chronic lymphatic leukemia have had a relatively better 

 prognosis with this complication. 



Occasionally a patient has developed severe, intractable pruritus in the 

 course of what would otherwise have been a comparatively benign disease. 

 These patients literally scratched their way into the grave and died of a 

 combination of inanition and infection, abetted by the complications which 

 followed large doses of steroids and chemotherapy. Severe liver disease has 

 resulted in intractable ascites or obstructive jaundice with ascending biliary 

 tree infection. 



If the lymphoma is first manifested in the stomach,-' 5 orbit, or naso- 

 pharynx, the prognosis may be unusually benign. 14 



Laboratory Findings 



There were several complications demonstrable by laboratory study that 

 grossly modified the interpretation based upon histopathology alone. Severe- 

 anemia, neutropenia, and thrombopenia out of line with the pathologic 



