230 The Lymphocyte and Lymphocytic Tissue 



Areas of Involvement by Lymphosarcoma. There were several regions in 

 which, for unknown reasons, lymphosarcoma tended to remain localized. 

 These Avere the skin, the orbit, and the stomach. 23, 30 > 31 > 37 Patients with 

 lesions in these areas have done equally well with surgery or local x-ray 

 therapy. One cannot but wonder if they would not have done as well if 

 untreated, aside from the local effects of the lesions. 



The rectal lymphoma may represent a biologically different, more benign 

 entity even though it may show microscopic features of lymphosarcoma or 

 giant follicular lymphoma. - 7 - "'•' However, no patient with this lesion has 

 been followed long enough to exclude possible spread to, or metaplasia of, 

 other sites. 



On the other hand other areas of involvement were correlated with a poor 

 prognosis, primarily because of the nature of the site of the lesion, rather 

 than because of the type of lymphosarcoma. Examples were intracranial or 

 spinal cord lymphosarcoma with secondary neurologic disease and extension 

 of mediastinal tumor into the lungs. In the latter, pulmonary drainage was 

 impaired, and the patient fell prey to intractable pneumonitis. 



The bone marrow was the most important of all extranodal sites of in- 

 volvement. As in other lymphomas, Ave are concerned with tw r o interdepend- 

 ent factors, the amount of lymphatic and of myeloid tissue. 



Lymphatic metaplasia has occurred at any stage in lymphosarcoma and 

 has had an ominous prognosis in direct correlation with the degree of mar- 

 row replacement. The node biopsy of Case 12 was morphologically similar 

 to that of Case 11 (Figs. 17-1 M and B vs. \7-\2A and B). However, Case 12 

 also had severe pancytopenia, and surgical biopsy of his marrow (Fig. 17- 

 12C) demonstrated almost complete replacement of myeloid tissue by small 

 lymphocytes, morphologically identical to those in his lymph node and in 

 the node of Case 11. Case 12 failed to respond to therapy and is noAv being- 

 maintained on transfusions. 



More frequently a less fulminating course has occurred. Over years, in- 

 dependently of therapy, the marrow underwent progressive lymphocytic 

 metaplasia (Fig. \1-MD vs. 17-1 \E). The lymphocytes may retain their orig- 

 inal cytology or may transform into medium-sized or large lymphocytes. In 

 the latter circumstance the prognosis and results of therapy were worse. Ac- 

 cording to Lumb, 37 this type of lymphatic metaplasia has occurred in about 

 15 per cent of all patients. My own experience suggested not only a higher 

 incidence but also indicated that in any patient the longer the patient sur- 

 vived, the more likely was metaplasia to occur. Frequently lymphatic meta- 

 plasia was accompanied by a leukemic blood picture in Avhich the 

 characteristic cell was a medium-sized lymphocyte. 5 The prognosis and re- 

 sponse to therapy were inversely related to the degree of marrow replace- 

 ment and directly to the degree of maturation to the small lymphocyte. 



