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Lymphoma - Histopathology 33 ORIGINAL ARTICLES 32,. Byarugaba J- The impact of urbanization on the health of black pre-school children in the Urntata district. Transkei. 1990. 5 AIr Med /1991; 790 444-448. LYMPHOMA - HISTOPATHOLOGY 33. Schoub BD, Martin DJ. Lessons from the 1992 measles epidemic in South Africa (Opinion). 5 AIr Med /1993; 83, 82-83. IN CHANGING CLINICAL 34. Edelson PJ. The need for innovation in immunization. Am ] Public Health 1995; 85: 1613-1614. 35. Miller E. The new measles campaign. BMI 1994; 309: 1102-1103. PERSPECTIVE 36. Shepard OS, Robe.rtson RL, Cameron CSM, et al. Cost-effectiveness of routine and campaign vaccination strategies in Ecuador. Bull World Health Organ 1989; 67: 649-662- 37. De Quadros CA. The winter 1996 mass immunisation campaign - is it the best strategy for South Africa at this time? 5 Afr Med /1996; 66, 1130. Peter Jacobs 38. Metcalf CA, Yach 0, de Beer ZJ. Missed opportunities for immunisation at hospitals in the Western Cape - a reappraisal. 5 AIr Med /1994; jj4, 149-152. On behalf of the Non-Hodgkin's Lymphoma Classification 39. Cutis FT, Zell ER, Soares AC et al. Obstacles to achieving immunization for all: missed. immunization opportwtities and inappropriately timed immunization.f Trop Pediatr 1991; 37: Project 153-158. 40. Hutchins SS, Jansen HAFM, Robertson SE,. et al. Studies of missed opportunities for immunization in developing and industralized countries. Bull World Health Organ 1993; 71: 549-560. Background. Lymphoma management has traditionally been 41. Bachmann MO, Barron P. Missed opportunities for immunisation in curative and preventive services in the community health centre. 5 Afr Med /1996; 66, 947-949. dominated by nodal histopathology. Unfortunately, many 42. Cutts F, Rodrigues Le Colombo 5, et al. Evaluation of factors influencing vaccine uptake in Mozambique.Int J Epidemio11989; 18: 427-433. different classifications coexisted and frequent revisions have 43. Brugha R, Kevany J. lnununization determinants in the Eastern Region of Ghana. Health often obscured clinical·correlations. Some improvement in Policy and Planning 1995; 10: 3U-31B. 44. Bhuiya A. Bhuiya I, Chowdhury M. Factors affecting acceptance of immunization among understanding histogenesis followed the introduction of children in rural Bangladesh. H""lth Policy and Planning 1995; 10: 304-311. immunophenotyping, while a number of new entities have 45. limtragool P; Stoeckel J, Charoenchai A, et al. Immunization: full coverage the aim. Warld Health Forum 1992; 13: 15-19. been described in the last decade. In addition the whole 46. Begg N, Nicoll A. Immunisation. BM/I994; 309, 1073-1074. question of lymphomagenesis is undergoing critical 47. Lakhani AOH, Morris RW, Morgan M, el al. Measles immunisation' feasibility of a 90% taIgel uptake- Arch Dis Child 1987; 620 UQ9-Ul4. exploration. The use of cellular and molecular biological 48. Health Worker KAP Survey - Immunisation. Mpumalanga Province, 1997. techniques is therefore shifting focus to the role of 49. Expanded Programme on Immunization. Contraindications foe vaccines used in EPI. Wldy Epidernwl Rec 1988; 63, 279-281. oncoproteins and the impact of mutation in the normally 50. Galazka A.M:, Lauer BA, Henderson RH, et al. Indications and contraindications for vacrines modulating suppressor genes. used in the Expanded Programme on Immunization. Bull World Health Organ 1984; 62: 357­ 366. To accommodate these advances the International 51. Hull D. Why children are not immunised./ R Coil PhysiciJms Land 1987; 21, 28-31. 52. Oements J. Opportunities to immunise. Child Health Dialogue 1996; 2: 3-4. Lymphoma Study Group has proposed the Revised 53. Hams OR. Lemeshow S. Evaluation of the EPI Survey Methodology for Estimating Relative European-American Lymphoma Oassification. While this is Risk. World H""lth 5tat Q 1991; 44,107-114. 54. LeBaron CW, Chaney M, Baughman AL, et a1. Impact of measurement and feedback on an undoubted advance, it has met with persisting concerns vaccination coverage in public clinics, 1988 -1994. JAMA 1997; 277: 631-635. regarding applicability to patient management. 55. Joseph A, Abraham S, Bhattacharji S, et al. lmproving immunization coverage. World Health Forum 1988; 9, 336-340. Study setting. In determining the extent to which the latter 56. Brugha RF, Kevany JP. Maximizing immunization coverage through home visits: a controlled trial in an urban area of Ghana. Bull World Health Organ 1996; 74: 517-524. reservation is valid, and at the same time directly testing the clinicopathological value of the new system, a group of Accepled 27 Sep 1999. acknowledged experts drawn from nine major academic centres worldwide analysed approximately 1 400 previously unreported cases, focusing on outcome. As part of that study 196 consecutive patients seen in Cape Town were separately examined. Results. Findings here were similar to those of the overall experience, although distinct geographical differences emerged. Specifically in the follicular centre-cell lymphomas there was no difference in the S-year failure-free survival rate, but these neoplasms accounted for 33% of lymphomas, which is similar to North America and London but contrasts with the 14% in the remaining six sites. Also, while mean survival for all types of peripheral T-eelllymphoma was 18% at 5 years, these accounted for 8% of lymphomas locally, as seen Haematology Department and Bone Marrow Transplantation Unit, Constantiaberg Medi-Clinic, Plumstead, Cape Town Peter Jacobs, MB BCh, MD, PhD, FCP (SA), FACp' FRCP (Edin), FRC Path (UK), FRSSAf -.----ORIGINAL ARTICLES Historically, nodal arChitecture was used to divide these also in London and Hong Kong, but exceeding the 3 - 6% tumours into follicular lymphomas, lymphosarcomas, and reported elsewhere. reticulum-cell sarcomas.' Unfortunately, this grouping was too Local experience, as in the other eight centres, documented vague to have predictive value with regard to outcome. good diagnostic com:ordance between trained Subsequently cytomorphology was combined with haematopathologists when this classification was used by disturbances in architecture, seeking to give clinical relevance them all. Furthermore, unusual subtypes were generally well to the growth pattern.3 Much of that focus was changed when accommodated within this revised system. It should be noted it was appreciated that these neoplasms originated from cells of that while histopathological features retain predictive value, the immune system.' There followed a period of enormous they should not be considered the predominant factor. It was confusion, since as many as 20 different classifications ~x;isted concluded that for management decisions to be appropriate, concurrently, precluding uniformity of patient entry into renewed and correct weighting must be assigned to other clinical trials, or even exchange of information between centres. prognostic variables that include clinical features and Some semblance of organisation was imposed on this chaos by markers of tumour biology. publication of the working formulation in 19825 Although intended as a means of interpreting data between systems, it Summary. This more enlightened prereCrmsite is the central became accepted as a classification in North America. In goal that underlies optimal treatment outcome, since it contrast, the Europeans favoured the system described by Karl determines stratification to appropriate and peer-reviewed_ Lennert.6 protocols. It follows that review of histopathology needs to precede management of all newly diagnosed cases, This unsatisfactory state of affairs has been reassessed preferably only by accredited multidisciplinary clinics. The recently for a number of reasons. There was a growing previous anachronism of basing therapy on opinions of non­ appreciation that new and distinct variants existed. specialist pathologists, without appropriate review, is unwise. Imrnunophenotyping became more readily available, so that Furthermore, treatment by lone practitioners, or even single­ B- or T-cell origin could be determined routinely and impact of specialty groups that lack the discipline to analyse their lineage could be explored as a separate variable. Cytogenetics, findings critically and regularly report their updated results, as in the leukaemias, was providing relevant prediction with can no longer be considered standard of practice and should regard to response to therapy and outcome, but was poorly be discouraged. accommodated in most routine reports. Furthermore, the shortcomings of older classifications were giving way to the . 5 Afr Med J2000; 90: 135-141. more clinically based prognostic index.' In an attempt to redress persisting concerns, the International Lymphoma Study Group combined salient features from the Evaluation of the enlarged lymph gland is an everyday working formulation with the Kiel approach to produce what problem in primary care medicine, as it is in all other is known as the Revised European-American Lymphoma disciplines. In many instances there is an underlying (REAL) Classification.sDespite this undoubted advance, some inflammatory lesion that resolves swiftly with appropriate reservations have persisted, particularly among clinicians. treatment. Less frequently, but perhaps more importantly, the Reservations have focused mainly on the undue weight given palpable node is malignant. After excluding metastatic cancer, to histopathological features, the lack of reproducibility of the remaining lymphomas require investigation and diagnostic criteria between centres, or indeed' even
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