الفهرس 
Material and methodsOnly 14 pages are availabe for public view
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Abstract
Non-Hodgkin’s lymphoma is one of the common malignant
diseases world wide. In 1995, more than 45,000 new cases were
diagnosed in the USA. In Egypt, MHLs represent 11% of malignant cases
presenting to the National Cancer institute (Ibrahim, 1997).
Over the last 20 years, diagnosis and management ofNHL at the
National Cancer Institute, Cairo University have passed into different trial
generations.
. The first generation regimen included the use of non-anthracycline
• containing regimens e.g. COP, C-MOPP, and other simple combinations
or single agents, as well as anthracycline containing CHOP regimen. The
second generation regimens started with the use of standard BECQP
regimen and its dose intensified versions. These modified versions
included giving BECOP with the same doses every 3 weeks instead of 4
weeks, or achieving further increase in the dose intensity by 25% dose
increase of the 2 most active agents in the combination i.e.
cyclophophamide and epidoxorubicin together with growth factors
support. The third generation regimens included the use of either
continuous infusion chemotherapy e.g. EPOCH regimen, other third
generation combinations e.g. m-BACOD, COP-BLAM, or the use of
interferon as a maintenance therapy after induction therapy.
In the current study a trial has been made to evaluate the clinicopathologic
profile, end results of treatment, and the impact of the various
prognostic factors on treatment response, and survival of most ofNHL
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patients presenting to the National Cancer Institute, Cairo University
during a five years period (1995-1999).
In Egypt, diffuse aggressive lymphomas (intermediate and high
grades ofworking fonnulation) Predominate and in one series (Tawfik et
at, 1984) diffuse aggressive lymphomas represented by 68.3% of their
patients respectively and Nearly similar results were reported by Mokhta,
(1991) 83.3%. In our series and like other Egyptian servies aggressive
and Indolent NHL represented by 68.4% and 3 I.5% respectively.
In contrast to Egyptian data most western studies reported an
incidence of 40% of aggressive NHL (Anderson et al., 1982).
Malignant Jymphom~ in Egyptian patients present special
unmvourable features, which are distinctly different from those reported
in the western Jiterature.Thus, in addition to the predominance of diffuse
aggressive pathologic subtypes as previously mentioned; the patients
usually present at advanced stages, with 85% of cases in stages III and IV
of Ann Arbor classification. They also present with bulky disease, higher
incidence of primary extranoda1lymphomas (34%) and high serum levels
ofLDH (Abou Rabia, and Khaletl, 1994; EI Bolkainy et aL, 1984).
In accordance with these observations and other published data
reported by £l-Bokainy et al; (1984); Tawfik et al, (1984) and
Mokihtar (1991) and the data of our series. Systemic B-symptoms were
present in 66% of our cases (52% in Abou rabia and Khaled’s Series,
1994). Stages III and IV were observed in 47.6% and extra nodal
affection was encountered in 43% of our patients included in this series.
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For along period of time, the standard staging system for NHL than
HD, and that it does not conelate well with prognosis so, many clinical
features has been identified as being of influence on response to treatment
and on survival.
On applying this international index to the present retrospective
series of patients presented to the National Cancer Institute clinics during
the period 1995-1999, where at that time, the prognostic index was not
yet developed, we found that it is very difficult to guarantee that the 5
prognostic constituents of this index have been looked for. So, we
presented our data in an approximate way by ensuring that at least
1.2,3.~.etc of the factors are present in each patient. This means that for
each case, the index category could be more than that presented due to
some missed one or more of the international index constituent factor (s)
put it cannot be less than that scored for each case. In view of this and
applying this international index on our patients.
About half of our patients belonged to the high risk categories i.e.
presence of more than 2 risk factors. In a study by Shipp et al., (1993),
35% of their cases were of low risk (0-1 factor), 27% low intermediate (2
factors), 22% high intermediate (3 factors), and 16%were of the high risk
category, (4-5 factors). Although, our data are incomplete due to the
known nature of any retrospective study, and thus its evaluation in
relation to other studies would be difficult but our study revealed 15% of
our cases were low risk (0-1 factor), 37% low intermediate (2 factors),
27.6% high intermediate (3 factor), and 20.5% were of the high risk
category (4-5 factors).
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For further and more comprehensive analysis of our patients
according to the international index, we have also individually compared
the five pretreatment characteristics which determine the international
index of our cases reported by SI,ipp et al., (1993). While those patients
whose age was > 60 years represented 20% of our series, 41% of the
patients in Shipp’$ study belonged to the old age group.
Tumour stage III and IV among our Patients was 47.6%, while it
was 66% in Shipp’s predictive model.
Extranodal involvement to of more than one site was encountered
In 55% vs 30% among our patients and those of Shipp’s study
respectively. Performance status of the patients in the present study was
51.5%, 38.3%, 8.6% and 1.6% for PS 1,2,3, and 4 respectively, while it
was 27%, 34%, 12%, 4%, and 2% for PS 0, J , 12,3, and 4 in SIIIPP’s
series. The serum LDH was high in 58.3% vs 40%.
Most of our patient (50.7%) received chop chemotherapy and
(25%) received other lines of chemotherapy and (24.2%) did not receive
any chemotherapy but the majority of these patient; weren’t regular in
receiving therapy and didn’t complete their planned treatment.
These alarming observations of treatment irregularity and
incomplete therapy for the majority of patients analysed in this series may
be partially explained by the known mutual reluctancy of both the patient
and the physician to aggressively treat low grade NIll.. due to its long
natural history and lack of curative therapy specially in advanced cases.
However, several other factors can explain this observation. These
factors are multifactorial and include those related to the patient, meidcal
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profession, the hospital, social workers, nature of the disease and its
treatment, and the general environment of our society.
Patients may be irregular in their follow up and in treatment due to
several reasons. These reasons include poverty and fmancial problems
specially if they are living far from Cairo, unawareness of the impact of
their disease and its fatal sequalae if untreated, fear of coming to a
hospital where ”cancer” is treated, or of receiving chemotherapy or its
•side effects, and other social problems. In addition, apparent and
deceiving initial remission that may occur in cases sensitive to
chemotherapy may give the patient a false belief that he is cured, and
there is no need to continue therapy.
Regarding medical profession, many factors may be responsible for
this lack of information and regular follow up of patients. Inaccuracy and
reluctance to report and record the clinical data and follow up notes in
patients. Inaccuracy and reluctance to report and record the clinical data
and follow up notes in patients files is one factor. Also, relative lack of
unified treatment stratigies and protocols, irregular attendance in the
clinic, and the psychological relation of the patient to a special doctor and
his wish not to be examined by another one, all those may contribute to
this high incidence of irregular follow up and treatment.
On the other hand, factors related to the hospital and health care
facilities include the following (1) : the presence of increasing number of
patients in the clinics with the relative deficiency of doctors and other
health care profession, (2) relative lack of enough beds in the inpatient
department, (3) unavailability of regular supply of some
chemotherapeutic agents and other medications due to financial or
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administrative causes, (4) unavoidable delay in getting the result of the
different laboratory and radiological investigations of some cases due to
the large number of patients treated at the hospital, (5) loss offiles of
some patients due to inadequate,filing system, (6) lack of cooperation in
certain instances between the different service and clinical departments,
and (7) suboptimal social services.