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INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 8
Original Article-I
Sentinel Node Biopsy in Cervical Cancer - A Pilot Study
MANOJ BABU R, ALTAF GAUHAR HAJI, D.K VIJAY KUMAR,
K. CHITRATHARA, PADMA SUNDARAM, SHANMUGHA SUNDHARAM
ABSTRACT: detected by ninety minutes. Two out of the
thirteen patients had sentinel node positive
BACKGROUND: We conducted a pilot study for metastasis. These patients also had
to assess the feasibility of doing sentinel additional positive nodes. There were no
node biopsy in patients with early stage false negatives. Bilateral nodes were seen
cervical cancer. in three patients. More than one node was
METHODS: Thirteen patients with early identified in four patients. The sentinel node
stage carcinoma cervix (Stage I A-2 and was found to be the “internal iliac node /
eleven cases of stage I B1) were planned for nodes” in eight patients and the “obturator
radical hysterectomy (PLND). Early on the node / nodes” in seven patients.
day of surgery, patients had initial injection
of 0.4 to 0.6 ml radio-isotope, 37 MBq of Conclusion: Sentinel node biopsy is feasible
filtered 99m Technetium sulphur colloid, in patents of stage I A2 to stage I B2
either peritumourally or into the four carcinoma cervix, using radiocolloid
quadrants of the cervix when the lesion was injection and l ymphoscintig r aphy
not visible. The injections were given using techniques.
an insulin syringe taking precautions to
avoid intra-tumoural injection and back- INTRODUCTION
flow out of the injection tract. The patients
were then screened under the gamma Cervical cancer is a leading cause of cancer
camera at regular intervals in the nuclear deaths worldwide and is common cancer among
medicine department to determine the
women in India. The current management for
location of the sentinel node/nodes. Once
patients with cervical cancer stage I A2, stage I
the sentinel node was identified and
marked, patients were taken to the B1 and selected II A is a radical hysterectomy
operating room. During surgery the sentinel with a full pelvic node dissection.This may be
node was detected by means of a hand held associated with morbidities eg. bleeding, pelvic
gamma probe and sent separately for histo- lymphocoele formation, neurogenic bladder, leg
pathological examination. This was edema, nerve damage, etc.1
followed by a radical hysterectomy with
bilateral PLND in all cases. The sentinel node is defined as the very
first node or group of nodes that drain the
Results: The sentinel lymph node was
anatomical re gion or primary tumour. 2,3
detected in all cases except one patient
Therefore, the absence of metastatic disease
within thirty minutes after injection of the
within the sentinel node should enable a
radioisotope. In this patient the node was
reduction in extent of the lymphadenectomy
and a possible morbidity sparing effect. The
technique of sentinel node biopsy is now part
De par tment of Surgical Oncolo g y, and Nuclear Medicine
(Padma Sundaram, Shanmugha Sundaram) Amrita Institute of of the standard surgical management for breast
Medical Sciences and Research Centre, Kochi, Kerala. cancer and cutaneous malignant melanoma.
Correspondence to: MANOJ BABU R,
Email: manojbabu4@rediffmail.com
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 9
Currently its application in various 99m Technetium filtered sulpher colloid using
gynecological malignancies eg. vulval cancer, a 0.22-micron Millipore filter, (Dose less than 37
cervical cancer and endometrial cancer is being MBq in a volume of 0.4 ml – 0.6 ml) in the
evaluated. Earlier studies in cervical cancer nuclear medicine department. The total dose
have suggested that the procedure is less was divided into four injections and given into
reliable in advanced stages of disease, as the four quadrants of the cervix, at 12, 3, 6 and 9’O
afferent lymphatics tend to get blocked by the clock positions in cases where the lesion was not
tumour cells, leading to false negative study 4
. grossly visible (micro-invasive carcinoma). In
patients with grossly visible tumour, the
The concept of sentinel node biopsy injections were given peritumourally. The
appears attractive for cervical cancer as the injections were given by insulin syringe, taking
incidence of lymph node metastasis in stage I precautions to avoid intra-tumoural injection
A2 cervical cancer is only 7 % and in stage I BI and back flow out of the injection track.
it does not exceed 20 %, i.e. a significant
percentage of patients are not benefited from Immediately after the injection the patient
lymphadenectomy. 5 Cervix has a complex were shifted on to the gamma camera table and
lymphatic drainage due to its midline position. a high-resolution static image of the anterior
Complications associated with lymph node abdomen and pelvis was acquired for five
dissection develop more frequently if minutes. Subsequent static images of the
postoperative radiotherapy is administered.6, 7 abdomen and pelvis were acquired every 15
Cervical cancer patients with negative pelvic minutes to detect sentinel node / nodes. When
nodes benefit from radical hysterectomy, while the sentinel node was visualized as a hot spot, it
those with histologically proven lymph node was marked with a radioactive marker for
metastasis may benefit more from primary confirmation and then the corresponding site
chemo-radiation. Traditional imaging was marked on the patient’s skin with a marker
,
techniques including lymphangiography CT and pen.
MRI may fail to identify lymph node metastasis
with accuracy 8, 9 Present study is to find out the
. Intra-operative localization
feasibility of sentinel node biopsy in patients
with early stages of cervical cancer. During laparotomy, before proceeding with
,
lymphadenectomy a hand held battery operated
METHODS
gamma detector probe [Energy range-140 keV to
Patients: 360 keV, absolute sensitivity for 99mTc (140keV)
Thirteen patients with histologically proven -7500 cps/MBq and resolution (FWHM) of <
early cervical cancer with tumour size less than 12mm] was moved along the lymph node regions
4 cm were included in the study. The mean age to detect preoperatively marked sentinel lymph
of patients was 51.7 years (range= 37 to 71 nodes. The nodes containing radioactivity
years). Among the 13 cases, 11 had Stage IB 1 counts more than ten times the background
and the remaining two had stage I A2. 10 of 13 activity were removed and count checked ex-
cases were squamous cell cancers on histology vivo using the same probe. The gamma probe
and cytology All these cases were scheduled for
. needs to be angled laterally to avoid residual
radical hysterectomy with pelvic radioactivity emitted from the primary injection
lymphadenectomy. site (Figure I). Once the nodes were identified
the position of each node in relation to the major
Pre-operative lymphoscintigraphy: pelvic vessels were noted and the count
Preoperative lymphoscintigraphy was recorded. This was followed by a conventional
performed early during the day of surgery using lymphadenectomy in all cases.
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 10
.
morbidity The two common methods for sentinel
node detection are using vital dyes and
radioactive tracers. The vital dyes commonly
used are isosulfan blue, patent blue violet, and
methylene blue. Any blue-dyed node is
considered to be a sentinel node. Radioactive
tracers contain the 99m technetium
radioisotope. Three nanoparticles are used: 15-
50 nm colloidal sulphur, 5-80 nm human
albumin, and 2-3 nm human serum albumin.
Several images are obtained from different
projections, and the anatomical references are
Figure 1- Intra-operative lymphatic mapping- the gamma
marked in order to facilitate location. An
probe being angled laterally to avoid residual radioactiv- intraoperative gamma probe is used to trace the
ity of primary site. node chains under study systematically,
considering the sentinel node as the one that
shows, ex vivo, a 10-fold increase in the
Histopathological Examination radiation count relative to the basal count.
The sentinel nodes as well as the Since Echt et al reported the initial case
lymphadenectomy specimen were then sent series in 1999 using blue dye alone; several
separately for histopathological examination. authors have published their experience with
Histopathological examination was done using sentinel node detection in cervical cancer 10.
the standard technique with haematoxylin and More than for ty three studies involving
eosin stain. approximately 1600 patients have been reported
so far using either blue dye alone, radio-colloid
RESULTS alone or with the combined method using blue
Patients characteristics are shown in table I. The dye along with radio-colloid for detecting
sentinel nodes were detected in all the thirteen sentinel nodes in patients with cervical cancer.
cases, i.e. detection rate was 100%. Only 3 cases The largest series, reported by Rob et al
had bilateral sentinel nodes. The average time comprised of 183 cases, 100 cases using blue dye
taken for detection of sentinel nodes was 37 min alone and 83 cases using the combined method.
(SD= 17.8) with a range of 20 to 90 minutes. The The detection rate was 80% with blue dye and
commonest site was the internal iliac node/ 96.4% with the combined method. The negative
nodes (61.53%) followed by obturator nodes predictive value (NPV) was 99% and 100 % with
(53.8%). blue dye and the combined method
respectively. 11 Lin et al reported the largest
A total of 22 sentinel nodes were detected in series of 100 patients using lymphoscintigraphy
thirteen cases. The lymph nodes were positive followed by intraoperative lymphatic
for metastasis in two cases (both stage IB 1). Both mapping. 12 There is a paucity of studies
cases were squamous cell carcinomas. Among conducted and reported from India, even though
the node positive cases one was grade II and the it is the commonest malignancy in women.
other was grade III. In both these cases, other In nine cases of Stage IB1 lesions peri-
nodes were also positive. There were false tumoural injection technique was practiced. In
negatives so far in our series, i.e., whenever one case the lesion was mainly in the cervical
sentinel nodes were negative other nodes were canal and due to technical difficulties, four-
also negative. quadrant injection technique was used. Similar
DISCUSSION: procedure was adopted for the stage IA 2 cases.
Most of the patients reported mild pain after
Sentinel node biopsy is a relatively new injection, which did not persist. We felt that it
addition to the field of surgical oncology, which was helpful to use a thin 25 G needle with
has got great potential to reduce surgical constant gentle pressure to prevent spillage into
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 11
Table I - Patient and Tumour Characteristics.
Age (Mean) 51.7 years Range: 37-71 years
No of Patients
Stage IA2 02
IB1 11
Histology Squamous cell carcinoma 10
Adenocarcinoma 03
Grade Grade I 03
Grade II 07
Grade III 03
Internal iliac nodes 8 61.5%
External iliac nodes 2 15.48%
Obturator nodes 7 53.8%
*Standard deviation = 11.27
Table II -Characteristics of Sentinel Lymph Nodes
Characteristics No. Of patients Percentage
(N=13)
Detection rate 13 100%
Bilateral nodes 3 23%
Lymph node metastases 2 15.38%
Sentinel node metastases 2 15.38%
the vagina. For the first 2 cases,we injected 0.6 not obtained because we felt that marking in a
ml of radio colloid. But in the subsequent cases second plane did not add much to the easiness
we injected only 0.4 ml radio colloid with 0.1 ml of detection of the node using the sensitive
gamma probe. The only major use of
for each site for convenience, even though the
lymphoscintigraphy as per our experience was
dose remained the same (25 MBq tp 37 MBq). In
to detect the side of sentinel node so that one can
9 out of 13 cases the lymphoscintigraphic images be more focussed while doing intra-operative
were obtained within 30 minutes. In one case it gamma probe guided dissection. Other authors
took 90 minutes for localization of radioactivity. have re por ted similar experiences. 11 T he
The markings were made on the anterior minimum time taken was 20 min and the
abdominal wall corresponding to the maximum time taken for sentinel node detection
approximate site of the node. A lateral view was was 90 minutes.
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 12
The detection rate in our series was 100 serial sectioning.20 Molecular techniques such as
%. The detection-rate reported by Echt et al in real-time polymerase chain reaction (RT- PCR)
1999 was only 23%10 but the recent studies using are being evaluated for detecting micro
intra-operative lymphatic mapping as well as metastasis. However, the clinical significance of
the combined method using intraoperatve PCR-detected micro metastasis remains
lymphoscintigraphy (ILS) and blue dye together controversial.
have reported detection rates around 100%. 13, 14
The major drawbacks of the present study
In the two patients who had sentinel
include-the limited number of patients and the
nodes positive for metastasis, other nodes were
failure to use the combined method using blue
also positive. This emphasizes the need for
dye and radioactive tracers rather than using
perfor ming a complete lymphadenectomy,
radioactive tracers alone. The high cost of the
whenever sentinel nodes are positive for
equipments required and the lack of availability
metastasis. The negative predictive value (NPV)
of qualified and experienced personnel are the
was 100% i.e., whenever sentinel nodes were
major limiting factors for wider application of
negative, other nodes were also negative.
lymphoscintigraphy especially in countries like
Others have also reported similar results. 12, 15
India.
The present study included only early cases up
to stage I B1. This might have contributed to the In our view the major cause of morbidity
high NPV. Bar ranger et al re por ted false after surgery for cervical cancer is due to the
negative rate of 20% in locally advanced parametrial resection rather than the
cervical cancer and 0% in early stage disease.4 lymphadenectomy. An early cervical cancer i.e.,
The commonest anatomical location of ones which can be treated by surgery alone are
sentinel nodes was the internal iliac group those which are unlikely to have nodal
(61.5%), followed by obturator group (53.8%). metastasis. The morbidity of surgery is
This was in contrast to many case series where considerably increased when it is combined
the commonest site of sentinel nodes was the with radiotherapy. Hence sentinel node biopsy
external iliac group.16, 17 This can be attributed can be employed as a technique to detect nodal
to the limited number of cases in our series. metastasis with minimum morbidity. Role of
Lymphatic anatomy of the cervix is complex. laproscopic surgery for cervical cancer is likely
Cervix being a midline structure is likely to to increase in future. Once validated
have bilateral lymphatic drainage, as noted by laparoscopic sentinel node biopsy would have
Leveuf and Godard 18. But in our series only 3 out potential to reduce surgical intervention time,
of 13 (23%) patients had bilateral sentinel nodes. avoid removal of normal nodes and helps the
Indeed the bilateral detection rate in literature pathologist to concentrate on the limited
varies from 24% and 83%. number of nodes harvested by sentinel lymph
.
node biopsy Similarly detection of sentinel node
One of the key issues of the SN concept is
status can help in planning treatment. For
the histological assessment of the lymph node
example in patients found to have SNB positive
specimen(s). We have adopted standard
for nodal disease can be treated by primary
sectioning with haematoxylin and eosin for
chemo-radiation, thus avoiding additional
evaluation of sentinel lymph nodes. We have not
morbidity of surgery .
used intra-operative frozen section analysis,
because it has low sensitivity for detecting CONCLUSION
metastases; and the false negative rate of
identifying micrometastases can be as high as Sentinel node biopsy is a feasible technique in
70%19. Standard sectioning with haematoxylin early stage carcinoma cervix (I A2 to I B2) using
and eosin staining is not as sensitive as serial radiocolloid injection and lymphoscintigraphy
sectioning (variable intervals between 50 and techniques. The results of this study are
400 ìm) combined with immunohistochemistry encouraging; however studies with larger
(IHC) to detect micro metastases. In contrast, number of patients are needed to confirm these
Hakam et al. found no additional benefit of observations.
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 13
ACKNOWLEDGEMENT 10. Echt ML, Finan MA, Hoffman MS, Kline RC, Roberts
WS, Fiorica JV. Detection of sentinel lymph nodes
We would like to thank our colleagues in the with lymphazurin in cervical, uterine, and vulvar
department of pathology, Amrita Institute of malignancies. South Med J. 1999;92:204–8.
Medical Sciences and Research Centre, Kochi, 11. Rob L, Strnad P, Robova H, et al. Study of lymphatic
mapping and sentinel node identification in early
for their cooperation. stage cervical cancer. Gynecol Oncol. 2005;98(2):281-8.
12. Lin YS, Tzeng CC, Huang KF, Kang CY, Chia CC,
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Hsieh JF. Sentinel node detection with radiocolloid
lymphatic mapping in early invasive cervical cancer.
1. Soisson AP, Soper JT, Clarke-Pearson DL, et al.
Int J Gynecol Cancer. 2005;15:273–7.
Adjuvant radiotherapy following radical
hysterectomy for patients with stage IB and IIA 13. Chung YA, Kim SH, Sohn HS, et al. Usefulness of
cervical cancer. Gynecol Oncol. 1990;37(3):390-5. lymphoscintigraphy and intraoperative gamma probe
detection in the identification of sentinel nodes in
2. Gould EA, Winship T, Philbin PH, et al. Observations
cervical cancer. Eur J Nucl Med Mol Imaging.
on a “sentinel node” in cancer of the parotid Cancer.
2003;30:1014–7.
1960;13:77-8.
14. Merisio C, Berretta R, Gualdi M, et al. Radioguided
3. Cabanas RM, An approach for the treatment of penile
sentinel lymph node detection in vulvar cancer. Int J
carcinoma.Cancer.1977;39:456-66.
Gynecol Cancer. 2005; 15:493–7.
4. Barranger E, Coutant C, Cortez A, et al. Sentinel node 15. Angioli R, Palaia I, Cipriani C, et al. Role of sentinel
biopsy is reliable in early stage cervical cancer but lymph node biopsy procedure in cervical cancer: a
not in locally advanced disease. Ann Oncol. critical point of view. Gynecol Oncol. 2005;96:504–9.
16(8):1237-42
16. Malur S, Krause N, Kohler C, et al. Sentinel lymph
5. DiSaia PJ, Craesman TC. Invasive cervcal cancer, In node detection in patients with cervical cancer.
DiSaia PJ, Craesman TC (editors): Clinical Gynecol Oncol. 2001;80(2): 254-7.
Gynecolo gic Oncolog y. Pub Mosby, Philadelphia.
17. O’Boyle JD, Coleman RL, Ber nstein SG, et al.
2001,6 th edition p 61-71.
Intraoperative lymphatic mapping in cervix cancer
6. Corn BW, Lanciano RM, Greven KM, et al. Impact of patients undergoing radical hysterectomy: A pilot
improved irradiation technique, age, and lymph node study.Gynecol Oncol. 2000 Nov; 79(2): 238-43. 24.Grabau
sampling on the severe complication rate of DA, Rank F, Friis E. Intraoperative frozen section
surgically staged endometrial cancer patients: a examination of axillary sentinel lymph nodes in
multivariate analysis. Clin Oncol. 1994 ;12(3): 510-5. breast cancer. APMIS. 2005;113:7–12.21.
7. Magrina JF. Complications of irradiation and radical 18. Leveuf J, Godard H. Les lymphatiques de l’uterus.
surgery for gynecologic malignancies. Obstet Gynecol Rev Chir 1923;3:219-4833.
Surv. 1993;48(8): 571-5. 19. Scholz HS, Lax SF, Benedicic C, et al. Accuracy of
8. Scheidler J, Hricak H, Yu KK, et al. Radiological frozen section examination of pelvic lymph nodes in
evaluation of lymph node metastases in patients with patients with FIGO stage IB1 to IIB cervical cancer.
cervical cancer. A meta-analysis. JAMA. Gynecol Oncol. 2003;90:605–9.
19971;278(13):1096-101. 20. Hakam A, Nasir A, Raghuwanshi R, et al. Value of
9. Kokka F, Vorgias G, Tserke zo glou A, et multilevel sectioning for improved detection of
al.Preoperative work-up of early cervical micrometastases in sentinel lymph nodes in invasive
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INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 14
Original Article-II
Clinical and Radiological Features of Paediatric
Burkitt’s Lymphoma - A Four Year Study.
BOSCO J I E, APPAJI L, ARUNA K, RAGHURAM P, RAMA RAO C, VIDHYA A
ABSTRACT INTRODUCTION
Backg round: Burkitt’s lymphoma is a Burkitt’s lymphoma (BL), a high grade B cell
curable childhood malignancy with neoplasm showing monoclonal proliferation,
s i g n i f i c a n t g eo g r ap h i c a l va r i at i o n i n was first described in 1957, by an Irish surgeon-
incidence, clinical presentation and Denis Parsons Burkitt who mapped its peculiar
response to treatment. There is sparse geographic distribution across equatorial
literature on Burkitt’s lymphoma from Africa. Its etiological factors include the Epstein
India. Barr virus – the first reported oncogenic virus
in humans1. Prospective studies in Uganda2 have
Methods: Between 2003 and 2007, 19 cases
confirmed its role. In 1982 the C-myc gene3 was
of Burkitt’s lymphoma were diagnosed at
re ported and abnor mal production of B
our centre. Their clinical presentation and
lymphocytes was noted in translocation between
radiological features were studied.
long arms of chromosome 8 with 14 and, to a
Results: The mean age was 7.2 years (range- lesser extent between chromosomes 8, 22 and 2,
1 to 5 years). There was a slight male 8. Other complicating factors include falciparum
preponderance (M: F = 1.7:1). Almost all the malarial infection which acts by an EBV specific
cases were seen over a 2 to 3 month period. T cell immune deficiency. Radiology plays a
The most common presentation was an vital role in staging the disease 4 and further
abdominal mass followed by a maxillary- management as clinical and pathological
mandibular swelling. The most common examination alone cannot decide the extent of
imaging finding was a lobulated, hyper- disease – patients with a primary in head and
mixed echogenic abdominal mass on neck region may have clinically non-detectable
ultr asono g r aphy and a hypodense, disease in abdomen5 – necessitating abdominal
heterogeneously enhancing intra-abdominal imaging in all cases of BL. As BL is a fast
mass with necrotic foci on CAT scan. Most growing tumour, its earlier detection and
of the cases (84.2%), were stage III (St. treatment decides the outcome. Also response to
Judes staging) at the time of presentation. treatment can be correlated to decrease in size
Fourteen of 19 cases received treatment of of mass, and best evaluated by imaging studies.
which 10 (71.4 %) achieved remission.
Two distinct types of BL are known (i) the
Conclusion: Our cases show an intermediate African or endemic form seen in equatorial
pattern – having clinical characteristic of Africa and Papua New Guinea – here this is the
both the African and the American forms of commonest childhood malignancy (100 per
Burkitt’s lymphoma. million), classically associated with EBV
infection (upto 100 %), seen in malarial
Department of Pediatric Oncology Kidwai Memorial Institute of
, endemic areas, commonly involves the jaw,
Oncology, Bangalore
Corresponding author: JEROME I E BOSCO affects younger individuals with mean age of 7
Email : dr_vidhyajerome@rediffmail.com years, and shows good response to
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 15
chemotherapy (ii) American or sporadic form is lymphomas and 23.7% of the Non Hodgkin’s
uncommon (1 per million ), evidence of EBV lymphomas in a year. Of the 19 patients-12 were
infection is seen in 20 % of cases, median age diagnosed with cytology and karyotyping and 7
is relatively higher and there is male by biopsy and immunohistochemistry .
preponderance and poor response to
A total of 19 children were studied with
chemotherapy .
ages from 1 to 15 years – mean age of 7.2 (+- 3.9)
There have been reports of BL occurring years, shown in table 1. There was a slight male
7,8
in case clusters for place and time, the exact predominance – 12 boys to 7 girls (M: F = 1.7:1),
cause of which is only speculative. It has been (table 2).
attributed to endemic malaria in regions which
The most common clinical finding was an
in turn varies with climate, especially rainy
abdominal mass – seen in 14 individuals
season.
(73.7 %), cervical, inguinal lymphadenopathy
Even though disease has been in 9 children (47.4%), maxillary-mandibular
characterized in endemic and nonendemic swelling - in 6 cases (31.6 %). Others included
areas, little information is available from India. ,
hepatosplenomegaly ascites, proptosis, swelling
The present study tries to look for the type of in frontal region, and pallor.
presentation, radiological features, and
Imaging: The most common findings were
clustering of BL in a oncology referral centre
lobulated hyper – mixed echogenic mass in the
from South India.
abdomen on USG, or hypodense,
PATIENTS AND METHODS heterogeneously enhancing intraperitoneal mass
with areas of necrosis on CT scan (fig1)– often
This cross sectional study was conducted in the
encasing mesenteric vessels and bowel - seen in
department of Pediatric Oncology and
14 (73.7 %) patients. Of the abdominal masses –
Department of Radiodiagnosis, Kidwai
9 showed more than one site of involvement – 13
Memorial Institute of Oncology, Bangalore.
involved small/large bowel and adjacent
All patients of BL underwent complete mesentery, 9 occurred in the retroperitoneum –
evaluation and diagnosis was confirmed by paraaortic regions, 2 presented in the ileo-caecal
histomorpholog y, immunohistochemistry, region, and 2 in the uterus / adnexal region.
cytology and karyotyping, from 2003 onwards. Other intra-abdominal findings included renal
Bone marrow aspiration and CSF cytology was mass in 2, hepatomegaly-4, splenomegaly
done to stage the disease. The time of 3, adrenal mass in 1 and ascites in 2 patients. The
presentation was an interesting finding, with extra-abdominal findings included maxillary
cases presenting in clusters – in the year 2003,
all the 5 cases of BL presented between July and
September, and in the year 2006-07 - 7 out of the
8 cases, presented between October and
.
January St. Jude’s Children Research Hospital
Staging system was used for staging. 9
Radiological findings– including chest
radiograph, OPG, ultrasonography, CT and MRI
were tabulated. The treatment course was
charted for all patients. Parental consent was
taken, if any patient was photographed.
Results (table1 & 2 )
A total of 1600 cases of childhood malignancies
were seen in the year 2003 to 2006 with an
average of 400 per year, 12.4% of these were
lymphomas (both Hodgkin’s and non FIGURE 1. CECT of a case of abdominal Burkitt’s
Hodgkin’s). BL comprised 9.1% of all lymphoma in a child.
INDIAN JOURNAL OF MEDICAL & PAEDIATRIC ONCOLOGY Vol. 28 No 4, 2007 16
Table 1: Patient’s Characteristics
Total no of patients 19
Age 7.2years (range=1-15 )
Sex= Male:female 12:7
Clinical findings Number of patients PERCENTAGE
1)Abdominal mass 14 73.7
2)Cervical / inguinal lymphadenopathy 9 47.4
3)Maxillary-mandibular swelling 5 26.3
4)Hepatomegaly 4 21
5)Splenomegaly 3 15.8
6)Ascites 2 10.5
7)Proptosis 1 5.3
8)Frontal swelling 1 3.3
9)Pallor 6 31.6
Diagnosis
Biopsy+Immunohistochemistry 7
Cytology+karyotyping 12
Staging
I 1
IIE 1
III 16
IV 1
Table 2: Radiological Findings in Burkitt’s lymphoma (n=19)
RADIOLOGICAL FINDING Number of patients PERCENTAGE
Mass involving / encasing - bowel / mesentery 14 73.7
Intra / retroperitoneal lymphadenopathy 9 47.4
Maxillary swelling 4 21
Hepatomegaly 4 21
Splenomegaly 3 15.8
Renal mass 2 10.5
Uterine / adnexal mass 2 10.5
Mediastinal / hilar mass 2 10.5
Bone lesion 2 10.5
Ascites 2 10.5
Mandibular swelling 1 5.3
Testicular mass 1 5.3
Adrenal mass 1 5.3
