An Unusual Case of Composite Lymphoma Involving Chronic Lymphocytic Leukemia Follicular Lymphoma and Hodgkin Disease

Composite lymphomas constitute the presence of two different types of non-Hodgkin lymphoma or Hodgkin and non-Hodgkin lymphoma at the same anatomic site. We report an unusual case of a 73-year-old woman who initially presented with a composite lymphoma of chronic lymphocytic leukemia (CLL) and follicular lymphoma. After 5 years of follow-up and intermittent treatment, she developed Hodgkin disease with diffuse liver involvement. Biopsy of the liver showed Reed-Sternberg cells with typical morphology and immunophenotype. While fluorescent in situ hybridization (FISH) analyses for t(14;18) were positive in the lymph node tissue with follicular lymphoma, we were unable to show the same in the liver biopsy specimen. Here, we describe the clinical, morphologic, immunophenotypic, and cytogenetic features of this unusual composite lymphoma case involving CLL and follicular lymphoma, with the subsequent development of a Hodgkin lymphoma.

The Role of Anthracyclines in Combination Chemotherapy for the Treatment of Follicular Lymphoma: Retrospective Study of theIntergruppo Italiano Linfomion 761 Cases

In order to elucidate the role of anthracycline based combination chemotherapy regimens for the treatment of follicular lymphoma we conducted a retrospective study on a large series of patients with a histologically confirmed diagnosis of follicular lymphoma. The Italian lymphoma intergroup (ILI) promoted a retrospective study of patients with follicular lymphoma treated in cooperative trials between 1985 and 1996. Six hundred and thirty three cases were treated with an anthracycline-containing regimen and 128 patients were treated without anthracyclines. The two groups were prognostically comparable; in particular, no difference was observed according to both IPI and ILI prognostic index. Results showed a complete remission (CR) rate for patients treated with anthracyclines was 69.2% and overall response rate was 92.5%. After a median follow-up of 51 months (54 months for patients still alive), the 5- and 10-year overall survival (OS) rates were 80 and 66%, respectively. Disease-free survival (DFS) and failure-free survival (FFS) rates at 5 years were 61 and 49%, respectively. In the group of patients treated with combination chemotherapy not including anthracyclines, the CR rate was 67.5% and the overall response rate was 85.4%. A longer OS (80% at 5 years) was observed in patients treated with anthracyclines compared to 67% OS rate in patients treated without anthracyclines (p = 0.0004). FFS was significantly longer in patients treated with anthracyclines (49 vs. 34% p = 0.006). Patients treated with anthracyclines with low or intermediate risk according to ILI prognostic index showed a significantly longer OS (p = 0.0001 andp = 0.0009, respectively); those in the high-risk group showed a trend for a longer survival. In conclusion, this retrospective study shows that patients with follicular lymphoma treated with an anthracycline containing regimen had a better outcome compared to patients treated with other combination regimens non including anthracyclines in terms of CRs, OS and FFS. On the basis of these results anthracycline-containing regimens (ACR) should be considered as the standard treatment of patients with advanced follicular lymphoma.

Malignant lymphoma in an atomic-bomb survivor

Atomic bomb survivors outside of Japan are few and often hard to follow-up. Spinal malignant lymphoma among these survivors is rare in established studies from Japan or the United States. Here, we report an 81-year-old woman, who experienced the atomic bomb explosion in Nagasaki when she was 19 years old, who presented with papillary thyroid carcinoma when she was 70 years old. Both follicular lymphoma over the right elbow region and vertebral malignant lymphoma were found when she turned 81 years old. Bone scan did not show any increased uptake of isotope. However, thoracolumbar spine magnetic resonance imaging showed multiple infiltrative soft tissue masses involving vertebral bodies at the T10-11 level. Computed tomography-guided biopsy further showed lymphocyte infiltration. Fortunately, the neurological deficit was improved after chemotherapy. The diagnosis of malignant lymphoma in atomic bomb survivors should be more careful and aggressive, even when their bone scan results show negative findings. In addition, the authors suggest that atomic bomb survivors should be followed-up carefully throughout their entire life.

Bone marrow involvement in follicular lymphoma: Comparison of histology and flow cytometry as staging procedures

Bone marrow (BM) examination is a routine staging procedure in follicular lymphoma (FL). Commonly, both BM histology as well as flow cytometry (FCM) of BM aspirates are performed. In order to compare the diagnostic value of these two techniques, we retrospectively evaluated trephine BM biopsies and listmode data of patients with a confirmed diagnosis of FL, obtained in parallel during a 5-year period. One hundred and thirty nine specimens from 91 patients with FL were eligible for analysis. After joint review, nine cases (6.5%) were reclassified, either in histology (six cases) or FCM (three cases). Seventy nine specimens (57%) showed no infiltration with both methods. Sixty specimens (43%) were scored positive for BM involvement by any of the two techniques. Concordant positive results were obtained in 41 cases (68% of positive BM). False negative results were obtained by FCM in 14 cases (23% of positive BM) and by histology in five cases (8%). Discrepant results between BM histology and FCM are frequent in patients with FL, most likely due to the predominantly paratrabecular infiltration and fibrosis typical for FL. Due to the lower false negative rate, trephine BM biopsy remains crucial for the detection of BM involvement in FL.

Role of the molecular staging and response in the management of follicular lymphoma patients

Bcl-2/IgH rearrangement is the molecular hallmark of follicular lymphoma which is present in 70 - 90% of cases at diagnosis. The significance of the bcl-2 rearrangement at onset of disease and of its clearing after treatment (molecular response) is still controversial. The aims of the present analysis are: to evaluate the incidence of bcl-2 rearrangement in blood and marrow in a cohort of patients systematically investigated at diagnosis, to describe the correlation between bcl-2 and presenting features, to clarify the correlation of molecular response with outcome. Of 98 patients studied at initial staging for the presence of bcl-2 rearrangement, 64 (65%) showed bcl-2/IgH rearrangement in peripheral blood (PB) and/or bone marrow (BM) (58 at Major Breakpoint Region, MBR, and 6 at minor cluster region, mcr) while no bcl-2/IgH rearrangement was detected in the remaining 34 (35%) (germline status). No statistically significant differences were found between bcl-2 positive and bcl-2 negative cases as concerns presenting clinical features and response to first-line therapy. The median event-free survival, EFS, was not reached for the bcl-2 negative patients in PB and was 11 months for bcl-2 positive patients (statistically significant, P = 0.01) and, similarly, the median EFS was not reached for the bcl-2 negative patients in BM and was 11 months for bcl-2 positive patients (statistically significant, P = 0.04). Of the 64 bcl-2 positive cases, patients were analysed for molecular response (48 in BM and 40 in PB): 16 were molecular responders in BM and 20 were molecular responders in PB. The median EFS was 19 months for molecular responders in PB and 9 months for non-responders; 1-year-EFS was 68% (95% CI; 49 - 88), for responders in PB and 42% (95% CI; 22 - 61) for non-responders (P = 0.05). The median EFS was 11 months both for molecular responders and non-responders in BM; 1-year-EFS was 52% for responders in BM (CI; 30 - 73), and 43% (CI 33 - 71) for non-responders (P = 0.7). No clinical feature showed significant correlation with PB and BM molecular responses. This analysis shows that bcl-2 rearrangement in blood and bone marrow is frequently detected at staging, even in stage I disease. Absence of the bcl-2 rearrangement is related to a better EFS and the achievement of a molecular response in peripheral blood after therapy is associated with a better EFS.

Glutathione-S-transferase genotypes influence prognosis in follicular non-Hodgkin's Lymphoma

Polymorphisms in detoxification enzymes of the glutathione S-transferase (GST) family have been associated with risk and prognosis of several cancer types. We studied deletions of GSTM1 and GSTT1, and the GSTP1 Ile(105)Val polymorphism in 89 patients with follicular lymphoma (FL). Patients with a GSTM1 or GSTT1 deletion had a significantly worse event-free survival, when compared with patients with undeleted genotype (p = 0.03 and p = 0.03, respectively). Outcome was even worse in patients with a double negative genotype, in comparison with patients with only one GST deletion or normal genotype (p = 0.01). In the multivariate analysis, the GSTM1/GSTT1 genotype tended to have a prognostic significance independent from the Follicular Lymphoma International Prognostic Index (FLIPI) score. In particular, GSTM1/T1 deletions identified patients with negative prognosis in the low (<3) FLIPI score group (p = 0.01). Larger prospective studies including homogeneously treated patients will be needed to confirm these results.

[Composite lymphoma consisting of Hodgkin lymphoma and follicular lymphoma]

A 58-year-old man noticed a right inguinal tumor in 2004. He also recognized a left inguinal tumor in 2006 and entered our hospital. During biopsy of the inguinal lymph node, he was diagnosed with composite lymphoma consisting of Hodgkin lymphoma (HL) (nodular sclerosis) and follicular lymphoma (FL) (Grade 2) in the same tissue. Reed-Sternberg cells in the HL region were positive. We could not find evidence to clarify whether these lymphomas were both generated from the same origin in this case. However, examining the origins in this case would be a very significant contribution to understanding these lymphomas.

Sensitivity and reproducibility of conventional qualitative and quantitative PCR assays for detection of the t(14;18)(q32;q21) chromosomal translocation in biopsy material from patients with follicular lymphoma

Follicular lymphoma (FL) is characterized by the t(14;18)(q32;q21) chromosomal translocation which can be detected by polymerase chain reaction (PCR) in approximately 70% of cases. The aim of our retrospective study was to evaluate the sensitivity and the reproducibility of both conventional qualitative and quantitative PCR assays for detection of the t(14;18)(q32;q21) chromosomal translocation in biopsy material. Fifty-seven formalin-fixed, paraffin-embedded tumor lymph node (LN) specimens from 50 patients with FL were included in the study. Qualitative PCR was performed with primer sets specific for the MBR, far3'-MBR and the mcr regions, respectively. Quantitative PCR was performed using the LightCycler instrument and the LightCycler - t(14;18) Quantification Kit (MBR). The overall detection rate of the t(14;18) in our study (52.6%) was in accordance with the literature. Of the t(14;18)-positive cases, 49.1% had breakpoints within the MBR and only 3.5% had breakpoints within the mcr. The most sensitive method was LightCycler-based PCR with a detection rate of 47.4%, followed by MBR1,2 assay (43.9%). We observed good agreement between qualitative MBR1,2 and quantitative LightCycler-based assay with a slightly higher detection rate of the quantitative method. The sensitivities of both methods were in accordance with results from other studies. Since LightCycler-based assay detects only breakpoints within the MBR, qualitative PCR should be employed in routine diagnostic settings for detection of breakpoints within the mcr and far3'-MBR regions.

Aiming at a curative strategy for follicular lymphoma

Follicular lymphoma is often managed as an incurable disease. However, a substantial and growing fraction of patients are achieving long-term disease-free survival from aggressive treatment approaches. The application of novel therapeutic tools, including monoclonal antibodies, radioimmunotherapy, and vaccines, as well as new and more active chemotherapeutic agents, is producing complete responses in the majority of treated patients, with a 2-fold increase in disease- and progression-free survival in randomized trials. For some of these treatment approaches, follow up has not yet been long enough to determine a median response duration, but it certainly exceeds the "2 to 3 years" that is routinely stated as dogma to patients with this illness. Furthermore, some patients remain in complete remission beyond a decade from their initial treatment, implying that the assumption of inevitable relapse also must be challenged. One clear fact is that no patients will ever be cured by adopting a palliative treatment approach. The assumption that patients with follicular lymphoma are incurable is certain to be a self-fulfilling prophecy. Here the author summarizes the large and growing body of knowledge that suggests an expectant approach to management is not appropriate for all patients.

Cutaneous lesions as the first manifestation of systemic follicular lymphoma in an HIV patient

Human immunodeficiency virus (HIV) patients have an increased incidence of lymphomas, particularly when there is a significant immunosuppression. Most commonly, they are non-Hodgkin B cell type with a high or intermediate grade and have an extranodal presentation. We report the case of a 38-year-old man with HIV infection who presented with a 1-year history of a painless tumor on the back and lymphadenopathies. The diagnosis of B cell lymphoma follicle center cell type was established by skin biopsy. Staging included a bone marrow biopsy revealing infiltration by the lymphoma and a whole-body computed tomographic scan showing multiple cervical and axillary lymphadenopathies with necrotic center. Biopsy of an axillary lymph node revealed caseating epithelioid granulomas and Ziehl-Neelson staining was positive for acid-fast bacilli. The patient started therapy for tuberculosis and polychemotherapy for lymphoma with complete response. This report illustrates a case of simultaneous occurrence of tuberculosis and systemic follicular lymphoma presenting in skin in an HIV patient.

Simultaneous lymphoma and squamous cell carcinoma presenting as a neck lump

We describe the unusual presentation of a patient with simultaneous follicular lymphoma and metastatic head and neck squamous cell carcinoma. He was initially treated for his lymphoma and then, following no regression in his cervical lymphadenopathy was referred for further assessment. This revealed squamous cell carcinoma arising from the left tongue base with metastatic disease in the left neck.

Molecular characteristics and prognostic significance of Bcl-2/IgH gene rearrangement in Serbian follicular lymphoma patients

Follicular lymphoma (FL) is characterized by the presence of a t(14;18) chromosomal translocation that results in overexpression of bcl-2 protein. Bcl-2/IgH gene rearrangement is detected in 80-90% of follicular lymphomas in Western countries. The aim of this study was to analyze the bcl-2/IgH rearrangement in FL lymphoma patients in Serbia, by PCR technique, correlate molecular findings with clinical characteristics and outcome and assess the prognostic significance of these rearrangements. One hundred-seven patients (median age, 54 years; male/female ratio:60/47) diagnosed with FL were included in the study. DNA samples were obtained from paraffin embedded lymphoid tissue of patients. Bcl-2/IgH rearrangement was assessed for the major breakpoint region (MBR), 5' MBR and the minor cluster region (mcr) breakpoints by PCR technique. We detected a t(14;18) in 81.3% (87/107) of patients. The distribution of bcl-2-IgH rearrangement was as follows: 88,5% (77/87) in MBR breakpoint, 10,35% (9/87) in 5' MBR, whereas mcr bcl-2-IgH rearrangement was observed in one patient (1.15%). No rearrangements were detected in remaining 20 patients (18.7%). This is the first analyses of the frequency of the bcl-2/IgH gene rearrangement in Serbian FL patients, as well as in Eastern European countries. There was no correlation between presence of bcl-2/IgH gene rearrangement and clinical outcome of disease. Incidence of bcl-2/IgH gene rearrangement in Serbian FL patients is relatively high, and similar to frequency in Western countries. Presence of this rearrangement in tumor tissue is not of prognostic significance.

Protein-losing enteropathy in a case of nodal follicular lymphoma without a gastrointestinal mucosal lesion

Protein-losing enteropathy (PLE) is characterized by gastrointestinal loss of serum protein. It is usually caused by hypersecretion from a tumor, ulcer, or long standing lymphangiectasia. However, we report a 47-year-old man of peritoneal nodal follicular lymphoma who developed PLE with none of them. Oozing of whitish fluid from duodenal bulbar mucosa was endoscopically seen, resulting in continuous loss of protein. Chemotherapy was effective and PLE was rapidly diminished. Nodal lymphoma lesion was considered to disturb lymphatic flow and to regurgitate it to duodenal mucosa. To our knowledge, this is the second report of a lymphoma patient presenting PLE without a gastrointestinal mucosal lesion.

Primary cutaneous follicle center lymphoma -'crosti lymphoma': what can we learn?

In 1951, Crosti reported on seven patients with 'reticulo-histiocytoma of the back' who presented with figurate erythematous plaques and nodules on the back or lateral trunk. Reticulo-histiocytoma of the back was later classified as a primary cutaneous follicle center lymphoma (PCFCL). A definitive diagnosis of the condition is frequently delayed because of a relative lack of clinical symptoms and difficulties in interpretation of the histologic findings. Indeed, a number of primary cutaneous B-cell lymphomas have been mislabeled as pseudolymphomas in the past. We present a case of PCFCL that initially demonstrated predominantly small T lymphocytes on histology. These findings were interpreted as an inflammatory pseudolymphomatous reaction. However, small lymphocytes, whether B or T cells, in early lesions of cutaneous B-cell lymphomas should not automatically be considered 'reactive.' Persistent antigenic stimulation of lymphocytes in a neoplastic process or by an antigen, for example, Borrelia burgdorferi, can lead to transformation and cell division with development of large blast cells. In our patient, the initial scarcity of B lymphocytes also led to further diagnostic difficulties. Although the association of primary cutaneous B-cell lymphoma with Borrelia infection is known, there are still difficulties in differentiating the condition from pseudolymphoma. Such difficulties can in part be ascribed to the morphologic changes such lymphomas can undergo over time. The initially small number of B cells that may be seen at first in PCFCL infiltrates may increase in number in longer-standing lesions. It is also important to recognize that inability to verify monoclonality should not exclude the diagnosis of lymphoma.

Treatment of follicular lymphoma--a review

Follicular non-Hodgkin's lymphomas are indolent malignancies that have to be treated repeatedly when symptoms occur. Traditionally, several chemotherapeutic schedules are used. As a result there is a progressive shortening of the disease-free periods and no chemotherapeutical treatment has resulted in a survival benefit so far. The introduction of rituximab, a monoclonal anti-CD 20 antibody, and the association of rituximab with first-line chemotherapy has resulted in a prolongation of the progression-free survival (PFS) and seems to have an impact on (overall survival) OS. The low toxicity profile has even made maintenance therapy with rituximab possible. Trials with rituximab in maintenance suggest a survival benefit. The most optimal schedule of administration and the pharmaco-economical implications are, however, not obvious yet. Autologous stem cell transplantation (SCT) at first remission is another treatment option that has to be re-evaluated. Apart from that there is also the possibility of radio-immunotherapy, of which the advantage will have to become clear during follow-up of recent phase III trails.

''Minor'' BCL2 breakpoints in follicular lymphoma: frequency and correlation with grade and disease presentation in 236 cases

Follicular lymphomas are frequently associated with the t(14;18)(q32;q21). This translocation can be detected by karyotype, polymerase chain reaction (PCR), and fluorescence in situ hybridization (FISH). In addition to the breakpoints currently used for diagnosis located in the major breakpoint region (MBR) and the minor cluster region (mcr), recent studies have reported the existence of other breakpoints (3' BCL2, 5'mcr, and icr). In this study, we examined the frequency of all five breakpoints in 236 cases of follicular lymphomas by real-time PCR analysis. The distribution of breakpoint sites consisted of MBR in 118 cases (50%), mcr in 11 (5%), icr in 32 (13%), 3' BCL2 in 13 (6%), and 5' mcr in three cases (1%). These findings illustrate significantly higher frequency of the icr breakpoint as compared with the more frequently studied mcr. Correlation of breakpoints with histology showed that MBR breakpoints occur more frequently in grade 2 lymphomas (P = 0.042). A majority of the PCR-negative cases (75%) contained an IGH/BCL2 translocation with FISH methods, suggesting the presence of other BCL2 breakpoints. Correlation of breakpoints with survival did not reveal significant differences. Diagnostic laboratories should consider expanding their PCR methods to include other BCL2 breakpoints and correlating with FISH methods when appropriate.

Natural history of follicular grade 3 non-Hodgkin's lymphoma

PURPOSE OF REVIEW

Follicular lymphoma grade 3 is recognized as a distinct entity in the World Health Organization classification of lymphomas. There is confusion regarding the natural history of these lymphomas, because some studies indicate an indolent behavior and others show more aggressive behavior. This review examines the biological and clinical characteristics of follicular lymphoma grade 3 and compares these characteristics with other lymphomas.

RECENT FINDINGS

Several reports suggest that follicular lymphoma grade 3 has molecular and genetic characteristics that distinguish these lymphomas from other grades of follicular lymphoma. These characteristics are often more common in patients with diffuse large B-cell lymphoma than follicular lymphoma. It is impossible to make firm recommendations on management because prospective trials are lacking. Nevertheless, recent studies have demonstrated that follicular lymphoma grade 3 patients treated with anthracycline-based therapy have similar outcomes to patients with diffuse large B-cell lymphoma.

SUMMARY

Patients with follicular lymphoma grade 3 should be treated with curative intent. They should receive aggressive anthracycline-based therapy combined with rituximab, which is identical to therapy used for patients with diffuse large B-cell lymphoma.

[Follicular (nodular) non Hodgkin's lymphoma of tonsil--case report]

INTRODUCTION

Non Hodgkin's lymphomas quite often present in the head and neck region and after squamous cell carcinoma are the second most common neoplasm of this area. The most predominant localization for extranodal NHL in the head and neck region is the tonsil. The vast majority of NHL at this site are B-cell lymphomas, including diffuse large B-cell lymphoma, follicular lymphoma, mantle cell lymphoma, extranodal marginal zone B-cell of MALT type.

MATERIAL AND METHODS

The authors presented the case of primary extranodal non Hodgkin's lymphoma of the right tonsil in patient with the long history of chronic tonsillitis and after bilateral tonsillectomy. The affected tonsil together with enlarged lymph node was surgically removed. The histologic examination detected follicular (nodular) non Hodgkin's lymphoma, grade 3. The patient was refered to the Hematology and Oncology Department for additional treatment.

RESULTS

In the Hematology and Oncology Department staging was conducted recognizing lymphoma--clinical stage I according to Ann Arbor. The patient was treated with R-COP regiment (six cycles rituximab + COP- cyclophosphamid, vincristin, prednisolon). The complete remission was achieved. The patient is in observation period both in Otolaryngology and Hematology Department.

CONCLUSION

Recurrent, non-typical chronic tonsillitis with enlarged neck nodes may be follicular lymphoma's symptom, especially in older patients.

Pseudolymphomatous Cutaneous Angiosarcoma: A Rare Variant of Cutaneous Angiosarcoma Readily Mistaken for Cutaneous Lymphoma

Cutaneous angiosarcoma is probably the most malignant neoplasm involving the skin. Three clinical variants of cutaneous angiosarcoma are recognized, including angiosarcoma of the scalp and face of elderly patients, angiosarcoma associated with chronic lymphedema, and postirradiation angiosarcoma. Histopathologically, these three variants of angiosarcoma show similar features, which consist of poorly circumscribed, irregularly dilated, and anastomosing vascular channels lined by prominent endothelial cells that dissect through the dermis. Focally, neoplastic endothelial cells show large, hyperchromatic, and pleomorphic nuclei, protruding within vascular lumina and creating small papillations. Usually, inflammatory infiltrate is sparse and consists of a patchy, perivascular lymphoid infiltrate around the neoformed vessels. In rare instances, cutaneous angiosarcomas may exhibit prominent inflammatory infiltrate, and the neoplasm may be mistaken for an inflammatory process, both from clinical and histopathologic points of view. We describe four examples of cutaneous angiosarcomas with dense lymphocytic infiltrates involving the neoplasm. Immunohistochemically, lymphocytes expressed immunoreactivity for CD3, CD5, and CD45 markers, whereas the germinal centers were positive for CD20, CD79a, and Bcl-6. The neoplastic endothelial cells expressed immunoreactivity for the CD31, CD34, podoplanin, Prox-1, Lyve-1, and D2-40. We discuss the possible relationship between neoplastic endothelial lymphatic cells and reactive lymphocytes. Cutaneous angiosarcoma with prominent lymphocytic infiltrate may be readily mistaken for cutaneous follicle center cell lymphoma or cutaneous pseudolymphoma.

Value of ultrasound-guided core biopsy in the diagnosis of malignant lymphoma

PURPOSE

Ultrasound-guided core needle biopsy for the diagnosis and management of malignant lymphomas is controversial and has not been accepted as an alternative to surgical biopsy. We investigate the clinical usefulness of this procedure in a large series of patients.

METHODS

Over a 5-year period (2000-2004), ultrasound-guided core needle biopsies were performed in 102 malignant lymphomas. Five diagnostic categories were considered: large B-cell lymphomas (LBCL), small B-cell lymphomas (SBCL), Hodgkin's disease (HD), T cell lymphomas, and miscellaneous. Surgical excisional biopsy of the node was performed in 47 cases (46.1%) for diagnostic confirmation.

RESULTS

The overall diagnostic accuracy of ultrasound-guided core needle biopsy was 88.2% (90/102). SBCL (39), LBCL (36), HD (15), T cell lymphomas (5), and miscellaneous (7) [including T cell-rich B cell (2), natural killer cell (1), Burkitt's lymphoma (1), and non-Hodgkin's lymphoma of the B cell type, NOS (3)] were correctly diagnosed. Three HDs, 1 natural killer cell lymphoma, 1 follicular lymphoma, and 1 LBCL were not correctly diagnosed. The core needle biopsy did not yield tumor tissue in 6 cases.

CONCLUSIONS

Ultrasound-guided core needle biopsy is effective in the diagnosis of malignant lymphomas and can be used as the first diagnostic approach in selected clinical situations.