Successful treatment of a child with late-onset T-cell post-transplant lymphoproliferative disorder/lymphoma

We report a novel regimen for refractory post-transplant T-cell lymphoma (PTL). Our patient presented with non-Epstein-Barr virus (EBV) related, T-cell post-transplant lymphoproliferative disease (PTLD) 3.5 years after liver transplantation. Initially diagnosed as polyclonal PTLD, the disease progressed to a monoclonal, T-cell PTL that was refractory to several chemotherapy regimens but responded to a regimen consisting of fludarabine, cyclophosphamide, cytarabine, and alemtuzumab. Consolidation therapy included high-dose chemotherapy, autologous hematopoietic stem cell rescue, and radiation therapy. She remains in remission 2.5 years later. T-cell PTL is a rare disease with a poor prognosis; this regimen provides a novel, potentially curative approach for its treatment.

[Clinical characteristics and prognostic factors in 73 patients with peripheral T cell lymphoma]

OBJECTIVE

To investigate the clinical features,therapy and prognosis of patients with peripheral T cell lymphoma(PTCL), and to find out the prognostic factors of the disease.

METHODS

The clinical data of 73 patients with PTCL were reviewed.The median pre-treatment disease course was 3 months.Fifty-five patients were males, and 18 were females, with the median age of 42 years.Five patients received the combined chemo-radio therapy, 65 received chemotherapy alone, and the other 3 patients were treated with auto hematopoietic stem cell transplantation (HSCT).

RESULTS

Of all the patients, the overall 3 -year and 5-year survival rates were 38% (28 /73) and 22% ( 16 /73) respectively.The survival rates decreased with the progression of the Ann Arbor stages.The survival rate of the patients with B symptom (fever, night sweat, and weight loss) or the international prognostic factors index ( IPI)>2 was lower than those of the patients without B symptom or IPI<2.The patients with the increased CA125 or D-dimer lever had the worst curative effect.

CONCLUSION

Peripheral T cell lymphoma is highly aggressive with poor prognosis.The clinical features,Ann Arbor staging, IPI and B symptom are important prognostic factors.CA125 and D-dimer may be also important prognostic factors.

[A case of peripheral T cell lymphomas-unspecified in vertebra canal]

Peripheral T cell lymphomas-unspecified (PTCL-U) is an uncommon malignant tumor, accounting for 5%-7% of non-Hodgkin's lymphoma. Clinical feature of a case of PTCL-U was investigated and the optimal treatment protocol was proposed. The clinical presentation of this case was progressing limbs weakness with sudden paralysis. Multiple superficial lymph nodes swelling and decreased sensation in all modalities below T10 level were found in physical examination. Bilateral leg paralysis (Grade 0/5) with high muscle tension, overactive knee reflex, bilateral Babinski sign (+) were present. Magnetic resonance imaging(MRI) showed the mass, which was around spinal cord located in T6-T8 vertebra canal, with intense enhancement after the administration of gadolinium diethylenetriamine penta-acetic acid. Abnormal signal in multiple centrum and accessories could also be found in MRI scan. Initial diagnosis was lymphoma, multiple systems involved. Laminectomy and epidural tumor resection were performed immediately. The dural sac was narrowed obviously by surrounding tumor. The result of pathological examination was PTCL-U. After operation, the level of pain sensation was descent, and touch sensation recovered. The patient received chemotherapy and his muscle strength was partly recovered in 4 months. Early diagnosis of peripheral T cell lymphomas-unspecified was difficult and easily misdiagnosed with poor prognosis. A review of literature showed central nervous system lesions occurred in advanced stage. However, the report of representation of intraspinal mass as initial symptom like the case was rare. For acute paraplegia, laminectomy and tumor resection should be performed as soon as possible. Regular radiotherapy and chemotherapy should be considered after operation. However, the value of local chemotherapy need to be further investigated.

Ocular involvement as the initial manifestation of T-cell chronic lymphocytic leukemia

PURPOSE

To present a case of T-cell chronic lymphocytic leukemia (T-CLL) manifesting as an intraocular lymphoma.

DESIGN

Interventional case report.

METHODS

We performed a vitreous biopsy in a 67-year-old woman who presented with blurred vision and vitreous cellular infiltration. Morphologic, immunohistochemical, flow cytometry, and molecular analysis by polymerase chain reaction of vitreous fluid, peripheral blood, bone marrow aspirate, and biopsy were performed.

RESULTS

Cytofluorographic and molecular analysis of vitreous cells demonstrated a monoclonal T-cell population consistent with a T-cell intraocular lymphoma. Systemic evaluation established diagnosis of T-cell CLL.

CONCLUSION

T-CLL is a rare disease with an aggressive clinical course. We present a case of T-cell intraocular lymphoma as the initial manifestation of an otherwise asymptomatic T-CLL.

Peripheral T-cell Lymphomas

Peripheral T-cell lymphomas (PTCLs) are a biologically diverse and uncommon group of diseases. Compared to their B-cell counterparts, PTCLs remain largely unexplored and the optimal treatment ill-defined due to disease rarity and biological heterogeneity. With the notable exception of ALK-pos anaplastic large cell lymphoma (ALCL), the prognosis of most PTCL subtypes is extremely is poor with a 5 y overall survival of approximately 15-30% in most series. The international prognostic index has been useful in defining different risk groups within some PTCL subtypes, including PTCL unspecified (PTCLU). Attempts have been made to define disease subgroups within the biologically heterogeneous PTCLU based on T-helper chemokine receptor profile and/or gene expression profiling which may aid in tailoring new therapies. Future clinical trials are needed that focus specifically on PTCL to advance our understanding and define the optimal management in this disease.

The role of high-dose therapy and stem cell rescue in the management of T-cell malignant lymphomas: a BSBMT and ABMTRR study

Peripheral T-cell lymphomas (PTCL) are a rare and heterogeneous subset of lymphomas with a poorer prognosis compared with B-cell lymphomas. We conducted a retrospective study of 82 patients who received high-dose therapy for PTCL (autologous SCT (ASCT) N=64; allogeneic SCT (Allo-SCT) N=18). With a median follow-up from ASCT of 37 months from transplant, 33 patients were alive; 20 died of progressive disease, 10 died from non-relapse mortality (NRM) with 1 unknown cause. Three-year overall survival (OS) and progression-free survival (PFS) were 53% (95% confidence interval (CI) 42, 67) and 50% (95% CI 39, 64), respectively. Factors significantly affecting OS and PFS on univariate analysis were histological subtype and chemotherapy sensitivity. In a multivariate analysis, the only factor with significant impact was chemotherapy sensitivity. After a median follow-up from Allo-SCT of 57 months, five patients were alive; five died of progressive disease and eight died from NRM. The 3-year OS and PFS were 39% (95% CI 22, 69) and 33% (95% CI 17, 64), respectively, and the 3-year relapse rate was 28% (95% CI 6, 50). These results demonstrate that high-dose chemotherapy with autologous stem cell rescue has a substantial role in the management of T-cell lymphoma. The use of full-intensity allogeneic transplantation is limited by high transplant-related mortality, and exploration of reduced intensity regimens is warranted.

Peripheral T-cell lymphoma, unspecified - the analysis of the data from the Czech Lymphoma Study Group (CLSG) registry

BACKGROUND

Peripheral T-cell lymphoma, unspecified (PTCL-US) is one of the entities from the infrequent family of nodal mature T-cell lymphomas. The clinical course is aggressive, and despite multiagent chemotherapy, the median survival is about 2 years. Published data are limited to retrospective, mostly single-center studies or reviews and usually include more lymphoma subtypes.

AIM

To evaluate the current treatment modalities, clinical outcome and prognostic factors in unselected, new diagnosed patients with PTCL-US in the population of the central european region (Czech Republic).

METHOD

Czech Lymphoma Study Group is a national scientific organization which provides an on-line database registry which collects a data about almost all new diagnosed lymphoma patients since year 2000. All diagnostic biopsies were reviewed by a reference pathologist.

RESULTS

We analyzed 63 patients with new diagnosis of PTCL-US. The median age was 59 years (25-81), chemotherapy (CHT) was administered in 56 of the 63 patients: anthracyclin-based CHT in 51%, intensive CHT in 21% and non-anthracyclin regimen was applied in 13% of the patients. The overall response rate was 74.4%, (CR in 57.4%). After a median follow-up of 19.6 months, 41% of the patients were in CR, 3.4% in PR or stable disease and 55% of the patients died. The estimated survival probability in 3 years was 36%. Clinical stage (IV) and CR achievement were found to be independent survival predictors in a multivariate analysis.

CONCLUSIONS

Although the current treatment modalities are mostly ineffective in PTCL-US, appropriate intensive treatment may lead to prolonged remission but not survival.

Primary ocular natural killer/T-cell lymphomas: clinicopathologic features and diagnosis

PURPOSE

Primary ocular natural killer/T-cell lymphoma (NKTL) is rare. This study aims to characterize the clinical manifestations, diagnosis and treatment methods of primary ocular NKTL.

METHODS

Clinical data of seven patients with ocular NKTL from 1982 to 2004 were collected. A morphologic, immunohistochemical and molecular analysis was undertaken.

RESULTS

Clinical manifestations and computed tomography of the patients were typical. LCA CD56 CD3epsilon Ki-67 granzyme B (GrB) and T-cell intracellular antigen-1(TIA-1) were mostly positive. Clonal T-cell-receptor gene rearrangements of five patients showed negative findings, and the detection of Epstein-Barr virus showed positive. All patients died 5 months to 28 months after presentation.

CONCLUSION

Ocular NKTL is a highly aggressive clinical course with poor prognosis. The diagnosis relies on clinicopathologic findings.

Spontaneous regression of non-Hodgkin's lymphoma in the oral cavity after incisional biopsy

We report a case of gingival T cell non-Hodgkin's lymphoma that responded initially to chemotherapy, recurred at another site a year later, but regressed spontaneously after incisional biopsy. We are not aware of any other reports about spontaneous regression of T cell lymphomas in the oral cavity.

The results of consolidation with autologous stem-cell transplantation in patients with peripheral T-cell lymphoma (PTCL) in first complete remission: the Spanish Lymphoma and Autologous Transplantation Group experience

BACKGROUND

Peripheral T-cell lymphoma (PTCL) is a heterogeneous group of aggressive lymphomas associated with poor prognosis with standard chemotherapy. Consolidation with autologous stem-cell transplantation (ASCT) may improve survival. We present 74 patients transplanted in first complete response (CR) from the Spanish Lymphoma and Autologous Transplantation Group cooperative group.

PATIENTS AND METHODS

Median age was 46 years. Eighty-eight percent presented advanced (III-IV) Ann Arbor stage; 53% had B symptoms; 52% had high lactate dehydrogenase; 65% had two or three risk factors of the adjusted-International Prognostic Index; 58% presented a high Tumor score and in 14% more than two adverse factors of the Prognostic Index for peripheral T-cell lymphoma (PIT) were observed.

RESULTS

With a median follow-up of 67 months from diagnosis, the 5-year overall survival (OS) was 68% and progression-free survival (PFS) reached 63%. The multivariate analysis showed that the only factor associated with a shorter OS and PFS was the presence of more than two risk factors from the PIT risk system.

CONCLUSIONS

In a retrospective study with a prolonged follow-up, consolidation with ASCT in CR patients who had presented unfavorable prognostic factors at diagnosis substantially increased the OS and PFS when compared with conventional chemotherapy. The PIT risk system identified 14% of patients without benefit from ASCT consolidation. Thus, other innovative therapies are still necessary in certain cases.

Prolonged survival of patients with angioimmunoblastic T-cell lymphoma after high-dose chemotherapy and autologous stem cell transplantation. The GELTAMO experience

OBJECTIVES

Angioimmunoblastic T-cell lymphoma (AIL) is a rare lymphoma with a poor prognosis and no standard treatment. Here, we report our experiences with 19 patients treated with high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT) within the GELTAMO co-operative group between 1992 and 2004.

METHODS

The median age at transplantation was 46 yr. Fifteen patients underwent the procedure as front-line therapy and four patients as salvage therapy. Most patients received peripheral stem cells (90%) coupled with BEAM or BEAC as conditioning regimen (79%).

RESULTS

A 79% of patients achieved complete response, 5% partial response and 16% failed the procedure. After a median follow-up of 25 months, eight patients died (seven of progressive disease and secondary neoplasia), while actuarial overall survival and progression-free survival at 3 yr was 60% and 55%. Prognostic factors associated with a poor outcome included bone marrow involvement, transplantation in refractory disease state, attributing more than one factor of the age-adjusted-International Prognostic Index, Pretransplant peripheral T-cell lymphoma (PTCL) Score or Prognostic Index for PTCL.

CONCLUSIONS

More than half of the patients with AIL that display unfavourable prognostic factors at diagnosis or relapse would be expected to be alive and disease-free after 3 yr when treated with HDC/ASCT. Patients who are transplanted in a refractory disease state do not benefit from this procedure.

High-dose chemotherapy and autologous stem cell transplantation for peripheral T-cell lymphoma: complete response at transplant predicts survival

Although the role of high dose chemotherapy (HDT) and autologous stem cell transplantation (ASCT) in the treatment of aggressive lymphoma has been established in several large prospective studies, its effectiveness in patients with peripheral T cell lymphoma (PTCL) has not been defined. We aimed to evaluate the efficacy of HDT and ASCT and prognostic factors for survival in patients with PTCL. We retrospectively analyzed the results of 40 PTCL patients treated with HDT and ASCT at Asan Medical Center between January 1995 and December 2005. Twenty patients had PTCL-U (peripheral T cell lymphoma, unspecified), 10 had extranodal natural killer/T cell lymphoma, 5 had anaplastic large cell lymphoma, 3 had angioimmunoblastic T cell lymphoma, 1 had hepatosplenic gammasigma T cell lymphoma, and 1 had disseminated mycosis fungoides. Disease status at transplant was complete response (CR)1 in 3 patients, CR2 or greater in 8, partial remission in 25, and refractory in 4. At a median follow-up of 16 months (range, 5 to 135 months) for surviving patients, the median overall survival (OS) was 11.5 months and the 1-year probability of survival was 46.1%. The median event free survival (EFS) was 3.6 months (95% confidence interval, 2.5 to 4.8 months). Ten patients (25%) remain alive without evidence of disease. The median OS of 11 patients with CR at ASCT was not reached; of these, 7 patients (63.6%) were alive with CR. In multivariate analysis, CR at ASCT was a prognostic factor for EFS (P = 0.025) and OS (P = 0.027) and normal lactate dehydrogenase (LDH) at ASCT was a prognostic factor for improved OS (P = 0.025). Chemosensitive patients with PTCL who achieved CR before ASCT seem to benefit from HDT and ASCT. Pretransplant values of LDH had potential to predict the survival.

Combination chemotherapy followed by autologous stem cell transplant for enteropathy-associated T cell lymphoma

Enteropathy-associated T cell lymphoma (EATL) is a rare entity associated with coeliac disease, with a poor prognosis due to perforation and gastro-intestinal bleeding during treatment, and a high relapse risk. Six patients were treated with two cycles of IVE (ifosphamide, etoposide, epirubicin), followed by two cycles of high-dose methotrexate (3 g/m(2)) with folinic acid rescue and a BEAM (carmustine, etoposide, cytarabine, melphalan) autograft. Enteral feeding was given throughout treatment. Four patients remain alive in complete remission at 1.83-4.32 years; two have relapsed. Given the historically poor outcome in these patients, this regimen appears very promising in the treatment of EATL.

A malignant itch

We report an unusual presentation of a previously healthy three-year-old Chinese girl with a four-week history of apparently unexplained generalized intense itch. She had no past history of atopy or xerosis. Despite the severe itch, she had only minimal scratch marks on her right gluteal region but no flexural involvement. The girl was treated as having scabies and eczema and with oral antihistamines by various dermatologists without much improvement. She subsequently presented to a regional hospital with right hip pain and fever. Radiological and histopathological investigations confirmed that she had a peripheral T-cell lymphoma. The itch pattern prior to and following chemotherapy, as documented by the DigiTrac wrist-held movement monitor, showed a dramatic reduction of her nocturnal itch. The pattern was also very different from that of atopic dermatitis in that the scratching was of much higher intensity but lower frequency. Intractable pruritus associated with a peripheral T-cell lymphoma has not been previously reported in the pediatric literature. This report serves to alert clinicians of the gold paradigm that in a patient with an unexplained generalized itch, lymphoma and other malignancies must be considered.

[Prolonged remission after immunotherapy of a previously refractory peripheral T-cell non-Hodgkin lymphoma]

HISTORY AND ADMISSION FINDINGS

A 54-year-old woman in good condition was admitted because of a rapidly growing tumor in the right groin with skin infiltration. There were no B-symptoms and no increased susceptibility to infections.

INVESTIGATIONS

Histology revealed a peripheral T cell non-Hodgkin lymphoma (NHL). Laboratory tests showed borderline elevation of lactate dehydrogenase. Staging computed tomography (CT) revealed widespread moderately enlarged lymph nodes and the main lesion in right groin measuring 5 x 6 cm which was classified as stage IIIAE.

TREATMENT AND COURSE

According to the phase-II-trial DSHNHL-2003 - 1 (German study group for high grade NHL) the patient was scheduled for cycles of CHOEP at 14-day intervals plus granulocyte colony stimulating factor. During the first cycle she developed a worsening wound infection and an infection of her port catheter. Because response to treatment was only minimal a biopsy was performed which showed persisting malignant lymphoma. As a result she was not given the 4-weekly addition of alemtuzumab, as provides in the study protocol. Instead she received alemtuzumab subcutaneously for eight weeks at a dose of 3 x 30 mg/week plus prophylactic antibiotics. A good partial response was obtained, followed by radiotherapy with 36 Gy to the main lesion in the right groin. The follow up CT-scans one year after treatment showed a stable remission.

CONCLUSION

In T-NHL with primary non-response it is especially difficult to induce a stable remission. Despite a course which was complicated by infections and a failing response to increased chemotherapy a remission was achieved in this patient with a monotherapy of alemtuzumab for eight weeks without complications, followed by radiotherapy.

Fulminant Epstein-Barr virus (EBV)-associated T-cell lymphoproliferative disorder with hemophagocytosis following autologous peripheral blood stem cell transplantation for relapsed angioimmunoblastic T-cell lymphoma

Post-transplant lymphoproliferative disorder (PTLD) is a complication that can develop after either solid-organ or hematopoietic stem cell transplantation (HSCT). T-cell PTLD is a rare disorder, especially following autologous HSCT. Here we report a case of T-cell PTLD which occurred after autologous peripheral blood stem cell transplantation (PBSCT) for relapsed angioimmunoblastic T-cell lymphoma (AILT). Three months after the transplant, the patient developed fever with elevated plasma Epstein-Barr virus (EBV)-PCR values. The patient subsequently developed pneumonitis, hepatomegaly and marked pancytopenia due to hemophagocytosis. The patient died of multi-organ failure, despite antiviral and steroid pulse therapy. Our post-mortem study confirmed the marked proliferation of EBV-infected T-cells that differed from the original AILT clone and macrophages/histiocytes were observed in the marrow, liver, lymph nodes and lungs. Phagocytosis was most evident in the bone marrow. The patient's AILT remained in complete remission. To the best of our knowledge, this is the first case of fulminant EBV-associated T-cell lymphoproliferative disorder (LPD) following autologous HSCT.

Autologous transplantation for relapsed or primary refractory peripheral T-cell lymphoma

Autologous transplantation (ASCT) is the standard of care for chemosensitive relapsed or primary refractory aggressive lymphoma, but little is known about its efficacy in the subset of patients with peripheral T-cell lymphoma (PTCL). We undertook a retrospective review of patients with PTCL who underwent ASCT for relapsed or refractory disease after responding to second-line therapy, excluding patients with indolent histologies and those with anaplastic lymphoma kinase (ALK) expressing anaplastic large cell lymphoma. The results of 24 patients with PTCL were compared with those of 86 consecutive patients with chemosensitive relapsed or primary refractory diffuse large B-cell lymphoma (DLBCL). With a median follow-up time of 6 years for surviving patients with PTCL and DLBCL, the 5-year progression-free survival (PFS) rates for PTCL and DLBCL patients were 24% and 34% respectively (P = 0.14); the corresponding overall survival (OS) rates were 33% and 39% respectively. There were no significant differences between the two groups with respect to time to disease progression or survival after progression. The second-line age-adjusted international prognostic index was the only variable prognostic for PFS and OS in a multivariate analysis. The outcome of ASCT for patients with chemosensitive relapsed or primary refractory PTCL is similar to that for patients with DLBCL.

Peripheral T-cell lymphoma with involvement of the expanded mantle zone

Peripheral T-cell lymphoma (PTCL) with a nodular architecture is rare. Recently, two variants have been described with infiltration of the B-cell follicle, one variant that localizes to the marginal zone with a so-called perifollicular growth pattern, and a variant that localizes to the germinal center. These lymphomas have a CD4+ phenotype and may express Bcl-6. We have studied five similar cases of PTCL with involvement of the B-cell follicle. However, our cases differ from the cases previously described by their predominant and frequently patchy involvement of the expanded mantle zone of the B-cell follicle at onset. Later biopsies in three of the cases show diffuse infiltration of the lymph node, without features of angioimmunoblastic TCL (AILT). All cases expressed Bcl-6 in addition to CD4. Cytogenetics was available in four of the cases but revealed no recurrent chromosomal aberrations or changes associated with other types of PTCL. No mutations of the BCL-6 gene were observed. Together, the cases seem to have an intermediately aggressive clinical behavior. Whether our cases are part of a spectrum of PTCLs that encompasses previously described variants with predominant marginal zone or germinal center infiltration or they represent a separate T-cell lymphoma type remains to be demonstrated by a study of more of such cases.

[Treatment outcome and prognosis of 112 patients with nasal and nasopharyngeal peripheral T cell lymphomas]

OBJECTIVE

To retrospectively analyze the treatment outcomes and prognostic factors of nasal and nasopharyngeal peripheral T cell lymphomas (PTCL) patients.

METHODS

One hundred and twelve patients with pathologically confirmed nasal and nasopharyngeal PTCL were included, among which 39 were CD56(+) NK/T cell lymphomas. The median pre-treatment disease course was 4 months. 84 were males and 28 females median age was 46 years. The tumors mainly involved nasal cavity (88 cases) and/or nasopharynx (50 cases) and adjacent structures, and 83 cases with extra-cavity diseases. 91.1% of the patients had Ann Arbor I(E)/II(E) diseases. The International Prognostic Indices (IPI) were less than 2 scores in 78.8% of the patients. Seventy two patients received combined chemo-radiotherapy, 32 chemotherapy only, 3 radiotherapy only and 5 no any treatment.

RESULTS

Median follow-up duration was 42 months. Chemotherapy achieved a complete remission (CR) rate of 34.4% for initial treatment, and of 65.1% after primary treatment. The local tumor controlled rate was 50.5%, and the median time to tumor progression (TTP) was 11 months. There were evidences of systemic relapse in more than 30% of the patients. The extra-cavity tumors usually had a shorter TTP (r(s) = -0.191, P = 0.024). The progress-free survival and overall survival rates were 38.8% and 52.4% at 3 years, and 34.9% and 44.8% at 5 years respectively. Univariate analysis showed that favorable prognostic factors for survival were pre-treatment course > 3 months, earlier clinical stage, non NK/T lymphoma, no skin involvement, lower IPI, CR after initial chemotherapy, radiotherapy, CR after primary treatment and local tumor controlled. Multivariate analysis showed that, pre-treatment course > 3 months (P = 0.011), non NK/T lymphoma (P = 0.007), CR after initial chemotherapy (P = 0.008) and radiotherapy (P = 0.000) were favorable prognostic factors for survival.

CONCLUSIONS

Although most nasal and nasopharyngeal peripheral T-cell lymphomas were diagnosed at early stage diseases, some of them were highly aggressive with poor prognosis, particularly CD56(+) NK/T cell lymphomas. Combination chemo/radiotherapy, though remained principal treatments, more effective therapeutic modalities are expected.

The Role of High-Dose Therapy in Peripheral T-Cell Lymphomas

Peripheral T-cell lymphomas (PTCLs) represent a heterogeneous group of non-Hodgkin's lymphomas. With few exceptions (eg, anaplastic large-cell lymphoma expressing the anaplastic lymphoma kinase), PTCLs have generally been reported to have a worse prognosis compared with B-cell lymphomas. Despite the poor outcome after conventional therapy, the impact of high-dose therapy with autologous or allogeneic stem cell transplantation (SCT) in these rare diseases is poorly defined mainly because of the lack of prospective PTCL-restricted studies. Most data exist for high-dose therapy with autologous SCT in relapsing or refractory disease. Because most studies showed similar results for PTCL compared with aggressive B-cell lymphomas in which high-dose therapy with autologous SCT is accepted as standard therapy, this approach seems appropriate in relapsing or refractory PTCL. Results for high-dose therapy with autologous SCT as first-line therapy mainly rely on studies on aggressive lymphomas that also included lymphomas of the T-cell phenotype. Our own recently published PTCL-restricted prospective study confirmed the feasibility with only moderate toxicity and a good response rate. Overall, patients with a good remission status after induction therapy exhibited a high complete response rate after transplantation, and at least a subgroup of patients remained in long-term remission. The greatest uncertainty exists for the impact of allogeneic SCT after high-dose therapy. In refractory or relapsing PTCL, this approach might improve the outcome for eligible patients, especially when using reduced-intensity conditioning. Overall, because data on high-dose therapy for PTCL are limited, larger and randomized studies are necessary to definitely confirm the preliminary results.

Therapy of Peripheral T/NK Neoplasms

The mature T/natural killer (NK) lymphoma/leukemias represent 5–15% of all non-Hodgkin lymphoma. These diseases have a geographic variation, with more nodal disease in North America and Europe, including peripheral T cell lymphomas, unspecified, anaplastic large cell lymphoma, and angioimmunoblastic T cell lymphoma; and more extranodal disease in Asia due to Epstein-Barr virus–related nasal NK/T lymphoma and human T-cell leukemia virus (HTLV)-1–associated adult T cell leukemia/lymphoma. The prognosis in most peripheral T/NK neoplasms is poor, with 5-year survival less than 30%. Progress has been slow due to the rarity of the diseases, geographic variation, relative chemoresistance, and lack of randomized trials. There is no consensus about optimal therapy in T/NK neoplasms, and recommendations are based on anecdotal reports, small series, and phase II trials. In this review, topics include the question of CHOP as standard therapy, prognostic factors, disease-adapted therapy, novel approaches, monoclonal antibody therapy, and stem cell transplantation.

Peripheral T-cell lymphoma together with myelofibrosis with elevated plasma transforming growth factor-beta1

Myelofibrosis is usually observed in myeloproliferative disorders, such as chronic myeloid leukemia. However, there are only a few reports showing an association between T-cell lymphoma and myelofibrosis. We report a case of peripheral T-cell lymphoma, unspecified (diffuse large cell) type, involving the bone marrow that was associated with severe myelofibrosis. In the present case, the plasma concentration of transforming growth factor-beta1 (TGF-beta1) was increased to 8.95 ng/ml (normal range: 1.56-3.24 ng/ml). No lymphadenopathy or skin lesions were observed during the entire clinical course. Although the mechanism of secondary myelofibrosis is still unclear, elevated plasma TGF-beta1 might be involved in the pathogenesis of bone marrow fibrosis in the present case.

The International Prognostic Index determines the outcome of patients with nodal mature T-cell lymphomas

The World Health Organization (WHO) lymphoma classification recognises anaplastic large cell lymphoma (ALCL), angioimmunoblastic lymphoma (AIL) and peripheral T-cell lymphoma, unspecified (PTCU) as nodal mature T-cell lymphomas. Little is known about long-term outcome and prognostic factors of these diseases. A retrospective analysis on 125 patients with ALCL, AIL or PTCU was performed to evaluate outcome parameters, taking into account histological subtype and the International Prognostic Index (IPI). Median age was 54 years (range 17-90 years). Complete remission (CR) was achieved in 51% of patients. Five-year overall survival (OS) was 43%, and 5-year relapse-free survival was 69%. Five-year OS was 61% for ALCL, 45% for PTCU and 28% for AIL. With regard to the IPI, 5-year OS was 74%, 49%, 21% and 6% for the low, low-intermediate, high-intermediate and high risk groups, respectively. In the multivariate analysis, the IPI but not the histological subtype significantly predicted survival. To a large extent, the IPI score explains the differences in survival between histological subtypes of nodal mature T-cell lymphomas. The IPI may therefore be used for risk stratification in clinical trials to identify patients who would benefit most from new treatment strategies, such as high-dose chemotherapy followed by stem cell or bone marrow transplantation.

Treatment of a Patient with a Nodal Peripheral T-Cell Lymphoma (Angioimmunoblastic T-Cell Lymphoma) with a Human Monoclonal Antibody Against the CD4 Antigen (HuMax-CD4)

A patient with a CD4+ refractory peripheral T-cell lymphoma (PTL), subtype angioimmunoblastic T-cell lymphoma (AILD), was treated with a human monoclonal anti-CD4 antibody (HuMax-CD4) iv once weekly for 10 wk. Early during treatment all palpable enlarged lymph nodes disappeared. A decline of normal CD4+ T-cells in the blood mirrored the treatment effect. Shortly after stopping treatment the patient relapsed with new enlarged lymph nodes. This time no antitumor effect was seen when HuMax-CD4 treatment was reinstituted. No severe side effects were observed during the antibody treatment. This case report is the first describing that HuMax-CD4 has antilymphoma activity in PTL and is an interesting drug to study further in patients with CD4+ PTL.

Aggressive Peripheral T-Cell Lymphomas (Specified and Unspecified Types)

Peripheral T-cell lymphomas (PTCLs) are a biologically diverse and uncommon group of diseases. Compared to their B-cell counterparts, PTCLs remain largely unexplored and the optimal treatment ill-defined due to disease rarity and biological heterogeneity. For the majority of PTCL subtypes, prognosis is poor with a 5-year overall survival of approximately 30% in most series.

The notable exception is ALK-positive anaplastic large-cell lymphoma (ALK-pos ALCL), which has a superior outcome. The international prognostic index can be used to some extent to define risk groups within some PTCL subtypes, including PTCL unspecified (PTCLUS). It is likely that the observed clinical heterogeneity reflects differences at the molecular level. With the more widespread availability of gene expression profiling, it may be possible in the future to further refine the classification of PTCLs and elucidate novel therapeutic targets. Future clinical trials are needed that focus specifically on PTCL to advance our understanding and define the optimal management in this disease.

Understanding the group of peripheral T-cell lymphomas, unspecified

Presumably diverse cases are at present lumped under the heading peripheral T-cell lymphoma, not otherwise categorized, or unspecified (PTCL-U), which comprise the largest group of T-cell neoplasms in Western countries. Although a variety of morphologic subtypes have been described, no consistent immunophenotypic, genetic, or clinical features have been associated with most of them. Hopefully, some progress can be expected from the novel sophisticated and powerful genomic and proteomics technologies, which may uncover the group of T-cell neoplasms, and perhaps identify some specific disease entities. An improved understanding of their biology may improve our ability to develop better treatments for these disorders. Indeed, these disorders are among the most aggressive lymphomas, representing a wide variety of infrequent clinicopathologic syndromes that share a dismal prognosis. The treatments used for diffuse large B-cell lymphoma have produced disappointing results in peripheral T-cell lymphoma. Clinical trials focusing specifically on these subtypes are therefore warranted. Novel strategies need to be developed and specific regimens including active agents in peripheral T-cell lymphoma should be investigated. This effort will be successful only if a large international collaboration can be set up because of the rarity of most subtypes.

Lymphoma of the colon

PURPOSE OF REVIEW

This review updates the status of the diagnosis of colonic lymphoma, whether primary or as part of a generalized presentation. Emphasis is on new entities such as mantle cell (MCL) and marginal zone (MZL) lymphomas. Presenting symptoms and signs are described where applicable and treatment and prognosis are covered briefly.

RECENT FINDINGS

Mantle cell lymphoma has a much higher incidence of colonic presentation than previously reported, presents mostly in asymptomatic patients, and is detected microscopically in 50% of patients after a biopsy of a visually benign mucosa. Likewise, patients with MZL have a higher incidence of colonic involvement than previously described. There are reports suggesting a receptor-driven homing mechanism in lymphoma genesis for both of these entities. Newer pathologic techniques are also making possible the diagnosis of unusual entities such as peripheral T-cell lymphomas and Hodgkin disease in patients with a history of chronic inflammatory disease.

SUMMARY

Gastrointestinal evaluation should be a part of the initial evaluation of patients with MCL and MZL, especially if it influences the decision to treat and the choice of treatment. Gastrointestinal evaluation should also be part of an adequate assessment of response and remission status in these patients, especially if the colon was originally involved. Patients with a history of chronic inflammatory bowel disease should have their biopsy specimens subjected to rigorous analysis including immunophenotypic and genotypic studies to rule out underlying lymphoma.

Autologous stem cell transplantation in adult patients with peripheral T-cell lymphoma: a nation-wide survey

Limited experience is available on the feasibility and efficacy of high-dose therapy (HDT) supported by autologous stem cell transplantation (ASCT) in patients with peripheral T-cell lymphoma (PTCL). Therefore, a nation-wide survey was conducted in adult patients transplanted for PTCL in Finland during 1990-2001. After histopathology review, 37 patients were identified. The median age was 46 years (16-68) at the time of ASCT. Histology included PTCL not otherwise specified in 14 patients, anaplastic large cell lymphoma (ALCL) in 14 patients, and other in nine patients. Disease status at the time of ASCT was CR/PR1 in 18 patients; CR/PR2 in 14 patients, and other in five patients. HDT consisted of either BEAC (N=22) or BEAM (N=15), supported by blood stem cells in 34 patients (92%). Early transplant-related mortality was 11%. With a median follow-up of 24 months from HDT, 16 patients (43%) have relapsed or progressed. The estimated 5-year overall survival (OS) was 54%. Patients with ALCL had superior OS when compared with other subtypes (85 vs 35%, P=0.007). OS at 5 years was 63% in patients transplanted in CR/PR1 vs 45% in those transplanted in other disease status (P=NS). Prospective studies are needed to define the role of ASCT in this lymphoma type.

Graft-Versus-Lymphoma Effect in Relapsed Peripheral T-Cell Non-Hodgkin's Lymphomas After Reduced-Intensity Conditioning Followed by Allogeneic Transplantation of Hematopoietic Cells

Purpose

Peripheral T-cell lymphomas (PTCLs) are a heterogeneous group of malignancies characterized by a poor prognosis. We performed a pilot study to investigate the role of reduced-intensity conditioning (RIC) followed by allogeneic stem-cell transplantation in relapsed or refractory PTCLs.

Patients and Methods

We have conducted a phase II trial on 17 patients receiving salvage chemotherapy followed by RIC and allogeneic transplantation of hematopoietic cells. The RIC regimen consisted of thiotepa, fludarabine, and cyclophosphamide. The acute graft-versus-host disease prophylaxis consisted of cyslosporine and short course methotrexate.

Results

Patients had a median age of 41 years (range, 23 to 60 years). Two patients were primary chemorefractory, and 15 had relapsed disease; eight patients (47%) had a disease relapse after an autologous transplantation. After a median follow-up of 28 months from the day of study entry (range, 3 to 57 months), 14 of 17 patients were alive (12 in complete remission, one in partial remission, and one with stable disease), two died as a result of progressive disease, and one died as a result of sepsis concomitant to acute graft-versus-host disease. The estimated 3-year overall and progression-free survival rates were 81% (95% CI, 62% to 100%) and 64% (95% CI, 39% to 89%), respectively. The estimated probability of nonrelapse mortality at 2 years was 6% (95% CI, 1% to 17%). Donor lymphocyte infusions induced a response in two patients progressing after allografting.

Conclusion

RIC followed by allogeneic stem-cell transplantation is feasible, has a low treatment-related mortality, and seems to be a promising salvage treatment for relapsed PTCL. These findings suggest that the existence of a graft-versus-T-cell lymphoma effect.

Peripheral T- cell lymphomas: diagnosis and management

Peripheral T-cell lymphomas are a diverse group of diseases with varying clinical manifestations. Response to conventional chemotherapy generally is poor. Treatment using purine analogs has achieved response rates between 25% and 60% in relapsed/refractory patients, with minimal toxicity. The highest response rates were seen with pentostatin and gemcitabine. Using purine analogs in combination therapy may improve response rates, albeit with an increased risk of toxicity. The role of purine analogs as first line therapy in patients who have otherwise favorable prognostic factors has not been defined. Monoclonal antibody therapy has emerged in the last decade as a promising approach in treating T-cell malignancies. Campath-1H is an effective and well-tolerated therapy in these diseases. Durable remissions have been seen in heavily pretreated patients and in up to two thirds of patients who had T-PLL, which is the largest disease group studied. These results in T-PLL are significantly better than those reported with other therapies; this suggests that Campath-1H should be moved to first line therapy in this aggressive disease. The way in which monoclonal antibodies work indicate that they may be particularly useful in treating patients who have minimal residual disease, and, in this setting, facilitate stem cell transplantation. In addition, the activity of Campath-1H to deplete T cells has been exploited in preparative regimens before allogeneic bone marrow transplantation. These approaches may be worth further investigation in patients who have T-cell lymphomas. None of the therapies that are available to treat the mature T-cell neoplasms seems to be curative, other than in selected patients who have favorable ALCL. Much of the data have been drawn from small, non-randomized studies. There is a need for larger, prospective, randomized trials to examine these novel therapies and to further explore combination regimens, which may exploit potential synergism.

[Successful treatment of refractory peripheral T-cell lymphoma by allogeneic peripheral blood stem cell transplantation]

A 40-year-old man was admitted to our hospital suffering from abdominal pain. He revealed marked splenomegaly, lymphadenopathy and pancytopenia. Lymph node biopsy showed diffuse proliferation of medium to large atypical lymphoid cells. Immunohistochemically the cells were positive for T-cell markers. He was diagnosed as having peripheral T cell lymphoma (PTCL) with involvement of the spleen and bone marrow. Because of refractoriness to combination chemotherapies and splenic irradiation, we performed allogeneic peripheral blood stem cell transplantation from an HLA-identical sister. Conditioning was consisted of conventional doses of total body irradiation and cyclophosphamide, and GVHD prophylaxis was performed with cyclosporine and methotrexate. After the patient developed grade III graft-versus-host disease, his splenomegaly improved dramatically. Although the effectiveness of allogeneic hematopoietic cell transplantation in the treatment of malignant lymphoma is controversial, we should consider this as a second-line therapy to refractory subsets of PTCL.

Peripheral T cell lymphoma: The Sheffield Lymphoma Group experience (1977-2001)

Peripheral T-cell lymphomas (PTCL) account for approximately 10% of all non-Hodgkin's lymphomas. The aim of this retrospective study was to analyse the presentation, management, outcome and significant prognostic factors in a large series of patients with PTCL. It includes 104 consecutive patients who presented to the Sheffield Lymphoma Group between 1977 and 2001. Clinical parameters were recorded for each subgroup. End points were response to treatment and survival. Survival analysis was used to assess the prognostic value of the variables. PTCL not otherwise specified contributed 52% of cases followed by anaplastic large cell lymphoma with 17% and angiocentric type with 13% of cases. The overall complete remission (CR) of the series was 59%. Stage at diagnosis affected response to treatment with 81% of cases in stage 1 and 2 achieving CR compared to 43% in stages 3 and 4 (p</=0.001). Extranodal presentations also showed a favourable response with 74% obtaining CR compared to 46% of nodal presentations (p<0.01). Median survival of all patients was 87 months with a five-year probability of survival of 52%. Variables found to be related to poor outcome are age >60 years (p<0.05), high grade histology (p<0.001), presence of B symptoms (p<0.005), nodal presentation (p<0.005) and advanced stage at diagnosis (p<0.001). Histological sub-type did not significantly correlate to outcome. In conclusion whilst a number of prognostic indicators can assist in determining the outcome in PTCL, these lymphomas are complex and often follow an unpredictable course. In order to make the best clinical decisions in individual cases, more clinical study is required.

Successful treatment of a patient with subcutaneous panniculitis-like T-cell lymphoma with high-dose chemotherapy and total body irradiation

A 24-yr-old man was referred for fever, right cheek swelling, subcutaneous tumor and liver dysfunction. Physical examination showed an elastic hard subcutaneous tumor on the right cheek, left axillary lymph node swelling and multiple small subcutaneous tumors in the trunk. Laboratory examinations showed elevated levels of transaminase, soluble interleukin-2 receptor and ferritin. Biopsy of the subcutaneous tumor showed proliferation of medium-sized cells with abundant clear cytoplasm and hyperchromatic nuclei among the subcutaneous fat tissues. These cells showed CD3+, CD4-, CD8+, CD56- and CD20- phenotype and possessed cytotoxic molecules such as granzyme B and T-cell intracellular antigen-1. Bone marrow aspiration showed proliferation of small numbers of abnormal lymphocytes with severe hemophagocytosis. He was thus diagnosed as having subcutaneous panniculitis-like T-cell lymphoma (SPTCL) and treated with dose-escalated CHOP regimen. After three courses of the chemotherapy, he was further treated with high-dose chemotherapy and total body irradiation (TBI) with autologous peripheral blood stem cell rescue. Thereafter, he has been in remission for more than 2 yr. We consider that SPTCL with hemophagocytosis is an extremely aggressive disease, and high-dose chemotherapy and TBI should be included for the choice of the treatment.

Peripheral T cell lymphoma-associated hemophagocytic syndrome in a patient with human adjuvant disease

Hemophagocytic syndrome (HPS) is a rare complication of lymphoma. We report a 70-year-old woman with human adjuvant disease who developed lymphoma-associated HPS (LAHPS) and elevated serum soluble interleukin (IL)-2 receptor. Despite intensive therapy, she died of pneumonia. Necropsy revealed a prominent spleen containing atypical T cells and many erythrophagocytizing histiocytes.

Successful treatment of advanced peripheral T-cell lymphoma with an angiocentric growth pattern complicated with hemophagocytic syndrome by high-dose chemotherapy and autologous peripheral blood stem cell transplantation

Peripheral T-cell lymphomas (PTCL) account for about 10% of all lymphomas in Western countries, respond poorly to therapy, and have short survival with no sustained remission. Furthermore, the complication of hemophagocytic syndrome (HPS) sometimes makes the prognosis of this disease extremely worse. We report here a case of PTCL with an angiocentric growth pattern complicated with HPS successfully treated by high-dose chemotherapy and autologous peripheral blood stem cell transplantation. Our case suggests this approach is an excellent candidate for the treatment of this disease.

Treatment of peripheral T-cell lymphomas (PTCL) with high-dose chemotherapy and autologous or allogeneic hematopoietic transplantation

Peripheral T-cell lymphomas (PTCL) are a rare entity of non-Hodgkin's lymphomas (NHL). Despite the poor outcome after conventional chemotherapy, the impact of high-dose chemotherapy (HDCT) and autologous or allogeneic stem cell transplantation is not well defined in these patients. In a retrospective study, we evaluated the outcome of 15 patients (9 male, 6 female) with PTCL after HDCT with autologous (10 patients) and allogeneic (5 patients) stem cell transplantation between 1996 and 2001 at our department. At the time of transplantation three patients were in second remission, seven patients were in partial remission (PR), and three patients had refractory disease. Two patients were treated with sequential HDCT (cyclophosphamide, adriamycin, vincristine, etoposide, prednisolone, m-CHOEP). The conditioning regimes were heterogeneous. After HDCT ten patients (67%, autologous 7, allogeneic 3) achieved CR, two patients (13%, autologous 2, allogeneic 0) had refractory disease, and three patients (20%, autologous 1, allogeneic 2) died because of toxic side effects before evaluation of response was performed. The median overall survival (OS) was 12 months. The 1-year probability of survival for the autologous and allogeneic groups was 58% and 40%, respectively. At the time of evaluation, six patients are alive and nine patients have died (four severe infection, one late toxicity, two disease progression, and two relapse). Despite the small number of patients in this study, HDCT with autologous or allogeneic hematopoietic transplantation seems to be an effective treatment option that can achieve CR for patients with PTCL. Because of the poor outcome of these patients after conventional chemotherapy, HDCT seems to be a rational option in first-line therapy. Whether it improves survival in these patients should be further investigated.

Gamma delta T-cell neoplasms: a clinicopathological study of 11 cases

BACKGROUND

The majority of T-cell neoplasms express T-cell antigen receptor (TCR) alpha beta on their cell surface, and a few cases show the TCR gamma delta phenotype. Recently, a variety of gamma delta T-cell neoplasm was recognized; however, its clinicopathological features have not been extensively analyzed. Here we report the results of a clinicopathological study of 11 cases of gamma delta T-cell neoplasm.

PATIENTS AND METHODS

During the 11-year period from 1989 to 1999, 104 patients with T-cell neoplasms were examined by flow cytometric analysis and/or immunohistochemical analysis. Tumor cells from all 104 patients expressed one or more of the T-cell antigens-CD2, CD3, CD5 and CD7. Forty-nine of the 104 cases of T-cell neoplasms were examined immunophenotypically for TCR alpha beta/gamma delta subsets.

RESULTS

Expression of TCR gamma delta on tumor cells was found in five (33%) of 15 patients with precursor T-cell lymphoblastic leukemia/lymphoma, one (25%) of four with T-cell granular lymphocytic leukemia and five (26%) of 19 with peripheral T-cell lymphoma (PTCL), whereas no expression was found in 11 patients with adult T-cell leukemia-lymphoma. Primary sites of the five patients with gamma delta PTCL were as follows: lymph node, three; skin, one and liver, tonsil and skin, one. The courses of the three patients with gamma delta PTCL of nodal onset were very short (3, 5 and 9 months, respectively), and they were all resistant to combination chemotherapies.

CONCLUSIONS

Although gamma delta T-cell neoplasm constitutes a heterogeneous population, it is important to examine the expression of TCR with the view to identifying possible poor prognostic subgroups, such as primary nodal gamma delta T-cell lymphoma.

High-dose chemotherapy and autologous peripheral blood stem cell transplantation for treatment of unspecified peripheral T-cell lymphoma presented with hepatosplenomegaly and hypercytokinemia syndrome: report of three cases

We report here three cases of peripheral T-cell lymphoma unspecified (PTCL-US), which presented with bone marrow infiltration and hepatosplenomegaly and were successfully treated with high-dose chemotherapy (HDCT) and autologous peripheral blood stem cell transplantation (auto-PBSCT). The patients were all characterized by cytokine-induced symptoms such as fever, anasarca, cytopenia, poor general condition, and disseminated intravascular coagulation syndrome. Laboratory data showed extremely high levels of soluble interleukin-2 receptor, beta(2)-microglobulin, and ferritin. All three patients were negative for anti-adult T-cell leukemia antibody. In one patient, hemophagocytosis was revealed by a histological examination of the bone marrow. The International Prognostic Index was high for all three patients, and they all achieved complete remission after the intensive chemotherapy for remission induction. During complete remission, they were treated with HDCT [modified interleukin-converting enzyme regimen] followed by auto-PBSCT. The recovery of hematopoiesis after auto-PBSCT was prompt and sustained engraftment was obtained. No serious adverse effects other than myelosuppression were noted. One patient died due to cerebrovascular disease without relapse 18 months after auto-PBSCT. The other two patients are still alive and have not suffered from relapse. Our observations suggest that auto-PBSCT following HDCT may be an effective and safe therapeutic modality for high-risk PTCL-US patients characterized by hepatosplenomegaly and cytokine-induced syndrome.

Peripheral T-cell lymphoma

Peripheral (post-thymic) T-cell lymphoma consists of a wide spectrum of disorders with marked differences in biology and behavior. Proper classification is pivotal for evaluating treatment results, and most studies performed a decade ago lump together different disease entities and cannot be interpreted. With improved use of immunophenotyping and molecular methods for these disorders, their exact nature is better defined in the Revised European-American Lymphoma and subsequent World Health Organization (WHO) classifications. The WHO classification of post- thymic T/natural killer (NK)-cell lymphoma consists of 15 entities, including about 30% that are unclassified cases. A wide range in incidence exists between different populations, but it is likely to be lower than previously estimated. Certain entities, like nasal/nasal-type T/NK-cell lymphoma and human T-cell leukemia/lymphoma virus 1, are much more prevalent in certain racial groups and show exquisite viral association. In these entities as a group, prognosis and treatment seem inferior to those of their B-cell counterparts, but treatment must be tailored to the exact pathologic diagnosis and prognostic index. Aggressive combination chemotherapy appears to be curative for certain entities (eg, anaplastic lymphoma kinase-positive), whereas purine analogues may be useful for low-grade entities. The role of autologous and allogeneic stem cell transplantation is still poorly defined. Specific antibody-based therapy is also on the horizon.

Primary cutaneous non-Hodgkin's lymphoma with aggressive histology: inferior outcome is associated with peripheral T-cell type and elevated lactate dehydrogenase, but not extent of cutaneous involvement

BACKGROUND

The aim of this study was to explore the association between extent of cutaneous involvement, presenting features and progression-free survival (PFS) in patients with primary cutaneous non-Hodgkin's lymphoma (PCNHL) of aggressive histology.

METHODS

Previously untreated patients with localized or extensive PCNHL of aggressive histology, treated with combination chemotherapy, but excluding lymphoblastic lymphoma and mycosis fungoides and its variants, were reviewed retrospectively.

RESULTS

We identified 53 patients, of whom 52 (35 males, 17 females) were treated with doxorubicin-based regimens. Median age was 52 years (range 25-81 years), and disease was localized and extensive in 37 and 16 patients, respectively. Twenty-four patients had diffuse large B-cell lymphoma, nine had grade 3 follicular lymphoma, 13 had peripheral T-cell lymphoma (PTCL; not otherwise specified) and seven had anaplastic large cell lymphoma (WHO classification). With a median follow-up of 101 months (range 2-237 months) for survivors, the 10-year PFS was 65 +/- 7% and overall survival was 72 +/- 8%. The first failure involved the skin in 33% of B-cell and 91% of relapsing T-cell lymphomas. Univariate analysis revealed that PTCL (P = 0.005), lymphopenia (P = 0.01) and high serum levels of beta(2)-microglobulin (P = 0.0006) and LDH (P = 0.002), but not extent of skin involvement, were associated with inferior PFS. Multivariate analysis revealed that only PTCL and high serum lactate dehydrogenase (LDH) were independently associated with inferior PFS.

CONCLUSIONS

PTCL and elevated serum LDH level, but not extent of cutaneous involvement are associated with inferior PFS in aggressive PCNHL treated with combination chemotherapy.

Multifocal primary CNS T cell lymphoma of the spinal cord

The majority of primary central nervous system lymphomas (PCNSL) are of B cell origin, and those of T cell origin are a distinct rarity. Furthermore, spinal cord involvement of T cell PCNSL is extremely rare and only a small number of cases have been reported. The authors report a case of multifocal T cell PCNSL mainly involving the intramedullary (IM) portion ofthe spinal cord in a 57-year-old woman. Neurological examination showed right leg weakness and hypesthesia below the T10 level. Magnetic resonance images revealed multiple well enhancing masses in the IM portion ofthe cervical and thoracic spinal cord and the cerebellum. Cytological examination of the cerebrospinal fluid revealed no malignant cells. As the mass at the C7 level was the largest among multiple masses, open biopsy was performed at that level. Histopathological examination confirmed malignant peripheral T cell lymphoma, unspecified (PTCL-U), small- and medium-sized cell type. Clinical and laboratory investigations failed to reveal any evidence of lymphomatous deposits elsewhere in the body. After biopsy, the patient received cranio-spinal irradiation, which included the whole brain and the spinal neuraxis. The clinical course, pathological findings and treatments are discussed and a review of the literature included.