Optic neuropathy due to anaplastic large cell lymphoma

PURPOSE

To report a case of anaplastic large cell lymphoma (ALCL) of the central nervous system (CNS) producing an optic neuropathy.

METHODS

Observational case report.

RESULTS

A 29-year-old male presented with new onset headaches. Magnetic resonance imaging (MRI) of the brain revealed a large enhancing parietal lobe mass. Ocular exam at that time was normal. Initial diagnoses included possible bacterial cerebritis and fungal abscess. Serial lumbar punctures showed increased white blood cells but cytology was negative. A brain biopsy was non-diagnostic. The patient then presented with a left optic neuropathy. Repeat MRI of the brain and orbits revealed infiltration of the clivus and left orbital apex including the optic nerve. The patient had elevated liver function studies and an abdominal ultrasound disclosed two hypoechoic lesions. Liver biopsy confirmed the diagnosis of ALK-1 positive ALCL. The patient was treated with chemotherapy but expired seven months after the initial presentation.

CONCLUSION

ALCL should be considered to be a very rare but potential cause of optic neuropathy. To our knowledge, this is the first reported case of ALCL causing an optic neuropathy.

Post transplant anaplastic large T-cell lymphoma

Post transplant lymphoproliferative disorders (PTLD) are a heterogeneous group of lymphoid proliferation that ranges from polyclonal hyperplasia to monoclonal malignant lymphoma. We report a 13-year-old boy who was diagnosed with PTLD in February 2007 after 3 1/2 years of deceased renal transplantation. We treated him with an adapted ACVBP (doxorubicin, cyclo-phosphamide, vincristine, bleomycin and prednisone) regimen. He responded well to the chemo-therapy without deterioration of graft function.

Antineoplastic agents for pediatric anaplastic large cell lymphoma: Vinblastine is the most effectivein vitro

Anti-neoplastic effects of a total of 11 agents (adriamycin, briplatin, cytarabine, dexamethasone, etoposide, 4-hydroperoxycyclophosphamide, 4-hydroperoxyifosphamide, methotrexate, predonisolone, vinblastine, vincristine) were tested on 4 cell lines (DEL, Ki-JK, SR-786, SU-DHL-1) established from pediatric ALCL cases. The individual cell lines were treated with those agents at different concentrations (0.01 microM/L, 0.1 microM/L, 1 microM/L, 10 microM/L, 100 microM/L) for 1 h or 24 h, and their cellular growths were measured by the microculture tetrozolium (MTT) assay. Of those anti-neoplastic agents, methotrexate, vinblastine, and vincristine were highly effective on the cell growth inhibition in all these cell lines with time- and dose-dependent manner. Among them, vinblastine was found to be the most effective in 3 cell lines (DEL, Ki-JK, SR786) with 50% effective doses (ED50, concentrations causing 50% cell survival after treatment) ranging from 0.0016 to 1.27 microM/L for the 1-h treatment and 0.0002 - 0.59 microM/L for the 24-h treatment. Further experiments demonstrated that vinblastine treatment induced cellular apoptosis and caused severe disruption in mitotic spindle formation on these cell lines. The results support the protocol of ALCL 99 study, which uses vinblastine as one of the first-line anti-neoplastic agents for the high-risk ALCL patients in the pediatric age group.

[Efficacy of modified B-NHL-BFM-90 protocol on anaplastic T-cell lymphoma in children and adolescents]

BACKGROUND AND OBJECTIVE

Anaplastic T-cell lymphoma in children and adolescents is an aggressive malignant non-Hodgkin's lymphoma (NHL). The optimal treatment regimen needs to be investigated. This study was to evaluate the efficacy of modified B-NHL-BFM-90 protocol on anaplastic T-cell lymphoma in children and adolescents.

METHODS

From October 2002 to January 2008, 18 untreated anaplastic T-cell lymphoma patients aged less than 16 years were enrolled, and treated with modified B-NHL-BFM-90 protocol including cyclophosphamide, vincristine, ifosfamide, etoposide, adriamycin, HD-methotrexate, vindesine, dexamethasone, cytarabine/HD-cytarabine. Intrathecal injection was given every course.

RESULTS

Of the 18 patients, 15 (83.3%) achieved complete remission (CR), and three (16.7%) achieved partial remission (PR). The patients were followed up for 4-68 months (median, 31 months). The 3-year event-free survival (EFS) rates were (87.4+/-8.4)% for all patients, 100% for stage II patients, and (85.1+/-9.7)% for stage III/IV patients; 100% for low risk group, (88.9+/-10.5)% for moderate risk group, and (80.0+/-17.9)% for high risk group. Most patients suffered from grade 3-4 myelosuppression and recovered after active support care. One patient with stage IV disease received autologous peripheral blood stem cell transplantation (PBSCT) after CR and was still alive. Two patients had tumor relapsed and died at three and five months after off treatment, respectively.

CONCLUSIONS

Modified B-NHL-BFM-90 protocol, with tolerable toxicity, is an effective treatment regimen for anaplastic T-cell lymphoma in children and adolescents. It should be used in experienced cancer centers and hematological units.

[Primary bone anaplastic large cell lymphoma]

INTRODUCTION

Anaplastic large cell lymphoma (ALCL) is a neoplasia of T-cell or null-cell origin accounting for approximately 3% of non-Hodgkin lymphomas in adults and 10-30% of lymphomas in children. It involves the lymph nodes as well as various extranodal sites, but the involvement of bone as either the primary or secondary site of spread, is rare.

CASE REPORT

A 47-year-old male presented with an ALCL and multiple bone lesions involving the vertebrae, ribs, and iliac bone, with no other site of involvement. Histologic findings included interstitial and focal bone infiltrate consisting of large pleomorphic cells with an inflammatory background and marked fibrosis. There was immunohistochemical expression of CD30, EMA, CD45RO, CD43, CD8, Glut-1 and ALK-1.

DISCUSSION

There are 20 reported cases of ALCL (T/null cell) arising from the bone. To diagnose primary bone lymphoma it is necessary to first exclude systemic lymphoma of the lymph nodes or the skin with bone spread. The differential diagnoses include osteomyelitis, small round cell tumors, mainly Ewing sarcoma/PNET, metastatic carcinoma, melanoma, Hodgkin lymphoma and Langerhans' cell histiocytosis. In this case, the differential FDG accumulation in the lesions observed in the PET-CT was associated with the degree of Glut-1 expression.

[High-dose polychemotherapy of patients with poor-prognosis anaplastic T.0-large cell ALK+ lymphosarcoma]

AIM

To evaluate efficacy of the protocol NHL BFM-90 in the treatment of adult anaplastic large cell lymphosarcoma (ALCL) ALK+ and validity of addition of transplantation of autologous stem hemopoietic cells (ASHC) into first line treatment.

MATERIAL AND METHODS

We treated 13 patients with stage III-IV ALCL ALK+. The age of the patients ranged from 17 to 44 years (median 26 years). The diagnosis was made using morphological, histological, immunohistochemical methods with application of monoclonal antibodies to CD30, ALK, CD3, CD4, CD8, CD7, CD34, CD15, CD68, CD20, CD45RO, CD45RA. The patients were treated according to the protocol NHL BFM-90. ASHC was made in two patients with the disease stage IV.

RESULTS

We obtained a complete remission in 12 of 13 patients, one woman died of infectious complications in the beginning of the treatment, one man had early recurrence 45 days after the end of the treatment with lethal outcome and disease progression. Two patients at stage IV and poor prognosis had undergone ASHC transplantation. They are now in remission for 5 and 12 months.

CONCLUSION

ALCL ALK+ is characterized by an aggressive clinical course (11 of 13 patients had stage III-IV), high rate of extranodal lesions. Twelve patients achieved a complete remission, 11 (91.6%) of 12 patients are alive in observation median 27 months. We effectively used ASHC transplantation in the first-line treatment of 2 patients with stage IV of the disease and poor prognosis.

Clinical analysis of primary systemic anaplastic large cell lymphoma: a report of 57 cases

BACKGROUND AND OBJECTIVE

The clinical characteristics and prognosis of primary systemic anaplastic large cell lymphoma (ALCL) are various according to different reports. Anaplastic lymphoma kinase (ALK), a specific marker of primary systemic ALCL, is related with its clinical characteristics and prognosis. This study was to investigate the clinical characteristics and prognosis of primary systemic ALCL, and to explore the expression and clinical significance of ALK.

METHODS

Clinical data of 57 primary systemic ALCL patients, treated in Cancer Center of Sun Yat-sen University from January 1997 to January 2006, were reviewed. The expression of ALK in 46 tumor specimens was detected by SP immunohisochemistry.

RESULTS

The median age of the 57 patients was 30. The male/female ratio was 1.9:1. Of the 57 patients, 33 (57.9%) had B symptoms, 23 (40.4%) had Ann Arbor stage III-IV tumors, and 23 (40.4%) had extranodal disease at diagnosis. All patients received chemotherapy. Of the 56 evaluable patients, 40 (71.4%) achieved complete remission. The overall response rate was 96.4%. With a median follow-up of 49.1 months, the median time to progression was 35.2 months and the expected 5-year survival rate was 65.2%. The expected 5-year survival rate was significantly higher in low/low-intermediate International Prognostic Index (IPI) risk group than in high-intermediate/high IPI risk group (68.9% vs. 33.3%, p = 0.010). The positive rate of ALK was 63.0% in the 46 cases detected. Compared with ALK-negative patients, ALK-positive patients were younger (p = 0.001) and had higher expected 5-year survival rate (p < 0.01). Multivariate analysis confirmed the independent prognostic values of ALK expression, primary disease site and lactate dehydrogenase (LDH) level.

CONCLUSIONS

Primary systemic ALCL usually occurs in young patients, with good response to chemotherapy and good prognosis. No ALK expression, high-intermediate/high IPI, extranodal disease and elevated LDH level are correlated to unfavorable prognosis.

[HIV-related multiple non-Hodgkin lymphomas]

A 35-year-old man was admitted with continuous general fatigue and low grade fever. He was HIV-positive, and had gastric diffuse large B-cell lymphoma and renal T-cell anaplastic large cell lymphoma (T-ALCL). We diagnosed double lymphomas related to AIDS. The patient received anti-retroviral therapy, and started the CHOP regimen for the double lymphomas, resulting in transient improvement. However, fever again appeared during HAART and CHOP treatment, and a right inguinal subcutaneous lesion appeared. Biopsy specimen demonstrated null cell ALCL, and this patient demonstrated multiple lymphomas. This case suggested that cancer generation was promoted by low immunity, although it is known that ambivalent tumors such as non-Hodgkin lymphomas can occur frequently.

Successful use of the anti-CD25 antibody daclizumab in an adult patient with hemophagocytic lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) is a rare and severe inflammatory disorder marked by abnormal cytotoxic T and natural killer cell activity, resulting in impaired clearance of pathogen, excessive cytokine production, and continued immune system activation. Soluble IL-2 receptor (sIL-2R or sCD25) is typically elevated in HLH and can serve as a marker of disease activity, although its role in the pathophysiology of the disease is unclear. Here we present a case of an adult patient with steroid-dependent HLH who was treated successfully with daclizumab, a monoclonal anti-CD25 antibody, allowing successful withdrawal of steroid therapy without an increase in symptoms.

Long-term remission of children with relapsed and secondary anaplastic large cell non-Hodgkin lymphoma (ALCL) following treatment with pulsed dexamethasone and low dose etoposide

Anaplastic large cell lymphoma (ALCL) accounts for approximately 15% of childhood NHL. Relapsed ALCL represents a formidable challenge because outcome is poor despite the use of high-dose chemotherapy regimens. We report two patients with relapsed T-type and 0-type ALCL who achieved long-term 3rd and 4th remissions with 4-weekly oral dexamethasone (DEX) and etoposide pulses for 2 years. This regimen also induced and maintained remission in a third patient with Nijmegen breakage syndrome (NBS) with secondary T-type ALCL. These patients demonstrate that low-intensity oral chemotherapy can induce long-term remissions and offer a curative perspective in refractory, relapsed and secondary ALCL.

[Efficacy of therapy of different variants of anaplastic large T-cell lymphomas]

AIM

To compare efficacy of NHL-BFM-90 and CHOP-like courses in the treatment of anaplastic large cell lymphoma (ALCL).

MATERIAL AND METHODS

Twenty-two patients with ALCL participated in the study. The diagnosis was made basing on the findings of clinical, device, morphological, immunohistochemical and molecular-genetic examinations with application of a panel of monoclonal antibodies to CD30, ALK, CD3, CD4, CDS, CD7, CD34, CD15, CD68, CD20, CD45RO, CD45RA, Ki-67. 14 cases of 22 were negative by kinase of anaplastic lymphocytes (ALK-) and 8 were positive (ALK+). Mean age of ALK-ALCL patients was 39.6 +/- 4.1 years, of ALK+ALCL patients - 23.4 +/- 2.6 years. 14 patients were treated by the protocol NHL-BFM-90, 8 were initially treated with other schemes (CHOP, MACOP-B, BEACOPP and others). All 14 patients treated according to NHL-BFM-90 had ALCL stages III-IV with B-symptoms. 12 patients who completed treatment by the above protocol achieved complete remission after the forth course, 2 patients failed the treatment. Of 8 ALCL patients treated initially according to other schemes, a complete remission was achieved in 4 patients (2 had stage II). One of 4 patients with remission had recurrence. Four patients who had failed to achieve complete remission died of the disease progression.

CONCLUSION

ALCL occurs more frequently in young and middle-aged patients. The disease has an aggressive course with rapid generalization. For such processes it is more preferable to use a modified protocol NHL-BFM-90.

Successful treatment for recurrence of primary cutaneous anaplastic large-cell lymphoma in elderly patient with etoposide, mitoxantrone, cyclophosphamide, vincristine, prednisolone and bleomycin (VNCOP-B) therapy

Primary cutaneous anaplastic large cell lymphoma (C-ALCL) is a malignant lymphoma with a relatively good prognosis, consisting of CD30-positive, undifferentiated, large cells. We report an elderly patient with C-ALCL which recurred after cyclophosphamide, doxorubicin, vincristine and prednisone (CHOP) therapy, but was effectively treated with the third-generation etoposide, mitoxantrone, cyclophosphamide, vincristine, prednisolone and bleomycin (VNCOP-B) regimen. It is characterized by the completion of treatment in 8 weeks, its applicability on an outpatient basis, and a low incidence of cardiotoxicity and mucosal symptoms. Although our patient had no side-effects during chemotherapy, patients should be carefully monitored for side-effects, especially infection. In conclusion, the VNCOP-B regimen might be an effective treatment for elderly patients with good performance status, CHOP-resistant patients or patients with aggressive non-Hodgkin's lymphoma.

Infant anaplastic lymphoma: case report and review of the literature

Anaplastic large cell lymphoma (ALCL) is a well-known entity, but there are no data on prognosis according to the age of the patient, especially in infants. A 2-month-old girl was admitted with a 2-week history of coughing, fever, and lymphadenopathy. Physical examination revealed mild respiratory distress, an erythematous macular rash on her trunk, massive cervical lymphadenopathy, splenomegaly, and very mild ascites. Chest radiograph showed bilateral pulmonary infiltrates, pleural effusion, and a mediastinal mass. CBC count showed WBC: 172,000/microL (PMN 40%, lymphocytes 47%, monocytes 3%); hemoglobin concentration: 8.7 g/dL; platelets: 390,000/microL. Cervical lymph node biopsy revealed anaplastic lymphoma with positive staining to ALK 1 and TIA 1. Immunophenotypic analysis of peripheral and bone marrow lymphoid cells showed an aberrant T-cell immunophenotype, including expression of CD3, CD45R0+, CD43+, and CD30+. Cytogenetic analysis performed on blood and bone marrow samples demonstrated the translocation t(2;5) (p23;q35), and trisomy 47. After leucophoresis, the child received chemotherapy according to the ALCL-99-EICNHL protocol, and was started on corticosteroids and cyclophosphamide, which resulted in marked improvement. After the second course, WBC decreased to 6000/microL without tumor lysis syndrome, but the child developed bacterial and fungal disseminated infections and died of septic shock with multiorgan failure. This report is of a rare case of infant anaplastic lymphoma and excellent response to treatment. Unfortunately, she did succumb to overwhelming infection. More reports of similar cases may determine the cause and prognosis of such children, helping to tailor therapy according to the age of the child and other prognostic factors, especially bone marrow involvement.

[Expression and clinical significance of Mcl-1 in T-cell non-Hodgkin's lymphoma]

BACKGROUND & OBJECTIVE

The prognosis of T-cell non-Hodgkin's lymphoma (T-NHL) is poor. Overexpression of myeloid cell leukemia-1 (Mcl-1) gene could inhibit irradiation-and drug-induced apoptosis in several lymphoma cell lines. This study was to detect the expression of Mcl-1 in T-NHL of various subtypes, and explore its correlation to clinicopathologic features and prognosis of T-NHL.

METHODS

The expression of Mcl-1 protein in 72 specimens of T-NHL was detected by immunohistochemistry. The clinical features, treatments, and outcomes of the T-NHL patients were analyzed retrospectively.

RESULTS

The weak positive rates of Mcl-1 were 44.4% in precursor T lymphoblastic lymphoma (T-LBL), 0% in anaplastic large T-cell lymphoma (ALCL), and 18.9% in other peripheral T-cell lymphoma (PTL); the positive rates were 0%, 100%, and 49.1%, respectively (P<0.001). Weak diffuse cytoplasmic staining of Mcl-1 was detected in T-LBL, and strong cytoplasmic staining with perinuclear accentuation was detected in ALCL. The overall survival time was significantly longer in the PTL patients with high Mcl-1 expression than in the PTL patients with weak/negative Mcl-1 expression (>32 months vs. 15 months, P=0.007), and longer in the T-LBL patients without Mcl-1 expression than in the T-LBL patients with weak Mcl-1 expression (21 months vs. 7 months, P=0.58).

CONCLUSIONS

The intensities of Mcl-1 expression in T-NHL of various histological subtypes are different. It is specifically highly expressed in ALCL. High expression of Mcl-1 is correlated to better prognosis of PTL.

Translocations and mutations involving the nucleophosmin (NPM1) gene in lymphomas and leukemias

Nucleophosmin (NPM) is a ubiquitously expressed nucleolar phoshoprotein which shuttles continuously between the nucleus and cytoplasm. Many findings have revealed a complex scenario of NPM functions and interactions, pointing to proliferative and growth-suppressive roles of this molecule. The gene NPM1 that encodes for nucleophosmin (NPM1) is translocated or mutated in various lymphomas and leukemias, forming fusion proteins (NPM-ALK, NPM-RARalpha, NPM-MLF1) or NPM mutant products. Here, we review the structure and functions of NPM, as well as the biological, clinical and pathological features of human hematologic malignancies with NPM1 gene alterations. NPM-ALK indentifies a new category of T/Null lymphomas with distinctive molecular and clinico-pathological features, that is going to be included as a novel disease entity (ALK+ anaplastic large cell lymphoma) in the new WHO classification of lymphoid neoplasms. NPM1 mutations occur specifically in about 30% of adult de novo AML and cause aberrant cytoplasmic expression of NPM (hence the term NPMc+ AML). NPMc+ AML associates with normal karyotpe, and shows wide morphological spectrum, multilineage involvement, a unique gene expression signature, a high frequency of FLT3-internal tandem duplications, and distinctive clinical and prognostic features. The availability of specific antibodies and molecular techniques for the detection of NPM1 gene alterations has an enormous impact in the biological study diagnosis, prognostic stratification, and monitoring of minimal residual disease of various lymphomas and leukemias. The discovery of NPM1 gene alterations also represents the rationale basis for development of molecular targeted drugs.

Anaplastic large cell lymphoma of bone--is it a bad tumor?

A teenage boy presented with a CD30-positive anaplastic large cell lymphoma (ALCL) affecting his scapula and was successfully treated with chemotherapy. His clinical features and outcome were compared with other cases described in the literature. A further review of 11 ALCL cases with bony involvement treated in the UK since 1990, including two with primary bone disease, did not suggest an unfavorable treatment outcome. This finding will need to be confirmed by further study on a larger patient cohort with primary bone ALCL.

Limited predictive value of real-time quantitative PCR cytomegalovirus monitoring in the blood. Fatal CMV pneumonia in an autologous stem cell transplant recipient previously treated with alemtuzumab

BACKGROUND

Patients treated with alemtuzumab are at very high risk for cytomegalovirus (CMV) reactivation. Also, in those who develop reactivation short time before stem cell transplantation the risk of fatal complications is extremely high.

CASE REPORT

We describe a 21-year-old patient with anaplastic large T-cell lymphoma who developed CMV reactivation after alemtuzumab treatment and received high-dose chemotherapy with autologous stein cell transplantation for progressive disease and severe bone marrow aplasia. Blood samples of the patient were tested regularly for CMV reactivation with real-time quantitative PCR. Even though it is considered the most sensitive available method it did not allow us to predict in advance development of fatal CMV pneumonia in this patient.

CONCLUSIONS

The case report illustrates limitations of prognostic value of quantitative real-time PCR CMV assessment in blood samples.

CD30+, large T-cell lymphoma: diagnostic distinction and management

Cutaneous T-cell lymphoma (CTCL) has a variable presentation and comprises a broad diagnostic group. Histologic and immunophenotypic confirmation is needed to establish a precise diagnosis. Once the categorization is determined, prognosis and therapeutic algorithms unfold. Primary cutaneous, CD-30+, anaplastic, large T-cell lymphoma represents an indolent form of CTCL that often spontaneously involutes.