Primary non-Hodgkin's lymphoma of the nose and nasopharynx: clinical features, tumor immunophenotype, and treatment outcome in 113 patients

Natural Killer T-Cell Lymphoma of the Tongue

Lymphoma, which represents about 5.4% of all neoplasms and, more significantly, 19% to 28% of malignant neoplasms, is the most common nonepithelial malignancy of the head and neck area in Koreans. Natural killer T-cell (NK/T-cell) lymphoma is a lymphoma of putative natural killer cell lineage. NK/T-cell neoplasms are generally rare, but they are more common in people of East Asian, Mexican, or South American descent. These neoplasms are highly aggressive and show a strong association with Epstein-Barr virus. The preferential site of extranodal NK/T-cell lymphoma is the nasal cavity, and there has been no report of NK/T-cell lymphoma developing from the tongue. We encountered a rare case of NK/T-cell lymphoma of the tongue, which we report with a review of the literature.

Esophageal metastasis secondary to extranodal nasal-type natural killer/T-cell lymphoma: A case report

We herein report a case of recurrent nasal natural killer (NK)/T-cell lymphoma in a 21-year-old male patient. The patient presented with an esophageal mass, fever and difficulty in swallowing. There were no other obvious sites of recurrence apart from the esophageal lesion. Metastatic esophageal lesions are extremely rare. The histological analysis demonstrated a highly aggressive tumor with a characteristic angiodestructive growth pattern and nasal cavity necrosis. The lymphoma cells were immunopositive for leukocyte common antigen, T-cell intracytoplasmic antigen 1 and CD68, negative for CD56 and CD3, and positive for Epstein-Barr virus. A computed tomography scan revealed mild thickening of the wall of the lower esophagus. The barium swallow revealed stiffness of the esophageal wall, with limited expansion and mucosal damage. The final diagnosis was primary nasal NK/T-cell lymphoma, with metastasis to the esophagus. Clinically, it is important to distinguish nasal-type NK/T-cell lymphoma from other types of tumors, as its prognosis and treatment of secondary metastases differ significantly.

Clinical findings of extranodal SNT lymphoid malignancies in a four-decade single-centre series

Sinonasally located lymphoid malignancies are rare lesions with first symptoms similar to other obstructive conditions. Additionally, they often coexist with nasal inflammation and mucosal necrosis. Therefore, time from the first symptoms to diagnosis tends to be long. Awareness and early diagnosis of this disease entity could improve treatment outcome. Altogether, 142 patients with sinonasal or nasopharyngeal (i.e. sinonasal tract, SNT) lymphoid malignancies, diagnosed and treated at the Helsinki University Hospital, during a 39-year period from 1975 to 2013, were retrospectively reviewed. There were 90 males (63 %) and 52 females (37 %) with a median age of 64 years (range 26-92). Eighty-four percent of the patients had primary diseases and 16 % had relapses of lymphoid malignancies primarily diagnosed at other locations. The mean duration of symptoms prior to diagnosis was 4.8 months (range 0.5-24). The most common histological entity was diffuse large B-cell lymphoma (43 %), followed by plasmacytoma (18 %). The most common location was nasopharynx (58 %) followed by nasal cavity (44 %) and paranasal sinuses (35 %). Sixty-nine percent of the lesions were at a single anatomic location of the sinonasal tract. Fifty-two percent of the cases were of Ann Arbor Stage I. Lymphoid malignancies form an important and diverse group in the differential diagnosis of SNT tumours. They most often present with general obstructive nasal symptoms due to tumour location. Most of them are primary lesions, highlighting the importance of an accurate diagnosis as early as possible.

Nasal Cavity and Paranasal Sinuses

The nasal cavity and paranasal sinuses occupy the top of the upper respiratory tract and form pneumatic spaces connected with the atmosphere. They are located immediately beneath the base of the cranium, where crucial vital structures are harbored. From this region, very much exposed to airborne agents, arise some of the more complex and rare benign and malignant lesions seen in humans, whose difficulties in interpretation make this remarkable territory one of the most challenging in the practice of surgical pathology.

Contents of this chapter cover inflammations and infections, polyps and pseudotumors, fungal and midfacial destructive granulomatous lesions, as well as benign, borderline, and malignant neoplasms. Among the neoplasms, emphasis is made on those entities characteristic or even unique for the sinonasal region, such as Schneiderian papillomas, glomangiopericytoma, intestinal- and non-intestinal-type adenocarcinomas, olfactory neuroblastoma, nasal-type NK-/T-cell lymphoma, and teratocarcinosarcoma. Moreover, recently recognized entities involving this territory, i.e., HPV-related non-keratinizing carcinoma, NUT carcinoma, and SMARCB1-deficient basaloid carcinoma, are also discussed in the light of their specific molecular findings. Furthermore, the text is accompanied by numerous classical and recent references, several tables, and 100 illustrations.

NHL - Extranodal T-cell lymphoma

Extranodal NK/T-cell lymphoma, nasal type (ENKL) is a rare lymphoid neoplasm that in the past has been grouped with a variety of granulomatous diseases. ENKL occurs in all age groups. However, it seems to occur more often in people in their 50s and affects more men than women. It is strongly linked to the Epstein-Barr virus (EBV), especially in people of Asian countries. Because this type of lymphoma occurs in organs or tissues other than lymph nodes, it is called ENKL. This is a case report of a 25-year-old female patient who presented with a nonhealing ulcer at the right nasal ala involving the upper lip and cheek for the last 2 months, which had been treated with antitubercular treatment without success. After biopsy and immunohistochemical (IHC) analysis, the patient had been diagnosed a case of extranodal T-cell lymphoma.

Primary cutaneous lymphomas: diagnosis and treatment

Primary cutaneous lymphomas (CLs) are a heterogeneous group of lymphoproliferative neoplasms, with lymphatic proliferation limited to the skin with no involvement of lymph nodes, bone marrow or viscera at the diagnosis. Cutaneous lymphomas originate from mature T-lymphocytes (65% of all cases), mature B-lymphocytes (25%) or NK cells. Histopathological evaluation including immunophenotyping of the skin biopsy specimen is the basis of the diagnosis, which must be complemented with a precise staging of the disease and identification of prognostic factors, to allow for the choice of the best treatment method as well as for the evaluation of the treatment results.

Extranodal natural killer/T-cell lymphoma, nasal type, of the orbit mimicking recurrent orbital cellulitis

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, is a rare type of lymphoma that is endemic to East Asia and parts of Central and South America. Most patients present with nasal obstruction, sinusitis, ulcer, and epistaxis due to a destructive mass involving the midline facial tissues. The patient visited our clinic approximately 1 year ago; she had right-sided orbital swelling and pain. The patient was sent to the department of ear, nose, and throat (ENT), and computed tomographic scan was performed. Computed tomographic imaging showed a soft tissue density in the right frontal, maxillary, and ethmoidal sinus and demonstrated fungal sinusitis in the right maxillary sinus. Then, she underwent the operation at ENT; her symptoms seemed to have disappeared. After 6 months, however, she had visited our clinic again because of a left-sided orbital cellulitis that seemed to be similar to the previous right-sided symptoms 1 year ago. She received treatments immediately and the operation again at ENT. In addition, a biopsy of left ethmoid sinus tissue was performed. The biopsy result revealed "chronic inflammation." However, unfortunately, the patient had a relapse of almost the same symptoms in a month. An excisional biopsy was performed for histopathologic diagnosis again. The left ethmoid sinus biopsy results were consistent with extranodal NK/T-cell lymphoma, nasal type. The patient then transferred her care to the department of internal medicine for chemotherapy. The authors demonstrate how the progressive-staging extranodal NK/T-cell lymphoma can present in a similar fashion as a recurrent orbital cellulitis.

Peripheral T-cell and NK cell lymphoproliferative disorders: cell of origin, clinical and pathological implications

T-cell lymphoproliferative disorders are a heterogeneous group of neoplasms with distinct clinical-biological properties. The normal cellular counterpart of these processes has been postulated based on functional and immunophenotypic analyses. However, T lymphocytes have been proven to be remarkably capable of modulating their properties, adapting their function in relationship with multiple stimuli and to the microenvironment. This impressive plasticity is determined by the equilibrium among a pool of transcription factors and by DNA chromatin regulators. It is now proven that the acquisition of specific genomic defects leads to the enforcement/activation of distinct pathways, which ultimately alter the preferential activation of defined regulators, forcing the neoplastic cells to acquire features and phenotypes distant from their original fate. Thus, dissecting the landscape of the genetic defects and their functional consequences in T-cell neoplasms is critical not only to pinpoint the origin of these tumors but also to define innovative mechanisms to re-adjust an unbalanced state to which the tumor cells have become addicted and make them vulnerable to therapies and targetable by the immune system. In our review, we briefly describe the pathological and clinical aspects of the T-cell lymphoma subtypes as well as NK-cell lymphomas and then focus on the current understanding of their pathogenesis and the implications on diagnosis and treatment.

Long-term Outcome of Extranodal NK/T Cell Lymphoma Patients Treated With Postremission Therapy Using EBV LMP1 and LMP2a-specific CTLs

Extranodal NK/T-cell lymphoma (ENKTCL) is associated with latent Epstein-Barr virus (EBV) infection and frequent relapse even after complete response (CR) to intensive chemotherapy and radiotherapy. The expression of EBV proteins in the tumor provides targets for adoptive immunotherapy with antigen-specific cytotoxic T cells (CTL). To evaluate the efficacy and safety of EBV latent membrane protein (LMP)-1 and LMP-2a-specific CTLs (LMP1/2a CTLs) stimulated with LMP1/2a RNA-transferred dendritic cells, we treated 10 ENKTCL patients who showed complete response to induction therapy. Patients who completed and responded to chemotherapy, radiotherapy, and/or high-dose therapy followed by stem cell transplantation (HDT/SCT) were eligible to receive eight doses of 2 × 10⁷ LMP1/2a CTLs/m². Following infusion, there were no immediate or delayed toxicities. The 4-year overall survival (OS) and progression-free survival (PFS) were 100%, and 90% (95% CI: 71.4 to 100%) respectively with a median follow-up of 55·5 months. Circulating IFN-γ secreting LMP1 and LMP2a-specific T cells within the peripheral blood corresponded with decline in plasma EBV DNA levels in patients. Adoptive transfer of LMP1/2a CTLs in ENKTCL patients is a safe and effective postremission therapeutic approach. Further randomized studies will be needed to define the role of EBV-CTLs in preventing relapse of ENKTCL.

A modified international prognostic index including pretreatment hemoglobin level for early stage extranodal natural killer/T cell lymphoma

In this study, we investigated the prognostic role of pretreatment hemoglobin level in 321 patients with stage I/II extranodal natural killer (NK/T cell lymphoma (ENKTL). Patients with pretreatment hemoglobin level < 120 g/L had significantly inferior progression-free survival (PFS) and overall survival (OS) than those with hemoglobin level ≥ 120 g/L (p < 0.05). In a multivariate Cox regression model, age, Eastern Cooperative Oncology Group (performance status), lactate dehydrogenase level, Ann Arbor stage and pretreatment hemoglobin level were all independent prognostic factors for PFS and OS (p < 0.05). Using these five parameters, a modified international prognostic index (mIPI) model was constructed. This mIPI could categorize three groups with significantly different PFS and OS (both p < 0.0001) in both the training set and the validation set. In conclusion, this study confirmed the prognostic role of pretreatment hemoglobin level in ENKTL, and a newly modified IPI including pretreatment hemoglobin level could be used to further optimize treatments for patients with stage I/II ENKTL, especially in the era of asparaginase.

Prognostic biomarkers in patients with localized natural killer/T-cell lymphoma treated with concurrent chemoradiotherapy

Concurrent chemoradiotherapy has become one of the standard management approaches for newly diagnosed localized nasal natural killer (NK)/T-cell lymphoma (NKTCL). Few data are available on the prognostic biomarkers of NKTCL among patients treated with concurrent chemoradiotherapy. To evaluate the prognostic significance of immunophenotypic biomarkers for patients treated with concurrent chemoradiotherapy, latent membrane protein 1 (LMP1), cutaneous lymphocyte antigen (CLA) and cell origin were examined in samples from 32 patients who were enrolled in the Japan Clinical Oncology Group 0211 trial and treated with concurrent chemoradiotherapy. LMP1 and CLA were positive in 66% (19/29) and 29% (9/31) of the cases examined, respectively. The median follow-up duration was 68 months (range, 61–94). The patients with LMP1-positive tumors showed a better overall survival (OS) than the patients with LMP1-negative tumors (hazard ratio, 0.240; 95% confidence interval [CI], 0.057–1.013; 80% CI, 0.093–0.615; P = 0.035). All five patients with LMP1-negative tumors who experienced disease progression died of lymphoma, and both patients with local failure had LMP1-negative tumors. There was no significant difference in OS according to CLA expression. A total of 27 (84%) cases were of NK-cell origin, two were of αβ T-cell origin and three were of γδ T-cell origin. In contrast to those with tumors of NK-cell origin, all five patients with NKTCL of T-cell origin were alive without relapse at the last follow up. Our results indicate that LMP1 expression is a favorable prognostic marker and suggest that a T-cell origin of the tumor may be a favorable prognostic marker for patients with localized NKTCL treated with concurrent chemoradiotherapy.

CD30-Negative Cutaneous T-Cell Lymphomas Other than Mycosis Fungoides

Cutaneous T-cell lymphomas (CTCLs), other than mycosis fungoides/Sézary syndrome and the group of cutaneous CD30(+) lymphoproliferative disorders, are rare. These include subcutaneous panniculitis-like T-cell lymphoma (SPTCL); extranodal natural killer/T-cell lymphoma, nasal type; primary cutaneous peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS); and rare subtypes of PTCL, NOS. Apart from SPTCL and primary cutaneous CD4-positive small-medium pleomorphic T-cell lymphoma, these lymphomas have in common aggressive clinical behavior and poor prognosis. Differentiation between these different types of CTCL may be difficult and requires integration of histopathologic findings with clinical data and the results of phenotypic and often molecular genetic studies.

Nasal natural killer/t cell lymphoma

Nasal natural killer/T cell lymphomas are locally destructive mid-facial necrotizing lesions. It is an uncommon disease but, usually shows a highly aggressive clinical course. Amongst the sino-nasal lymphomas, it is the most common type. The non-specific clinical features constitute a major stumbling block in the early diagnosis and management of these lymphomas. We report here a case of nasal NK/T cell lymphoma in a 23-year old male with review of literature.

Pathogenesis and treatment of extranodal natural killer/T-cell lymphoma

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKL) is one of the uncommon subtypes of malignant lymphoma, and predominantly occurs in the nasal or paranasal areas and less frequently in the skin. Previously, its prognosis was poor due to the expression of P-glycoprotein, which actively exports several anticancer agents outside the lymphoma cells. However, in recent years, novel therapeutic approaches such as simultaneous chemoradiotherapy or l-asparaginase-based regimens including SMILE (steroid, methotrexate, ifosfamide, l-asparaginase, and etoposide) improved the response to therapy and survival of ENKL patients. Epstein-Barr virus (EBV) is present in lymphoma cells of almost all patients, accounting for the pathogenesis of ENKL. Fragmented EBV-DNA is released from tumor cells, and can be detected in the peripheral blood of patients. The EBV-DNA copy numbers are associated with tumor burden, and can predict the prognosis of ENKL, as well as the toxicity against chemotherapy. Based on this recent progress, ENKL is currently categorized as a lymphoma with intermediate prognosis, but the overall treatment results are not satisfactory. Further improvement of the prognosis of ENKL is therefore warranted, including the optimal use of hematopoietic stem cell transplantation (HSCT).

Extranodal T-cell lymphoma of nasal cavity

A rare case of primary extranodal lymphoma of nasal cavity is here with reported in a 11 years old female child. Patient presented with space occupying extensive lesion in nasal cavity with destraction of nasal septum and obliteration of paranasal sinuses. After histological examination and routine stain showed a round cell tumor with provisional diagnosis of large cell non-Hodgkin's lymphoma was made. Immunohistochemical stain were used to further differentiate from other possibilities mimics as carcinoma and round cell tumors. Immunohistochemical stain confirm the diagnosis of extranodal T-cell lymphoma. We report this case for its rarity in paediatric patients.

Reversion-inducing cysteine-rich protein with Kazal motifs gene expression and its clinical significance in peripheral T-cell lymphoma

The reversion-inducing cysteine-rich protein with Kazal motifs (RECK) gene was originally identified as a transformation suppressor gene that is widely expressed in normal tissues. In tumor tissues, RECK expression levels are significantly reduced, and the downregulation of RECK has been implicated in tumors that are more aggressive with a poor prognosis. In the present study, RECK expression in peripheral T-cell lymphoma (PTCL; n=82) was examined using immunohistochemistry, and its correlation with clinicopathological factors was analyzed. According to the proportion of positively-stained cells and the staining intensity (SI), the patients were categorized into RECK-negative or RECK-positive groups. RECK expression was observed in 30 of the 82 patients (36.6%). The 3-year survival rate of the patients with RECK-positive tumors (65.5%) was significantly high compared with that of the patients with RECK-negative tumors (20.3%; P=0.046). Reduced RECK expression was found to be significantly correlated with extranodal lymphomatous involvement (P=0.012). The survival analysis showed that RECK-negative expression was an independent and significant factor for predicting a poor prognosis. RECK status is a useful prognostic factor for assessing the biological behavior in PTCL.

NK/T-cell lymphomas: pathobiology, prognosis and treatment paradigm

The current World Health Organization (WHO) classification includes two types of natural killer (NK)-cell lymphomas: extranodal NK/T-cell lymphoma, nasal type (ENKL), and aggressive NK-cell leukemia (ANKL). These diseases are mostly endemic to East Asia and Latin America. The Epstein-Barr virus (EBV) is usually detected in tumor cells, suggesting that EBV plays an important role in lymphomagenesis. At the site of origin, ENKL can be divided into two major subtypes: nasal and extranasal diseases. The advanced disease presentation, highly aggressive clinical course, and poor prognosis of the latter are analogous to ANKL. It is well known that P-glycoprotein, which is a product of the multi-drug resistance (MDR1) gene, is expressed on neoplastic cells of ENKL or ANKL. This is a major cause of the refractoriness of malignant lymphoma to conventional chemotherapeutic regimens containing anthracycline. Recent studies, however, have identified that L-asparaginase-containing regimens, such as SMILE (steroid, methotrexate, ifosfamide, L-asparaginase and etoposide), are effective for ENKL. Considering the myelotoxicity of SMILE, its use in the treatment of ANKL needs some modifications, but this treatment scheme is promising in improving the prognosis of NK-cell lymphomas.

Clinical analysis and prognostic significance of lymphoma-associated hemophagocytosis in peripheral T cell lymphoma

This study aims to retrospectively analyze the clinical characteristics, treatments, and prognosis of aggressive peripheral T cell lymphoma (PTCL) patients with a lymphoma-associated hemophagocytosis syndrome (LAHS). We compared the clinical features and the overall survival (OS) rates of 159 PTCL patients with and without LAHS as well as the treatment outcomes of these patients with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or intensive chemotherapy regimens. We observed that in 23 % (36/159) patients PTCL was associated with LAHS. Different subtypes of PTCL in LAHS patients were diagnosed and peripheral T cell lymphoma, not otherwise specified (PTCL-NOS) was the main subtype (78 %). The median survival rates of the LAHS and non-LAHS groups were 3 and 16 months, respectively. The elevated rates of serum β2-microglobulin, ferritin, fasting triglycerides, and hypofibrinogen levels were higher in the LAHS group, so were bone marrow involvement, liver dysfunction, hepatosplenomegaly, and B symptoms. Three patients who were treated with a plasma exchange had a longer survival time. There was no statistically significant difference in the OS rates between the intensive chemotherapy and CHOP regimen groups (P > 0.05). PTCL patients with LAHS had a poorer prognosis. Awareness of the clinical symptoms and laboratory findings are crucial in order to diagnose LAHS in an early stage and repeated biopsies of multiple bone marrows from different locations in those patients without enlargement of superficial lymph nodes are necessary to improve the diagnosis. Intensive chemotherapy due to its severe toxicity was not obviously advantageous for the OS rate compared to the CHOP regimen.

Nasal Natural Killer/T-cell Lymphoma with Skin, Eye, and Peroneal Nerve Involvement

Nasal-type natural killer (NK)/T-cell lymphoma (NKTL) is a rare disease strongly associated with Epstein-Barr virus and is often localized to the upper aerodigestive tract at presentation. Extranodal NKTL may involve any extranodal site and disease beyond the nasal cavity is highly aggressive, with short survival time and poor response to therapy. Herein we present a 57-year-old male that had been treated with systemic chemotherapy and cranial radiotherapy for nasaltype NKTL in the palate with skin, right eye, and right peroneal nerve involvement. He was given salvage chemotherapy consisting of 3 cycles of ICE and his response to the therapy was satisfactory, except for persistent right drop foot. About 6 weeks later, the patient presented with bilateral total loss of vision and proptosis; therefore, DHAP chemotherapy was started. Unfortunately, after 1 cycle of the second salvage chemotherapy, he died due to severe fungal infection of the hard palate.

Despite the fact that involvement of any extranodal site is possible, concurrent involvement of many systems in NKTL patients is unusual. Nasal-type NKTL has a poor prognosis, despite local radiotherapy and systemic chemotherapy. Physicians should be aware of this rare disorder than can only be diagnosed after extensive immunohistochemical studies.

Conflict of interest:None declared.

Immunomorphologic profile and Epstein-Barr virus status of a cohort of 35 cases of extranodal natural killer/T-cell lymphoma, nasal type of upper aerodigestive tract from a tertiary care center in South India

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (EN-NK/T-NT) is a lymphoma of NK-cell or cytotoxic T-cell origin, which occurs most commonly in the upper aerodigestive tract. We have studied the immunomorphologic profile and Epstein-Barr virus (EBV) status of a cohort of 35 cases of EN-NK/T-NT of the upper aerodigestive tract (UADT) diagnosed in our institution during the period May 2002 to April 2012. At our institution these lymphomas constitute 0.7% of total non-Hodgkin lymphomas (NHLs) and 5.1% of total peripheral T-cell lymphomas (PTCLs). The median age at diagnosis was 40 years with a male-to-female ratio of 4:1, and the most common site of involvement was the nasal cavity. Morphologically, the neoplastic cells were predominantly medium sized in most cases. Necrosis and angiocentricity were common histologic features. Thirty cases (85.7%) showed NK-cell immunophenotype, CD3+ (29/30, 96.7%), CD56+ (30/30, 100%) and TIA1/Granzyme B+ (30/30, 100%). Five cases (14.3%) showed cytotoxic T-cell immunophenotype, CD3+ (5/5, 100%), CD56- (5/5, 100%) and TIA1/Granzyme B+ (5/5, 100%). EBV-encoded RNA-in situ hybridization (EBER-ISH) was positive in all 35 cases, whereas EBV latent membrane protein-1 (EBVLMP1) was positive in only 19/35 (54.3%) of cases. In conclusion, this is the first large study from India to report the immunomorphologic profile and EBV association of EN-NK/T-NT, which is known to have geographic variation. The frequency of these lymphomas in our study is comparable to that of Western and European countries and much less than that of Far Eastern countries.

Primary testicular non-Hodgkin's lymphoma associated with hemophagocytic syndrome: Case report and review of the literature

Primary testicular non-Hodgkin's lymphoma (TNHL) was first described as a clinical entity in 1866. It is a rare disease which accounts for 1% of all non-Hodgkin's lymphoma, 2% of all extranodal lymphomas and 5% of all testicular neoplasms. Hemophagocytic syndrome (HPS) is a rare but distinct condition caused by inappropriate and dysregulated activation of the immune system. We report a 47-year-old man with primary TNHL who developed HPS four months after occurrence of scrotal swelling. To the best of our knowledge, primary TNHL associated with HPS has not previously been reported.

Complete remission after first-line radio-chemotherapy as predictor of survival in extranodal NK/T cell lymphoma

Background

Extranodal nasal-type NK/T-cell lymphoma is a rare and severe disease. Considering the rarity of this lymphoma in Europe, we conducted a multicentric retrospective study on nasal-type NK/T cell lymphoma to determine the optimal induction strategy and identify prognostic factors.

Methods

Thirty-six adult patients with nasal-type NK/T-cell lymphoma were recruited and assessed. In total, 80 % of patients were classified as having upper aerodigestive tract NK/T-cell lymphoma (UNKTL) and 20 % extra-upper aerodigestive tract NK/T-cell lymphoma (EUNKTL).

Results

For advanced-stage disease, chemotherapy alone (CT) was the primary treatment (84 % vs. 10 % for combined CT + radiation therapy (RT), respectively), while for early-stage disease, 50 % of patients received the combination of CT + RT and 50 % CT alone. Five-year overall survival (OS) and progression-free survival (PFS) rates were 39 % and 33 %. Complete remission (CR) rates were significantly higher when using CT + RT (90 %) versus CT alone (33 %) (p < 0.0001). For early-stage disease, CR rates were 37 % for CT alone versus 100 % for CT + RT. Quality of response was significantly associated with survival, with 5-year OS being 80 % for CR patients versus 0 % for progressive disease patients (p < 0.01).

Conclusion

Early RT concomitantly or sequentially with CT led to improved patient outcomes, with quality of initial response being the most important prognosticator for 5-year OS.

Extranodal non-hodgkin lymphomas of the oral cavity and maxillofacial region: a clinical study of 58 cases and review of the literature

PURPOSE

Approximately one third of non-Hodgkin lymphomas (NHLs) arise in tissues other than the lymph nodes. The purposes of this study are to evaluate the clinical outcome of NHLs of the oral cavity and maxillofacial region in a group of 58 patients who were diagnosed in our clinic and to discuss the clinical, histologic, and immunohistochemical features of these malignant neoplasms, as well as the prognosis.

MATERIALS AND METHODS

The study included 58 patients with extranodal NHLs of the oral cavity and maxillofacial region. There were 32 male and 26 female patients. The patients' ages ranged from 7 to 81 years. The most frequent sites of occurrence were the salivary glands (24 patients) and intraoral mucosa (21 patients). Other sites were the paranasal sinus (3 patients), Waldeyer ring (4 patients), bone of the jaws (3 patients), and orbit (3 patients). The histologic subtype was extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) in 21 patients, diffuse large B-cell lymphoma (DLBCL) in 19, chronic lymphocytic leukemia in 10, mantle cell lymphoma in 4, follicular lymphoma in 2, Burkitt lymphoma/leukemia in 1, and B-cell acute lymphocytic leukemia (B-ALL) in 1. Of the DLBCL cases, 13 were stage IIE and 6 were stage IE. All the MALT lymphomas were stage IE.

RESULTS

The mean follow-up was 5 years after the initial diagnosis. A better prognosis was found in patients with MALT lymphomas (19 of 21 patients are alive) compared with those with DLBCLs (10 of 19 patients are alive).

CONCLUSIONS

MALT lymphomas have a more favorable outcome (about 90%) in comparison with DLBCLs. Careful examination of the oral cavity and neck by the maxillofacial surgeon is essential for the diagnosis and staging of lymphomas.

High frequency of fatal haemophagocytic lymphohistiocytosis syndrome in enteropathy-associated T cell lymphoma

INTRODUCTION

Enteropathy-associated T-cell lymphoma is a rare form of T-cell lymphoma associated with a poor prognosis and the relative ineffectiveness of standard chemotherapy. The occurrence of haemophagocytic lymphohistiocytosis has been reported only once with this entity.

PATIENTS AND METHODS

A retrospective study of 15 patients with enteropathy-associated T-cell lymphoma (type 1 in 12), followed-up in our units, since 1985. Two patients died before starting chemotherapy. The remaining 13 patients were treated with standard chemotherapy (n=7) and purine nucleotide analogues (n=6).

RESULTS

Median follow-up was 8.7 (1-97) months. Surgery was required in 10 patients (66%) for intestinal complications (n=7) or elective small bowel resection (n=3). Survival probability was 40% and 20% at 1 and 5 years, respectively (Kaplan-Meier method). Survival was not significantly different between the two chemotherapy regimens. However, a slight decrease of febrile neutropenia was observed in the purine nucleotide analogues group (p=0.06). Haemophagocytic lymphohistiocytosis occurred in 6/15 (40%) cases. In these six patients, haemophagocytic lymphohistiocytosis was always fatal within 3 months.

CONCLUSION

Enteropathy-associated T-cell lymphoma is associated with a poor outcome, independently of the chemotherapy regimens administered and frequent occurrence of haemophagocytic lymphohistiocytosis. The latter complication should be considered for urgent rescue therapy.

Intraocular involvement of a nasal natural killer T-cell lymphoma: a case report

Herein, we report a case of nasal natural killer T-cell lymphoma (NKTL) with intraocular involvement. A 57-year-old woman was referred due to a three-day history of photophobia and diplopia in the left eye. One-month previously, she was diagnosed with nasal NKTL of the right nasal cavity. Ophthalmic examination revealed conjunctival injection and ptosis. The left pupil was fully dilated and non-reactive to light. Ocular motion was restricted on left-upper gaze. Five days later, anterior uveitis developed and persisted despite topical steroid treatment. An orbital magnetic resonance imaging was without specific findings, however, ophthalmoplegia, vitreous opacity, and an iris mass were observed. A diagnostic anterior chamber aspiration was performed. Aqueous humor aspiration revealed 35% morphologically atypical lymphocytes. After an intravitreal triamcinolone injection, radiotherapy and chemotherapy were administered; this resolved the uveitis and iris mass. When refractory uveitis or orbital pseudotumor occurs in patients with nasal NKTL, ocular and orbital involvement of the NKTL should be considered.

Aggressive sinonasal natural killer/T-cell lymphoma with hemophagocytic lymphohistiocytosis

Extranodal natural killer/T-cell lymphoma of the nasal cavity is a rare malignancy with poor overall prognosis. We report the case of a rapidly fatal natural killer/T-cell lymphoma of the nasal cavity complicated by the concominant development of hemophagocytic lymphohistiocytosis. This disorder is marked by clinical findings such as fever and splenomegaly, a multitude of abnormal laboratory findings, and a profound proliferation of circulating macrophages. Left untreated, multi-organ failure and death are common. Prompt diagnosis is essential to the successful management of this disorder and for subsequent recovery.

Comments on cutaneous lymphomas: since the WHO-2008 classification to present

The last classification of lymphomas of the World Health Organization in 2008 made a few changes from the preceding classification. Although useful, at the same time, it has posed new questions, concerns, and dilemmas which have been raised in the literature. The current report highlights some of these controversies, of each of these primary cutaneous entities, going through cutaneous mature T-cell and NK-cell neoplasms, mature B-cell neoplasms, precursor neoplasms, and other entities, which for several reasons do not fit in the previous categories. It also reviews some advances on many of these lymphomas published in the last 2 years.

Pathobiology of Epstein-Barr virus-driven peripheral T-cell lymphomas

In the present review, the authors described the pathobiological features of Epstein-Barr virus (EBV)-driven T/natural killer cell-derived malignancies. These rare tumors appear to be quite heterogeneous with regard to both clinical and pathologic features. Nonetheless, some elements, especially regarding the possible role of EBV (ie, genomic predisposition, pathogenesis, pattern of latency), are similar, enforcing the concept of a causative role for the virus. In clinical practice, although definitely rare in Western countries, the tumors are not exceptional; thus, they should be taken into account in the differential diagnosis of T-lymphoproliferative disorders, also considering the need for extremely prompt intervention. The prognosis of such tumors is generally poor using current approaches. A better understanding of their molecular pathogenesis may lead to significant therapeutic improvements. For example, the nuclear factor-KB pathway and platelet-derived growth factor receptor inhibition may represent 2 options to be tested in clinical trials.

State of the art in natural killer cell malignancies

The recently updated World Health Organization (WHO) classification of tumors of hematopoietic and lymphoid tissues, published in 2008, has made great advances in revising the disorders previously included in the pool of natural killer (NK) cell tumors. Although NK cell neoplasms represent a relatively rare group of diseases, accounting for <5% of all lymphoid neoplasms, they include very distinctive conditions both clinically and pathologically. This family of diseases includes the most indolent clinical forms, such as the provisional new entry of chronic lymphoproliferative disorder of NK cells (CLPD-NK) in the WHO classification, as well as one of the most fatal diseases recognized in medical oncology, aggressive NK cell leukemia (ANKL), which is characterized by a prognosis of weeks, or even days. In addition, some disorders previously identified as blastic NK cell lymphoma within the NK cell system have been more properly defined and included in the blastic plasmacytoid dentritic cell neoplasms, although rare cases of bona fide immature NK lymphoid tumors (now classified as NK cell lymphoblastic leukemia/lymphoma) have been reported in the literature. This paper focuses on recent concepts and progress in morphology, pathogenesis, clinicopathological features, treatment approaches, and outcomes of NK cell malignancies.

Magnetic resonance imaging features of nasopharyngeal carcinoma and nasopharyngeal non-Hodgkin's lymphoma: are there differences?

PURPOSE

To describe differences in the primary tumour and distribution of cervical lymphadenopathy for cases of nasopharyngeal carcinoma (NPC) and nasopharyngeal non-Hodgkin's lymphoma (NPNHL) using magnetic resonance (MR) imaging.

MATERIALS AND METHODS

MR images of patients with NPC (n = 272) and NPNHL (n = 118) were independently reviewed by two experienced radiologists.

RESULTS

NPC had a higher incidence of tumour invasion associated with the levator and tensor muscles of the velum palatine, the longus colli and medial pterygoid muscles, the base of the pterygoid process, the clivus, the base and greater wing of the sphenoid bone, the petrous apex, the foramen lacerum, the foramen ovale, the hypoglossal canal, and intracranial infiltration. In contrast, NPNHL had a higher incidence of tumour invasion associated with the hypopharynx, the palatine and lingual tonsils, as well as the ethmoid and maxillary sinuses. NPNHL also had a higher incidence of extensive and irregular bilateral lymphadenopathy, and lymphadenopathy in the parotid.

CONCLUSIONS

NPC more often involved an unsymmetrical tumour with a propensity to invade both widely and deeply into muscle tissue, the fat space, the neural foramen, and the skull base bone. In contrast, NPNHL tended to be a symmetrical and diffuse tumour with a propensity to spread laterally through the fat space and along the mucosa to the tonsils of the oropharynx and hypopharynx. These differences facilitate a differentiation of these diseases using MR images, and enhance our understanding of the biological behavior of these malignant tumours of the nasopharynx.

Clinical behavior and treatment outcome of primary nasal diffuse large B-cell lymphoma

BACKGROUND

Nasal diffuse large B-cell lymphoma (DLBCL) is rare. The objective of this study was to evaluate the clinical features and treatment outcomes of patients with nasal DLBCL.

METHODS

Twenty-five patients were included in the study. All patients received combination chemotherapy with or without radiotherapy.

RESULTS

Patients with nasal DLBCL usually were older and were predominantly men with early stage disease, low frequency of B symptoms and elevated lactate dehydrogenase (LDH), good performance status, and a low-risk international prognostic index (IPI) score. The overall response rate after initial treatment was 76%, the 3-year overall survival (OS) rate for the whole group was 44%, and the median OS was 35 months. Performance status and IPI were significant prognostic factors for OS. For patients with IPI scores of 0 or 1, the 3-year OS rate was 54%, and the median OS was 52 months compared with 17% and 11 months, respectively, for patients with IPI scores of 2 or 3 (P = .033). The prognosis for patients who achieved a complete response (CR) was significantly better than that for patients who did not achieve a CR. Extranodal spread was the primary pattern of failure.

CONCLUSIONS

The current results indicated that primary nasal DLBCL appears to have distinct clinical features; its poor outcome and propensity for extranodal failure illustrate the need for innovative therapies.

Physiological Oxidants Induce Apoptosis and Cell Cycle Arrest in a Multidrug-resistant Natural Killer Cell Line, NK-YS

Natural-killer (NK) cell-derived malignant tumors, such as angiocentric lymphoma, is often resistant to various chemotherapeutic agents and follows an aggressive clinical course. We report the effects of physiological oxidants (hydrogen peroxide, H2O2; sodium hypochlorite, NaOCl and monochloramine, NH2Cl) on the cell growth and cell death in a multidrug-resistant NK tumor cell line, NK-YS. Among the oxidants tested, NH2Cl was most cytotoxic, in which more than 90% of the cells died at 150 nmol/1 x 10(6) cells. H2O2 was less cytotoxic, whereas NaOCl showed no significant cell death at this dose. The cell death induced by NH2Cl was accompanied by DNA cleavage and caspase activation, which suggested apoptosis. In addition, lower dose of NH2Cl (70 nmol/1 x 10(6) cells) retarded cell growth and inhibited the cell cycle transition from G1 to S. This cell cycle arrest accompanied a decrease in the phosphorylation of retinoblastoma tumor suppressor protein at serine 795. These observations suggest that NH2Cl may induce apoptotic cell death and growth arrest in multidrug-resistant NK cell tumors.

Immunophenotypic characteristics and clinical relevance of CD56+ and CD56- extranodal nasal-type natural killer/T-cell lymphoma

This study aimed to determine whether the phenotypic characteristics of the two subtypes of CD56+ and CD56- lymphoma have relevance for their clinical behavior and prognosis. The immunophenotypes of all patients were confirmed using standard criteria for CD20, CD3ε, CD56, cytotoxic molecules (T-cell intracellular antigen-1 [TIA-1] and granzyme B), and Ki-67, and in situ hybridization for Epstein-Barr virus (EBV)-encoded RNA (EBER). CD56 was expressed in 90 of 118 (76.3%) patients. The majority (83.3%) of patients with nasal natural killer/T-cell lymphoma (NKTCL) presented with CD56+ lymphoma, whereas patients with NKTCL of the extranasal upper aerodigestive tract were more likely to have CD56- lymphoma (53.6%, p < 0.000). A lower percentage of expression of granzyme B and Ki-67 (>50%) was found in patients with CD56- lymphoma compared with those with CD56+ lymphoma (p <0.05). The clinical characteristics and prognosis were comparable between patients with CD56+ and CD56- lymphomas. The corresponding overall survival and progression-free survival rates were 74.1% and 56.7%, respectively, for patients with CD56+ lymphoma compared with 81.6% and 60.5% for those with CD56- lymphoma (p > 0.05). There was no clinical or prognostic significance in determining the two subtypes of CD56+ and CD56- NKTCL based on their immunophenotypic profiles, which has clinical implications for pathological diagnosis and insight into disease behavior.

A Systematic Review and Meta-Analysis of Front-line Anthracycline-Based Chemotherapy Regimens for Peripheral T-Cell Lymphoma

Anthracycline-based chemotherapy remains standard treatment for peripheral T-cell lymphoma (PTCL) although its benefits have been questioned. We performed systematic literature review and meta-analyses examining the complete response (CR) and overall survival (OS) rates for patients with PTCL. The CR rate for PTCL patients ranged from 35.9% (95% CI 23.4-50.7%) for enteropathy-type T-cell lymphoma (ETTL) to 65.8% (95% CI 54.0-75.9%) for anaplastic large cell lymphoma (ALCL). The 5-year OS was 38.5% (95% CI 35.5-41.6%) for all PTCL patients and ranged from 20.3% (95% CI 12.5-31.2%) for ETTL to 56.5% (95% CI 42.8-69.2%) for ALCL. These data suggest that there is marked heterogeneity across PTCL subtypes in the benefits of anthracycline-based chemotherapy. While anthracyclines produce CR in half of PTCL patients, this yields reasonable 5-year OS for patients with ALCL but not for those with PTCL-NOS or ETTL. Novel agents and regimens are needed to improve outcomes for these patients.

Diagnosis and management of natural killer-cell malignancies

Natural killer (NK)-cell malignancies are uncommon neoplasms, which have been referred to as polymorphic reticulosis or angiocentric T-cell lymphomas in the past. In the current WHO classification, they are categorized as extranodal NK/T-cell lymphoma, nasal type and aggressive NK-cell leukemia. NK-cell malignancies show a geographical predilection for Asian and South American populations and are rare in the west. Pathologically, NK-cell lymphomas show a polymorphic neoplastic infiltrate with angioinvasion and angiodestruction. The lymphoma cells are CD2(+), cytoplasmic CD3ε(+) and CD56(+), with germline T-cell receptor gene. There is an almost invariable clonal episomal infection with Epstein-Barr virus. Clinically, NK-cell lymphomas can be classified into nasal, non-nasal and aggressive lymphoma/leukemia subtypes. Most nasal NK-cell lymphomas present with stage I/II disease. The early use of radiotherapy, either alone or concomitantly/sequentially with chemotherapy, is the most important factor in achieving successful treatment. Many stage I/II patients receiving radiotherapy alone fail systemically, so the use of chemotherapy is also considered necessary. Chemotherapy is indicated for stage III/IV nasal NK-cell lymphoma, and the non-nasal and aggressive subtypes. Recent regimens that incorporate the use of L-asparaginase have resulted in substantial improvements in outcome in high-risk, refractory or relapsed patients. High-dose chemotherapy and hematopoietic stem-cell transplantation with autologous or allogeneic hematopoietic stem cells may be beneficial to selected patients. Prognostication of patients with clinical prognostic models and presentation circulating Epstein-Barr DNA load may be useful in the stratification of patients for various treatment modalities.

Current diagnostic strategies for undifferentiated tumours of the nasal cavities and paranasal sinuses

Several malignant tumours occurring in the sinonasal tract may present with an undifferentiated morphology. Overall, these lesions pose significant diagnostic difficulties for the surgical pathologist, especially in limited biopsy material, but their correct classification is becoming increasingly important for an appropriate treatment strategy. This review deals with the criteria for differential diagnosis of these neoplasms, with emphasis on recent advances in immunohistochemistry and molecular biology, as well as with previous progress in electron microscopy. Through careful microscopic examination of haematoxylin and eosin-stained sections, in the light of clinical information and imaging data, a list of differential diagnoses can be made and an appropriate panel of antibodies can be chosen to further categorize the tumour. An initial panel including cytokeratins, synaptophysin, S100 protein, desmin and CD45 may allow the classification of most lesions or may help to narrow the list of differential diagnoses. Further refinement can be obtained through second-line markers, including in-situ hybridization for Epstein-Barr virus, other neuroendocrine markers, melanocytic markers, myogenin, CD99, other lymphocyte markers, and CD138 and light chains. Finally, molecular analysis can further assist in the recognition of specific entities such as nuclear protein in testis midline carcinoma, Ewing's sarcoma/peripheral neuroectodermal tumour, alveolar rhadbomyosarcoma, and poorly differentiated synovial sarcoma.

Primary cutaneous Epstein-Barr virus-associated T-cell lymphoproliferative disorder-2 cases with unusual, prolonged clinical course

Hydroa vacciniforme-like lymphoma and extranodal-type natural killer (NK)/T-cell lymphoma are prototypes of Epstein-Barr virus (EBV)-associated cutaneous T- or NK-cell lymphomas. Hydroa vacciniforme-like lymphoma with systemic spread and extranodal-type NK/T-cell lymphoma are characterized by aggressive clinical course. We describe 2 patients with primary cutaneous EBV-associated T-cell lymphomas who did not satisfy the criteria for well-defined entities and showed unusual, prolonged clinical course. They presented with skin ulcerations and mass lesions confined to the extremities without systemic involvement. Skin biopsies demonstrated dense superficial and deep perivascular and periappendageal lymphoid infiltrates expressing CD3 and CD8, but not CD56. The EBV genomes were found within the tumor cells, and monoclonal T-cell receptor gene rearrangement was present. We suggest that these cases represent a peculiar subtype of EBV+ cutaneous T-cell lymphoma, with a tendency to localize in the skin of the extremities and has an indolent clinical course.

Diagnosis of systemic metastatic retinal lymphoma

PURPOSE

Systemic metastatic retinal lymphoma (SMRL) is exceptionally rare, as systemic lymphomas most often metastasize to the uvea. We have evaluated a series of SMRL cases to elucidate the clinical and pathological features of SMRL.

METHODS

The pathological specimens of intraocular lymphomas (IOLs) at the National Eye Institute from 1991 to 2009 were retrospectively reviewed. These cases were diagnosed by cytology, cytokine measurement (ELISA for interleukin (IL)-10 and IL-6 levels) and Immunoglobulin-Heavy (IgH) and T-cell-receptor (TCR) gene analyses.

RESULTS

There were nine B-cell SMRLs (B-SMRL) among 96 B-cell retinal lymphomas (9.4%) and three T-cell SMRLs (T-SMRL) among five T-cell retinal lymphomas (60%) from a total of 116 IOLs, in which 101 were retinal lymphoma. The original sites were nasopharynx (3), testis (2), skin (2), breast (1), blood (1), retroperitoneum (1), ileo-caecum (1) and stomach (1). Cytology of vitreous samples illustrated atypical lymphoma cells with either B- or T-monoclonality. More B-SMRLs had a high ratio of vitreal IL-10 to IL-6 than T-SMRLs. Molecular pathology demonstrated lymphoma cells with gene rearrangements of IgH in all B-SMRLs and TCR in all T-SMRLs.

CONCLUSIONS

SMRL and primary retinal lymphoma present with similar clinical manifestations. Systemic T-cell lymphoma invades the retina and vitreous more aggressively than systemic B-cell lymphoma. A diagnosis of SMRL is made when there is a clinical history of systemic lymphoma (particularly from nasopharynx, testis and skin), and lymphoma cells are identified in the vitreous or retina. Molecular analysis is more useful than vitreal cytokine measurement for SMRL diagnosis.