Anaplastic large-cell lymphoma which showed severe inflammatory status and myelodysplasia with increased VEGF and IL-6 serum levels after long-term immunosuppressive therapy

Anaplastic Large Cell Lymphoma (ALCL) With a Sarcomatoid Variant Presenting As Distributive Shock in a 41-Year-Old Female: A Case Report

The sarcomatoid variant is considered a rare subtype of anaplastic large cell lymphoma. We present a 40-year-old diabetic female who was evaluated in the ER for distributive shock, requiring vasopressors and mechanical ventilation. An extensive workup was negative for infection. A serial CT scan of the abdomen and pelvis showed evolving lymphadenopathy, and a biopsy revealed malignant anaplastic lymphoma cells with a sarcomatous variant. The oncology team recommended the initiation of inpatient chemotherapy; however, the family opted to proceed with comfort care measures.

Leukemic presentation of ALK-negative anaplastic large cell lymphoma in a patient with myelodysplastic syndrome

A 50-year-old woman with a history of aplastic anemia developed cervical lymphadenopathy and atypical lymphocytosis. Atypical cells of lymph nodes were positive for CD3 and CD30 but negative for anaplastic lymphoma kinase (ALK). Bone marrow examination showed trilineage myelodysplasia. She was diagnosed with ALK-negative anaplastic large cell lymphoma (ALCL) with leukemic transformation and myelodysplastic syndrome (MDS) which presumably developed from aplastic anemia. The lymphoma was resistant to intensive chemotherapies, ultimately leading to death. Leukemic presentation of ALK-negative ALCL as an initial manifestation is extremely rare, and the progression of the disease may be influenced by MDS through alteration of immune functions.

Inflammation and cancer: how friendly is the relationship for cancer patients?

Evidence has emerged in the last two decades that at the molecular level most chronic diseases, including cancer, are caused by a dysregulated inflammatory response. The identification of transcription factors such as NF-kappaB, AP-1 and STAT3 and their gene products such as tumor necrosis factor, interleukin-1, interleukin-6, chemokines, cyclooxygenase-2, 5 lipooxygenase, matrix metalloproteases, and vascular endothelial growth factor, adhesion molecules and others have provided the molecular basis for the role of inflammation in cancer. These inflammatory pathways are activated by tobacco, stress, dietary agents, obesity, alcohol, infectious agents, irradiation, and environmental stimuli, which together account for as much as 95% of all cancers. These pathways have been implicated in transformation, survival, proliferation, invasion, angiogenesis, metastasis, chemoresistance, and radioresistance of cancer, so much so that survival and proliferation of most types of cancer stem cells themselves appear to be dependent on the activation of these inflammatory pathways. Most of this evidence, however, is from preclinical studies. Whether these pathways have any role in prevention, progression, diagnosis, prognosis, recurrence or treatment of cancer in patients, is the topic of discussion of this review. We present evidence that inhibitors of inflammatory biomarkers may have a role in both prevention and treatment of cancer.

Co-existent de novo myelodysplastic syndrome and T-cell non-Hodgkin lymphoma: a common origin or not?

The co-existence of de novo myelodysplastic syndrome (MDS) and non-Hodgkin lymphoma (NHL) prior to therapy is an extremely unusual finding. We report here a case of co-existent de novo MDS-refractory cytopenia with multilineage dysplasia and T-cell NHL, including clinical features, histopathological findings, molecular assessment, treatment course and outcomes. Other cases from the literature showing co-existence of both disorders are also reviewed; to date 19 similar cases have been reported. Among all cases (including the present patient), eight cases were diagnosed with de novo MDS and NHL simultaneously, which were considered to be true coincidences. The mechanisms responsible for the appearance of co-existence have not yet been ascertained, however in the present case a common chromosomal abnormality (20q deletion) was found in bone marrow and lymph node preparations. We conclude, therefore, that the co-existent de novo MDS and T-cell NHL seen in the present case may have a common origin.

Primary cutaneous anaplastic large cell lymphoma associated with vascular endothelial growth factor arising from a burn scar

We present a case of primary cutaneous anaplastic large cell lymphoma manifesting with widespread erythema around an ulcer. Skin biopsy from the ulcer showed CD30-positive atypical lymphocytes throughout the dermis, and immunostaining demonstrated that these cells produced vascular endothelial growth factor, a potent stimulus for angiogenesis. Skin biopsy from the erythema revealed rich neovascularization, which was probably associated with vascular endothelial growth factor.

Cytokine production by hepatic anaplastic large-cell lymphoma presenting as a rheumatic syndrome

OBJECTIVES

A variety of malignancies can present as rheumatic syndromes. Our aim was to describe a case of primary hepatic anaplastic large-cell lymphoma (ALCL) presenting as a rheumatic syndrome. We also describe cytokine production by the tumor.

METHODS

A patient with ALCL presenting with arthralgia and systemic inflammation is described. Cytokine production by the resected tumor and adjacent normal liver was assayed by enzyme-linked immunosorbent assay following in vitro culture. Medline database search of the English literature between 1976 and August 2006 was performed.

RESULTS

A 44-year-old man was admitted with generalized arthralgias, fatigue, weight loss, and night sweats. Despite a high clinical suspicion of underlying malignancy, repeated radiologically guided biopsies of bone and liver abnormalities failed to demonstrate any malignant cells. The patient improved dramatically on empirical corticosteroids but symptoms recurred on attempting to reduce the steroid dosage. He ultimately underwent partial hepatectomy for an enlarging liver lesion, which was demonstrated to be primary hepatic ALCL on immunohistochemistry. There are a few reports of ALCL presenting as bone lesions, but to our knowledge this is the first report of hepatic ALCL presenting with a rheumatic syndrome. The clinical and biochemical inflammation resolved following resection of the tumor but returned on tumor recurrence. The tumor produced large quantities of the proinflammatory cytokines interleukin-6 (IL-6) and IL-8 but did not produce tumor necrosis factor-alpha (TNF-alpha), IL-1, or IL-4.

CONCLUSIONS

Repeat biopsies may be required to diagnose underlying tumor. The ALCL tissue in our patient produced large quantities of the IL-6, which we believe was associated with the patient's systemic inflammation.

Hepatosplenic αβ T-cell lymphoma with myelodysplastic syndrome

We describe a patient with hepatosplenic 33 T-cell lymphoma who showed pancytopenia and myelodysplasia. A 35-year-old man was admitted with fever, pancytopenia, and hepatosplenomegaly but with no lymphadenopathy. We also found trilineage myelodysplasia in the bone marrow on his first admission. The patient had high fever and anemia but no evidence of infection and was tentatively treated with prednisolone. This treatment resulted in a transient improvement of the cytopenia and a reduction of spleen size. However, 10 months after the first manifestation, progression of the splenomegaly and fever became apparent, and a splenectomy was performed. The pathologic findings for the spleen showed diffuse and disseminated infiltration of medium- to large-sized T-lymphocytes in the splenic red pulp. These cells were immunohistochemically positive for CD3, CD5, CD7, CD8, CD16, CD56,T-cell receptor 33 (TCR33),T-cell intracellular antigen 1, and granzyme B but were negative for CD4, CD30, CD57, and TCR33. These data suggested a diagnosis of hepatosplenic 33 T-cell lymphoma. A Southern blot analysis revealed gene rearrangement of the TCR 3-chain gene but not the immunoglobulin heavy chain gene in the spleen cells. An in situ hybridization analysis for the Epstein-Barr virus revealed negative results. The patient received 8 courses of combination chemotherapy and achieved a partial remission; however, the dysplastic features of the marrow cells persisted after the partial remission was obtained. Additional treatment with allogeneic bone marrow transplantation resulted in a transient complete remission; however, the patient relapsed 11 months later. Because he had experienced no lymphadenopathy and showed dysplastic features in the bone marrow, the diagnosis was highly dependent on the pathologic findings for the resected spleen.