Non-Hodgkin's lymphoma of Waldeyer's ring and nasal cavity. Clinical and immunologic aspects

HIV-Associated "Double-Hit" Lymphoma of the Tonsil: A First Reported Case

Double-hit lymphoma (DHL) is a unique subtype of non-Hodgkin lymphoma characterized by atleast two rearrangements involving MYC, BLC2, and/or BCL6. These lymphomas are uncommon and aggressive, responding poorly to typical chemotherapy regimens. Lymphomas rarely arise from the oral cavity or tonsils, and those presenting as a neck mass are predominantly diffuse large B-cell lymphoma. To date, primary DHL of the tonsils has yet to be described in the literature. Here, we report a case of a 44 year-old male patient with well-controlled human immunodeficiency virus (HIV) who presented with a sore throat. He subsequently developed acute respiratory compromise due to a rapidly enlarging tonsillar mass. Pathologic and genetic analysis confirmed the presence of BCL6 and MYC rearrangements suggestive of DHL of the tonsils. In a young patient with HIV and a neck mass, it is essential that lymphoma remains on the list of differential diagnoses as prompt diagnosis and treatment may prevent complications from its rapid expansion.

Lymphomas of the head and neck region: an update

The field of haematopathology is rapidly evolving and for the non-specialized pathologist receiving a specimen with the possibility of a lymphoid malignancy may be a daunting experience. The coincidence of the publication, in 2017, of the WHO monographies on head and neck and haematopoietic and lymphoid tumours prompted us to write this review. Although not substantially different from lymphomas elsewhere, lymphomas presenting in this region pose some specific problems and these are central to the review. In addition, differences in subtype frequency and morphological variations within the same entity are discussed. The difficulty in diagnosis related to some specimens led us to briefly mention common subtypes of systemic lymphomas presenting in the head and neck region.

Analysis of the intensity of immune cell infiltration and immunoreactivity of RCAS1 in diffuse large B-cell lymphoma of the palatine tonsil and its microenvironment

Non-Hodgkin lymphoma of Waldeyer's ring constitutes a small percentage of cases of palatine tonsil malignancies and its precise etiology remains unknown. RCAS1 (receptor cancer-binding antigen expressed on SiSo cells) has been demonstrated to be associated with poor prognosis, the development of lymph node metastases and participation in tumor microenvironment remodeling. Our aim is to analyze the potential role of RCAS1 expression in the tumor and tumor microenvironment in the development of early-stage palatine tonsil B-cell lymphomas. We selected 20 patients and analyzed tissue samples from the lymphoma and tumor microenvironment of each patient and from a reference group of 20 patients with chronic tonsillitis. The presence of RCAS1 protein immunoreactivity was demonstrated in 65% of the examined tissue samples of diffuse large B-cell lymphoma and in 25% of the analyzed stromata in which it was exhibited by CD68-positive cells identified as macrophages and dispersed throughout the stroma. RCAS1 immunoreactivity in the lymphoma tissue samples remained at a level comparable with that of the reference and was significantly higher in these samples than in those from the stroma. Chronic inflammation of the palatine tonsils thus results in intensive infiltration by various types of immune system cells and in excessive RCAS1 immunoreactivity, both of which confirm the important regulatory role of RCAS1 in the immune response in the mucosa-associated lymphatic tissue of Waldeyer's ring. RCAS1 seems to be involved in creating tumor-induced inflammation in the tumor and its microenvironment.

Sino-nasal T-cell lymphoma invading the brain: A case study

Lesions occupying the anterior cranial fossa may arise de novo or are extensions from the sino-nasal areas with a handful of differentials in either group. The imaging findings, though to a large extent standardized are not full proof. Primary central nervous system lymphoma and sino-nasal lymphoma are uncommon variants of extranodal non-Hodgkin's lymphoma (NHL). We encountered a 35-year-old lady presenting with headache and seizures with a mass lesion involving the ethmoids with invasion into the anterior cranial fossa diagnosed as T-cell extranodal NHL. Gross total resection and reconstruction of the skull base were done. She was treated with chemotherapy and radiotherapy and is doing well at 6 months follow-up. This is the first report of a sino-nasal T-cell lymphoma invading the brain-parenchyma in an immuno-competent person. Sino-nasal primary T-cell lymphoma presenting as skull base pathology should form an essential differential diagnosis along with other routine lesions of anterior cranial fossa. Since these lesions have a good response to chemo and radiotherapy, a trans-nasal biopsy may obviate the need of a craniotomy if neurosurgeons are aware of this rare entity.

Clinical characteristics, pathological distribution, and prognostic factors in non-Hodgkin lymphoma of Waldeyer's ring: nationwide Korean study

BACKGROUND/AIMS

In Asia, the incidence of non-Hodgkin lymphoma (NHL) has increased in recent decades. Waldeyer's ring (WR) is the most common site of NHL involving the head and neck. In this study, the pathological distribution of WR-NHL and its clinical features were analyzed retrospectively.

METHODS

From January 2000 through December 2010, we analyzed the medical records of 328 patients from nine Korean institutions who were diagnosed with WR-NHL.

RESULTS

The study group comprised 197 male and 131 female patients with a median age of 58 years (range, 14 to 89). The rate of localized disease (stage I/II) was 64.9%, and that of low-risk disease (low/low-intermediate, as defined by the International Prognostic Index) was 76.8%. Diffuse large B-cell lymphoma (DLBCL; 240 patients, 73.2%) was the most common pathologic subtype, followed by peripheral T-cell lymphoma (14 patients, 4.3%) and nasal NK/T-cell lymphoma (14 patients, 4.3%). WR-NHL occurred most frequently in the tonsils (199 patients, 60.6%). Extranodal involvement was greater with the T-cell subtype (20 patients, 42.5%) compared with the B-cell subtype (69 patients, 24.5%). Multivariate analyses showed that age ≥ 62 years, T-cell subtype, and failure to achieve complete remission were significant risk factors for overall survival.

CONCLUSIONS

DLBCL was found to have a higher incidence in Korea than those incidences reported by other WR-NHL studies. T-cell lymphoma occurred more frequently than did follicular lymphoma. T-cell subtype, age ≥ 62 years, and complete remission failure after first-line treatment were significant poor prognostic factors for overall survival according to the multivariate analysis.

Characteristics and prognostic factors for head and neck non-Hodgkin's lymphoma in Chinese patients

BACKGROUND AND OBJECTIVES

The head and neck region is the second most frequent anatomical site of extranodal lymphomas. These tumours affect many individuals worldwide, justifying epidemiological studies in different countries. This study evaluated the characteristics, treatments and prognostic factors for non-Hodgkin's lymphoma of the head and neck in Chinese patients.

METHOD

The clinical manifestations, clinicopathological characteristics, multidisciplinary treatment and prognostic factors for 102 patients with extranodal non-Hodgkin's lymphoma of the head and neck were analysed retrospectively.

RESULT

The tonsil was the most commonly involved primary site, followed by the nasal cavity. The most common histological subtype was diffuse large B-cell lymphoma, followed by natural killer T-cell lymphoma. Patients receiving a combination of rituximab and chemotherapy did better than those receiving chemotherapy alone. Prognosis was significantly associated with both International Prognostic Index and histological subtype; the former was especially strongly associated with poor survival.

CONCLUSION

In this group of Chinese patients, diffuse large B-cell lymphoma was the most common pathological subtype, but the incidence of T-cell lymphomas was higher than that reported in the USA. Combined rituximab and chemotherapy led to better outcomes than chemotherapy alone. Prognosis depended on both International Prognostic Index and histological subtype.

Monocytes enhance cell proliferation and LMP1 expression of nasal natural killer/T-cell lymphoma cells by cell contact-dependent interaction through membrane-bound IL-15

Nasal natural killer (NK)/T-cell lymphoma (NNKTL) is an Epstein-Barr virus (EBV)-related malignancy with poor prognosis and has distinct histological features characterized by angiocentric and polymorphous lymphoreticular infiltrates including inflammatory cells such as granulocytes, monocytes, macrophages and lymphocytes. Here, we show that the monocytes enhance proliferation as well as LMP1 expression of NNKTL cells by cell contact-dependent interaction through membrane-bound interleukin (IL)-15. We used two EBV-positive NK-cell lines, SNK6 and KAI3, which originated from two patients-SNK6 from a patient with NNKTL and KAI3 from a patient with a severe mosquito allergy. We cocultured the cell lines with granulocytes or monocytes and examined whether proliferation, survival and LMP1 expression of the cells changed. Although cocultured granulocytes did not affect proliferation, survival or LMP1 expression of the cells, cocultured monocytes enhanced both proliferation and LMP1 expression in a dose-dependent manner. These phenomena were not seen when monocytes were placed in a separate chamber. Moreover, the monocyte-inducible proliferation and LMP1 expression were inhibited by treatment with an antibody against IL-15. Furthermore, production of interferon-gamma-inducible protein (IP)-10 were enhanced by coculture with monocytes and were inhibited by the antibody. Immunohistological studies confirmed that a number of infiltrating CD14-positive monocytes contacted CD56-positive lymphoma cells in all of 20 NNKTL tissues tested. These results suggest that monocytes enhance cell growth as well as LMP1 expression of NNKTL cells by cell contact-dependent interaction through membrane-bound IL-15. In the microenvironment of NNKTL tissue, a positive feedback loop of interaction between lymphoma cells and monocytes may be present and contribute to lymphoma progression.

B lymphoblastic lymphoma presenting as a tumor of the nasopharynx in an adult patient

In adults, non-Hodgkin's lymphoma (NHL) is the second most common neoplasm found in the head and neck region after squamous cell carcinoma. Within this region, primary NHL of the nasopharynx is rare. We report the case of a 28-year-old male diagnosed with a B lymphoblastic lymphoma (CD20-; CD79a+; CD3-; CD10+; PAX5+, CyclinD1-; TdT+) of the nasopharynx extending to the deep and superficial structures of the right hemiface, to the skull base with an intracranial component and a small but detectable bone marrow involvement, who was started on chemotherapy with a complete response. To the best of our knowledge, this is the first case of a primary nasopharynx B-LBL in an adult patient with such aggressive regional spread to be reported in the literature.

Primary non-Hodgkin's lymphoma of the nasopharynx: Prognostic factors and outcome of 113 Indian patients

This single institutional study evaluated the prognostic factors and treatment outcome of 113 Indian patients with primary nasopharyngeal non-Hodgkin's lymphoma. At presentation, 28% had stage I and 62% had stage II disease. Treatment comprised of a combination of chemotherapy (CTh) and radiotherapy (RT) in the majority of the patients (76%). After a median follow-up of 56 months, the 5-year disease-free survival (DFS) and overall survival (OS) for the whole group were 55.8% and 57.9%, respectively. Multivariate analysis showed that; age > 30 years [hazard ratio (HR) = 6.59, 95% confidence interval (CI) = 2.59 - 16.7, P < 0.0001], WHO performance score > or = 2 (HR = 2.34, 95% CI = 1.01 - 5.46, P = 0.050), T-cell lymphomas (HR = 2.81, 95% CI = 1.14 - 6.96, P < 0.001) and the presence of B symptoms (HR = 3.65, 95% CI = 1.77 - 7.53, P = 0.025), had a negative influence on survival. Patients treated with a combination of CTh and RT had a significantly better outcome than those treated with CTh alone (OS: 69%vs. 31%, P < 0.00001). HR for death in the CTh alone group was 3.73 (95% CI = 1.95 - 7.13). The CR (P = 0.01), DFS (P = 0.01) and OS (P = 0.03) rates were significantly better for patients receiving a RT dose of > or =4500 cGy. HR in the subgroup that received a RT dose of <4500 cGy was 2.51 (95% CI = 1.04 - 6.06). These results suggest that combined modality treatment, comprising of CTh and RT (with an RT dose of > or =4500 cGy), results in satisfactory outcome in patients with this rare neoplasm.

Primary non-Hodgkin's lymphoma of the infratemporal fossa: a rare case report

BACKGROUND

The head and neck are two of the most common sites of extranodal non-Hodgkin's lymphoma (NHL). However, primary tumors of the infratemporal fossa are infrequent, and NHL in this region is extremely rare.

CASE PRESENTATION

We present a case of a 41-year-old female that presented with swelling in the right preauricular region that had persisted for the past two years. The patient was diagnosed as having a small lymphocytic NHL. She initially underwent chemo-radiation but reported relapse. The tumor was excised and again the patient underwent chemotherapy. The patient remained symptomatic and developed a second primary squamous cell carcinoma in the right retromolar trigone.

DISCUSSION AND CONCLUSION

We discussed NHL with an emphasis on extranodal manifestations. Extranodal NHL that is limited to a single site can be managed by surgery and regular follow up. To the best of our knowledge, this is only the second case of primary NHL of the infratemporal fossa to be reported in the literature.

Non-Hodgkin lymphoma of the Waldeyer's ring: clinicopathologic and therapeutic issues

Extranodal non-Hodgkin lymphoma (NHL) in head and neck region is most commonly seen in the Waldeyer's ring. Waldeyer's ring is a unique subtype of mucosa associated lymphoid tissue (MALT), which shows rarity of low-grade or MALT-type lymphomas and a high incidence of diffuse large B cell lymphoma (DLBCL). The commonest histology is DLBCL with natural history similar to primary nodal NHL. However, high association with gastrointestinal involvement is reported. The diagnostic workup is similar to that of the usual nodal NHL, and in absence of a specific staging system, the Ann Arbor staging is followed. As compared with T-cell subtypes, B-cell phenotypes are less likely to present with mucosal ulceration, epitheliotropism and angioinvasion. Stage of disease, histology and use of combined modality treatment have been proposed as significant prognostic factors. Treatment has evolved from the use of extended field radiotherapy (RT) alone to the use of combined chemotherapy and RT leading to almost doubling of survival. Advances in pathology and further risk stratification of patients into prognostic groups could lead to the development of novel therapeutic strategies to improve outcome.

Systemic lymphoproliferative diseases

With advancements in diagnosis and treatment for lymphoma, it is important that physicians be up to date in the management of these lymphoproliferative disorders, their associated complications, and the complications of treatment. The importance of a thorough examination of the oro-facial complex and neck on all patients cannot be overemphasized. Oral and maxillofacial surgeons continue to make significant contributions in what has become a multidisciplinary approach to managing lymphoproliferative disease.

Primary diffuse large B-cell lymphoma of the tonsil

BACKGROUND

The purpose was to evaluate the prognostic factors and treatment outcome of Indian patients with primary diffuse large B-cell lymphoma (DLBCL) of the tonsil treated at a single institution.

METHODS

In all, 121 patients with DLBCL of the tonsil, treated at the Tata Memorial Hospital, Mumbai, India, from January 1990 to December 2002, were included. The median age was 45 years and the majority of patients (68%) were males. Systemic symptoms were present in 12% of patients; 28% presented with stage I and 67% had stage II disease. Treatment consisted of a combination of chemotherapy (CTh) and radiotherapy (RT) for the majority of patients (69.4%). Among those receiving RT, 64% received an RT dose of > or =45 Gy.

RESULTS

After a median follow-up of 62 months, disease-free survival (DFS) and overall survival (OS) were 66.4% and 81.6%, respectively. Significant prognostic factors included: WHO performance score > or =2 (OS: 72.1% vs 95.6%, P = .016), bulky tumors (OS: 68.5% vs 86.9%, P = .001), presence of B-symptoms (OS: 36.7% vs 79.6%, P < .001), and Ann Arbor stage. On multivariate analysis; WHO performance score > or =2 (hazard ratio [HR], 4.27; 95% confidence interval [CI], 1.20-15.12), and B symptoms (HR, 6.27; 95% CI, 2.38-16.48), retained statistical significance. CTh + RT resulted in a significantly better outcome than those treated with CTh alone (OS: 85.7% vs 70.7%, P = .008). The complete response (P = .053), DFS (P = .039), and OS (P = .014) rates were significantly better for patients receiving an RT dose > or =45 Gy.

CONCLUSIONS

Tumor bulk, WHO performance score, the presence of B symptoms, and Ann Arbor stage significantly influence outcome. A combined modality treatment, consisting of CTh and RT (with an RT dose of > or =45 Gy), results in a satisfactory outcome in patients with this uncommon neoplasm.

Expression of interleukin-9 in nasal natural killer/T-cell lymphoma cell lines and patients

PURPOSE

Nasal natural killer (NK)/T-cell lymphoma is associated with EBV and has distinct clinical and histologic features. However, little is known about its genetic features. In this study, we examined the genes expressed by SNK-6 and SNT-8 cells, which were established from nasal NK/T-cell lymphomas, and found that interleukin (IL)-9 was specifically expressed in these two cell lines.

EXPERIMENTAL DESIGN

cDNA array was used to examine the genes expressed by SNK-6 and SNT-8 cells. Expression of IL-9 and IL-9 receptor was investigated by reverse transcription-PCR, ELISA, and flow cytometry. Cell growth was assessed by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay. Immunohistologic staining and ELISA were used to examine IL-9 expression in biopsies and sera from patients, respectively.

RESULTS

In cDNA array, expression of IL-9 mRNA was much higher in SNK-6 and SNT-8 cells than in NK-92 cells from non-nasal NK-cell lymphoma and peripheral blood mononuclear cells from healthy volunteers. Furthermore, IL-9 was specifically expressed by SNK-6 and SNT-8 cells but not by other NK-cell, NK-like T-cell, and T-cell lymphoma/leukemia cell lines. IL-9 receptor was also expressed on the surfaces of SNK-6 and SNT-8 cells. An IL-9-neutralizing antibody inhibited the growth of these two cell lines, whereas recombinant human IL-9 enhanced their growth. Most significantly, IL-9 was present in biopsies and sera from patients with this lymphoma.

CONCLUSIONS

These results suggest that IL-9 plays an important role in nasal NK/T-cell lymphoma possibly via an autocrine mechanism.

P53, N- and K-Ras, and beta-catenin gene mutations and prognostic factors in nasal NK/T-cell lymphoma from Hokkaido, Japan

We have shown previously that nasal natural killer (NK)/T-cell lymphoma was associated with Epstein-Barr virus (EBV) and had peculiar clinical features. However, little is known about its biological and genetic changes. The aim of this study is to determine the p53, N- and K-ras, and beta-catenin status in this lymphoma in relation to EBV status and clinical features. The study group consisted of 32 Japanese patients with nasal NK/T-cell lymphoma. The p53 and beta-catenin expression, phenotype, and EBV-oncogenic protein latent membrane protein type 1 (LMP-1) were determined by immunoperoxidase staining. The presence of EBV-encoded small nuclear early region (EBER) RNA was determined by in situ hybridization. The p53 mutations (exons 5 to 9), N- and K-ras mutations (exons 1 and 2), and beta-catenin mutations (exon 3) were analyzed by direct sequencing of the PCR-amplified products that were obtained from laser-microdissected tissues. CD56, CD43, and CD3 were expressed in 32 (100%), in 31 (96%), and in 18 (56%) tumors, respectively. EBER RNA was detected in 31 (96%) tumors. LMP-1 was expressed in 15 (48%) tumors, and p53 and beta-catenin protein were overexpressed in 18 (56%) and 4 (13%) tumors, respectively. Six mutations of the p53 gene, 1 mutation of each N- and K-ras gene, and 8 mutations of beta-catenin gene were detected in 6 (19%), 1 (3%), and 5 (16%) tumors, respectively. The p53 missense mutation was associated with LMP-1 expression (P = 0.038), but not with p53 overexpression. Kaplan-Meier analysis as well as univariate analysis using Cox proportional hazards model showed that high lactate dehydrogenase (LDH) level (P = 0.009, P = 0.0100, respectively), large cell, immunoblastoid polymorphous histology (P = 0.005, P = 0.0162, respectively), and p53 missense mutations (P = 0.021, P = 0.0342, respectively) were significantly related to worse cause-specific survival. Multivariate analysis showed that p53 missense mutation was the most independent among these 3 factors. Although the incidence of thep53, N- and K-ras, and beta-catenin gene mutations is not high, p53 missense mutation has a prognostic value for aggressive course in nasal NK/T-cell lymphoma.

Focal follicular features in tonsillar diffuse large B-cell lymphomas: follicular lymphoma with diffuse areas or follicular colonization

Focal follicular features in diffuse large B-cell lymphomas (DLBCLs) are bound to raise the question of follicular lymphoma (FL) with diffuse areas, because the diagnosis of FL is based on the presence of follicular areas, even though focal. We report 7 cases of primary tonsillar DLBCLs with focal follicular features that presented with morphologic, immunohistochemical, and biological features distinct from those of FL. Histologically, these tumors were characterized by involvement of pericryptal follicles with adjacent dominant diffuse areas. Monomorphous large tumor cells were evenly spaced with abundant, often clear cytoplasm, and blastoid nuclei often with a delicate nuclear membrane. Importantly, residual germinal centers (GCs) were present in the form of either an intrafollicular GC remnant or an isolated GC in the midst of diffuse tumor. An extrafollicular and/or parafollicular growth pattern was also observed. Bcl-6 staining revealed a predominantly sporadic occurrence of Bcl-6(+) cells, comprising <50% of tumor cells, and none displayed diffusely dense collections (>75%) of Bcl-6(+) tumor cells characteristic of the GC or FL. Staining for CD10 was negative in 6 cases. Five of 7 patients were younger than 60, the median age of other patients with primary tonsillar DLBCL. No extratonsillar involvement was seen at 18 months after diagnosis. After chemotherapy or radiotherapy, complete remission was achieved with ease in all patients, but 2 patients who were treated with chemotherapy alone relapsed at 24 and 30 months. In conclusion, tonsillar DLBCL includes a small (10%) but distinct subgroup that warrants distinction from FL with predominant diffuse areas or de novo DLBCL. It appears that the focal follicular features in tonsillar DLBCL likely represent follicular colonization of marginal zone B-cell lymphoma, probably high-grade, if the possibility of FL is excluded.

Marginal zone B cell lymphomas of Waldeyer's ring--a report of two tonsillectomy cases resembling histomorphological features of inflammatory lesions

We identified two cases of lymphoma of the mucosa-associated lymphoid tissue (MALT) type in 11 tonsillectomy specimens of primary B cell lymphoma of Waldeyer's ring. Both patients were Japanese females presenting with bilateral enlargement of the palatine tonsils. One had a history of chronic otitis media. In that case, the lesion was characterized by an extrafollicular growth pattern with marginal zone-like arrangement. The tumor was mainly composed of medium-sized cells with round or indented nuclei with scant cytoplasm (centrocyte-like cells). In the other patient, most tumor cells were mature plasma cells, plasmacytoid cells, proplasmacytes, and immunoblasts with scattered centrocyte-like cells. Tropism of tumor cells for the epithelium was noted in both lesions. Primary marginal zone B cell lymphoma of the MALT type arising from Waldeyer's ring has rarely been reported in the literature, causing certain diagnostic problems. Various florid reactive lymphoproliferative disorders, including chronic tonsillitis and infectious mononucleosis, should be differentiated from this type of primary Waldeyer's ring lymphoma.

Characterization of novel natural killer (NK)-cell and gammadelta T-cell lines established from primary lesions of nasal T/NK-cell lymphomas associated with the Epstein-Barr virus

Studies on nasal T/natural killer (NK)-cell lymphoma have been hampered by its tendency to cause necrosis. Thus, the establishment of cell lines of this neoplasm would seem to be valuable. This study attempted to establish cell lines from primary lesions of this tumor, and successfully obtained 2 novel Epstein-Barr virus (EBV)-positive cell lines, SNK-6 and SNT-8, by means of high-dose recombinant interleukin 2. Flow cytometry showed that SNK-6 had an NK-cell phenotype, CD3- CD4- CD8- CD19- CD56+ T-cell receptor (TCR) alpha/beta- TCR gamma/delta-, whereas SNT-8 was CD3+ CD4- CD8- CD19- CD56+ TCR alpha/beta- TCR gamma/delta+. These were consistent with immunophenotypes of their original tumors, and the cell lines had monoclonal EBV clones identical to ones in their original tumors. Thus, the cell lines developed from cells forming the primary lesions. Genotypic analysis showed that SNK-6 had unrearranged TCR and immunoglobulin heavy-chain genes, supporting the conclusion that SNK-6 was of NK-cell lineage. On the other hand, SNT-8 had rearranged TCR beta-, gamma-, and delta-chain genes, and together with its phenotype, SNT-8 proved to be a gammadelta T-cell line. This is the first report of the establishment of cell lines from primary lesions of nasal T/NK cell lymphomas, and the results demonstrated that there are at least 2 lineages, NK- and gammadelta T-cell, in this neoplasm. Moreover, it has been suggested that nasal T/NK cell lymphomas of these lineages may belong to the same clinicopathologic entity because both types of cases shared common clinical and histopathologic features.

Non-Hodgkin's malignant lymphoma of the sinonasal tract--treatment outcome for 53 patients according to REAL classification

OBJECTIVE

Although the Working Formulation is commonly used to classify NHL in Japan, it has been recognized as imperfect for primary extranodal lymphoma, especially for patients with sinonasal disease because of their histological characteristics. The present study investigated the clinical characteristics and the prognosis of sinonasal lymphomas according to REAL classification.

METHODS

Fifty-three patients with non-Hodgkin's malignant lymphoma (NHL) of the sinonasal tract were treated between 1981 and 1997. The age at clinical presentation was from 10 to 84 years (mean, 52.4 years). According to the Ann Arbor system, there were 30 patients with Stage IE, 13 with Stage IIE, 4 with Stage IIIE, and 6 with Stage IVE lymphomas. Twenty-two patients (41.5%) had B symptoms. The primary sites were the nasal cavity (67.8%), maxillary sinus (20.8%), ethmoidal sinus (9.4%), and frontal sinus (1.9%). The survival data was calculated by Kaplan-Meier method. Statistical analysis was performed with a generalized Wilcoxon method.

RESULTS

All of the lymphomas showed a diffuse growth pattern. Based on the origin of the tumor cells, the authors classified NHL of the sinonasal tract into five groups with the REAL classification of Japan: diffuse large B-cell lymphoma (22.6%), peripheral T-cell lymphomas (15.1%), angiocentric lymphoma (35.9%), other lymphomas and unclassified types. Of 53 patients, 39 (73.6%) received chemotherapy and radiotherapy, eight patients received chemotherapy alone, and four patients received radiotherapy alone. The cumulative 5-year survival rates were 28.5% for all of the types, 55.0% for diffuse large B-cell lymphoma, 33.3% for peripheral T-cell lymphoma, and 19.7% for angiocentric lymphoma. Results suggest that conventional combined treatment (CHOP chemotherapy+radiotherapy) is ineffective for NHL of the sinonasal tract, and especially so for NHL in the nasal cavity, NHL with tumor cells with positive T-cell markers, NHL further than Stage IIE and NHL with B symptoms.

CONCLUSION

(1) In light of this ineffectiveness, new therapies must be developed to improve patient outcome instead of the conventional combined treatment; (2) REAL classification is clear and useful for sinonasal lymphomas in Japan.

Nasopharyngeal carcinoma

Nasopharyngeal carcinoma represents a morphologic spectrum of neoplasms localized to the nasopharynx and arising from nasopharyngeal epithelium. Nasopharyngeal carcinomas have rather unique clinical, epidemiologic, pathologic, and biologic features. The morphologic spectrum of nasopharyngeal carcinoma includes keratinizing, nonkeratinizing, and undifferentiated subtypes. The separation of these morphologic types is not an academic exercise, but has practical importance relative to differential diagnosis, management, and prognosis. A similar morphologic classification applies to carcinomas arising in the palatine tonsils and the base of tongue. The nasopharynx, palatine tonsils, and base of tongue are collectively designated as Waldeyer's tonsillar tissues. Awareness of the morphologic spectrum of Waldeyer's ring carcinomas may assist in suggesting the primary tumor site in the face of an occult metastatic carcinoma to cervical neck lymph nodes.

Sinonasal lymphoma: a clinicopathologic analysis of 58 cases from the Massachusetts General Hospital

Few large series compare lymphomas of the nasal cavity with those of the paranasal sinuses. We studied the cases of 58 patients, 34 males and 24 females, aged 7 to 92 years (mean, 57 years), who had lymphoma involving the nasal cavity or paranasal sinuses. Thirty-three patients had diffuse large B-cell lymphoma (DLBCL). Twenty-three were male and 10 were female, with an age range of 7 to 91 years (mean, 63 years); two were HIV-positive. Only 2 of 11 cases tested (one in an HIV-positive patient and one of lymphomatoid granulomatosis type) were Epstein-Barr virus (EBV)-positive. Thirty (91%) involved paranasal sinuses, 10 with nasal involvement, whereas three cases had nasal, but not sinus, involvement. At last follow-up, 16 (67%) were free of disease 7 to 169 months later (mean, 65 months), and 8 (33%) had died of disease 2 to 166 months later (mean, 45 months). Seventeen patients had nasal-type natural killer (NK)/T-cell lymphoma. There were 10 women and 7 men, aged 27 to 78 years (mean, 48 years). Thirteen of 14 were EBV-positive. Sixteen patients had nasal involvement, eight with sinus involvement. Eleven (73%) of 15 were alive and well 6 to 321 months later (mean, 139 months), three (20%) died of lymphoma 1, 11, and 12 months later, and one (7%) is alive with disease. There was one case each of marginal zone B-cell lymphoma, Burkitt's lymphoma, Burkitt-like lymphoma, peripheral T-cell lymphoma of unspecified type, and adult T-cell lymphoma/leukemia. In an additional three cases, the lymphomas were composed predominantly of large cells, but no immunophenotyping could be performed for subclassification. In 19 cases (17 DLBCLs, 1 Burkitt-like lymphoma, and 1 lymphoma of uncertain lineage), presenting symptoms included complaints related to the eyes. In 16 cases (13 DLBCLs, 1 Burkitt-like lymphoma, 1 nasal NK/T-cell lymphoma, and 1 lymphoma of uncertain lineage), the orbit was invaded by lymphoma. In our series, the most common lymphoma to arise in the sinonasal area is DLBCL, followed by nasal NK/T-cell lymphoma. Comparison of these two types of lymphoma showed that lymphomas involving sinuses without nasal involvement were predominantly DLBCLs (20 of 21), whereas nasal cavity lymphomas without sinus involvement were usually NK/T-cell type (8 of 11) (p = 0.000125). Compared with patients with DLBCL, patients with nasal NK/T-cell lymphoma were overall younger, with a lower male-to-female ratio. Lymphomas of B-cell lineage were more likely to be associated with symptoms related to the eyes (p < 0.0005) and to have extension to the orbit (p < 0.01) than were lymphomas of T- or NK-cell lineage. In contrast to results of Asian studies in which nasal NK/T-cell lymphoma has a very poor prognosis, our nasal NK/T-cell lymphomas had an outcome similar to that of DLBCL.

Nasal lymphomas in Japan: a high prevalence of Epstein-Barr virus type A and deletion within the latent membrane protein gene

The majority of nasal lymphomas are of the natural killer (NK)/T cell lineage. We analyzed 33 specimens of nasal lymphoma from Japanese patients for Epstein-Barr virus (EBV). Phenotypic and genetic analyses showed 28 cases with NK/T cell type and 5 cases with B cell type. All NK/T lymphomas were of pleomorphic cell type except 2 large cell (centroblastoid) and one lymphoblastic lymphoma. All cases with nasal B cell lymphoma were of large (centroblastoid) cell type. EBV was detected in all cases of NK/T cell type with the exception of one lymphoblastic case, and was monoclonally integrated in all cases examined (14/14 cases). All but one case had subtype A of EBV infection with 30-base paired deleted LMP-1 gene. One case of B cell lymphoma showed the presence of EBV infection with subtype A and deletion of LMP-1. Our results indicate that the majority of nasal lymphomas in Japanese patients are of the nasal NK/T cell type, have pleomorphic morphology, a high prevalence of EBV with a monoclonal integration, subtype A and deleted LMP-1 gene. In contrast, nasal B cell lymphoma showed monomorphic appearance and rare EBV infection.

Microscopic detection of occult malignancy in the adult tonsil

Microscopic evaluation of all adult tonsillar specimens has been considered essential despite the low incidence of unsuspected pathologic conditions. We evaluate whether routine histologic examination of clinically benign adult tonsillar specimens is indicated. We retrospectively reviewed pathology results from all tonsillectomies performed on patients ages 18 years or older at our institution from 1989 through 1996. Three groups were created on the basis of indications for tonsillectomy: (1) routine tonsillectomies for benign disease, (2) asymmetric tonsils, and (3) search for unknown primary lesions. Demographic data and pathologic findings in each group were analyzed. In 1280 tonsillectomies performed for benign disease there were no malignancies (0%) and 32 cases (2.50%) with clinically unsuspected benign pathologic conditions. In 31 cases of tonsillar asymmetry, two cases with malignant lymphoma (6.5%) and three cases with benign pathology (9.7%) were identified. In nine patients with squamous cell carcinoma metastatic to the neck, two occult primary lesions were identified in the ipsilateral tonsil. Our results suggest that histologic evaluation of adult tonsils removed for benign disease may be clinically unnecessary. The elimination of microscopic examination of tonsils removed from patients whose clinical presentation is entirely consistent with benign disease poses minimal risk of missing clinically significant pathologic conditions. Substantial costs for negative examinations may be avoided.

Lymphoma of the nasal cavity and paranasal sinuses: improved outcome and altered prognostic factors with combined modality therapy

BACKGROUND

Lymphoma of the nasal cavity and paranasal sinuses is a rare presentation of extranodal lymphoma with a natural history that is not well characterized in this era of combination chemotherapy. The goals of this retrospective study were 1) to define the natural history of sinonasal lymphomas; 2) to compare the results of radiation therapy (XRT) alone with those of combined modality therapy (CMT) in the treatment of patients with lymphoma of the nasal cavity and paranasal sinuses; and 3) to define prognostic factors for each treatment.

METHODS

Between 1947 and 1993, 70 patients with newly diagnosed lymphoma of the nasal cavity and paranasal sinuses were treated. The Ann Arbor stages were: Stage IE: 42 patients; Stage IIE: 14 patients; Stage IIIE: 2 patients; and Stage IV: 12 patients. The distribution of T classifications of the primary tumors was as follows: T1: 2 patients; T2: 16; T3: 18; and T4: 34. Greater than 90% of the patients had intermediate grade lymphoma (Working Formulation), and none had follicular lymphoma. Twenty-eight patients received XRT alone, and 42 received CMT.

RESULTS

The actuarial 5-year freedom from progression (FFP) and overall survival (OS) rates for the entire group were 57% and 52%, respectively. For patients with localized disease (Stages IE and IIE) receiving CMT, the actuarial 5-year FFP and OS were 83% and 67%, respectively. In multivariate analysis, treatment with CMT (P = 0.0005) and stage (IE vs. IIIE-IV) (P = 0.0001) were associated with improved FFP. In the group of patients receiving XRT, extent of disease (Stage IE, T1-3 vs. Stage IE, T4 vs. Stage IIE-IV) (P = 0.0001) was the only clinical characteristic associated with improved FFP in multivariate analysis. For patients receiving CMT, International Index (0 vs. 1-3 vs. 4, 5) (P = 0.0001) was the only significant factor predictive of improved FFP in multivariate analysis. One patient failed in the central nervous system (CNS) after initial therapy as a result of a radiation therapy marginal miss.

CONCLUSIONS

In a Western population, patients with localized lymphoma of the nasal cavity and paranasal sinuses have a favorable prognosis when treated with CMT. FFP is significantly improved by treatment with CMT. For patients treated with XRT, extent of disease is the strongest predictor of outcome. International Index is the most significant prognostic factor for patients receiving CMT. Failure in the CNS is rare after initial therapy and is associated with local failure.

Nasal lymphoma: results of local radiotherapy with or without chemotherapy

BACKGROUND

Primary nasal lymphoma is a rare disease. Although most patients are initially seen in early Ann Arbor stages, their prognosis is poor. The prognostic significance of local tumor bulk has not been well studied.

METHODS

Twenty-one patients with nasal lymphoma treated between 1985 and 1992 were retrospectively studied. Sixteen patients (76%) below the age of 75 years received combined radiotherapy and chemotherapy. One young patient with early disease and 4 elderly patients had radiotherapy alone. Twelve cases (57%) were diagnosed as pleomorphic T-cell lymphoma based on typical histologic features alone. Immunophenotyping was performed in 10 cases; 8 were T cell and 2 were B cell. Seventeen patients (81%) had Ann Arbor clinical stage IE disease, and 4 had stage IIE disease. The local tumor extent was assessed by endoscopy in all patients and by computerized tomography (CT) in 14 patients. Eleven local tumors (52%) extended to the posterior ethmoids, sphenoid sinus, orbit, or beyond. Using a T-stage system, the prognostic significance of local tumor bulk was evaluated for stage IE patients.

RESULTS

At a median follow-up time of 16.8 months, the lymphoma recurred in 13 patients; 10 patients had systemic relapse and 10 patients, local relapse. The 5-year actuarial overall survival rate was 24%. Complete response to chemotherapy was achieved in 5 of 16 patients (31%). Four of the 6 patients who remained alive and disease-free were chemotherapy complete responders. Among stage IE patients, those with early and those with advanced local disease did not have significantly different survival.

CONCLUSIONS

In view of the high systemic and local relapse rates, more-effective chemotherapy is needed to improve the survival rates, and the role of combined chemotherapy and radiotherapy should be evaluated. Further studies are required to identify patients at high risk of relapse for clinical trials with investigational treatment.

The Epstein-Barr virus in malignant non-Hodgkin's lymphoma of the upper aerodigestive tract

Sixty malignant non-Hodgkin's lymphomas originating in the upper aerodigestive tract have been analyzed for their cytologic type, immunophenotype and association with the Epstein-Barr virus (EBV). The majority of these tumors were B-cell lymphomas of blastic cytology (78%) with the exception of lymphomas in the parotid gland. Large B-cell lymphomas were the most frequent encountered in the sinonasal region and Waldeyer's ring. Twelve lymphomas were of T- or T/NK (natural killer)-cell lineage. They were in the nasal cavity and the paranasal sinuses (4), the tonsil (5), and the oral cavity (3). Epstein-Barr sequences were detected in five angiocentric T/NK-lymphomas, one peripheral T-cell lymphoma, one lymphoma of lymphomatoid granulomatosis type, one large B-cell lymphoma, and in a lymphoroliferative disorder in an HIV-positive patient. These results suggest that EBV is not involved in lymphomagenesis of B-cell tumors, but is associated with angiocentric T/NK-cell lymphoma in the upper aerodigestive tract.

Prognostic factors and treatment outcome in non-Hodgkin's lymphoma of Waldeyer's ring

Prognostic factors and treatment outcome of 71 patients with non-Hodgkin's lymphoma of Waldeyer's ring were analyzed retrospectively. In univariate analyses, unfavorable prognosis was associated with primary disease in the base of the tongue, stage III-IV diseases, B-symptoms, high-grade histology, T-cell phenotype, elevated serum LDH levels, decreased peripheral blood lymphocyte counts, and negative response on delayed type hypersensitivity skin reactions. Multivariate analysis showed that stage III-IV and T-cell phenotype were significant independent risk factors for death. In stage I-II lymphomas, patients with unilateral large or bilateral cervical lymph node involvement had a poorer prognosis. In stage I-II lymphomas with intermediate or high-grade histology, patients who had received radiotherapy with MTCOP-P chemotherapy (pirarubicin, cyclophosphamide, vincristine, methotrexate with leucovorin rescue, peplomycin, and predonisolone) showed significantly better 5-year disease-free survival rate compared with patients treated with radiotherapy alone.

Clinicopathologic study of nasal T/NK-cell lymphoma among the Japanese

A high prevalence of nasal lymphoma expressing a T- or natural killer (NK)-cell phenotype (NTCL) with frequent association of Epstein-Barr virus (EBV) has been indicated in Asians. To characterize NTCL among the Japanese, the clinicopathologic features of 32 cases were evaluated and the cases were also analyzed for EBV-RNA using an ISH method. Morphologically, 31 cases were identified by atypical pleomorphic lymphoid infiltrates with polymorphous, angicentric, and necrotic features. Their lymphoma cells ranged in size from small to large and were mixed in varying proportion from case to case. The other one case showed a monomorphic 'blastic' appearance. EBV-encoded small RNA (EBER) was detected in the neoplastic cells of 27 of the 32 cases examined. In the five EBV-negative cases, one was the 'blastic' type. Clonal T-cell receptor gene rearrangement was detected in none of seven cases examined. The patients had a median follow-up of 9 months (range, 1 month to 14 years and 11 months). The Kaplan-Meier estimate of overall survival was 49% at 5 years, correlating with clinical stage. These data support the concept that most cases of NTCL are identified as tumors with T/NK-cell characteristics and EBV association, distinctly different from other peripheral T-cell lymphomas. Furthermore, the one case of an EBV-negative 'blastic' variant appears not to fit well into the pleomorphic category but more closely resembles the pathologic features of extranasal angiocentric lymphoma with lymphoblastoid appearance. This study also showed no clear difference in clinical aspects other than the original site or in prognosis, between NTCL and extranasal angiocentric lymphomas despite the higher incidence of EBV association and the tendency for that peculiar anatomical site to be restricted to the former group.

Nasal T/NK cell lymphoma: a clinico pathologic study of 30 west Chinese patients with special reference to proliferation and apoptosis

Midfacial T-cell lymphomas are more prevalent in Asia than in Europe or North America. Clinically, these lymphomas are noted as one major differential diagnosis in the malignant midline granuloma syndrome. During the past years, the group of nasal T/NK cell lymphomas has been recognized that is frequently associated with EBV-infection. The aim of the current publication was to describe the clinical presentation and course of 30 patients attending the West China University of Medical Sciences, Chengdu, P.R. China, between 1991 and 1994. Clinical records were assessed and the patients were followed for 6 to 29 (mean 12.4) months. Several microscopic features thought to be associated with this entity were carefully evaluated together with immunohistochemical data. The proliferation of the tumour cells was assessed by determining the mitotic index and the ratio of MIB-1 labelled cells. In addition, the incidence of apoptotic cells was investigated by means of the in-situ end labelling (ISEL) technique. Our data confirm the expression of T-cell markers by T/NK cell lymphomas as determined by the immunohistochemistry. The apoptotic index was found to correlate with the ratio of MIB-1 labelled cells. Expression of the bcl-2 oncoprotein was not associated with increased or diminished proliferation or cell death, respectively. Eight of the thirty patients succumbed to their disease during the follow-up period. Kaplan-Meier cumulative survivals and log-rank tests revealed a significant impact of MIB-1 labelling on mean survival times.

Circulating intercellular adhesion molecule-1 and its cellular expression in head and neck non-Hodgkin's lymphomas, including lethal midline granuloma

Extranodal non-Hodgkin's lymphoma in the head and neck, especially T-cell lymphoma of the lethal midline granuloma (LMG) type, has unique clinical and histologic features differentiating it from other lymphomas. The authors measured soluble intercellular adhesion molecule-1 (ICAM-1) in sera from 12 patients with T-cell lymphoma of the LMG type and from 52 patients with other head and neck non-Hodgkin's lymphomas, by double-determinant immunoassay. The expression of ICAM-1 in lymphoma tissue was examined in 26 patients by the avidin-biotin immunoperoxidase method. The serum ICAM-1 levels were significantly higher in T-cell lymphoma of the LMG type than in other head and neck lymphomas or in healthy adult controls. Elevated levels of serum ICAM-1 were associated with increased levels of serum lactate dehydrogenase, poor prognosis, and impaired T-cell-dependent immune functions, both in T-cell lymphoma of the LMG type and in other head and neck lymphomas. When we monitored serum ICAM-1 levels in individual patients, the level decreased in the complete remission interval compared to before treatment and went up again when the lymphoma relapsed. Although the staining intensities of ICAM-1 in lymphoma cells were not related to serum ICAM-1 levels, a markedly intense expression of ICAM-1 was found on the angiocentric or angiodestructive lymphoreticular infiltrate region in the tissues from T-cell lymphoma of the LMG type. A higher serum ICAM-1 level and its tissue expression in T-cell lymphoma of the LMG type may be one of the clues to understanding this particular lymphoma. The serum ICAM-1 level could be an efficient parameter for monitoring the clinical course of head and neck non-Hodgkin's lymphomas.

Nasal T-cell lymphoma causally associated with Epstein-Barr virus: clinicopathologic, phenotypic, and genotypic studies

BACKGROUND

The authors have previously demonstrated nasal T-cell lymphoma (NTL) associated with Epstein-Barr virus (EBV). The detailed clinical, phenotypic, and genotypic features and the role of EBV in lymphomagenesis remain to be clarified.

METHODS

The study group consisted of 18 patients with NTL. The phenotype was determined by immunoperoxidase staining with various monoclonal antibodies. Genotypic study was done using Southern blot hybridization. The presence of EBV-encoded small nuclear early region (EBER) RNA and EBV DNA were determined by in situ hybridization. The expression of EBV-encoded nuclear antigen (EBNA) and latent membrane protein (LMP1) were identified by immunohistologic methods. Clonotypic analysis of EBV genomes was performed by Southern blot hybridization with EBV termini fragment probe.

RESULTS

The clinical features of NTL were characterized as prolonged fever (16 patients), widespread dissemination into distant sites (13 patients), and poor prognosis with a median survival of only 6 months. EBER transcripts were identified in 16 of 18 patients. Monoclonal EBV genomes EBNA1 and LMP1 were also detected in all EBER-positive cases tested. All 18 patients expressed pan-T antigens such as MT1, CD45RO, and/or CD2. The rearrangements of T-cell receptor (TCR)-beta, -gamma, and/or -delta genes were shown in all 11 patients tested. The natural killer (NK) cell phenotype CD56 was expressed in all EBV-positive cases tested, and was not detected in EBV-negative cases. Seven EBV-positive cases expressed a TCR-delta chain with rearranged TCR-gamma or -delta genes whereas both EBV-negative cases corresponded to alpha beta T-cell lymphoma, which expressed a TCR-beta chain with a rearranged TCR-beta gene.

CONCLUSIONS

These data suggest that EBV-positive NTL may be derived from the lineage of NK-like T-cells or gamma delta T-cells, and that EBV may play a role in lymphomagenesis. Therefore, we propose that NTL which has peculiar clinical and histologic features could be classified as a new lymphoma entity.

Experience of radiotherapy in lethal midline granuloma with special emphasis on centrofacial T-cell lymphoma: a retrospective analysis covering a 34-year period

Lethal midline granuloma (LMG) is characterized by progressive ulceration and destruction of the midfacial tissue. It occurs more frequently in Oriental than in Western populations. Because of the progress in clinical pathology and immunohistochemistry, most cases have been proven to be malignant lymphomas, especially of T-cell lineage. We describe 92 cases of lethal midline granuloma or centrofacial malignant lymphoma in the period 1959-1993. All received complete courses of radiotherapy. Twenty of them also received combination chemotherapy. Thirty-six cases had specimens available for immunohistochemical study; 25 (69%) of these had a T-cell phenotype, and 6 (17%) were of B-cell lineage. The dose to the nasal region was in the range of 3000-7500 cGy in 11-58 days, and to the neck 3000-6400 cGy in 11-48 days. The overall survival rate for the LMGs was 59.5% at 5 years and 56.2% at 10 years (Kaplan-Meier). Combined chemotherapy seemed not to improve the overall survival in this study (p = 0.63), but the patient number was too small to make a firm conclusion. Based on the results of this study, we recommend a dose of 4500-5000 cGy to the midfacial region, since a higher dosage did not improve the treatment results (p = 0.88). Irradiation has a definite role in good locoregional control of this disease. The recent clarification of the disease nature and the recognition of the background clinicopathological features should provide valuable information for future patient management and prospective studies.

Nasal T-cell lymphoma: a clinicopathological and immunophenotypic analysis of 13 cases

Thirteen cases of nasal lymphomas with T-cell or natural killer (NK)-cell phenotype were studied, with attention to clinical presentation and follow-up, the presence of Epstein-Barr virus (EBV) using in situ hybridization (EBER), the immunophenotype, and the presence of cytotoxic granules. All but two patients presented with stage I disease. In three cases local progression resulted in involvement of the central nervous system. When dissemination occurred, this was predominantly to extranodal localizations, in two cases to the skin. Response to therapy was highly variable, but patients treated with radiotherapy with or without additional chemotherapy had a better prognosis than patients treated with initial chemotherapy alone. All lymphomas were associated with EBV, and most cases showed cytotoxic features, ten of which were CD56 positive. In eight cases a T-cell origin was proven, but in five cases a possible NK-cell origin could not be excluded. No clinical differences were seen between true T-cell lymphomas and possible NK-cell neoplasms. Nasal T-cell lymphomas should be considered as a distinct clinicopathological entity, strongly associated with EBV, and with cytotoxic features in most cases. No prognostic parameters were detected to predict dissemination and response to therapy.

Mucosal mantle cell (centrocytic) lymphomas

The morphology, phenotype, genotype and clinical behaviour of four cases of mantle cell lymphoma (centrocytic lymphoma) presenting primarily in mucosa (two gastric, one in large bowel and one tonsillar) are reviewed. Their relationship with the broader group of mantle cell and mucosa-associated lymphoid tissue (MALT) lymphomas is also discussed. All four tumours showed a monomorphic picture of mantle cells (centrocytes) arranged in a diffuse, or vaguely nodular, pattern. Scattered non-neoplastic germinal centres were entrapped within the tumour cells, although there was no follicular colonization. In two cases distinct epithelial infiltration by tumour cells was observed. All four tumours had a CD19, CD20, CD5, IgD, Leu8 immunophenotype, whereas KiM1P and CD10 expression were absent. DRC antibody showed loose aggregates of dendritic cells in three of four cases. Three cases showed PRAD-1/Cyclin D1 overexpression by Northern blot analysis. Although we were not able to detect bcl-1 rearrangement in the major translocation cluster (MTC) breakpoint, the possibility of bcl-1 rearrangement involving other cluster breakpoints cannot be ruled out. The four cases evolved as a disseminated disease, involving either peripheral lymph nodes, spleen or bone marrow. The biological behaviour of mantle cell lymphoma presenting in mucosa appears, irrespective of localization or macroscopic presentation, similar to that of nodal mantle cell lymphoma. Their tendency to dissemination contrasts with MALT lymphomas, which tend to remain localized, and from which mucosa mantle cell lymphoma must be distinguished. The presence of lymphoepithelial lesions does not seem to be a useful differential feature, since occasional epithelial infiltration was seen in two cases. Reactivity with CD5 appears to be especially useful in distinguishing these, since all four cases were clearly positive, in contrast with what is usually found in MALT lymphomas.

Non-Hodgkin's lymphoma of the sinonasal tract. A clinicopathologic and immunophenotypic study of 120 cases

BACKGROUND

Non-Hodgkin's lymphomas (NHLs) of the sinonasal tract are uncommon neoplasms that can be morphologically difficult to distinguish from destructive nonneoplastic processes or other malignant neoplasms in this site.

METHODS

From the files of the Otolaryngic Tumor Registry-Armed Forces Institute of Pathology from 1965 to 1992, 120 cases of NHL involving the sinonasal tract were selected for which clinical records and paraffin-embedded tissue blocks were available. The histologic features and immunophenotypic findings of each patient were examined, and follow-up data were obtained for 66 (55%).

RESULTS

The ratio of males to females was 1.35:1, and the ages ranged from 3 to 94 years (median, 59 years). Sixty percent of the cases of NHL occurred in the patients' sixth to eighth decades of life. Clinical presentations varied according to histologic type. The low grade lymphomas presented with a nasal cavity or paranasal sinus mass associated with obstructive symptoms. The high grade lymphomas were more likely to present with aggressive signs and symptoms including nonhealing ulcer, cranial nerve manifestations, facial swelling, epistaxis, or pain. Of note, the high grade B-cell lymphomas tended to present with soft tissue or osseous destruction, particularly of the orbit with associated proptosis, whereas the T-cell lymphomas were associated with nasal septal perforation and/or destruction. Sites of disease included the nasal cavity, one or more paranasal sinuses, or multiple regions within the sinonasal tract. Of patients who received adequate follow-up, nodal and extranodal dissemination were identified in a limited number (n = 11). Nodal dissemination occurred in cervical and axillary lymph nodes. Extranodal sites of involvement included the larynx, skin, liver, uvula, kidney, breast, lacrimal gland, testis, and prostate gland. There was a wide spectrum of morphologic types of lymphoma, classified according to the Working Formulation. Immunophenotypic analysis on paraffin embedded tissue sections of all patients demonstrated a B-cell to T-cell ratio of 1.18:1. Treatment primarily included radiotherapy and chemotherapy. Follow-up information was available for 66 (55%) patients ranging from 1 to 16 years (median, 3 years). Of these 66 patients, 24 (36.4%) died of disease, 17 (25.7%) are alive without disease, 13 (19.7%) are alive with disease, and 12 (18.2%) are dead of unrelated or unknown causes.

CONCLUSIONS

Non-Hodgkin's lymphomas of the sinonasal tract are heterogeneous diseases that can be clinically aggressive. The frequency of these lymphomas in the United States cannot be estimated accurately because all of our cases were of histologic slides submitted for consultations. There appears, however, to be a slight B-cell predominance in this population that previously has been observed, unlike in South America and Asia where the majority of cases have a T-cell phenotype.

Sinonasal lymphomas

Advances in immunocytochemical phenotyping and molecular genetics have nearly resolved the histopathologic and therapeutic quandaries brought about by a diagnostic nomenclature that provided little guidance in the management of midfacial necrotizing lesions. Gone are terms like midline granuloma syndrome, lethal midline granuloma, polymorphic reticulosis, lymphomatoid granulomatosis, midline destructive granuloma, and idiopathic midline destructive disease. They have been replaced by the appreciation that the majority of the lesions are lymphomas of the sinonasal tract. The lymphomas are of B- or T-cell lineage and have a broad biologic spectrum from low to high grade. Still to be addressed are apparent geographic differences in biologic behavior, the epidemiologic significance of a preponderance of T-cell nasal lymphomas in the Orient, and optimum therapeutic regimens.

Non-Hodgkin's lymphomas of the nose and paranasal sinuses in the pediatric population

Paranasal and nasal neoplasms often elude early diagnosis in the pediatric population. This report examines 3 cases of nasal and paranasal sinus lymphomas out of 29 lymphomas and lymphoproliferative disorders seen from 1983 to 1990. Diagnostic delays are common. The development of orbital signs and symptoms often leads to diagnosis. Computed tomography and magnetic resonance imaging are important in delineating the extent of disease and allow appropriate staging. Transnasal biopsy yields the definitive diagnosis, with low associated morbidity. Aggressive chemotherapy and irradiation prolongs survival; with this regimen all of our patients have remained alive, although 1 has residual disease. B-cell lymphomas are more common than T-cell varieties in children. One patient demonstrated B-cell immunodeficiency and preleukemia prior to developing primary paranasal sinus non-Hodgkin's lymphoma; this case reiterates the systemic nature of lymphoma, Key differences between children and adults in the manifestations of nasal and sinus lymphomas are emphasized.

Nasal T-cell lymphoma

Nasal T-cell lymphomas represent a controversial subset of malignant lymphomas and include lesions previously termed midline malignant reticulosis, lymphomatoid granulomatosis, and polymorphic reticulosis. Nasal T-cell lymphomas are rare in Western populations and much more prevalent in Asian countries. Clinically, adult males are most often affected. Histologically, an angiocentric infiltrate composed of a spectrum of atypical cells is usually present. Phenotypically, the neoplastic cells lack expression of B-lineage markers, and usually express the T-lineage-associated markers CD2, CD45RO, and CD43; however, they often lack other pan-T-lineage markers. They often express the natural killer marker CD56, but usually lack the natural killer markers CD16 and CD57. Gene rearrangement studies have shown a germline configuration for the antigen receptor genes in the majority of cases. To date, evidence of Epstein-Barr virus has been consistently demonstrated, regardless of the geographic region studied. In situ hybridization studies have localized the Epstein-Barr virus to the atypical cells.

Adult T-cell leukaemia-lymphoma in Waldeyer's ring: a report of three cases

Adult T-cell leukaemia-lymphoma (ATLL) is a new type of T-cell malignancy which has an adult onset, a rapidly progressive terminal course and a clustering at patients' birthplaces in southeast Japan and the Caribbean. We report the clinical features of three cases of ATLL in Waldeyer's ring, which has been rarely reported in the literature. The patients complained of throat pain and lump in the neck. They received combination chemotherapy, but all died within a year of first noticing the symptoms.

Malignant lymphoma of Waldeyer's ring. A histological and immunohistochemical study

The histopathological and immunohistological features of non-Hodgkin's lymphoma limited to the Waldeyer's ring were studied in 22 Japanese patients using a panel of T- and B-cell markers on paraffin-embedded sections. All cases showed a diffuse growth pattern. Twenty cases were B-cell lymphomas and two were T-cell lymphomas. In contrast to the primary malignant lymphomas of the nasal cavity and paranasal sinuses, in which T-cell neoplasms are more frequently seen, the majority of the primary Waldeyer's ring lymphomas were B-cell neoplasms. Sixteen of the 20 cases of B-cell lymphoma were centroblastic lymphomas, and the monomorphic variant comprised the majority of these; the other three B-cell lymphomas were immunocytomas. Two of the T-cell lymphomas showed morphological features of angiocentric lymphomas.