Extranodal natural killer/T-cell lymphoma, nasal type: clinical and computed tomography findings in the head and neck region

Sinonasal lymphoma: A primer for otolaryngologists

Objective

Sinonasal lymphomas are a rare entity that commonly present with nonspecific sinonasal symptoms and are often recognized immediately. Through this review, we aim to summarize important principles in diagnosis and treatment of sinonasal lymphomas, with the goal of disseminating the current knowledge of this under-recognized malignancy to otolaryngologists.

Methods

Systemic review using PRISMA guidelines of foundational scholarly articles, guidelines, and trials were reviewed focusing on clinical characteristics of key sinonasal lymphoma subtypes, along with available treatments in the otolaryngology, medical oncology, and radiation oncology literature.

Results

Sinonasal lymphoma are derived from clonal proliferation of lymphocytes at various stages of differentiation, of which diffuse large B-cell lymphoma (DLBCL) and extranodal natural killer/T-cell lymphoma (ENKTL) are the most common. Diagnosis and staging require biopsy with immunohistochemistry in conjunction with imaging and laboratory studies. Treatment is ever evolving and currently includes multi-agent chemotherapy and/or radiation therapy.

Conclusion

Otolaryngologists may be the first to recognize sinonasal lymphoma, which requires a comprehensive workup and a multidisciplinary team for treatment. Symptoms are nonspecific and similar to many sinonasal pathologies, and it is crucial for otolaryngologists to keep a broad differential.

Level of Evidence

5.

Nasal-Type NK/T-Cell Lymphoma Involvement of the Vocal Cord on FDG PET/CT

ABSTRACT

Nasal-type extranodal natural killer/T-cell lymphoma (ENKTL) rarely involves the vocal cord. Herein, we present a case of an ENKTL patient with vocal cord involvement revealed by FDG PET/CT. Nasopharyngoscopy showed a neoplasm in the larynx, which was eventually confirmed as ENKTL by immunohistochemical results. PET/CT was subsequently performed for staging, and intense FDG uptake in the left side of vocal cord suggested ENKTL involvement.

Extranodal nasal-type natural killer/T-cell lymphoma with nasal septal perforation

There are very few reports of extranodal nasal-type NKTL with septal perforation, as seen in our patient. In addition, extranodal nasal-type NKTL is often diagnosed as chronic inflammation on histopathological examination. Therefore, if nasal septal perforation does not improve with appropriate conservative treatment, clinicians should consider a malignant disease such as extranodal nasal-type NKTL.

NK/T-cell lymphoma of the nasal cavity: an unexpected diagnosis

Nasal-type Natural Killer/T-cell Lymphoma (NKTL) is a rare form of extranodal non-Hodgkin's lymphoma, typically arising in the nasopharynx and displaying an aggressive and ultimately fatal clinical course. The disease is linked to Epstein-Barr virus infection and is endemic to Asia and South America, but extremely few cases have been reported in Europe. We present two cases of nasal NKTL unexpectedly diagnosed in elderly patients, following very different presentations to our otolaryngology service. The first case is that of a 73-year-old Irish man with recurrent nasal vestibulitis despite antibiotic treatment. The second case involves a 79-year-old Irish woman presenting with a large mass on the hard palate, found to invade into the floor of the nose. NKTL can pose diagnostic challenges, as the initial clinical presentation can be non-specific and overlap with other nasal conditions, leading to a delay in diagnosis. Biopsy with histopathological and immunohistochemistry analysis is required to establish the definitive diagnosis. Treatment involves multidisciplinary input from radiotherapy and medical oncologists. Clinicians must be aware of this disease and have an index of suspicion when dealing with persistent or aggressive nasal conditions.

Differentiation between sinonasal natural killer/T-cell lymphomas and diffuse large B-cell lymphomas by RESOLVE DWI combined with conventional MRI

OBJECTIVE

To explore the feasibility of using RESOLVE DWI combined with conventional magnetic resonance imaging (MRI) to discriminate between sinonasal NKTLs and DLBCLs and to investigate the correlation between ADC value and Ki-67 expression in the two subtypes of NHLs.

MATERIALS AND METHODS

Sixty patients with NKTLs and twenty-six patients with DLBCLs in the sinonasal region who were confirmed by histopathology underwent high-resolution DWI and conventional MRI. The apparent diffusion coefficients (ADCs) and conventional MRI features associated with NKTLs and DLBCLs were compared using multivariate logistic regression. Receiver operating characteristic (ROC) curve analysis was performed, and the area under the curve (AUC) values for conventional MRI and MRI in combination with DWI were compared to determine the diagnostic performances of the approaches in the differentiation of NKTLs and DLBCLs. Spearman's rank correlations were used to analyze the correlation between ADC value with the higher AUC and Ki-67 expression.

RESULTS

For conventional MRI, localization in the nasal cavity and poor or moderate enhancement indicated an NKTL, whereas localization in the paranasal sinus and intense enhancement indicated a DLBCL, with sensitivity, specificity and area under the curve(AUC)value of 88.5%, 85.0% and 0.883, respectively. A combination with a cut-off ADC value of 0.646 × 10^-3 mm²/s yielded sensitivity, specificity and AUC values of 100.0%, 80.0% and 0.951, respectively. A significant difference between the AUCs for conventional MRI and MRI in combination with DWI (p = 0.02) was identified. Ki-67 expression of NKTLs was significantly lower than that of DLBCLs (p < 0.001). Besides, there was an inversely poor correlation between them in the overall sample (r = -0.395, p < 0.001). However, the ADC value was not significantly correlated with Ki-67 LI in neither NKTLs nor DLBCLs (both p > 0.05).

CONCLUSIONS

Location and enhancement degree were the most valuable conventional MRI features for differentiating between NKTLs and DLBCLs. A combination of DWI and MRI could significantly improve the differential performance. ADC values may be used to noninvasively evaluate the proliferation level of sinonasal NHLs.

Extranodal NK/T-cell lymphoma in adolescents: imaging findings of a consecutive 7-year case series

Objectives

Extranodal NK/T-cell lymphoma is reportedly a rare but emerging type of lymphoma in adolescents. The present study was performed to specify its imaging characteristics.

Methods

Our hospital’s picture archiving and communication systems were searched from January 2009 to December 2016. We identified 13 patients aged <18 years with pathologically confirmed extranodal NK/T-cell lymphoma in the head and neck region. The computed tomography and magnetic resonance images were reviewed to summarize the imaging characteristics of extranodal NK/T-cell lymphoma in adolescents.

Results

The mean age at onset was 15.2 ± 1.46 years (range, 12–17 years) with a male:female ratio of 1.17:1.00. Most of the patients (n = 10) displayed nasal cavity and/or paranasal involvement. The tumor was homogeneous in both computed tomography and magnetic resonance images and showed slight enhancement. No calcification or liquefactive necrosis was observed. Adjacent structures were usually involved.

Conclusion

Suggestive imaging characteristics could acquaint specialists with extranodal NK/T-cell lymphoma in adolescents, facilitating improved early recognition of the diagnosis and helping to improve the patient’s outcome.

Deceptive nasal NK/T-cell lymphoma

Nasal NK/T cell lymphoma is rare and it easily masquerades as chronic rhinosinusitis. It has a very poor prognosis and hence early diagnosis, although difficult, is necessary for better outcome. We present a case of a 30-year-old man who presented with nasal obstruction, facial oedema and crusts. High-resolution computed tomography found soft tissue in all sinuses and the nasal cavity. Endoscopic biopsy revealed necrotic and inflammatory tissue with fungi on culture. A diagnosis of fungal rhinosinusitis was made but the patient did not respond to antifungal drugs. A histopathology review with immunohistochemistry suggested nasal NK/T cell lymphoma. The patient was started on chemotherapy but died within 1 week.

Patterns of Primary Tumor Invasion and Regional Lymph Node Spread Based on Magnetic Resonance Imaging in Early-Stage Nasal NK/T-cell Lymphoma: Implications for Clinical Target Volume Definition and Prognostic Significance

PURPOSE

This study aimed to determine the pathways of primary tumor invasion (PTI) and regional lymph node (LN) spread based on magnetic resonance imaging (MRI) in early-stage nasal NK/T-cell lymphoma (NKTCL), to improve clinical target volume (CTV) delineation and evaluate the prognostic value of locoregional extension patterns.

METHODS AND MATERIALS

A total of 105 patients with newly diagnosed early-stage nasal NKTCL who underwent pretreatment MRI were retrospectively reviewed. All patients received radiation therapy with or without chemotherapy.

RESULTS

The incidences of PTI and regional LN involvement were 64.7% and 25.7%, respectively. Based on the incidence of PTI, involved sites surrounding the nasal cavity were classified into 3 risk subgroups: high-risk (>20%), intermediate-risk (5%-20%), and low-risk (<5%). The most frequently involved site was the nasopharynx (35.2%), followed by the maxillary (21.9%) and ethmoid (21.9%) sinuses. Local disease and regional LN spread followed an orderly pattern without LN skipping. The retropharyngeal nodes (RPNs) were most frequently involved (19.0%), followed by level II (11.4%). The 5-year overall survival (OS), progression-free survival (PFS), and locoregional control (LRC) rates for all patients were 72.8%, 65.2%, and 90.0%, respectively. The presence of PTI and regional LN involvement based on MRI significantly and negatively affected PFS and OS.

CONCLUSIONS

Early-stage nasal NKTCL presents with a high incidence of PTI but a relatively low incidence of regional LN spread. Locoregional spread followed an orderly pattern, and PTI and regional LN spread are powerful prognostic factors for poorer survival outcomes. CTV reduction may be feasible for selected patients.

Delayed diagnosis of sinonasal lymphoma due to bilateral manifestation

The objective of this study is to analyze the presenting symptoms, the time to correct diagnosis and outcome of a European patient cohort with sinonasal lymphoma focusing on unilateral vs. bilateral sinonasal involvement. In a retrospective setting in a European tertiary referral center, eleven patients (9 males, 2 females) with sinonasal lymphoma diagnosed between 2002 and 2015 were identified and divided into a unilateral and bilateral group according to their CT finding. Clinical findings on first presentation, the presence of B symptoms, the radiologic findings, overall survival and disease-specific survival were assessed. 55 % of the patients suffered from bilateral manifestation, which was associated with a delayed diagnosis (10 vs. 1.5 months, p < 0.05). B symptoms (67 vs. 0 %) and death of disease (50 vs. 0 %) were observed only in the bilateral group. Nasal NK/T-cell lymphoma was the most frequent diagnosis, followed by diffuse large B-cell lymphoma. Bilateral mucosal manifestation with B symptoms was shown to be common within the rare entity of sinonasal lymphomas and patients with bilateral sinonasal manifestation are at risk for a delayed diagnosis with worse outcome.

Extranodal non-Hodgkin lymphoma of the sinonasal cavities: A 22-case report

OBJECTIVE

To determine presenting features, management and prognosis in extranodal non-Hodgkin lymphoma of the sinonasal tract.

MATERIAL AND METHODS

A retrospective study between 2004 and 2013 in the University Hospital Center of Nantes (France) recruited patients with lymphoma discovered by sinonasal involvement. Epidemiologic, diagnostic, clinical and prognostic criteria were analyzed, with survival studied on the Kaplan-Meier estimator and Log-rank test.

RESULTS

Twenty-two patients were included: 14 male, 7 female, with a mean age of 65 years at diagnosis. All had non-Hodgkin lymphoma, with strong predominance of diffuse large B-cell lymphoma (77%). Seven patients had risk factors for lymphoma (infection by HIV, EBV or chronic lymphocytic leukemia). A majority (68%) had advanced tumor at diagnosis (stage IV on the Ann Arbor classification). Most were located in the craniofacial bones (68%), mainly involving the maxillary or ethmoidal sinuses. The most frequent presenting symptoms were unilateral nasal obstruction, mucopurulent rhinorrhea, recurrent epistaxis or diplopia. Treatment consisted in chemotherapy, in some cases associated to radiotherapy. Overall survival was 82% at 12 months and 73% at 36 months. Recurrence-free survival was 76% at 12 months and 64% at 36 months.

CONCLUSION

Lymphoma is an aggressive pathology; revelation by sinonasal involvement is rare. Recommended treatment is chemotherapy, possibly associated to radiotherapy. Prognosis depends on histologic type, Ann Arbor stage at diagnosis and the therapeutic options available for the individual patient.

Nasal endoscopic evaluation and its impact on survival in patients with stage I/II extranodal natural killer/T-cell lymphoma, nasal type

BACKGROUND

Endoscopic findings of extranodal natural killer/T-cell lymphoma (ENKTL), nasal type, are heterogeneous, but not fully understood. The objective of this study was to evaluate the role of nasal endoscopic examination and its implications for treatment of stage I/II ENKTL.

METHODS

This retrospective study included 60 consecutive patients diagnosed with stage I/II ENKTL, nasal type, from 2000 to 2011.

RESULTS

The endoscopic findings were classified into early (45%) and advanced (55%) lesions. Furthermore, the primary tumor extent assessed by endoscopy was significantly correlated with the radiologic imaging (p < 0.001). The results of univariate analysis showed that the patients with advanced lesions had worse overall survival (p = 0.004) and disease-free survival (p = 0.001) than those with early lesions. In multivariate analysis, advanced lesions on nasal endoscopy was an independent prognostic factor (p = 0.024; hazard ratio 5.29; 95% confidence interval, 1.25-22.39).

CONCLUSION

We found that nasal endoscopic findings were important prognostic factors in stage I/II ENKTL, nasal type, suggesting that comprehensive endoscopic evaluation of primary tumor should be performed in this setting.

Extranodal natural killer/T-cell lymphoma nasal type: detection by computed tomography features

OBJECTIVES/HYPOTHESIS

Nasal natural killer/T-cell lymphoma (NKTL) often has an infiltrative pattern in computed tomography that makes them difficult to distinguish from benign inflammatory diseases. This study aimed to design a method of measuring the thickness of the nasal floor and nasal septum, determine the critical value of mucosal thickness that may implicate these NKTL cases from benign inflammatory disease, and finally make a complete flowchart to detect NKTL with minimal mistake.

STUDY DESIGN

Thirty-two patients with nasal NKTL and 173 patients with severe chronic rhinosinusitis with or without polyposis were enrolled. The patients' data were collected retrospectively.

METHODS

All patients underwent standard computed tomography of the paranasal sinuses. The coronal section near the vertical part of the ground lamina was chosen for measurement, and the thickest points along the nasal floor and septum were measured.

RESULTS

Patients with NKTL had thicker nasal floors and/or septa than those with chronic rhinosinusitis, recurrent sinusitis, or pansinusitis (P < .001). If the cutoff points of the nasal floor and nasal septum thickness were set at 2.0 mm and 2.5 mm, respectively, the probability of being thicker than the corresponding points in the CRS group was <2%, and the possibility of other diagnoses should be considered.

CONCLUSIONS

Nasal floor mucosal thickness >2.0 mm or nasal septum mucosal thickness >2.5 mm may be indicators serving as one of several important hints for implicit NKTL. Finally, we established a diagnostic flowchart to include all of these important hints.

LEVEL OF EVIDENCE

4.

Effectiveness of 3 T PROPELLER DUO diffusion-weighted MRI in differentiating sinonasal lymphomas and carcinomas

AIM

To evaluate the value of 3 T Periodically rotated overlapping parallel lines with enhanced reconstruction (PROPELLER) DUO diffusion-weighted MRI (DW-MRI) in differentiating sinonasal lymphomas from carcinomas.

MATERIALS AND METHODS

PROPELLER DUO DW-MRI was performed in 23 patients with sinonasal lymphomas and 28 patients with carcinomas histologically confirmed at 3 T MRI. Apparent diffusion coefficients (ADCs) were obtained with two different b-values (b = 0 and 700 s/mm(2), b = 0 and 1000 s/mm(2)) and two different regions of interest (ROIs) sampling strategies [whole section (WS), partial section (PS)], respectively. Difference in ADCs between sinonasal lymphomas and carcinomas was evaluated using the independent samples t-test or Mann-Whitney U-test. The utility of ADC thresholds for discriminating between them was evaluated by receiver operating characteristic analysis.

RESULTS

ADCs of sinonasal lymphomas (WS ADCb0,700, 0.838 × 10(-3) mm(2)/s) were significantly (p < 0.001) lower than those of carcinomas (WS ADCb0,700, 1.396 × 10(-3) mm(2)/s). Using a WS ADC b0,700 value of 1.040 × 10(-3) mm(2)/s as the threshold value effectively differentiated sinonasal lymphomas from carcinomas with 100% sensitivity, 82.1% specificity, and 82.1% positive and 100% negative predictive values and 90.2% accuracy (b = 0, 700 s/mm(2)). There was no significant difference in diagnostic ability between different b-values settings (p > 0.05) and different sampling strategies of ROIs (p > 0.05), respectively. Additionally, there was significant differences in the ADCs between diffuse large B-cell lymphomas and natural killer (NK)/T-cell lymphomas (p < 0.05).

CONCLUSION

PROPELLER DUO DW-MRI can effectively differentiate sinonasal lymphomas from carcinomas.