1
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Guan J, Lin W, Liu W, Hui D. Primary central nervous system extranodal NK/T-cell lymphoma, nasal type with CD20 expression: Case report and review of the literature. Neuropathology 2024; 44:222-229. [PMID: 37963650 DOI: 10.1111/neup.12954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/22/2023] [Accepted: 10/25/2023] [Indexed: 11/16/2023]
Abstract
Primary central nervous system (PCNS) extranodal NK/T-cell lymphoma, nasal type (ENKTCL), is an exceedingly rare tumor. To the best of our knowledge, only 27 cases and only one reported aberrant CD20 expression have been documented in the literature. Here we present a second case of PCNS ENKTCL with aberrant CD20 expression in a 43-year-old immunocompetent Chinese female. The patient presented with tremors, weakness in the right upper limb, and a slow reaction. Magnetic resonance imaging revealed multiple brain lesions. A histological examination revealed a diffuse distribution of intermediate-sized pleomorphic lymphocytes with angiocentric growth. The tumor cells expressed CD2, CD3, CD56, T-cell intracellular antigen-1, granzyme B, and Epstein-Barr virus-encoded RNAs (EBERs), with additional partial and weak CD20 and CD30 expression. Despite a confirmatory pathological diagnosis, the patient refused treatment and was discharged, ultimately dying from the disease. In the literature review, the clinical, immunohistochemical, EBERs, treatment, and prognostic features of PCNS ENKTCL were summarized. Although PCNS ENKTCT is extremely rare, it does occur and should always be included in differential diagnoses. CD20 expression should be evaluated routinely with relevant markers. The accumulation of cases is crucial for developing an effective treatment strategy for this rare and aggressive malignancy.
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Affiliation(s)
- Jiexia Guan
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weizhen Lin
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Weimin Liu
- Department of Radiology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Dayang Hui
- Department of Pathology, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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2
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Yim J, Koh J, Kim S, Song SG, Bae JM, Yun H, Sung JY, Kim TM, Park SH, Jeon YK. Clinicopathologic and Genetic Features of Primary T-cell Lymphomas of the Central Nervous System: An Analysis of 11 Cases Using Targeted Gene Sequencing. Am J Surg Pathol 2022; 46:486-497. [PMID: 34980830 PMCID: PMC8923358 DOI: 10.1097/pas.0000000000001859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Primary central nervous system lymphoma (PCNSL) of peripheral T-cell lineage (T-PCNSL) is rare, and its genetic and clinicopathologic features remain unclear. Here, we present 11 cases of T-PCNSL in immunocompetent individuals from a single institute, focusing on their genetic alterations. Seven cases were subject to targeted panel sequencing covering 120 lymphoma-related genes. Nine of the eleven cases were classified as peripheral T-cell lymphoma, not otherwise specified (PTCL-NOS), of which one was of γδT-cell lineage. There was one case of anaplastic lymphoma kinase-positive anaplastic large cell lymphoma and another of extranodal natural killer (NK)/T-cell lymphoma (ENKTL) of αβT-cell lineage. The male to female ratio was 7 : 4 and the age ranged from 3 to 75 years (median, 61 y). Most patients presented with neurological deficits (n=10) and showed multifocal lesions (n=9) and deep brain structure involvement (n=9). Tumor cells were mostly small-to-medium, and T-cell monoclonality was detected in all nine evaluated cases. PTCL-NOS was CD4-positive (n=4), CD8-positive (n=3), mixed CD4-positive and CD8-positive (n=1), or CD4/CD8-double-negative (n=1, γδT-cell type). Cytotoxic molecule expression was observed in 4 (67%) of the 6 evaluated cases. Pathogenic alterations were found in 4 patients: one PTCL-NOS case had a frameshift mutation in KMT2C, another PTCL-NOS case harbored a truncating mutation in TET2, and another (γδT-cell-PTCL-NOS) harbored NRAS G12S and JAK3 M511I mutations, and homozygous deletions of CDKN2A and CDKN2B. The ENKTL (αβT-cell lineage) case harbored mutations in genes ARID1B, FAS, TP53, BCOR, KMT2C, POT1, and PRDM1. In conclusion, most of the T-PCNSL were PTCL-NOS, but sporadic cases of other subtypes including γδT-cell lymphoma, anaplastic lymphoma kinase-positive anaplastic large cell lymphoma, and ENKTL were also encountered. Immunophenotypic analysis, clonality test, and targeted gene sequencing along with clinicoradiologic evaluation, may be helpful for establishing the diagnosis of T-PCNSL. Moreover, this study demonstrates genetic alterations with potential diagnostic and therapeutic utility in T-PCNSL.
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MESH Headings
- Adolescent
- Adult
- Aged
- Anaplastic Lymphoma Kinase/metabolism
- Central Nervous System Neoplasms/genetics
- Central Nervous System Neoplasms/metabolism
- Central Nervous System Neoplasms/pathology
- Child
- Child, Preschool
- Female
- Humans
- Lymphoma, Extranodal NK-T-Cell/genetics
- Lymphoma, Extranodal NK-T-Cell/metabolism
- Lymphoma, Extranodal NK-T-Cell/pathology
- Lymphoma, Large-Cell, Anaplastic/genetics
- Lymphoma, Large-Cell, Anaplastic/metabolism
- Lymphoma, Large-Cell, Anaplastic/pathology
- Lymphoma, T-Cell, Peripheral/genetics
- Lymphoma, T-Cell, Peripheral/metabolism
- Lymphoma, T-Cell, Peripheral/pathology
- Male
- Middle Aged
- Young Adult
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Affiliation(s)
| | - Jiwon Koh
- Department of Pathology
- Center for Precision Medicine, Seoul National University Hospital
| | - Sehui Kim
- Department of Pathology
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine
| | | | - Jeong Mo Bae
- Department of Pathology
- Center for Precision Medicine, Seoul National University Hospital
| | - Hongseok Yun
- Center for Precision Medicine, Seoul National University Hospital
| | - Ji-Youn Sung
- Department of Pathology, Kyung Hee University School of Medicine
| | - Tae Min Kim
- Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
| | | | - Yoon Kyung Jeon
- Department of Pathology
- Cancer Research Institute, Seoul National University, Seoul, Republic of Korea
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3
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Lim G, Chong LL, Yu WY, Thirugnanam U. 'Killer' open ring in the brain. BMJ Case Rep 2022; 15:e248793. [PMID: 35301187 PMCID: PMC8932284 DOI: 10.1136/bcr-2022-248793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gareth Lim
- Neurology, National Neuroscience Institute, Singapore
| | | | - Wai-Yung Yu
- Department of Neuroradiology, National Neuroscience Institute, Singapore
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4
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Shafiee A, Shamsi S, Kohandel Gargari O, Beiky M, Allahkarami MM, Miyanaji AB, Aghajanian S, Mozhgani SH. EBV associated T- and NK-cell lymphoproliferative diseases: A comprehensive overview of clinical manifestations and novel therapeutic insights. Rev Med Virol 2022; 32:e2328. [PMID: 35122349 DOI: 10.1002/rmv.2328] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Revised: 12/27/2021] [Accepted: 01/13/2022] [Indexed: 11/09/2022]
Abstract
EBV is a ubiquitous virus that infects nearly all people around the world. Most infected people are asymptomatic and do not show serious sequelae, while others may develop Epstein-Barr virus (EBV)-positive T and NK-cell lymphoproliferations characterised by EBV-infected T or NK cells. These disorders are more common in Asian and Latin American people, suggesting genetic predisposition as a contributing factor. The revised WHO classification classifies the lymphoproliferative diseases as: extranodal NK/T-cell lymphoma nasal type (ENKTL), aggressive NK-cell leukemia (ANKL), primary EBV-positive nodal T or NK cell lymphoma (NNKTL), systemic EBV-positive T-cell lymphoproliferative disease of childhood (STCLC), systemic chronic active EBV infection (sys CAEBV), hydroa-vacciniforme (HV) and severe mosquito bite allergy (SMBA). Recent advances in the molecular pathogenesis of these diseases have led to the development of new therapeutic strategies. Due to the infrequency of the diseases and broad clinicopathological overlap, the diagnosis and classification are challenging for both clinicians and pathologists. In this article, we aim to review the recent pathological findings which can be helpful for designing new drugs, clinical presentations and differential diagnoses, and suggested therapeutic interventions to provide a better understanding of these rare disorders.
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Affiliation(s)
- Arman Shafiee
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Sahel Shamsi
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | | | - Maryam Beiky
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | | | | | - Sepehr Aghajanian
- Student Research Committee, Alborz University of Medical Sciences, Karaj, Iran
| | - Sayed-Hamidreza Mozhgani
- Department of Microbiology, School of Medicine, Alborz University of Medical Sciences, Karaj, Iran.,Non-communicable Disease Research Center, Alborz University of Medical Sciences, Karaj, Iran
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5
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Qin L, Li Y, He Y, Zeng R, Pan T, Zuo Y, Xiao L, Zhou H. Successful Treatment of Primary CNS Extranodal NK/T-Cell Lymphoma with Surgery and Chemotherapy Combined with Sintilimab: A Case Report and Literature Review. Onco Targets Ther 2022; 15:1-11. [PMID: 35023929 PMCID: PMC8747803 DOI: 10.2147/ott.s343400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/20/2021] [Indexed: 11/23/2022] Open
Abstract
Primary central nervous system extranodal natural killer/T-cell lymphoma (PCNS ENK/TCL) is an extremely rare lymphoma. Only 23 cases of PCNS ENK/TCL have been reported in the English literature. Due to the rarity of this lymphoma, an effective therapeutic strategy has not been defined. Generally, this type of lymphoma is treated with surgery, intrathecal chemotherapy, and postoperative chemoradiation therapy. The prognosis is poor. Herein, we present a case of primary brain NK/T cell lymphoma in a 50-year-old immunocompetent Chinese female and review the literature. The patient underwent intracranial tumor resection and was subsequently treated with a PD1 monoclonal antibody (Sintilimab) combined with chemotherapy. The patient survived 15 months after diagnosis. This is the first report of PCNS ENK/TCL treated with surgery and chemotherapy combined with immunotherapy and suggests an effective treatment regimen for PCNS ENK/TCL.
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Affiliation(s)
- Liping Qin
- Graduate Collaborative Training Base of Hunan Cancer Hospital, Hengyang Medical School, University of South China, Hengyang, Hunan, 421001, People's Republic of China.,Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Yajun Li
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Yizi He
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Ruolan Zeng
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Tao Pan
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Yilang Zuo
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Ling Xiao
- Department of Histology and Embryology of School of Basic Medical Science, Central South University, Changsha, Hunan, 410013, People's Republic of China
| | - Hui Zhou
- Department of Lymphoma and Hematology, Hunan Cancer Hospital and The Affiliated Cancer Hospital of Xiangya School of Medicine, Central South University, Changsha, Hunan, 410013, People's Republic of China
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6
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Kajtazi NI, Bafaquh M, Ghamdi JA, AlEissa Z, Shmeikh AA, Alsaeed A, Sulaiman T, Vizcaino MA, Al Hameed M, Raghunathan A. An Unusual Case of EBV-Negative Primary CNS Lymphoma of Natural Killer/T-Cell Lineage. Clin Med Insights Pathol 2021; 14:2632010X211065692. [PMID: 34927072 PMCID: PMC8671822 DOI: 10.1177/2632010x211065692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/01/2021] [Indexed: 11/16/2022] Open
Abstract
Extranodal NK/T-cell lymphoma (ENKTL) is a well-defined cytotoxic lymphoma strongly associated with Epstein–Barr virus (EBV) infection, commonly affecting the nasopharynx and upper aerodigestive tract. Primary central nervous system (CNS) involvement is rare, and only 17 cases were previously reported in the literature. Here, we report the case of a 44-year-old male admitted with a 3-month history of personality changes and progressive right leg weakness. Brain magnetic resonance imaging studies (MRIs) revealed multiple rim-enhancing brain lesions bilaterally. An extensive clinical and laboratory workup was unrevealing, and 2 brain biopsies were initially considered inconclusive. Pertinently, no systemic lymphoproliferative disorder was identified. The patient initially experienced remarkable clinical improvement with dexamethasone, pulse methylprednisolone, and rituximab therapy. However, he eventually had rapid clinical deterioration, was found to have increased brain lesions, and died nearly 6 months after the initial presentation. During this time, the second brain biopsy was found to show involvement by T-cell lymphoma of NK-cell lineage, which was EBV negative. No post-mortem examination was done to identify any systemic lymphoma. This case serves to expand the spectrum of lymphomas involving the CNS.
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Affiliation(s)
- Naim I Kajtazi
- Department of Neurology, National Neurosciences Institute, King Fahad Medical City, Riyadh, KSA
| | - Mohammed Bafaquh
- Department of Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, KSA
| | - Juman Al Ghamdi
- Medical Imaging Administration, Neurointervention Radiology, King Fahad Medical City, Riyadh, KSA
| | - Zahra AlEissa
- Department of Neurology, National Neurosciences Institute, King Fahad Medical City, Riyadh, KSA
| | - Arwa Al Shmeikh
- Department of Neurosurgery, National Neurosciences Institute, King Fahad Medical City, Riyadh, KSA
| | - Ali Alsaeed
- Internal Medicine Department, Infectious Diseases, King Fahad Medical City, Riyadh, KSA
| | - Tarek Sulaiman
- Internal Medicine Department, Infectious Diseases, King Fahad Medical City, Riyadh, KSA
| | - M Adelita Vizcaino
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Majed Al Hameed
- Department of Neurology, National Neurosciences Institute, King Fahad Medical City, Riyadh, KSA
| | - Aditya Raghunathan
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
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7
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Akbar M, Clasen-Linde E, Specht L. Extranodal NK/T-cell lymphoma, nasal type, with extranasal presentation - a case report and a review of the literature. Acta Oncol 2020; 59:1480-1487. [PMID: 32689856 DOI: 10.1080/0284186x.2020.1795250] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Extranodal NK/T-cell lymphoma (ENKTCL), nasal type is a very rare and aggressive non-Hodgkin lymphoma. Most commonly it occurs in the upper aerodigestive tract. But, it can also manifest at locations such as the skin, soft tissue, gastrointestinal tract (GI), lungs, testis, etc. These locations are designated as extranasal ENKTCL. The patients with the latter have often more adverse clinical features and poorer survival rate compared with nasal sites. We present a case of an 83-year-old patient with a primary ENKTCL, nasal type, with extranasal presentation in the right upper eyelid. MATERIAL AND METHODS Materials for the literature review was obtained by a comprehensive search on PubMed, which yielded 82 eligible cases with extranasal ENKTCL. RESULTS Sixty-eight cases (83 %) were localized as primary ENKTCL in the lungs (17), central nervous system (CNS) (14), testis (11), GI-tract (7), skin (6), orbit and intraocular tissue (4), pancreas (2), adrenal gland (2), breast (1), etc. 14 cases (17 %) presented as extended or disseminated diseases involving exclusively organs outside the upper aerodigestive tract. There was no systematic pattern of organ involvement in the extended/disseminated ENKTCL. 63 % of the patient with localized extranasal ENKTCL and about 50% of patients with extended/disseminated disease were reported to have died of the disease. Treatment strategies varied with no preferred option. Among the used treatment options were chemotherapy, radiotherapy, surgery, stem cell transplantation alone or in different combinations. CONCLUSION ENKTCL is a highly aggressive disease which may present in extranasal areas. Although the tumors respond to both chemotherapy and radiotherapy, durable complete remissions are very rare.
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Affiliation(s)
- Momena Akbar
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
| | - Erik Clasen-Linde
- Department of Pathology, Rigshospitalet, University of Copenhagen, Denmark
| | - Lena Specht
- Department of Oncology, Rigshospitalet, University of Copenhagen, Denmark
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8
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Morisako T, Shishido-Hara Y, Inaba T, Takeuchi H, Miyagawa-Hayashino A, Kodama Y, Takahashi Y, Konishi E, Hashimoto N. Primary CNS CD45-Depleted T-Cell Lymphoma: The First Pathologically Confirmed Case. J Neuropathol Exp Neurol 2020; 79:817-820. [PMID: 32529211 PMCID: PMC7304983 DOI: 10.1093/jnen/nlaa049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Revised: 03/02/2020] [Accepted: 05/05/2020] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Tohru Inaba
- Department of Infection Control & Laboratory Medicine
| | | | - Aya Miyagawa-Hayashino
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Sciences, Kyoto, Japan
| | | | - Yoshinobu Takahashi
- Department of Neurosurgery.,Department of Pathology and Applied Neurobiology
| | - Eiichi Konishi
- Department of Surgical Pathology, Kyoto Prefectural University of Medicine, Graduate School of Medical Sciences, Kyoto, Japan
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9
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Pan Q, Luo Y. Recurrence of nasal type NK/T cell lymphoma presenting as neurolymphomatosis on 18F-FDG PET/CT: A case report and literature review. Medicine (Baltimore) 2020; 99:e18640. [PMID: 31895825 PMCID: PMC6946263 DOI: 10.1097/md.0000000000018640] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION NK/T cell lymphomas seldom involve the peripheral nervous system. We report a case of recurrent nasal type NK/T cell lymphoma presenting as neurolymphomatosis and its manifestation on F-FDG PET/CT. PATIENT CONCERNS A 55-year old man presented with a mass in the right nasal cavity was diagnosed with extranodal NK/T cell lymphoma, nasal type. F-FDG PET/CT showed intense FDG uptake within the mass. After radiotherapy the nasal tumor was completely relieved, but the patient experienced numbness and amyosthenia in the right upper extremity one week after completion of radiotherapy. DIAGNOSIS PET/CT showed intense FDG uptake in the brachial plexus, axillary, suprascapular and median nerves, suggestive of recurrence of lymphoma presenting as neurolymphomatosis. INTERVENTIONS After 1 cycle of chemotherapy, the follow-up PET/CT showed markedly reduced FDG uptake in the previous involved nerves, demonstrating a very good response of neurolymphomatosis to chemotherapy. OUTCOMES The patient finally had a progression free survival of 8 months after completion of 4 cycles of chemotherapy and autologous stem cell transplantation. LESSONS As neurolymphomatosis is a rare neurologic manifestation in recurrence of NK/T cell lymphoma, recognition of its presentation is important for prompt diagnosis and initiating treatment approach.
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Affiliation(s)
- Qingqing Pan
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine; Beijing, PR China
| | - Yaping Luo
- Department of Nuclear Medicine, Chinese Academy of Medical Sciences and Peking Union Medical College Hospital
- Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine; Beijing, PR China
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10
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Primary Central Nervous System Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type Colliding with Meningioma. World Neurosurg 2018; 120:17-26. [PMID: 30144614 DOI: 10.1016/j.wneu.2018.08.065] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 08/10/2018] [Accepted: 08/11/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Collision tumors are defined as coexistence of 2 histologically different neoplasms occurring in the same anatomic location. Such co-occurrence of tumors in the brain is uncommon. To our knowledge, meningioma colliding with extranodal natural killer/T-cell lymphoma has not been described previously. CASE DESCRIPTION A 50-year-old man presented with a 1-year history of progressive memory decline and 2 weeks of drowsiness, bradykinesia, and aphasia. Magnetic resonance imaging revealed a heterogeneously enhanced mass beside the left frontal cerebral falx resulting in midline shift. The left frontal lobe mass was resected. Pathologic examination showed the tumor consisted of whorled spindle cells and diffuse medium-sized lymphoid cells. The spindle cells were positive for epithelial membrane antigen and negative for S-100. The lymphoid cells expressed CD3ε, CD56, TIA-1, and granzyme B. Epstein-Barr virus encoded small RNAs were detected by in situ hybridization. No monoclonal T-cell receptor gamma gene rearrangement was detected. Four weeks after surgery, the patient was treated with polychemotherapy and intrathecal methotrexate, but he died 2 months later. CONCLUSIONS This is the first report of a unique brain collision tumor consisting of a meningioma and an extranodal natural killer/T-cell lymphoma. Diagnosis depends on histopathology. Awareness of this entity is important to distinguish it from other intracranial tumors.
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11
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Li D, Fu F, Lian L. Primary central nervous system extranodal nasal-type natural killer/T-cell lymphoma with CD20 expression. Neuropathology 2017; 38:198-204. [PMID: 29063643 DOI: 10.1111/neup.12438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 09/29/2017] [Accepted: 09/30/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Dujuan Li
- Department of Pathology; Henan Provincial People's Hospital (People's Hospital of Zhengzhou University); Zhengzhou China
| | - Fangfang Fu
- Department of Radiology; Henan Provincial People's Hospital (People's Hospital of Zhengzhou University); Zhengzhou China
| | - Lifei Lian
- Department of Neurology, Tongji Hospital, Tongji Medical College; Huazhong University of Science and Technology; Wuhan China
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12
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Brett FM, Flavin R, Chen D, Loftus T, Looby S, McCarthy A, de Gascun C, Jaffe ES, Nor N, Javadpour M, McCabe D. EBV driven natural killer cell disease of the central nervous system presenting as subacute cognitive decline. HUMAN PATHOLOGY: CASE REPORTS 2017; 10:64-68. [PMID: 28845389 PMCID: PMC5568754 DOI: 10.1016/j.ehpc.2017.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Brain biopsy in patients presenting with subacute encephalopathyis never straightforward and only undertaken when a ‘treatable condition’ is a realistic possibility. This 63 year old right handed, immunocompetent Caucasian woman presented with an 8 month history of rapidly progressive right-sided hearing impairment, a 4 month history of intermittent headaches, tinnitus, ‘dizziness’, dysphagia, nausea and vomiting, with the subsequent evolution of progressive gait ataxia and a subacute global encephalopathy. The possibility of CJD was raised. Brain biopsy was carried out. Western blot for prion protein was negative. She died 9 days later and autopsy brain examination confirmed widespread subacute infarction due to an EBV positive atypical NK/T-cell infiltrate with positivity for CD3, CD56, granzyme B, perforin and EBER with absence of CD4, CD5 and CD8 expression. Molecular studies for T-cell clonality were attempted but failed due to insufficient DNA quality. Serology was consistent with past EBV infection (EBV VCA and EBNA IgG Positive). There was no evidence of disease outside the CNS. Primary central nervous system NK/T-cell lymphoma is extremely rare. The rare reported cases all present with a discrete intracranial mass, unlike the diffuse infiltrative pattern in this case. Whilst the diffuse interstitial pattern is reminiscent of chronic active EBV infection (CAEBV) seen in other organ systems such as the liver and bone marrow, the clinical presentation and epidemiologic profile are not typical for CAEBV.
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Affiliation(s)
- Francesca M Brett
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Richard Flavin
- Department of Histopathology, St James's Hospital Dublin, Ireland
| | - Daphne Chen
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Teresa Loftus
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Seamus Looby
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Allan McCarthy
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland
| | | | | | - Nurul Nor
- Midland Regional Hospital, Tullamore, Ireland
| | - Mohsen Javadpour
- Department of Clinical Neurological Sciences, RCSI, Beaumont Hospital Dublin, Ireland
| | - Dominick McCabe
- Department of Neurology, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Stroke Service, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Vascular Neurology Research Foundation, The Adelaide and Meath Hospital, Dublin, incorporating the National Children's Hospital, Dublin, Ireland.,Department of Clinical Neurosciences, Royal Free Campus, UCL Institute of Neurology, London, UK.,Academic Unit of Neurology, School of Medicine, Trinity College Dublin, Ireland
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13
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Brett FM, Looby S, Chalissery A, Chen D, Heaney C, Heffernan J, Cunningham F, Howley R, Loftus T, Kearney H, Farrell MA. Brain biopsies requiring Creutzfeldt-Jakob disease precautions in the Republic of Ireland 2005-2016. Ir J Med Sci 2017; 187:515-520. [PMID: 28803271 DOI: 10.1007/s11845-017-1673-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/04/2017] [Indexed: 10/19/2022]
Abstract
AIMS Creutzfeldt-Jakob disease (CJD) risk precautions are required when performing brain biopsies on patients with a dementing illness and in 'risk' groups. The impact on a diagnostic neuropathology service is considerable. We sought to determine if better case selection might reduce the necessity for application of CJD risk precautions. METHODS We reviewed the clinical information, contributory investigations and final neuropathologic diagnosis in a cohort of patients (n = 21), referred to the National CJD Surveillance Centre between January 1, 2005, and December 31, 2016. RESULTS Of this 21-patient cohort, five were positive for CJD, four belonged to the 'at risk of CJD' category requiring brain surgery, while the remaining 12 were referred to the National CJD Surveillance Unit with CJD as part of their differential diagnosis. CJD was confirmed in 5/21 (three sporadic [s]CJD, one variant [v]CJD and one iatrogenic [i] CJD). CJD was clinically probable in 4/5 proven CJD patients (80%). The patients (n = 4) in the 'at risk of CJD' group were diagnosed with tumour (n = 2), inflammation (n = 1) and non-specific changes (n = 1). Of the remaining 12 patients (in whom CJD was included in the differential diagnosis), the final neuropathologic diagnoses included tumour (n = 2), neurodegenerative (n = 2), inflammatory (n = 1), metabolic (n = 2), vascular (n = 2) and non-specific gliosis (n = 3). CONCLUSIONS More often than not, the clinical suspicion of CJD was not borne out by the final neuropathological diagnosis. Failure by clinicians to adhere to the recommended CJD investigation algorithm impacts adversely on the neuropathology workload and causes unnecessary concern among operating theatre, laboratory and nursing personnel.
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Affiliation(s)
- F M Brett
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland.
| | - S Looby
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - A Chalissery
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - D Chen
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - C Heaney
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - J Heffernan
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - F Cunningham
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - R Howley
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - T Loftus
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - H Kearney
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
| | - M A Farrell
- Department of Clinical Neurological Sciences, Royal College of Surgeons, Beaumont Hospital, Dublin 9, Ireland
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14
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Miyata-Takata T, Takata K, Kato S, Hu LM, Noujima-Harada M, Chuang SS, Sato Y, Maeda Y, Yoshino T. Clinicopathological analysis of primary central nervous system NK/T cell lymphoma: rare and localized aggressive tumour among extranasal NK/T cell tumours. Histopathology 2017; 71:287-295. [DOI: 10.1111/his.13223] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 03/17/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Tomoko Miyata-Takata
- Department of Pathology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Katsuyoshi Takata
- Department of Pathology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Seiichi Kato
- Department of Pathology and Laboratory Medicine; Nagoya University Hospital; Nagoya Japan
| | - Lei-Ming Hu
- Department of Pathology and Laboratory Medicine; Nagoya University Hospital; Nagoya Japan
- Department of Gastroenterology and Hepatology; Nagoya University Graduate School of Medicine; Nagoya Japan
| | - Mai Noujima-Harada
- Department of Pathology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | | | - Yasuharu Sato
- Department of Pathology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Yoshinobu Maeda
- Department of Hematology and Oncology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
| | - Tadashi Yoshino
- Department of Pathology; Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences; Okayama Japan
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15
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Imai A, Takase H, Imadome KI, Matsuda G, Ohnishi I, Yamamoto K, Kudo T, Tanaka Y, Maehara T, Miura O, Arai A. Development of Extranodal NK/T-cell Lymphoma Nasal Type in Cerebrum Following Epstein-Barr Virus-positive Uveitis. Intern Med 2017; 56:1409-1414. [PMID: 28566607 PMCID: PMC5498208 DOI: 10.2169/internalmedicine.56.7573] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 74-year-old woman developed bilateral uveitis with high Epstein-Barr virus (EBV) DNA load in the vitreous fluid without lymphoma cells. Four years after the onset, T2-weighted contrast-enhanced MRI revealed hyperintense lesions in the right occipital and parietal lobe. A biopsy resulted in the diagnosis of extranodal NK/T-cell lymphoma nasal type (ENKL). The repeat region of LMP1, an EBV gene, detected in the brain lesion was identical to that detected in the vitreous fluid. ENKL of the central nervous system is quite rare, and the pathogenesis has not been determined. The lymphoma in this case might have been closely associated with the EBV-positive uveitis.
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Affiliation(s)
- Ayano Imai
- Department of Ophthalmology, Tokyo Medical and Dental University, Japan
| | - Hiroshi Takase
- Department of Ophthalmology, Tokyo Medical and Dental University, Japan
| | - Ken-Ichi Imadome
- Division of Advanced Medicine for Virus Infections, National Research Institute for Child Health and Development, Japan
| | - Go Matsuda
- Division of Advanced Medicine for Virus Infections, National Research Institute for Child Health and Development, Japan
| | - Iichiro Ohnishi
- Department of Comprehensive Pathology, Tokyo Medical and Dental University, Japan
| | - Kouhei Yamamoto
- Department of Comprehensive Pathology, Tokyo Medical and Dental University, Japan
| | - Takumi Kudo
- Department of Functional Neurosurgery, Tokyo Medical and Dental University, Japan
| | - Yoji Tanaka
- Department of Functional Neurosurgery, Tokyo Medical and Dental University, Japan
| | - Taketoshi Maehara
- Department of Functional Neurosurgery, Tokyo Medical and Dental University, Japan
| | - Osamu Miura
- Department of Hematology, Tokyo Medical and Dental University, Japan
| | - Ayako Arai
- Department of Hematology, Tokyo Medical and Dental University, Japan
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16
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Primary Central Nervous System Natural Killer Cell Lymphoma in a Chinese Woman with Atypical 11 C-Choline Positron Emission Tomography and Magnetic Resonance Spectrometry Findings. World Neurosurg 2015; 84:1176.e5-9. [DOI: 10.1016/j.wneu.2015.06.063] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/23/2015] [Accepted: 06/24/2015] [Indexed: 11/22/2022]
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17
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Onur I, Crane GM, Maleki Z. Cytomorphologic and Flow Cytometric Analysis of Cerebrospinal Fluid with T-Cell Lymphoma Involvement: A Retrospective Study of Rare Cases. Acta Cytol 2015; 59:325-31. [PMID: 26315545 DOI: 10.1159/000439106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 07/31/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the efficacy of conventional cytomorphologic analysis and flow cytometry (FC) in the diagnosis of T-cell lymphoma in the cerebrospinal fluid (CSF). STUDY DESIGN We performed a retrospective review of CSF samples from 2002 to 2012 that showed involvement of a T-cell lymphoma, either by cytomorphologic analysis and/or FC. Patients' demographics, clinical history and follow-up were assessed. RESULTS Thirty-nine CSF samples were identified from 9 patients. A definitive diagnosis of T-cell lymphoma involvement was made by cytomorphologic analysis and FC in 6 (15.4%) and 39 (100.0%) specimens, respectively. In specimens with definitive cytopathologic diagnoses, the cytomorphologic features included increased cellularity, a monotonous lymphoid population and large, atypical lymphoid cells. Considering cytomorphologic features only, 9 specimens demonstrated atypical lymphocytes not fulfilling the criteria for malignancy, and 24 specimens were negative for malignancy. CONCLUSIONS CSF with T-cell lymphoma involvement may yield paucicellular or acellular specimens depending on the volume of the CSF, the time interval between specimen collection and specimen processing and the application of preservative to CSF. The rate of detection of T-cell lymphoma in the CSF by FC is unequivocally higher than by cytomorphologic analysis. Careful attention to clinical history is crucial, as FC testing may be tailored to evaluate for T-cell lymphoproliferative disorders in limited samples.
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Affiliation(s)
- Irem Onur
- Divisions of Cytopathology and Hematopathology, Department of Pathology, The Johns Hopkins Medical Institutions, Baltimore, Md., USA
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18
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Jiang X, Yin W, Song J, Chen X, Zhao C, Wen F. Primary central nervous system extranodal NK/T cell lymphoma, nasal type, with antecedent hemophagocytic syndrome in a child. Pediatr Dev Pathol 2014; 17:482-6. [PMID: 25207703 DOI: 10.2350/14-02-1441-cr.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Primary central nervous system (CNS) extranodal natural killer (NK)/T-cell lymphoma, nasal type (NKTCL), is an exceedingly uncommon entity. Here, we present a case of CNS NKTCL that manifested initially as hemophagocytic syndrome 4 months earlier in a 13-year-old girl. Histological examination revealed the cerebellum mass was composed of large-sized and atypical tumor cells, with an angiocentric and angiodestructive growth pattern and prominent necrosis. The tumor cells exhibited marked pleomorphism with conspicuous nucleoli and prominent mitotic activity. Immunohistochemical staining showed the tumor cells were positive for CD45, CD2, CD3ε, CD30, CD43, CD56, and granzyme B. Epstein-Barr virus--encoded ribonucleic acid was expressed in almost all of the nuclei of the lymphoma cells. The T-cell receptor γ chain gene rearrangement study showed no evidence of a clonal rearrangement. The patient was treated with etoposide and dexamethasone and died a few days after the operation. As far as we know, this case is the 1st pediatric and female patient of primary CNS NKTCL with antecedent hemophagocytic syndrome, which highlights the clinical data and is helpful for the diagnosis of this tumor.
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Affiliation(s)
- Xianping Jiang
- 1 Department of Pathology, Shenzhen Children's Hospital, 7019 Road Yitian, Futian District, Shenzhen 518026, China
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19
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Primary natural killer/T-cell lymphoma presenting as leptomeningeal disease. J Neurol Sci 2014; 343:46-50. [DOI: 10.1016/j.jns.2014.05.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2014] [Revised: 04/29/2014] [Accepted: 05/06/2014] [Indexed: 11/30/2022]
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20
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[Differential diagnosis of lymphoid infiltrates in the central nervous system: experience of the Network Lymphomas and Lymphomatoid Lesions in the Nervous System]. DER PATHOLOGE 2014; 34:186-97. [PMID: 23471726 DOI: 10.1007/s00292-013-1742-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The differential diagnosis of lymphoid lesions in the central nervous system covers a broad spectrum of neoplastic and inflammatory disorders. Complex cases benefit from the combined expertise in the fields of hematopoietic and neuroepithelial tumors as well as neuroimmunology. The Network Lymphomas and Lymphomatoid Lesions in the Nervous System (NLLLN) recommends performing a biopsy prior to any therapeutic intervention as a precise diagnosis was impossible in approximately 50 % of patients pretreated with corticosteroids. This is based on the analysis of approximately 1,000 cases in the past 4 years. In addition to total NLLLN experiences the characteristics, pathogenesis and differential diagnosis of primary lymphoma of the central nervous system are discussed.
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21
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Prajapati HJ, Vincentelli C, Hwang SN, Voloschin A, Crocker I, Dehkharghani S. Primary CNS natural killer/T-cell lymphoma of the nasal type presenting in a woman: case report and review of the literature. J Clin Oncol 2014; 32:e26-9. [PMID: 24419127 DOI: 10.1200/jco.2012.47.6796] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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22
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Gessi M, Kellner U, Stein H, Pietsch T. A 78-year-old male with a right occipital lesion. Brain Pathol 2013; 23:607-8. [PMID: 24137621 DOI: 10.1111/bpa.12077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Marco Gessi
- Inst. of Neuropathology, University of Bonn Medical Center, Bonn, Germany
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23
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Nwankwo N, Saba R, Mirrakhimov AE, Rao S. Non-healing pharyngeal ulcer in a middle-aged Caucasian man. BMJ Case Rep 2013; 2013:bcr-2013-008602. [PMID: 23475993 DOI: 10.1136/bcr-2013-008602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Extranodal natural killer NK/T-cell lymphoma is a rare malignancy. The disease is common in some Asian countries such as China, Japan as well as in South America. We present a case of extranodal NK/T-cell lymphoma which presented as a pharyngeal ulcer in a 35-year-old Caucasian man.
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Affiliation(s)
- Nwabundo Nwankwo
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
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24
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Ogura R, Aoki H, Natsumeda M, Shimizu H, Kobayashi T, Saito T, Takizawa J, Okamoto K, Hasegawa G, Umezu H, Ohshima K, Takahashi H, Fujii Y, Kakita A. Epstein‐
B
arr virus‐associated primary central nervous system cytotoxic
T
‐cell lymphoma. Neuropathology 2012; 33:436-41. [DOI: 10.1111/neup.12005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2012] [Revised: 11/10/2012] [Accepted: 11/11/2012] [Indexed: 11/30/2022]
Affiliation(s)
- Ryosuke Ogura
- Department of Neurosurgery University of Niigata Niigata Japan
| | - Hiroshi Aoki
- Department of Neurosurgery University of Niigata Niigata Japan
| | | | - Hiroshi Shimizu
- Department of Pathology Brain Research Institute University of Niigata Niigata Japan
| | | | | | - Jun Takizawa
- Division of Hematology University of Niigata Graduate School of Medical and Dental Science Niigata Japan
| | | | - Go Hasegawa
- Division of Cellular and Molecular Pathology University of Niigata Graduate School of Medical and Dental Science Niigata Japan
| | - Hajime Umezu
- Department of Pathology University of Niigata Hospital Niigata Japan
| | | | - Hitoshi Takahashi
- Department of Pathology Brain Research Institute University of Niigata Niigata Japan
| | - Yukihiko Fujii
- Department of Neurosurgery University of Niigata Niigata Japan
| | - Akiyoshi Kakita
- Department of Pathology Brain Research Institute University of Niigata Niigata Japan
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25
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Current world literature. Curr Opin Oncol 2012; 24:756-68. [PMID: 23079785 DOI: 10.1097/cco.0b013e32835a4c91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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26
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Walavalkar V, Oak J, Gu M. Cytological diagnosis of extranodal NK/T-cell lymphoma, nasal type, in cerebrospinal fluid. Cytopathology 2012; 24:342-4. [PMID: 22844965 DOI: 10.1111/j.1365-2303.2012.00999.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- V Walavalkar
- Department of Pathology and Laboratory Medicine, University of California Irvine Medical Center, Orange, CA, USA
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