Epstein–Barr virus-associated B-cell lymphoma secondary to FCD-C therapy in patients with peripheral T-cell lymphoma

Recommendations on prevention of infections in patients with T-cell lymphomas: a narrative review and synthesis

T/Natural killer (NK) cell lymphomas (TCL) represent a heterogenous subgroup of non-Hodgkin lymphoma, associated with poorer prognosis and higher treatment toxicity. A cohesive synthesis of infection outcomes among TCL patients is lacking. International guidelines offer no specific recommendations regarding prophylaxis or supportive infection care for TCL patients. This systematic narrative review highlights infection outcomes in TCL patients treated with conventional, and novel therapies. Recommendations for infection screening, antimicrobial prophylaxis and vaccination strategies are outined.

The bidirectional increased risk of B-cell lymphoma and T-cell lymphoma

Lymphoma survivors have a significantly higher risk of developing second primary lymphoma than the general population; however, bidirectional risks of developing B- and T-cell lymphomas (BCL; TCL) specifically are less well understood. We used population-based cancer registry data to estimate the subtype-specific risks of second primary lymphoma among patients with first BCL (n=288,478) or TCL (n=23,747). We observed nearly five-fold increased bidirectional risk between BCL and TCL overall (TCL following BCL: standardized incidence ratio [SIR]=4.7, 95% confidence interval [CI]=4.2-5.2; BCL following TCL: SIR=4.7, 95%CI=4.1-5.2), but the risk varied substantially by lymphoma subtype. The highest SIRs were observed between Hodgkin lymphoma (HL) and peripheral T-cell lymphoma-not otherwise specified (PTCL-NOS) (PTCL-NOS following HL: SIR=27.5, 95%CI=18.4-39.4; HL following PTCL-NOS: SIR=31.6, 95%CI=17.3-53.0). Strikingly elevated risks also were notable for angioimmunoblastic T-cell lymphoma (AITL) and diffuse large B-cell lymphoma (DLBCL) (AITL following DLBCL: SIR=9.7, 95%CI=5.7-15.5; DLBCL following AITL: SIR=15.3, 95%CI=9.1-24.2). These increased risks were strongest within the first year following diagnosis but remained persistently elevated even at ≥5 years. In contrast, SIRs were <5 for all associations of TCL with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL) and follicular lymphoma (FL). These patterns support etiologic heterogeneity among lymphoma subtypes and provide further insights into lymphomagenesis.

Deciphering the antitumoral potential of the bioactive metabolites from medicinal mushroom Inonotus obliquus

ETHNOPHARMACOLOGICAL RELEVANCE

The crude extracts of the medicinal mushroom Inonotus obliquus have been used as an effective traditional medicine to treat malicious tumors, gastritis, gastric ulcers, and other inflammatory conditions in Russia and most Baltic countries.

AIM OF THIS REVIEW

Deciphering the antitumoral potential of the bioactive metabolites from I. obliquus and addressing its possibility to be used as effective agents for tumor treatment, restoration of compromised immunity and protection of gastrointestinal damage caused by chemotherapy.

MATERIALS AND METHODS

We analysed the current achievements and dilemma in tumor chemo- or immunotherapy. In this context, we searched the published literatures on I. obliquus covering from 1990 to 2020, and summarized the activities of antitumor, antioxidation, and immunomodulation by the polysaccharides, triterpenoids, small phenolic compounds, and hispidin polyphenols. By comparing the merits and shortcomings of current and traditional methodology for tumor treatment, we further addressed feasibility for the use of I. obliquus as an effective natural drug for tumor treatment and prevention.

RESULTS

The diverse bioactive metabolites confer I. obliquus great potential to inhibit tumor growth and metastasis. Its antitumor activities are achieved either through suppressing multiple oncogenic signals including but not limited to the activation of NF-κB and FAK, and the expression of RhoA/MMP-9 via ERK1/2 and PI3K/Akt signaling pathway. The antitumor activities can also be achieved by inhibiting tyrosinase activity via PAK1-dependent signaling pathway or altering lysosomal membrane permeabilization through blocking tubulin polymerization and/or disturbing energy metabolism through LKB1/AMPK pathway. In addition, the metabolites from I. obliquus also harbour the potentials to reverse MDR either through selective inhibition on P-gp/ABCB1 or MRP1/ABCC1 proteins or the induction of G2/M checkpoint arrest in tumor cells of chemoresistant phenotypes mediated by Nox/ROS/NF-kB/STAT3 signaling pathway. In addition to the eminent effects in tumor inhibition, the metabolites in I. obliquus also exhibit immunomodulatory potential to restore the compromised immunity and protect against ulcerative damage of GI tract caused by chemotherapy.

CONCLUSIONS

I. obliquus possesses the potential to reduce incidence of tumorigenesis in healthy people. For those whose complete remission has been achieved by chemotherapy, administration of the fungus will inhibit the activation of upstream oncogenic signals and thereby prevent metastasis; for those who are in the process of chemotherapy administration of the fungus will not only chemosensitize the tumor cells and thereby increasing the chemotherapeutic effects, but also help to restore the compromised immunity and protect against ulcerative GI tract damage and other side-effects induced by chemotherapy.

Cerebellar EBV-associated diffuse large B cell lymphoma following angioimmunoblastic T cell lymphoma

Epstein-Barr virus (EBV)-associated B cell lymphoproliferative disorders may be seen in patients with angioimmunoblastic T cell lymphoma (AITL). Although both nodal and extranodal sites of involvement have been described, central nervous system involvement by B cell lymphoma following AITL has not previously been documented. We report a first example of such unusual presentation, in which an 80-year-old man developed diffuse large B cell lymphoma (DLBCL) in the cerebellum 4 months after the initial diagnosis of AITL. EBV-encoded RNAs were detected in the DLBCL, suggesting that EBV played a pivotal role in the pathogenesis of high-grade histologic progression of AITL. The patient survived less than 9 months after his initial diagnosis of AITL. We believe that this case expands the spectrum of extranodal manifestation of EBV-positive B cell lymphoma associated with AITL and illustrates the importance of recognition of this association when encountering unusual central nervous system lesions in patients with known AITL.

The Outcome of HyperCVAD Combined with Alemtuzumab for the Treatment of Aggressive T-Cell and NK-Cell Neoplasms

We report our experience in using six cycles of hyperCVAD in combination with alemtuzumab for the treatment of aggressive T-cell and NK/T-cell neoplasms. Seven females and six males with the median age of 41 (range 18-60) diagnosed with T-cell acute lymphoblastic lymphoma and peripheral T-cell and NK/T-cell neoplasms (n(PTCL) = 6, n(T-cell ALL) = 3, n(NK/T-cell neoplasms) = 4) from 2006 to 2008 were treated with alemtuzumab-hyperCVAD regimen. A total of nine patients (69%) responded to the regimen, with seven achieved complete remission and two achieved partial remission. The median progression free survival and overall survival duration among the responders with complete remission were 12.9 and 24.9 months respectively. The incidence of relapse among the responders was 44% and the overall survival rate was 23%. Only four (31%) patients completed the six cycles of alemtuzumab-hyperCVAD. Others were stopped earlier due to progressive disease (n = 2), cytomegalovirus (CMV) reactivation and/or disease (n = 3), death not due to disease (n = 2), and patient's refusal to continue alemtuzumab (n = 2). The incidence of death not due to disease, CMV reactivation and recurrent CMV reactivation were 50, 50 and 17%, respectively. This study shows that alemtuzumab in combination with hyperCVAD regimen is a feasible regimen but with high toxicity. The toxicity might be reduced with the incorporation of filgrastim and use of valganciclovir as CMV prophylaxis.

Secondary cutaneous Epstein-Barr virus-associated diffuse large B-cell lymphoma in a patient with angioimmunoblastic T-cell lymphoma: a case report and review of literature

Only a few cases of extranodal Epstein-Barr virus (EBV)-associated B-cell lymphomas arising from patients with angioimmunoblastic T-cell lymphoma (AITL) have been described. We report a case of AITL of which secondary cutaneous EBV-associated diffuse large B-cell lymphoma (DLBCL) developed after the initial diagnosis of AITL. A 65-year-old Chinese male patient was diagnosed as AITL based on typical histological and immunohistochemical characteristics in biopsy of the enlarged right inguinal lymph nodes. The patient initially received 6 cycles of chemotherapy with CHOP regimen (cyclophosphamide, vincristine, adriamycin, prednisone), but his symptoms did not disappear. Nineteen months after initial diagnosis of AITL, the patient was hospitalized again because of multiple plaques and nodules on the skin. The skin biopsy was performed, but this time the tumor was composed of large, polymorphous population of lymphocytes with CD20 and CD79a positive on immunohistochemical staining. The tumor cells were strong positive for EBER by in situ hybridization. The findings of skin biopsy were compatible with EBV-associated DLBCL. CHOP-R chemotherapy (cyclophosphamide, doxorubicin, vincristine, prednisone and rituximab) was then administered, resulting in partial response of the disease with pancytopenia and suppression of cellular immunity. To our knowledge, this is the first case of cutaneous EBV-associated DLBCL originated from AITL in Chinese pepole. We suggest the patients with AITL should perform lymph node and skin biopsies regularly in the course of the disease to detect the progression of secondary lymphomas.

CD30-positive EBV-associated diffuse large B-cell lymphoma occurring after immunosuppressive therapy for T-cell prolymphocytic leukemia

We describe the case of a 64-year-old man who developed diffuse large B-cell lymphoma (DLBCL) in less than a year after he was diagnosed and treated for T-cell prolymphocytic leukemia (T-PLL). At the time of diagnosis of T-PLL he had a white blood cell count (WBC) of 38.2×10(9)/L and only few small lymph nodes were identified on physical examination. Hepatosplenomegaly or skin lesions were not present. Peripheral blood examination was remarkable for 91% circulating prolymphocytes, which by flow cytometry immunophenotypic analysis were CD2, CD3, CD5, and CD7 positive and coexpressed CD4 and CD8 (absolute number, 33.4×10(9)/L). T-cell receptor (TCR) β and γ genes rearrangements were identified by polymerase chain reaction (PCR). The patient underwent chemotherapy, but did not completely achieve cytogenetic remission. Nine months after his diagnosis of T-PLL, he underwent surgical excision of a new 7 cm left inguinal mass, and was diagnosed with CD30 positive Epstein-Barr Virus (EBV)-associated DLBCL.

Intensified alemtuzumab-CHOP therapy for peripheral T-cell lymphoma

BACKGROUND

The prognosis of T-cell lymphoma is poor. To explore the addition of the monoclonal antibody alemtuzumab, we studied the efficacy and tolerability of an intensified alemtuzumab-chemotherapy combination for aggressive T-cell lymphoma in a phase II study by Dutch-Belgian Hemato-Oncology Group (HOVON).

PATIENTS AND METHODS

Patients (≤65 years) with newly diagnosed T-cell lymphoma received eight CHOP cycles (cyclophosphamide, doxorubicin, vincristine, prednisone) 2-weekly, each cycle with three doses of 30 mg alemtuzumab. Prophylaxis consisted of cotrimoxazole, fluconazole and valaciclovir. Cytomegalovirus (CMV) monitoring took place at least every fortnight.

RESULTS

Twenty patients from 10 centers, median age 50 years, were included. Eighty-five percent received six or more cycles. The overall response was 90% [12 complete remissions (CRs), 1 CR unconfirmed, 5 partial remissions]. Median duration of follow-up of patients still alive was 29 months (range 19-41 months). Median overall survival (OS) and event-free survival (EFS) were 27 and 10 months, with 55%/27% OS/EFS at 2 years. Adverse events consisted of neutropenic fever (n = 8) and CMV reactivation (n = 7), with one CMV disease. Three patients developed secondary Epstein-Barr virus (EBV)-related lymphoma, all after end of treatment.

CONCLUSIONS

Although intensified alemtuzumab-CHOP induces high responses, many patients relapse, and the scheme is associated with serious infection-related adverse events. EBV monitoring after end of treatment is required.

Impact of autologous and allogeneic stem cell transplantation in peripheral T-cell lymphomas

Peripheral T/NK-cell lymphomas (PTCLs) are rare malignancies characterized by poor prognosis. So far, no standard therapy has been established, due to the lack of randomised studies. High-dose therapy and autologous stem cell transplantation (HDT-autoSCT) have shown good feasibility with low toxicity in retrospective studies. In relapsing and refractory PTCL several comparison analyses suggest similar efficacy for PTCL when compared with aggressive B-cell lymphoma. In the upfront setting, prospective data show promising results with a long-lasting overall survival in a relevant subset of patients. Achieving a complete remission at transplantation seems to be the most important prognostic factor. Allogeneic stem cell transplantation (alloSCT) has been investigated only as salvage treatment. Especially when using reduced intensity conditioning regimen, eligible patients seem to benefit from this approach. To define the role for upfront stem cell transplantation a randomised trial by the German High-Grade Non-Hodgkin Lymphoma Study Group comparing HDT-autoSCT and alloSCT will be initiated this year.

Is it time for a change? The case for early application of unrelated allo-SCT for severe aplastic anemia

Severe aplastic anemia (SAA) is a BM failure syndrome in which allo-SCT remains a highly effective curative option. Its application remains limited by donor availability and by the potential for treatment-related morbidity and mortality. The improved outcomes with unrelated transplantation are a result of the advent of molecular donor-recipient matching, generation of effective novel conditioning regimens, improvement of supportive care and expansion of the donor registry. Decision making regarding the earlier use of unrelated transplant procedures is rapidly evolving. This paper reviews critical data relevant to these treatment options and recommends early consideration of related SCT for patients with SAA who show failure of immune suppressive therapy.

Differential diagnosis and treatment of primary, cutaneous, anaplastic large cell lymphoma: not always an easy task

Primary cutaneous anaplastic large cell lymphoma (PC-ALCL) is a rare and distinct neoplasm appearing de novo on the skin. We present a case of a 75-year-old man diagnosed with PC-ALCL in his left femoral region. We describe the morphology of lesions along with the differential diagnosis, treatment, clinical course and prognosis. We further discuss parameters concerning treatment that should be considered when a PC-ALCL is diagnosed. Our case report demonstrates the complexity in classification, staging, differential diagnosis and therapy selection of PC-ALCLs. It is crucial to emphasize the importance of clinical criteria in diagnosing a PC-ALCL in combination with immunohistochemistry.