Correlation between the clinicopathological features and prognosis in patients with extranodal natural killer/T cell lymphoma

What Effect Does Epstein-Barr Virus Have on Extranodal Natural Killer/T-Cell Lymphoma Prognosis? A Review of 153 Reported Cases

The primary aim of this review is to identify the relationship between Epstein-Barr virus (EBV) and prognosis in extranodal natural killer/T-cell lymphoma (ENKTL). Additionally, a literature review of ENKTL was carried out. The investigators designed and implemented a 21-year literature review using the online databases PubMed and Google Scholar. The total number of cases analyzed was 153 (64 case reports; one comparative study; one systematic review). Information related to ENKTL from July 1999 to February 2021 was included in the study. Study variables included: patient demographics, tumor classification, screening modalities, tumor characteristics, symptomatology, treatment, and prognosis. The average age at diagnosis was 50.9 years (range: 4-90 years). Patients of Asian ethnicity were most commonly affected, and there was a 1.6:1 male to female ratio. ENKTL was most frequently detected in the head and neck region, and 53.1% of cases metastasized. Of all head and neck cases, the nose was the most affected location. Immunohistochemistry positivity included: EBV (32.0%), CD2 (96.6%), CD3ϵ (81.7%), CD43 (91.7%), CD56 (86.4%), Granzyme (97.1%), Perforin (90.9%), TIA-1 (97.8%), p53 (33.3%). The most frequently employed single treatment modality was chemotherapy alone, and 34.2% of patients expired within five years of diagnosis. The average follow-up period was 16.51 months (range: 0.25-66 months). EBV was significantly associated with metastatic ENKTL (χ² = 4.36; CV = 3.84; p = 0.037). We found no association between EBV and ENKTL prognosis (χ² = 17.2; CV = 21.0; p = 0.14).

Extranodal NK/T-cell lymphoma, nasal type without evidence of EBV infection

Extranodal natural killer/T cell lymphoma-nasal type (EN-NK/T-NT) is extremely rare in Western countries; however, it is the most common subtype of peripheral T cell lymphoma in China. Despite this, there are a limited number of clinicopathological research studies on Epstein-Barr virus (EBV)-negative EN-NK/T-NTs. EBV-negative EN-NK/T-NT is a rare disease type, which has not been fully investigated. If other diagnostic criteria are met, such as the lesions being located predominantly in the upper aerodigestive tract, the presence of angiocentricity or angioinvasion, necrosis and expression of NK/T-cell phenotype, EN-NK/T-NT may be diagnosed, even if EBV is negative. In the present study, 99 cases of EN-NK/T-NTs were analyzed retrospectively, among which seven cases were EBV-negative EN-NK/T-NTs and selected for further investigation. In addition, the present study reviewed previously published research into EN-NK/T-NT, highlighting that EBV-negative EN-NK/T-NT is rare and that its geographical distribution is mainly in countries in Asia, Central America and South America. Patients with EBV-negative EN-NK/T-NT were all of Chinese ethnicity, with a median age of 32 years and primarily female. Furthermore, these patients shared similar clinicopathological characteristics (such as the tumor occurring mainly in the upper aerodigestive tract, the presence of vascular destruction, necrosis and cytotoxic phenotypes) to patients with EBV-positive EN-NK/T-NT. Immunohistochemistry and molecular analysis results indicated that tumor cells were primarily of NK or cytotoxic T origin; however, EBV-encoded small RNAs were not detected in any of these cases. Among the immunochemistry markers, T-bet was statistical significantly different between EBV-positive and -negative cases. Fluorescence in situ hybridization was also performed in two EBV-negative cases, including one case with a co-deletion of 6q21 and PR/SET domain 1 genes. There was only available follow-up data in 3/5 patients who survived for 37–113 months (median, 40 months). As EN-NK/T-NT can be diagnosed, even when EBV is negative, awareness of this subtype may prevent misdiagnosis or delayed diagnosis.

Primary Gastrointestinal Involvement in a Case of Extranodal-Extranasal Natural Killer T Cell Lymphoma

Extra-nasal types of Extra-nodal natural killer cell lymphoma (ENKL) have been known with poorer prognoses than nasal type with the worst responses to treatment. The current work introduces a case of ENKL with GI involvement with no nasal manifestations. We report a 56-year male farmer with fever, productive cough, dyspnea, anorexia, vomiting and chill in addition to malaise and cachexia of three months duration referred to a hospital with acute abdominal pain, and was diagnosed as peritonitis due to perforated terminal ileum ulcer before experiencing surgery as a case of acute abdomen. The pathologic study of the relevant biopsy showed "ulceration and necrosis with dense fibrinoleukocytic exudation and granulation tissue formation. CT scan determined a bilateral mass like haziness which was more likely to be metastatic. The review of the previous pathologic specimens raised Natural Killer/T cell Lymphoma (NKTL), the reason for which we focused on the patient's sinuses and nasal area as well as nasopharynx. There was no finding in examination and endoscopy of sinuses. Pathology also found malignant high grade non-Hodgkin T cell lymphoma in specimens obtained from debridement of ulcer at terminal ileum. It also showed that most of the tumor cells were positive for CD3, CD56, CD8, and LCA but negative for CD19, CD20 and AE1/AE3. Positive reactions for CD30 were shown by some cells. CD56, CD3, and CD8 were expressed by neoplastic cells and CD30 were positive in few cells. Proliferative activity (Ki67 index) was high (60-70%). This was the main base to diagnose an extra-nodal extra-nasal NK/T cell lymphoma. In conclusion, Intestinal changes at middle age, especially in men with nonspecific clinical manifestations is highly advised to be studied pathologically and genetically for T cell types like CD30 positive T cells which are usually engaged in ENKTL.

Causes of mortality in cases with extra nodal natural killer/T-cell lymphoma, nasal type: A cohort study

OBJECTIVE

Extra nodal natural killer/T-cell lymphoma (ENKTL), nasal type is a rare and highly aggressive type of non-Hodgkin's lymphoma (NHL) commonly presented in the nasal cavity or lymphatic system. However, the common causes of mortality in ENKTL remain unclear. We conducted a retrospective population-based cohort study to elucidate the different causes of mortality in ENKTL and illustrate the main causal and associated risk factors leading to death.

METHODS

The study included patients diagnosed with ENKTL from 1987 to 2014 in the Surveillance, Epidemiology, and End Results (SEER) program. Univariate survival analysis was conducted using Kaplan-Meier analysis, and multivariate analyses were performed using Cox proportional hazards regression model. Competing-risks regression model was applied to estimate specific risks associated with mortality.

RESULTS

The analysis demonstrated increased mortality in males and patients diagnosed at older age and higher disease stage. NHL was the most common cause of mortality in patients with ENKTL, accounting for 74.13% of deaths in the cohort, followed by other malignant cancers, heart diseases, and infection. However, NHL-specific death events were fewer in patients diagnosed with advanced disease stage compared with incidences of death by other causes such as disease of heart and infections. Significant difference was seen between patients diagnosed earlier than 2000, who showed a higher probability of dying from NHL, and those diagnosed later, who showed propensity to die from other malignant tumors and infection. No differences were found when comparing sex or age at diagnosis.

CONCLUSION

The most common cause of mortality in cases with ENKTL-NT is NHL. The female sex, diagnosis at young age and early stage are associated with improved prognosis. Further, the classification of Ann Arbor stage and year of diagnosis can provide references of specific causes of death, which might help decrease the mortality rate.

The correlation of clinicopathological features and prognosis in extranodal natural killer/T cell lymphoma: a report of 42 cases in the early stage

This study aimed to explore the clinicopathological features and prognostic correlation of extranodal natural killer (NK)/T cell lymphoma (ENKTCL) in the early stage, screen out the prognostic markers of ENKTCL, and to establish the molecular model of ENKTCL prognosis. A retrospective study was conducted in 88 patients from May 1999 to Dec 2013 in Chinese Academy of Medical Sciences Cancer Hospital, who were diagnosed with ENKTCL according to WHO lymphoid hematopoietic tumor classification (published in 2008). The clinical data and paraffin-embedded tissue blocks were collected. The expressions of CD56, MLH1, PDGFRA, VEGF, PD-L1, PD-1, CyclinD1, p53, and Ki-67 were detected by high-throughput tissue microarray and immunohistochemistry (IHC) staining. The relationship between nine protein expressions and the clinicopathological features and prognosis of patients with ENKTCL were analyzed. The survival time of the 42 patients with complete clinical and follow-up data was 0~153 months. The average survival time was 60.1 months. The survival rates of 1 year, 2 years, and 3 year were 85.7%, 78.6%, and 71.4%, respectively. Single factor survival analysis showed that the increase of serum lactate dehydrogenase (LDH ≥ 240UI/L) before treatment was associated with poor prognosis, and there was a significant difference in survival rate (P = 0.006). Different therapy methods were related with prognosis (P = 0.011); in specifically, radiotherapy alone had the best treatment effect, followed by concurrent chemoradiotherapy, and the worst was chemotherapy alone. But, multivariate statistics indicated that the LDH level and the treatment approach were not independent prognostic factors of ENKTCL. There was no statistical difference between epidemiological factors such as gender, age, and other clinicopathological factors including tumor location, B symptoms, β2-microglobulin levels before treatment, and prognosis. Survival analysis of single factor showed that the positive expression of PDGFRA and PD-L1 was, respectively, related to the poor prognosis of patients with ENKTCL (P = 0.040, 0.007). The patients with Ki-67 overexpression (≥ 50%) had a worse prognosis than those with lower expression (< 50%), and the difference of survival rate between the two groups has statistical significance (P = 0.038). The expression of CD56, MLH1, VEGF, PD-1, CyclinD1, and p53 has no effect on survival rate (P > 0.05). Multivariate survival analysis showed that the expression levels of PDGFRA, PD-L1, and Ki-67 were independent factors in the prognosis of patients with ENKTCL. And the positive expressions of these three proteins were risk factors for prognosis of patients with ENKTCL (PDGFRA: P = 0.045, HR = 8.265, 95% CI: 1.050-65.054; PD-L1: P = 0.005, HR = 9.369, 95% CI: 1.950-45.003; Ki-67: P = 0.023, HR = 3.545, 95% CI: 1.187-10.585). The elevation of serum lactate dehydrogenase (LDH ≥ 240UI/L) before treatment and the treatment approach were associated with poor prognosis, which could be used as adjunct indexes to the prognosis. However, they were not independent factors for the prognosis of patients with ENKTCL. The expressions of PDGFRA, PD-L1, and Ki-67 were independent factors in the prognosis of patients with ENKTCL and these three proteins were risk factors of prognosis. The above markers combined with clinical factors may establish the prognosis model of ENKTCL.