Stage IE/IIE extranodal NK/T-cell lymphoma arising in the nasal cavity: analysis of CT findings and their prognostic value

Combined Modality Treatment with “Dexamethasone, Methotrexate, Ifosfamide, L-Asparaginase, and Etoposide ” Chemotherapy and Involved Field Radiotherapy for Early Stage Natural Killer/T Cell Lymphoma with Local Tumor Invasiveness: A Single-institution Study from India

Context: Patients with early stage extranodal natural killer/T-cell lymphoma, nasal type (ES-NKTCL) and local tumor invasiveness (LTI) show poor treatment outcomes with standard approaches. Dexamethasone, methotrexate, ifosfamide, L-asparaginase, and etoposide (SMILE) is an intensive, highly active protocol mainly studied in advanced/recurrent disease. No prior study has utilized this protocol in high-risk ES-NKTCL. Methods: Between 2011 and 2016, all patients with ES-NKTCL with LTI at presentation were uniformly treated at our institute with a combination of SMILE chemotherapy for 5–6 cycles, and involved-field radiotherapy (IFRT). Records of these patients were retrospectively reviewed. Results: Sixteen patients were identified, 69% stage IE and 31% stage IIE. The majority of patients had B-symptoms (75%), paranasal sinus (PNS) invasion (81%), facial skin invasion (56%), palatal perforation (69%), or orbital extension (56%). 12/16 had B-symptoms, and 6/16 had elevated lactate dehydrogenase. All patients received the entire planned 5–6 cycles. IFRT was delivered after a mean 4 cycles. Complete remission was achieved in 13/15 (87%) patients. At a median follow up of 18.5 months, 1-year progression-free survival and overall survival was 84% and 94%, respectively. Grade 3–4 toxicity was seen in 81%, most commonly neutropenia (75%), anemia (44%), and thromobocytopenia (31%). Six patients required dose adjustments (predominantly in the first 1 or 2 cycles). No treatment-related mortality was noted. Conclusion: SMILE with RT is a toxic but tolerable protocol for ES-NKTCL with LTI with high efficacy. Prospective studies are warranted.

Nomograms based on SUVmax of 18F-FDG PET/CT and clinical parameters for predicting progression-free and overall survival in patients with newly diagnosed extranodal natural killer/T-cell lymphoma

BACKGROUND

The prognostic value of ¹⁸F-FDG PET/CT in extranodal natural killer/T-cell lymphoma (ENKTL) is not well established. We aimed to develop nomograms for individualized estimates of progression-free survival (PFS) and overall survival (OS) in patients with ENKTL using ¹⁸F-FDG PET/CT parameters and clinical parameters.

METHODS

A total of 171 patients with newly diagnosed ENKTL undergoing ¹⁸F-FDG PET/CT scanning were retrospectively analyzed. Nomograms were constructed according to multivariate Cox proportional hazards regression. The predictive and discriminatory capacities of the nomograms were then measured using the concordance index (C-index), calibration plots, and Kaplan-Meier curves. The C-index, the area under receiver operating characteristic (ROC) curve (AUC), and decision curve analysis (DCA) were used to contrast the predictive and discriminatory capacities of the nomograms against with the International Prognostic Index (IPI) and Korean Prognostic Index (KPI).

RESULTS

Multivariate analysis demonstrated that pretreatment SUVmax≥9.5, disease stage II and III-IV, elevated lactate dehydrogenase (LDH), and elevated β2-microglobulin (β2-MG) had the strongest association with unfavorable PFS and OS. In addition, hemoglobin (Hb) < 120 g/L had a tendency to be associated with PFS. Both nomogram models incorporated SUVmax, Ann Arbor stage, LDH, and β2-MG. The PFS nomogram also included Hb. The nomograms showed good prediction accuracies, with the C-indexes for PFS and OS were 0.729 and 0.736, respectively. The calibration plots for 3-year and 5-year PFS/OS reported good consistency between predicted and observed probabilities for survival time. The PFS and OS were significantly different according to tertiles of nomogram scores (p < 0.001). The C-index and AUCs of the nomograms were higher than that of IPI and KPI. Moreover, DCA showed that the predictive accuracy of the nomograms for PFS and OS were both higher than that of IPI and KPI.

CONCLUSIONS

This study established nomograms that incorporate pretreatment SUVmax and clinical parameters, which could be effective tools for individualized prognostication of both PFS and OS in patients with newly diagnosed ENKTL.

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.

Angiocentric Centrofacial Lymphoma as a Challenging Diagnosis in an Elderly Man

BACKGROUND Angiocentric centrofacial lymphomas, now known as nasal-type extranodal natural killer T-cell lymphomas, are neoplasms of highly destructive characteristics that mainly affect the nasal cavity and palate. The most frequent clinical presentation includes fever, weight loss, nasal obstruction, epistaxis, nasal or facial edema, as well as necrotic ulcers in the nasal cavity, gums, and palate. It has been found to have an important association with the Epstein-Barr virus. Diagnostic pathology could be difficult due to the typical widespread tissue necrosis. CASE REPORT A 72-year-old Caucasian male sought medical attention with a chief complaint of nasal obstruction for the past 3 years, which only responded partially to unspecific treatment. He also presented with intermittent fever and nocturnal hyperhidrosis. Physical examination with rhinoscopy demonstrated a deviated septum, congestive turbines, and fragile and pale mucous membrane with yellowish, thick mucus. The pathology report described an angiocentric centrofacial lymphoma and a positive serology for Epstein-Barr virus. CONCLUSIONS The objective of this case report was to show that this illness represents a diagnostic challenge for the treating physician. It may be concluded that despite the poor prognosis of the disease, this particular case showed slower evolution and the patient remained stable despite multiple consecutive complications.

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.

A Multicenter Retrospective Comparison of Sequential versus Sandwich Chemoradiotherapy for Stage IE-IIE Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type

Background: Chemotherapy and radiotherapy are critical for treating early-stage extranodal natural killer/T-cell lymphoma, nasal type (ENKTL); however, the optimal therapy sequence remains unclear. Therefore, we performed this study to compare the efficacy of L-asparaginase/pegaspargase-based sequential versus sandwich chemoradiotherapy for patients newly diagnosed with stage IE-IIE ENKTL.

Methods: Patients were categorized into sequential (N = 111) and sandwich (N = 104) groups. Chemotherapy regimens included GELOX, SMILE, and VLP. The median radiotherapy dose was 55.0 Gy (range, 40.0-63.0 Gy). Adverse events, treatment responses, and survival outcomes were analyzed.

Results: Patients' clinical characteristics were largely comparable between the 2 groups; however, the sandwich group comprised a larger number of Ann Arbor stage IIE patients. Local invasion was the most significant predictor of overall survival (OS); local invasion and Ann Arbor stage were significant predictors of progression-free survival (PFS). There were no significant differences in the complete response rate (85.6% vs. 89.4%, p = 0.396), 3-year OS (77.5% vs. 80.8%, p = 0.636), or 3-year PFS rates (74.8% vs. 76.9%, p = 0.806) in the sequential vs. sandwich groups, respectively. The incidence of grade 3/4 hematological toxicities was higher in the sandwich group than in the sequential group (27.9% vs. 15.3%, respectively, p = 0.025). The response rates and survival outcomes in stage IE and IIE patients did not differ between sequential and sandwich groups.

Conclusions: In the era of L-asparaginase/pegaspargase, both sequential and sandwich chemoradiotherapy are safe and similarly effective in patients with newly diagnosed stage IE-IIE ENKTL.

Hemoglobin level, a prognostic factor for nasal extranodal natural killer/T-cell lymphoma patients from stage I to IV: A validated prognostic nomogram

Although nasal extranodal natural killer/T-cell lymphoma (nasal ENKL) shares some prognostic factors with other lymphomas, seldom studies had explored the prognostic value of hemoglobin. The ENKL cases in stage I–IV during 2000 to 2015 were collected from two medical centers (group A, n = 192), and were randomly divided into the group B (n = 155) and C (n = 37). Although the significant factors identified by the univariate analysis differed between the group A and B, the multivariate Cox regression indicated the same factors. C-index of the model was slightly better than Yang’s, but its integrated Brier score (IBS) was obviously lower than Yang’s both in the group A and B. Additionally, minimal depth of random survival forest (RSF) classifier confirmed that the prognostic ability of hemoglobin was better than age both in the group A and B. In the calibration of the nomogram, the predicted 3-year or 5-year OS of our nomogram well agreed with the corresponding actual OS. In conclusion, Hemoglobin is a prognostic factor for nasal ENKL patients in stage I - IV, and integrating it into a validated prognostic nomogram, whose generalization error is the smallest among the evaluated models, can be used to predict the patients’ outcome.

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.

[Efficacy of GLIDE chemotherapy for patients with newly diagnosed advanced-stage or relapsed/refractory extranodal natural killer cell lymphoma]

目的

研究GLIDE（吉西他滨、门冬酰胺酶、异环磷酰胺、地塞米松、依托泊苷）方案治疗初发进展期及复发难治性结外鼻型NK/T细胞淋巴瘤（ENKL）患者的有效性及安全性。

方法

纳入2010年3月至2016年3月收治的初发进展期及复发难治性ENKL患者42例，给予GLIDE方案化疗，中位疗程数为3(2~6）个，评估化疗结束后缓解率及早期（2个疗程后）缓解率，采用Kaplan-Meier方法统计无进展生存（PFS）及总生存（OS），同时采用Cox回归方法进行多因素分析，寻找影响患者PFS及OS的独立预后因素。

结果

31例（73.8%）患者达到完全缓解（CR），其中22例（52.4%）为早期CR，31例CR患者中14例接受序贯自体造血干细胞移植（ASCT）。1年PFS与OS率分别为65.6％和82.7%，4年PFS与OS率分别为48.2％和63.1%，中位OS时间未达到，中位PFS时间为30.5个月。多因素分析提示美国东部肿瘤协作组体能状态评分（ECOG评分）0~1分以及CR后序贯ASCT为减少复发、延长患者生存的有利因素。

结论

GLIDE方案能够有效治疗初发进展期及复发难治性ENKL, ECOG评分0~1分及CR后序贯ASCT治疗是患者获得较长PFS和OS时间的独立预后因素。

The extent of local tumor invasion predicts prognosis in stage IE nasal natural killer/T-cell lymphoma: a novel T staging system for risk stratification

A heterogeneous treatment response and prognosis exists among patients with Ann Arbor stage IE natural killer/T-cell lymphoma (NKTCL), and further risk stratification is required to identify high-risk patients. Here, we assessed the extent of local tumor invasion (LTI) in 185 patients with Ann Arbor stage IE primary nasal NKTCL and proposed a novel four-level T staging system. We found that a more advanced T stage was associated with a significantly lower rate of complete remission (CR) after chemotherapy and a marginally lower rate of CR after radiotherapy. While patients with no LTI (T1) or mild LTI (T2) presented with similar 5-year overall survival (OS; 83.6 % vs. 86.0 %, P = 0.990), those with moderately or highly advanced local disease (T3 or T4) had significantly worse survival (5-year OS was 63.3 % and 35.1 %, respectively). A more advanced T stage (T3 or T4) was an independent prognostic factor for both OS and progression-free survival (PFS) in the Cox regression model. In addition, patients with T3 or T4 disease experienced locoregional failure more frequently than those with T1 or T2 disease, and patients with T4 disease had a significantly higher risk of distant failure. Our data demonstrated that the T staging system, based on the extent of LTI, could serve as an effective clinical parameter for further risk stratification among patients with primary nasal Ann Arbor stage IE NKTCL.