Cutaneous extranodal natural killer/T-cell lymphoma: a comparative clinicohistopathologic and survival outcome analysis of 45 cases according to the primary tumor site

Wait and see: a case of EBV + cutaneous extranodal NK/T-type lymphoma with indolent behaviour

Extranodal NK/T-cell lymphoma (ENKTL) is a rare lymphoma subtype associated with Epstein-Barr virus (EBV) infection, portending a poor prognosis despite systemic chemotherapy. We present the unusual case of an 85-year-old man receiving ibrutinib for mantle cell lymphoma, who developed a erythematous, subcutaneous nodule on the forehead, featuring a proliferation of pleomorphic CD8 + /CD56 - /EBV + cells. Given the negative staging and comorbidities, a watchful waiting strategy was performed, experiencing a benign course with self-resolution and complete remission over a 4-year follow-up. The literature on primary cutaneous ENKTL has been discussed, with particular attention to clinical and histological prognostic factors.

Extranodal NK/T-Cell Lymphoma, Nasal Type, Extranasal and Ulcerative Blister Variant, Case Report

The extranodal natural killer (NK) T-cell lymphoma of nasal type is a form of lymphoma that falls within the WHO/EORTC 2018 classification of cutaneous T-cell lymphomas. It is characterized for being aggressive, infrequent, and destroying midline facial structures; however, it can also be in primary or secondary form at extranasal sites, such as the skin or the gastrointestinal tract, among others. We report the case of an 18-year-old patient with an extranodal NK/T-cell lymphoma located in an extranasal site. The clinical presentation is characterized for being multifocal and with erythematous-violaceous plaques that progress to hemorrhagic blisters and necrotic ulcers. Although this type of lymphoma has been reported previously by others, the presence of blisters is an atypical finding, which we believe has been described only in one case in the medical literature.

Clinical analysis of 20 cases of cutaneous extranodal NK/T-Cell lymphoma

Background To investigate the clinical features, pathological features and prognostic factors of cutaneous extranodal natural killer/T-cell lymphoma (CENKTL). Methods A total of 20 cases with CENKTL from February 2013 to November 2021 were analysed retrospectively. Results The patients included 15 men and five women, and their ages ranged from 19 to 92 (median age of 61) years. The most common lesions were on the extremities, followed by the trunk. Histopathological examination showed atypical lymphocyte infiltrate in dermis and subcutaneous fat. The tumour tissue showed vascular proliferation, vascular occlusion, and coagulation necrosis. In situ hybridisation revealed that 20 patients were positive for Epstein-Barr virus-coding ribonucleic acid. Immunohistochemistry showed that the tumour cells were positive for CD3 (18/20 and 90%), CD56 (19/20 and 95%), T-cell intracellular antigen (TIA-1) (13/14 and 92.9%) and CD20 (5/20, 25%). About 20 patients were positive for Ki-67 with values of 30-90%. A total of 11 of the 20 patients died, and two patients were lost to follow-up. The 2-year overall survival was 24%, and the median overall survival was 17 months. Univariate analysis revealed that involvement of lymph nodes (P = 0.042) correlated with worse survival. Limitation This is a retrospective study design and has a limited number of patients. Conclusion CENKTL is rare and has a poor prognosis. Diagnosis is challenging due to non-specific clinical symptoms and histopathology results. A comprehensive judgement should be made based on related clinical manifestations and histopathological and molecular examination. Lymph node involvement is an independent prognostic factor for CENKTL.

Extranodal Natural Killer/T-cell Lymphoma Isolated to the Leg: A Case Report

Extranodal natural killer/T-cell lymphoma (ENKTL) is a subtype of non-Hodgkin's lymphoma, and it is exceedingly rare in North America. The "extranasal" subtype of ENKTL frequently involves the skin and typically has an aggressive course with no current standard of treatment available. In this report, we present a case of cutaneous ENKTL in an otherwise healthy middle-aged male.

Treatment of extranodal NK/T-cell lymphoma: From past to future

Extranodal NK/T-cell lymphoma (ENKTCL) is the most common subtype of T/NK-cell lymphoma in Asia and Latin America, but very rare in North American and Europe. Patient survival has improved significantly over the past two decades. However, standard treatment has not yet been established, although dozens of prospective trials have been conducted. To help understand how the treatment of ENKTCL has evolved in the past and what trends lie ahead, we have comprehensively reviewed the treatment of this aggressive malignancy, with a particular focus on neglected or unanswered issues, such as the optimal staging method, the best partner of asparaginase (Asp), the individualized administration of Asp, the preferred sequence of CT and RT and so on. Overall, the 5-year overall survival (OS) of patients with Ann Arbor stage I/II disease increased from < 50% in the early 20th century to > 80% in recent years, and the median OS of patients with Ann Arbor stage III/IV disease increased from < 1 year to more than 3 years. The improvement in patient survival is largely attributable to advances in radiation technology and the introduction of Asp and anti-PD-1/PD-L1 immunotherapy into practice. Radiotherapy is essential for patients with early-stage disease, while Asp-based chemotherapy (CT) and PD-1/PD-L1 inhibitors significantly improved the prognosis of patients with advanced-stage disease. ENKTCL management is trending toward simpler regimens, less toxicity, and higher efficacy. Novel drugs, such as manufactured T cells, monoclonal antibodies, and small molecule inhibitors, are being intensively investigated. Based on the fact that ENKTCL is highly resistant to cytotoxic drugs except Asp, and aggressive CT leads to higher toxicity rather than better outcomes, we recommend it is unnecessary to expend additional resources to compare different combinations of Asp with cytotoxic agents. Instead, more efforts should be made to optimize the use of Asp and immunotherapy to maximize efficacy and minimize toxicity, explore ways to overcome resistance to Asp and immunotherapy, identify novel treatment targets, and define subpopulations who may benefit more from specific treatments.

Pediatric Cutaneous Hematologic Disorders: Cutaneous Lymphoma and Leukemia Cutis: Experience of a Tertiary-Care Pediatric Institution and Review of the Literature

BACKGROUND

Cutaneous hematologic malignancies are rare in children, and the literature about them is still sparse.

OBJECTIVE

The purpose of our study was to report our experience with pediatric cases of cutaneous hematologic disorders and describe their clinical and histological features.

METHODS

Data were retrospectively collected from the histopathologic database of the CHU Sainte-Justine, University of Montreal, Montreal, Canada. All patients up to 18 years of age with a diagnosis of a primary cutaneous lymphoma (including lymphomatoid papulosis), secondary cutaneous lymphoma or cutaneous manifestations of leukemia, followed from 1980 to 2019 at our center were reviewed.

RESULTS

Thirty-six patients were included. Age at presentation ranged from birth to 18 years of age (mean 7.83 ± 5.16; median 7.0). Ten different hematologic disorders were identified according to the WHO-EORTC classifications: lymphomatoid papulosis (10 cases), mycosis fungoides (6 cases), anaplastic large cell lymphoma (4 cases), pre-B acute lymphoid leukemia (5 cases), primary cutaneous marginal zone B-cell lymphoma (4 cases), primary cutaneous CD4⁺medium T-cell lymphoproliferative disorder (1 case), extranodal NK/T-cell lymphoma (1 case), hydroa vacciniforme-like lymphoproliferative disorder (1 case), B-cell lymphoblastic lymphoma (1 case) and acute myeloid leukemia (3 cases).

CONCLUSION

The most common subtype of cutaneous hematologic disease in our single institution study was lymphomatoid papulosis (type A and type C), followed by mycosis fungoides. Recognition of this large clinical and histological spectrum by dermatologists is important because diagnosis is often established by biopsy of skin lesions, even in secondary cutaneous cases. Moreover, the clinicopathological correlation is of utmost importance for the final diagnosis of those pathologies.

Skin diseases in Asian individuals that you do not want to miss: A selection of unique or relatively more common conditions in Asian populations

The Asian population currently constitutes a simple majority of the global population, comprising nearly 60%. The percentage of the US population that identifies as Asian is expected to grow to 41 million by the year 2050, making up an eventual 9% of the US population. As the world and US populations of Asian individuals increase, the demand for dermatologic care from this population will increase, requiring dermatologists to become more familiar with the diagnosis and treatment of Asian-specific skin characteristics and diseases. In this contribution, we review skin conditions specific to or relatively more common in Asian patients to help recognition and management of diseases in an increasing Asian patient population. We discuss prurigo pigmentosa, primary cutaneous plasmacytosis, lipodystrophia centrifugalis abdominalis infantilis, Epstein-Barr viru-positive T- and natural killer-cell lymphoproliferative disorders, acquired bilateral nevus of Ota-like macules, and Behҫet disease.

Correlation between the prevalence of T-cell lymphomas and alcohol consumption

Background and aims

Alcohol is a psychoactive substance that causes dependence, with many thousands of years in the history of mankind, being widely used in different cultures. According to the International Agency for Research on Cancer, alcohol is involved in the development of cancer, being directly associated with it. Considering that alcohol is involved in the initiation and dissemination of gastrointestinal malignancies, the objective of the study was to assess its role in the pathogenesis of T-cell lymphomas, as well as its possible correlation with chronic consumption.

Methods

The patient cohort was compiled from the Sixth Medical Center of the People's Liberation Army Navy General Hospital in Beijing, China. A total of 30 patients matched the criteria and were enrolled in the study. Statistical analysis of the raw data was performed using R Statistics version R 3.5.1. released on the 29.08.2018.

Results

Our data demonstrate that the most common extranodal involvment of T-cell lymphoma patients is represented in decreasing order by bone marrow, peritoneum, rhino-oropharynx and the liver-biliary system. Nodal involvement is mainly represented in decreasing order by the laterocervical, axillary, mediastinal and inguinal regions.

Conclusions

These findings may be of value in further research and practical/clinical settings. Fever is the most common clinical feature and was present in most studied patients.

Diagnosis and prognostic stratification of cutaneous lymphoma

Primary cutaneous lymphomas are a heterogenous group of non-Hodgkin's lymphoma of both T/natural killer-cell and B-cell origin and defined to primarily present in the skin without extracutaneous involvement at diagnosis. In contrast to nodal non-Hodgkin's lymphoma, cutaneous T-cell lymphomas (CTCL) are more generally seen than cutaneous B-cell lymphomas (CBCL). CTCL and CBCL have various subtypes and each subtype has specifically characteristic clinical, pathological, and prognostic features. The diagnostic methods and staging evaluation of cutaneous lymphomas is mostly common in various guidelines created by professional societies. The diagnosis is made comprehensively based on clinical, pathological, laboratory, radiological, and genetic findings. On the other hand, definite prognostic stratification has not been completely established yet in most cutaneous lymphomas. This article focuses on the general and novel diagnostic methods and the current findings about prognostic factors and stratification in cutaneous lymphomas.

Clinicopathological and prognostic study of primary cutaneous extranodal natural killer/T-cell lymphoma, nasal type: A systematic review

Comprehensive studies of primary cutaneous extranodal natural killer/T-cell lymphoma (PCENKTL) are scarce. The objectives of this study are to describe PCENKTL in terms of its clinical features, histopathology, immunophenotypes, and prognosis, and to analyze factors affecting patient survival outcomes. We searched four databases and include studies with extractable data. We also searched the Asan Medical Center database for cases of PCENKTL. We include a total of 289 patients. The mean age at diagnosis was 52.8 years and the female to male ratio was 1:1.2. The most common clinical morphology was a subcutaneous nodule, followed by ulceration. About half of the patients presented with disseminated skin lesions. The median overall survival was 12.0 months and the 5-year survival rate was 22.0%. There was no correlation between the clinical morphology or the histopathological features of the skin lesions with the patient outcomes. Advanced TNM stage, a disseminated skin lesion, tumor location on the leg or trunk, the presence of B symptoms, and a high International Prognostic Index score were associated with a worse prognosis, and chemoradiotherapy was associated with a better survival outcome as compared with chemotherapy alone in univariable analyses. In multivariable analyses, only advanced TNM stage and tumor location on the leg were associated with a worse prognosis. In conclusion, PCENKTL is an aggressive cutaneous lymphoma and its prognosis is associated with TNM stage and tumor location.

Simultaneous intraocular and cutaneous extranodal NK/T-cell lymphoma refractory to multiple therapies including pembrolizumab

Floaters or visual disturbance in a patient with ENKL should prompt evaluation for possible vitreoretinal involvement. Lymphoma with ocular involvement should be treated aggressively and in most cases heralds CNS involvement.

[Extra-nodal NK/T-cell lymphoma, nasal-type, revealed by cutaneous and ocular involvement]

BACKGROUND

Extra-nodal NK/T-cell lymphoma (ENKTL) is a form of highly malignant non-Hodgkin's lymphoma. There are two types: nasal forms primarily affecting the oropharyngeal sphere and so-called nasal-type extra-nasal forms in which primary skin involvement is the most common feature enabling diagnosis. Herein, we report a case of systemic nasal-type ENKTL (ENKTL-NT) that was diagnosed based on skin involvement associated with ocular involvement.

PATIENTS AND METHODS

A 67-year-old female patient, without immunodepression, was admitted to the dermatology department for a worsening inflammatory scaly patch of skin on her right calf. Secondarily, further lesions appeared on her body as well as a generalized macropapular rash and sores. These were associated with fever spikes, as well as ophthalmoplegia and edema, preventing her from opening her right eyelid. Tests for infectious, autoimmune and inflammatory disorders were negative. A cerebro-orbital scan revealed infiltration and contrast enhancement of the right periocular fat without any mass effect or cerebral extension. A positron emission tomography (PET) scan revealed multiple hypermetabolic skin lesions. Histological analyses indicated dermal-hypodermal lymphomatous tumor proliferation, and immunohistochemical analyses revealed lymphocytes expressing NK-cell markers (strong CD56+ expression), cytotoxic markers (granzyme B and TIA-1), and the presence of Epstein Barr virus (EBV) in the tumor cells. The patient was diagnosed with systemic ENKTL-NT. Her condition deteriorated rapidly, with the onset of refractory macrophage activation syndrome leading to death due to multiple organ failure.

DISCUSSION

Skin involvement in ENKTL is non-specific and uncommon, which can delay diagnosis. Treatment is based on polychemotherapy comprising L-asparaginase and possibly consolidation therapy with autologous or allogeneic hematopoietic stem cell transplantation. The prognosis of ENKTL-NT is poor due the more aggressive nature of the disease compared with the nasal forms, with frequent visceral involvement and macrophage activation syndrome. Skin involvement seems to be a poor prognostic factor. Although ocular involvement is documented, its association with skin involvement is rare and mainly secondary to nasal forms of ENKTL. This case of an extra-nasal form of ENKTL-NT with systemic involvement illustrates the difficulty of diagnosis and the poor prognosis of this type of lymphoma.

CD30-positive cutaneous extranodal natural killer/T-cell lymphoma: clinicopathological features and survival outcomes

BACKGROUND

The prognostic value of CD30 expression in cutaneous extranodal natural killer/T-cell lymphoma is controversial.

METHODS

Clinicopathological features, survival outcomes, and prognostic implications of CD30 were retrospectively analyzed in 55 patients with cutaneous extranodal natural killer/T-cell lymphoma. We classified patients into (i) primary cutaneous extranodal natural killer/T-cell lymphoma and (ii) cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease depending on the primary tumor site.

RESULTS

CD30+ cutaneous extranodal natural killer/T-cell lymphoma was more common in patients with cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease than in those with primary cutaneous disease. CD30+ cases were more likely to present nodular lesions or cellulitis-like swelling than CD30- cases. Histologically, CD30+ cutaneous extranodal natural killer/T-cell lymphoma predominantly comprised large tumor cells compared with CD30- cases. However, the clinical morphology and tumor cell size were not associated with survival outcomes. CD30 expression was associated with better survival outcomes in patients with cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease.

CONCLUSION

CD30+ cutaneous extranodal natural killer/T-cell lymphoma presented peculiar clinicopathological features and had more favorable disease course in patients with cutaneous dissemination from nasal disease.

Multivariate analysis of prognosis for patients with natural killer/T cell lymphoma-associated hemophagocytic lymphohistiocytosis

OBJECTIVE

A major cause of hemophagocytic lymphohistiocytosis (HLH) is malignant neoplasms of the blood system, among which NK/T cell lymphoma is one of the most common risk factors. Patients with NK/T cell lymphoma hemophagocytic lymphohistiocytosis (NK/T-LAHS) have a worse prognosis and higher mortality. We aimed to explore the factors that affect the prognosis of NK/T-LAHS.

METHODS

Clinical data of 42 patients with NK/T-LAHS diagnosed by Beijing Friendship Hospital from June 2008 to June 2016 were analyzed retrospectively. The survival time was counted until 1 August 2016.

RESULTS

For the 42 NK/T-LAHS patients, 1-month survival rate was 48.9%, 2-month survival rate was 36.7%, 3-month survival rate was 28.8%, 6-month survival rate was 23.0%, and 12-month survival rate was 15.4%. NK/T-LAHS patients who underwent allogeneic hematopoietic stem cell transplantation (Allo-HSCT) (p = 0.000), exhibited peripheral blood Epstein-Barr virus (EBV)-positivity (p = 0.004), and achieved overall response (OR) remission after initial induction therapy (p = 0.007) had statistical significance.

CONCLUSION

NK/T-LAHS is a disease of poor prognosis and high mortality. NK/T-LAHS patients who achieved OR remission after the initial induction therapy had a better prognosis than non-remission patients and Allo-HSCT was an effective way to prolong the survival of NK/T-LAHS patients. However, EBV positivity in peripheral blood was a poor prognostic factor in NK/T-LAHS patients.

Cutaneous Lymphomas with Cytotoxic Phenotype

Primary cutaneous cytotoxic lymphomas are T-cell or natural killer-cell lymphomas that express 1 or more cytotoxic markers. These neoplasms constitute a spectrum of diseases. In this review, an overview of clinical, morphologic, and phenotypical features of each subtype is provided. Differential diagnosis is discussed with attention to scenarios in which diagnostic difficulties are most frequently encountered.

Multifocal primary cutaneous extranodal NK/T lymphoma nasal type

Nasal type extranodal NK/T-cell lymphoma is a distinct entity according to the World Health Organization classification. Although 60% to 90% of patients with this disease present with a destructive mass in the midline facial tissues, it may also primarily or secondarily involve extranasal sites, like the skin. We report the case of a 77-year-old patient that came to our department with erythematous plaques of the right leg and eczematous lesions of the trunk. These lesions were biopsied and the patient was diagnosed with extranodal NK/T-cell lymphoma, nasal type. He was treated with multi-agent systemic chemotherapy but died 5 months after diagnosis. This case highlights the rarity and variability of cutaneous features of this disease and its aggressive course and poor prognosis.

Facial swelling: an atypical presentation of cutaneous lymphoma

BACKGROUND

Cutaneous lymphomas (primary and secondary lymphomas involving the skin) are a heterogeneous group with various clinical manifestations, histological features, and prognoses.

METHODS

We describe eight cases of cutaneous lymphoma presenting with facial swelling.

RESULTS

Our case series included three cases of primary cutaneous extranodal natural killer/T-cell lymphoma, one case of secondary cutaneous extranodal natural killer/T-cell lymphoma, one case of subcutaneous panniculitis-like T-cell lymphoma, one case of cutaneous CD4+ small/medium pleomorphic T-cell lymphoma, and two cases of peripheral T-cell lymphoma (unspecified).

CONCLUSIONS

This collection of cases and literature review emphasizes the need for clinical suspicion of cutaneous lymphoma in the differential diagnosis of patients with refractory facial swelling.

Cutaneous manifestations of peripheral T-cell lymphoma, not otherwise specified: a case series highlighting the diagnostic challenges for this heterogeneous group

Peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) is a rare, heterogeneous group of nodal and extranodal mature T-cell lymphomas that do not correspond to any of the defined T-cell entities, according to the World Health Organization classification. Most cases present with late stage nodal disease; however extranodal involvement is common. Skin and subcutaneous involvement is reported in approximately 20% of cases. Little attention has been given to the highly variable skin manifestations in the literature. It is our experience that lesions can present in ways other than previously described nodular or tumourous lesions that often ulcerate. We present a case series from a large tertiary institution of seven cases of PTCL, NOS with skin involvement, highlighting the variable presentations and diagnostic challenges for this heterogeneous group.

Paediatric cutaneous lymphomas: a review and comparison with adult counterparts

Primary cutaneous lymphomas (CL) in children is rare. Only a few studies focused specifically on paediatric CL and therefore little is known whether primary CL in children are similar to or different from their adult counterparts with respect to the clinicopathological presentation, behaviour and prognosis. An extensive literature search using PubMed/MEDLINE from January 1995 through July 2014 was undertaken for articles reporting cases of paediatric CL. In addition, we identified 31 children with CL in our institutions. Mycosis fungoides and lymphomatoid papulosis are the two most prevalent lymphoma forms in children. A few entities of cutaneous lymphomas such as cutaneous diffuse large B-cell lymphoma leg type, and Sézary syndrome have not been reported so far in children. Other lymphoma entities such as hydroa vacciniforme-like lymphoma are mostly seen in certain geographic areas (Asia, Central and South America). In the paediatric population, low-malignant indolent forms such as primary cutaneous marginal zone lymphoma and primary cutaneous follicle centre lymphoma are very rare, whereas the more aggressive forms of B-cell lymphomas, precursor lymphoblastic lymphomas, and blastic plasmacytoid dendritic cell neoplasm are the most common forms in children, mostly involving the skin secondarily. Most paediatric lymphomas have similar clinicopathological features and course as their adults counterparts, particularly in the group of cutaneous T-cell lymphomas. The spectrum of cutaneous B-cell lymphomas in children significantly differs from the one in adults. Diagnostic work-up and treatment of paediatric patients with lymphomas are best achieved in close collaboration with paediatric haematopathologists and oncologists.

Extranodal natural killer/T-cell lymphoma, nasal type, involving the skin, misdiagnosed as nasosinusitis and a fungal infection: A case report and literature review

The present study reports a case of extranodal natural killer (NK)/T-cell lymphoma, nasal type, involving the skin. The clinical manifestations, pathological characteristics, treatment and prognosis of the case were analyzed to improve the clinical diagnosis and treatment for this disease. The patient was a 56-year-old male, presenting with dark red nodules and plaques that had been visible on the nose for half a year. Based on the skin lesions and histopathological and immunohistochemical examination results, the patient was diagnosed with extranodal NK/T-cell lymphoma, nasal type. This disease has unique histopathological and immunohistochemical features and a high malignancy. The condition tends to be misdiagnosed and has a poor prognosis, but seldom involves the skin. In the present case, only radiotherapy was performed, with no relapse occurring within 6 months.