Early-stage splenic diffuse large B-cell lymphoma is highly associated with hepatitis C virus infection

Establishment of Prognosis Nomogram for Primary Splenic Diffuse Large B Cell Lymphoma: A Study Based on SEER Database

Despite being the most common primary tumor of the spleen, in the past, few studies have predicted the prognosis of primary spleen diffuse large B cell lymphoma. This study aimed to establish a nomogram prediction model of overall survival in primary DLBCL of the spleen. We screened out 347 patients with primary splenic DLBCL from surveillance, epidemiology, and end results database. According to the Cox regression results (age, Ann Arbor Stage, splenectomy and chemotherapy was the independent risk factor for primary splenic DLBCL), the nomogram was constructed. We evaluated the predictive ability of nomogram with C-Index (training cohort: 0.719 [0.669-0.769]; validation cohort: 0.711 [0.641-0.781]) and 3-year/5-year receiver operating characteristic area under curve (3-year/5-year ROCAUC, training cohort: 0.731/0.742; validation cohort: 0.721/0.742). Calibratioin plot shows that our predicted values fluctuate around the actual value, indicating good agreement with nomogram. The decision curve analysis (DCA) results showed that our nomogram could benefit more than Ann Arbor Stage for predicts the prognosis of the primary splenic DLBCL. The Kaplan-Meier and landmark analysis showed that a great discrimination between high-risk group and low-risk group (P < 0.05) and indicating that our nomogram has the good ability to identify high-risk patients. In this study, a nomogram prediction model for primary spleen DLBCL was established, which has good ability of prediction and generalization. It can help clinicians carry out individualized treatment measures.

Primary Splenic Diffuse Large B-cell Lymphoma: An Atypical Presentation

Primary splenic diffuse large B-cell lymphoma (PS-DLBCL) is an extremely rare type of non-Hodgkin's lymphoma. It typically presents with abdominal pain and a rapidly enlarging mass, often accompanied by B symptoms. Here, we present a rare presentation of PS-DLBCL in a 54-year-old woman who experienced splenomegaly. A CT scan of her abdomen revealed an enlarged spleen measuring 12 x 15 x 14 cm with a hypodense lesion. Confirmation of diffuse large B-cell lymphoma was obtained through a splenic core biopsy. A subsequent positron emission tomography scan showed a large hypermetabolic and centrally necrotic infiltrative splenic mass without any evidence of pathology in other parts of the body. The patient's condition was classified as stage I PS-DLBCL, and she underwent treatment with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy for four cycles. This case report highlights the unique presentation of diffuse large B-cell lymphoma with exclusive involvement of the spleen and discusses the potential therapeutic role of radiation therapy and R-CHOP without the need for splenectomy.

Comparison of survival outcomes of different treatment modalities for patients with primary splenic diffuse large B cell lymphoma

Primary splenic diffuse large B cell lymphoma (DLBCL) is one of the most common primary tumors in the spleen, while its prevalence is relatively low. Recently, there has been an increase in the incidence rate of primary splenic DLBCL; however, the effectiveness of various treatments for it has not been adequately described previously. The purpose of this study was to compare the effectiveness of various treatments on survival time in primary splenic DLBCL. A total of 347 patients with primary splenic DLBCL were enrolled in The Surveillance, Epidemiology, and End Results (SEER) database. These patients were subsequently divided into four subgroups according to the treatment modalities: non-treatment group (patients who had not received chemotherapy, radiotherapy, or splenectomy, n=19), splenectomy group (patients who had received splenectomy only, n=71), chemotherapy group (patients who had received chemotherapy only, n=95), and the splenectomy combined with chemotherapy group (patients who had received splenectomy and chemotherapy, n=162). The overall survival (OS) and cancer specific survival (CSS) of four treatment groups were evaluated. Compared to the splenectomy group and the non-treatment group, the OS and CSS of the splenectomy combined with chemotherapy group was extremely significantly prolonged (P<0.01). Compared with the chemotherapy group, the OS and CSS of the splenectomy combined with chemotherapy group were longer, but there was no statistical difference (P>0.05). The Cox regression analysis showed that the treatment modality was identified as an independent prognostic factor for primary splenic DLBCL. The landmark analysis shows that the overall cumulative mortality risk was significantly lower in the splenectomy combined with chemotherapy group than in the chemotherapy group within 30 months (P<0.05), and the cancer-specific mortality risk was significantly lower in the splenectomy combined with chemotherapy group than in the chemotherapy group within 19 months (P<0.05). Splenectomy combined with chemotherapy may be the most effective treatment modality for primary splenic DLBCL.

Primary splenic diffuse large B-cell lymphoma presenting as a splenic abscess

Diffuse large B-cell lymphoma (DLBCL) arising in the spleen, also known as primary splenic DLBCL (PS-DLBCL), is a rare form of malignant lymphoma. It is defined as a lymphoma confined to the spleen or involving splenic hilar lymph nodes. Here we report a case of PS-DLBCL with CD30. The patient was a 62-year-old who presented with 2 weeks of left flank pain, chills, and abdominal distension. Computed tomography identified an 8-cm splenic mass with central necrosis interpreted as an abscess. A drain was placed, yielding purulent necrotic material; cytologically, only neutrophils were identified. However, purulent drainage continued for 28 days without resolution, prompting splenectomy. Pathological dissection revealed a multinodular mass with central necrosis. Microscopic examination revealed extensive karyorrhexis, abundant ghosts of large cells, and scattered large cells with pleomorphic, multilobated, and vesicular nuclei with moderately abundant cytoplasm. Immunohistochemical staining revealed large, atypical cells positive for CD20, CD30, CD45, PAX5, MYC (>40%), MUM1 (>30%), and p53 (focally). The large cells were negative for CD3 (polyclonal), CD4, CD5, CD8, CD10, CD15, CD34, BCL2, BCL6, AE1/AE3, S100, HHV8, and ALK. The Ki-67 proliferation rate was approximately 80% in large cells. Notably, this PS-DLBCL was positive for CD30, an unusual finding among non-Hodgkin B-cell lymphomas, which, coupled with the Reed-Sternberg-like morphology, raised the possibility of classic Hodgkin lymphoma. Therefore, we reviewed the literature to confirm the unique features of this large B-cell lymphoma, its abscess-like appearance, and its expression of CD30.

The effect of surgery on primary splenic lymphoma: A study based on SEER database

BACKGROUND

Although primary splenic lymphoma (PSL) is rare, it ranks first among splenic primary malignant cancers, and the incidence of lymphoma of spleen has gradually increased in recent years. However, the efficacy of surgery for PSL has not been clinically verified by large sample data, which has affected the formulation of relevant guidelines.

AIM

To assess whether surgery can enhance the prognosis PSL patients.

METHODS

Extracted the data of patients with PSL from The Surveillance, Epidemiology, and End Results (SEER) database, and divided the patients into surgery and non-surgery group. Kaplan-Meier curves and log-rank tests were used to compare the overall survival (OS) and cancer-specific survival (CSS). The propensity score matching (PSM) was used to match the data, then compared the OS and CSS again. The COX proportional hazard regression model was used for univariate and multivariate analysis. Finally, we performed subgroup analysis in different Ahmann stages.

RESULTS

A sum of 2207 patients with PSL were enrolled, of which 1062 (48.1%) patients received surgery, and 1145 (51.9%) patients did not undergo surgery. Overall, patients in the surgery group had better OS and CSS. After the propensity scores matching, surgery was not statistically significant in OS and CSS. In the subgroup analysis, surgery was a protective factor for the OS and CSS in Ahmann I/II. However, surgery was no statistical significance in OS and CSS in Ahmann III. In patients with Ahmann Ⅰ/Ⅱ SMZL, surgery was a protective factor for OS and CSS. In patients with Ahmann Ⅲ SMZL, surgery was also statistically significant of OS and CSS.

CONCLUSIONS

Surgery can significantly improve the prognosis of patients with Ahmann Ⅰ/Ⅱ primary splenic lymphoma, but there was no survival difference in the Ahmann Ⅲ patients with or without surgery. For patients with SMZL, surgery was effective for improving OS and CSS.

Rare Causes of Isolated and Progressive Splenic Lesions: Challenges in Differential Diagnosis, Evaluation, and Treatment of Primary Splenic Lymphomas

The spleen is among the most common extranodal sites for Hodgkin and non-Hodgkin lymphomas (NHLs); however, among lymphomas arising from the spleen, primary splenic lymphomas (PSLs) are rare. The group of PSLs includes primary splenic diffuse large B-cell lymphoma (PS-DLBCL), splenic red pulp small B-cell lymphoma, splenic marginal zone lymphoma (SMZL), and a splenic hairy cell leukemia variant. Delineating between the PSL variants can be challenging, especially as fine-needle aspirate and core needle biopsy of the spleen are not routinely offered at most medical centers. Herein, we describe the clinical course of 2 representative patients who presented with non-specific gastrointestinal symptoms, the first who was diagnosed with PS-DLBCL and the second who was diagnosed with SMZL. We review and contrast the clinical presentations, imaging techniques, and laboratory findings of these discrete lymphoma variants and offer strategies on how to delineate between these varied splenic processes. We also examine the use of splenectomy and splenic needle biopsy as diagnostics and, in the case of splenectomy, a therapeutic tool. Finally, we also briefly review treatment options for these varied lymphoma sub-types while acknowledging that randomized trials to guide best practices for PSLs are lacking.

No Stones, Some Groans, and Psychiatric Overtones with "Non-specific" Splenomegaly

Hypercalcemia is a potentially life-threatening electrolyte imbalance that is commonly caused by hyperparathyroidism, supplement or medication use, and/or malignancy. Splenomegaly is commonly a non-specific finding, but in the setting of hypercalcemia, may provide diagnostic insight into the underlying pathology and warrant further evaluation. A 70-year-old man presented from his outpatient provider with serum calcium > 15 mg/dL with complaints of one-month fatigue, weakness, poor oral intake, 10 lbs. unintentional weight loss, and periodic confusion noted by his wife. He received an extensive inpatient workup which was non-diagnostic. Splenomegaly was observed on radiographic imaging and reported as "nonspecific". Following discharge, denosumab was required to manage the hypercalcemia. Eventually, a diagnosis of primary splenic lymphoma was made months later. Laparoscopic splenectomy was planned but was advanced to an open laparotomy intraoperatively due to the rapid growth of the neoplasm. Early and close investigation of the spleen is warranted when splenomegaly presents in the setting of hypercalcemia and, as in this case, may prevent significant therapeutic burden.

Primary Splenic Diffuse Large B-Cell Lymphoma: A Rare Case of Massive Splenomegaly and Thrombocytopenia

Primary splenic diffuse large B-cell lymphoma (DLBCL) is a rare type of non-Hodgkin’s lymphoma. It often presents with abdominal pain or splenomegaly. We present a case of a 68-year-old male who presented to the emergency department with left sided abdominal pain. Workup revealed massive splenomegaly and thrombocytopenia. A splenic biopsy confirmed the diagnosis of primary splenic DLBCL. The patient was treated with chemotherapy. This case highlights the importance of considering primary splenic DLBCL with splenomegaly and treating it with chemotherapy and/or splenectomy.

Hepatitis C virus - associated B cell non-Hodgkin's lymphoma

The hepatitis C virus (HCV) infected patients are prone to develop bone marrow or various tissue infiltrates with monoclonal B cells, monoclonal B lymphocytosis or different types of B cell non-Hodgkin’s lymphoma (BCNHL), of which the most common are splenic marginal zone BCNHL, diffuse large BCNHL and follicular lymphoma. The association between chronic HCV infection and non Hodgkin’s lymphoma has been observed especially in areas with high prevalence of this viral infection. Outside the limitations of some studies that have been conducted, there are also geographic, environmental, and genetic factors that contribute to the epidemiological differences. Various microenvironmental signals, such as cytokines, viral antigenic external stimulation of lymphocyte receptors by HCV antigens, and intercellular interactions contribute to B cell proliferation. HCV lymphotropism and chronic antigenic stimulation are involved in B-lymphocyte expansion, as mixted cryoglobulinemia or monoclonal gammopathy of undetermined significance, which can progress to BCNHL. HCV replication in B lymphocytes has oncogenic effect mediated by intracellular HCV proteins. It is also involved in an important induction of reactive oxygen species that can lead to permanent B lymphocyte damage, as DNA mutations, after binding to surface B-cell receptors. Post-transplant lymphoproliferative disorder could appear and it has a multiclonal potentiality that may develop into different types of lymphomas. The hematopoietic stem cell transplant made for lymphoma in HCV-infected patients can increase the risk of earlier progression to liver fibrosis and cirrhosis. HCV infected patients with indolent BCNHL who receive antiviral therapy can be potentially cured. Viral clearance was related to lymphoma response, fact that highlights the probable involvement of HCV in lymphomagenesis. Direct acting antiviral drugs could be a solution for the patients who did not tolerate or respond to interferon, as they seem to be safe and highly effective. The use of chemotherapy in combination with rituximab for the treatment of BCNHL in patients infected with HCV can produce liver dysfunction. The addition of immunotherapy with rituximab can increase the viral replication, and severe complications can occure especially in patients co-infected with hepatitis B virus or immune immunodeficiency virus, in those with hepatocarcinoma, cirrhosis, or liver cytolysis. But the final result of standard immunochemotherapy applied to diffuse large BCNHL patients with HCV infection is not notably worse than in those without this viral infection. The treatment of patients chronically infected with HCV and having BCNHL is complex and requires a multidisciplinary approach and the risk / benefit ratio of rituximab treatment must be evaluated especially in those with liver cytolysis.

Possible association between hepatitis C virus and malignancies different from hepatocellular carcinoma: A systematic review

AIM: To summarize the current knowledge about the potential relationship between hepatitis C virus (HCV) infection and the risk of several extra-liver cancers.

METHODS: We performed a systematic review of the literature, according to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) Statement. We extracted the pertinent articles, published in MEDLINE and the Cochrane Library, using the following search terms: neoplasm/cancer/malignancy/tumor/carcinoma/adeno-carcinoma and non-Hodgkin lymphomas, kidney/renal-, cholangio-, pancreatic-, thyroid-, breast-,oral-, skin-, prostate-, lung-, colon-, stomach-, haematologic. Case series, case-series with control-group, case-control, cohort-studies as well as meta-analyses, written in English were collected. Some of the main characteristics of retrieved trials, which were designed to investigate the prevalence of HCV infection in each type of the above-mentioned human malignancies were summarised. A main table was defined and included a short description in the text for each of these tumours, whether at least five studies about a specific neoplasm, meeting inclusion criteria, were available in literature. According to these criteria, we created the following sections and the corresponding tables and we indicated the number of included or excluded articles, as well as of meta-analyses and reviews: (1) HCV and haematopoietic malignancies; (2) HCV and cholangiocarcinoma; (3) HCV and pancreatic cancer; (4) HCV and breast cancer; (5) HCV and kidney cancer; (6) HCV and skin or oral cancer; and (7) HCV and thyroid cancer.

RESULTS: According to available data, a clear correlation between regions of HCV prevalence and risk of extra-liver cancers has emerged only for a very small group of types and histological subtypes of malignancies. In particular, HCV infection has been associated with: (1) a higher incidence of some B-cell Non-Hodgkin-Lymphoma types, in countries, where an elevated prevalence of this pathogen is detectable, accounting to a percentage of about 10%; (2) an increased risk of intra-hepatic cholangiocarcinoma; and (3) a correlation between HCV prevalence and pancreatic cancer (PAC) incidence.

CONCLUSION: To date no definitive conclusions may be obtained from the analysis of relationship between HCV and extra-hepatic cancers. Further studies, recruiting an adequate number of patients are required to confirm or deny this association.

Characteristics of primary splenic diffuse large B-cell lymphoma and role of splenectomy in improving survival

BACKGROUND

Primary splenic diffuse large B-cell lymphoma (PS-DLBCL), an uncommon type of non-Hodgkin lymphoma, has been investigated only in small patient series before the rituximab era. The therapeutic role of splenectomy in addition to immunochemotherapy is unknown.

METHODS

The databases of 7 medical centers in Israel were searched for patients diagnosed with PS-DLBCL in 1982-2013, and clinical, treatment, and outcome data were collected for 87 patients. The mean patient age was 59.6 years; 57.5% were male.

RESULTS

Patients presented with abdominal pain (81%), B symptoms (59%), splenomegaly (84%), splenic masses (97%), and high lactate dehydrogenase (LDH) levels (84%); 61% had stage I or II disease. The diagnosis was made with core-needle biopsy in 46 patients and with diagnostic splenectomy in 39 patients. Eighty patients (92%) were treated with cyclophosphamide, doxorubicin, vincristine, and prednisone; 68 (78%) received rituximab. A complete response was achieved in 67 patients (77%), and a partial response was achieved in 8 (9%). At 5 years, the overall survival (OS) rate was 77%, and the progression-free survival (PFS) rate was 67%. When patients were stratified by splenectomy at diagnosis, the OS rates were 91% for splenectomized patients and 68% for nonsplenectomized patients (P = .08), and the PFS rates were 85% and 55%, respectively (P = .02). The respective values for the subgroup with early-stage disease were 96% and 63% for OS (P = .009) and 90% and 51% for PFS (P = .01). In a multivariate analysis, a low Eastern Cooperative Oncology Group performance status and splenectomy independently predicted better PFS (P < .03).

CONCLUSIONS

Patients with PS-DLBCL usually present with abdominal pain, high LDH levels, and a splenic mass. This study shows for the first time that splenectomy at diagnosis improves survival, specifically in patients with early-stage disease.