Malignant lymphoma in Nebraska and Guangzhou, China: a comparative study

Distribution of lymphoid neoplasms in the Republic of Korea: analysis of 5318 cases according to the World Health Organization classification

Compared with the West, the overall incidence of lymphoid neoplasms is lower, and the subtype distribution is distinct in Asia. To comprehensively investigate the subtype distribution with the age and sex factors, and temporal changes of subtype proportions, we re-assessed all patients with lymphoid neoplasms diagnosed at a large oncology service in the Republic of Korea from 1989 to 2008 using the World Health Organization classifications. Of the total 5,318 patients, 66.9% had mature B-cell neoplasms, 12.5% had mature T/natural killer (NK)-cell neoplasms, 16.4% had precursor lymphoblastic leukemia/lymphoma (ALL/LBL), and 4.1% had Hodgkin's lymphoma. The most common subtypes were diffuse large B-cell lymphoma (30.5%), plasma cell myeloma (14.0%), extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue type (MALT lymphoma; 12.4%), B-cell ALL/LBL (11.3%), Hodgkin's lymphoma (4.1%), peripheral T-cell lymphoma unspecified (4.0%), T-cell ALL/LBL (3.9%), and extranodal NK/T-cell lymphoma of nasal type (3.9%). Most subtypes showed male predominance, with an average M/F ratio of 1.3. Most mature lymphoid neoplasms were diseases of adults (mean age, 53.5 yr), whereas ALL/LBLs were of young individuals (mean age, 20.3 yr). When the relative proportion of subtypes were compared between two decades (1989-1998 vs. 1999-2008), especially MALT lymphoma has increased in proportion, whereas T/NK-cell neoplasms and ALL/LBL have slightly decreased. In summary, the lymphoid neoplasms of Koreans shared some epidemiologic features similar to those of other countries, whereas some subtypes showed distinct features. Although the increase in incidence of lymphoid neoplasms is relatively modest in Korea, recent increase of MALT lymphoma and decrease of T/NK-cell neoplasms and ALL/LBL are interesting findings.

Immunohistochemical profile and fluorescence in situ hybridization analysis of diffuse large B-cell lymphoma in northern China

CONTEXT

Gene expression profiling of diffuse large B-cell lymphoma using complementary DNA microarrays has revealed 2 major prognostic groups in Western countries: germinal center B-cell-like and nongerminal center B-cell-like lymphomas. Immunohistochemical analysis using antibodies specific for CD10, BCL6, and MUM1 has been proposed as a surrogate for gene expression profiling.

OBJECTIVE

To study the immunohistochemical features of diffuse large B-cell lymphoma cases from northern China because geographic differences for this disease are known to exist.

DESIGN

Morphologic, immunohistochemical, and fluorescence in situ hybridization analyses of 63 cases of diffuse large B-cell lymphoma from northern China.

RESULTS

There were 38 men and 25 women with a median age of 57 years (range, 12-87 years). CD10 was positive in 19 cases (30%), BCL6 was positive in 22 cases (35%), and MUM1 was positive in 32 cases (51%). Twenty-one (33%) cases were germinal center B-cell-like lymphoma, and 42 (67%) were nongerminal center B-cell-like lymphoma. BCL2 was expressed more often in nongerminal center B-cell-like disease versus germinal center B-cell-like disease (60% versus 24%, P = .01) and in nodal versus extranodal (64% versus 30%, P = .01) cases. Fluorescence in situ hybridization analysis showed BCL6, MYC , and BCL2 rearrangements in 11 of 32 (34%), 8 of 27 (30%), and 11 of 50 (22%) cases, respectively.

CONCLUSIONS

These results add to what is known about the geographic variation of diffuse large B-cell lymphomas. In northern China, the frequency of the germinal center B-cell-like type and BCL6 expression and/or BCL6 rearrangement is less and the frequency of MYC rearrangement is greater than have been reported in Western countries.

Molecular epidemiology of follicular lymphoma in Chinese: relationship with bcl-2/IgH translocation and bcl-6 397G/C polymorphism

The relative incidence of follicular lymphoma (FL) compared with diffuse large B-cell lymphoma (DLCL) is low in Chinese. This may be due to a lower incidence of t(14;18)-mediated disease, a rapid transformation of FL to DLCL, or a lower incidence of FL-prone genetic polymorphisms (e.g., bcl-6 G397C). Using a conventional and long-distance polymerase chain reaction technique, we showed that 93% (43/46) of Chinese FL cases are t(14;18) related and are molecularly indistinguishable from Caucasian cases. The translocation was uncommonly found in Chinese DLCL cases (8/58, 14%). Furthermore, the incidence of bcl-6 hypermutation in FL and DLCL cases appeared to be comparable. These data do not suggest a high incidence of transformation from FL to DLCL in Chinese. Sequencing study also did not show an increased incidence of G397C polymorphism (heterozygote+homozygotes) in FL compared to a population with Chinese background or DLCL cases (25+5% vs 30+4% vs 22+3%). The reasons for the lower incidence of FL in Chinese remain unanswered.

Incidence and spectrum of non-Hodgkin lymphoma in Chinese migrants to British Columbia

The incidence and spectrum of non-Hodgkin lymphoma (NHL) differ between the Chinese and Caucasian populations. Using population-based registries, we studied the pattern of NHL in Chinese migrants to British Columbia (BC). The records of all NHL cases of Chinese descent diagnosed between 1980 and 1997 were retrieved. Age-standardized incidences were calculated by 5-year intervals in terms of age and calendar years and the relative rates were compared between the migrant, Hong Kong and BC populations. The histological distribution of NHL was compared with 4500 consecutive NHL cases diagnosed in the two populations. A total of 211 cases of migrant NHL were identified, with an age-standardized incidence rate of 7.11 per 100 000 per year, compared with the Hong Kong and BC rates of 7.91 [standardized incidence ratio (SIR) = 0.86, P = 0.01] and 11.88 (SIR = 0.56, P < 0.01). The standardized rates of follicular lymphoma remained low, but the incidence of gastric and nasal natural killer/T lymphomas in migrants were lower than expected. Genetic factors appeared to be stronger than environmental factors in governing the overall incidence of NHL in Chinese. However, certain subtypes of lymphoma may show decreased rates in migrants because of environmental factors.

Pattern of Epstein-Barr virus association in childhood non-Hodgkin's lymphoma: Experience of University of Malaya Medical Center

The pattern of childhood non-Hodgkin's lymphoma (NHL) usually differs in adults. The most common subtypes are lymphoblastic, Burkitt's and anaplastic large cell lymphoma. Recent data indicate that a higher risk of developing lymphoma is associated in children of certain ethnic origins. The difference is probably related to the underlying etiological factors of these diseases, and Epstein-Barr virus (EBV) is a strong candidate. The present study aims to determine the disease pattern of childhood lymphomas in the University Hospital Kuala Lumpur, for a direct comparison to the reported data of adults from the same medical center. A total of 69 and 34 childhood NHL and Hodgkin's lymphomas, respectively, were retrieved. The most common subtypes were lymphoblastic (23 cases), Burkitt's (25 cases) and anaplastic large cell lymphomas (9 cases). Epstein-Barr virus association was more prevalent in B-cell (23%) than T-cell (12%) lymphomas. The most common EBV-associated tumor was Burkitt's lymphoma, and there was an increased risk of EBV association for Burkitt's lymphoma in Chinese patients. In conclusion, the pattern of childhood lymphoma in Malaysia is relatively similar to children elsewhere in the world. The EBV association of B- and T-NHL differs between children and adults from the same medical center because of differences in the subtype composition in these two age groups.

Insights into the molecular pathogenesis of follicular lymphoma arising from analysis of geographic variation

Incidence rates of follicular lymphoma (FL) inexplicably vary markedly between Western and Asian countries. A hallmark of FL is the bcl-2 translocation, characterized by 1 of 2 common breakpoints known as major breakpoint region (MBR) and minor cluster region (mcr). We analyzed previously published data to compare rates of bcl-2 translocation in FL across geographic regions. Available data from the literature suggest that the incidence of bcl-2 in healthy persons in the absence of FL may be as high as 50% in Western and Asian populations. However, in FL our results show that the frequency of bcl-2 positivity was significantly higher for US than for Asian populations (P <.0001). This pattern persisted for MBR and mcr subgroups. We conclude that a significant gradient exists in the bcl-2 frequency between these FL populations. We therefore suggest that the relatively low incidence of FL in Asian populations is caused not by a lower frequency of bcl-2 rearrangements in healthy populations but by distinct molecular pathways developing in different geographic regions that nonetheless culminate in FL, which is morphologically similar but molecularly distinct. Studies demonstrating differences in clinical characteristics according to the presence or absence of bcl-2 rearrangements support this concept. Thus we hypothesize that FL may in fact be a heterogeneous malignancy encompassing entities with distinct molecular pathogenesis and potentially distinct clinical manifestations. If these findings were confirmed in prospective studies, it would imply that different etiologic or genetic factors might influence the development of FL across separate regions.

Epstein-Barr virus (EBV) in Chinese pediatric Hodgkin disease: Hodgkin disease in young children is an EBV-related lymphoma

BACKGROUND

The Epstein-Barr virus (EBV) is thought to be involved in the pathogenesis of some Hodgkin disease (HD) cases. EBV may be associated particularly with childhood HD, a disease rare in the West compared with developing countries. In this study, a large series of Chinese pediatric HD cases has been examined to determine the age-specific prevalence of EBV.

METHODS

Paraffin sections from 104 pediatric and 52 adult Chinese HD cases were examined for EBV-RNA (EBERs) and EBV latent membrane protein-1.

RESULTS

Most pediatric cases arose in boys and showed an histology of mixed cellularity. Prominent interfollicular involvement was seen frequently in the childhood cases. EBV was identified in tumor cells in 113 of 156 (72%) HD cases but was more frequent in pediatric cases (93 of 104; 89%) compared with adult cases (20 of 52; 38%) (P < 0.01; chi-square test). EBV was found in 86 out of 91 (95%) cases in children aged 3-10 years and in 7 out of 13 (54%) cases in children aged 11-14 years (P < 0.01; chi-square test). The virus was less frequent in cases in young adults than in old adults, although this trend was not significant (P > 0.05; chi-square test). Pediatric HD was associated with EBV irrespective of histologic subtype. In adults, EBV was associated more frequently with mixed cellularity than with other subtypes.

CONCLUSION

To the authors' knowledge, this is to date the largest series of pediatric HD cases studied for EBV. Study findings provided further evidence that HD is etiologically heterogeneous. The authors believe that pediatric HD now should be regarded as a distinctive EBV-related lymphoma.

Host ethnicity influences non-Hodgkin's lymphoma subtype frequency and Epstein-Barr virus association rate: the experience of a multi-ethnic patient population in Malaysia

AIMS

The pattern of malignant lymphoma is known to vary in different populations. This study aims to elucidate the effect of ethnicity on subtype frequency of non-Hodgkin's lymphoma and EBV association rate.

METHODS AND RESULTS

A total of 232 reconfirmed lymphoma cases in Malaysian patients were retrieved from the archives in the Department of Pathology, University Hospital, Kuala Lumpur. There were 24 (10%) Hodgkin's and 208 (90%) non-Hodgkin's lymphomas, 173 of the latter were in adult group (aged > or = 15 years). The ethnic composition were 41 Malays, 107 Chinese, 21 Indians and four none of the above. A male : female ratio of 2.4 : 1 was observed. Complete immunohistochemical studies in 158 cases revealed 36 (23%) T-cell, 121 (76%) B-cell and one (1%) null-cell phenotype. Seventy-five percent of the T-cell lymphomas were peripheral T/NK-cell types. Among the classifiable lesions, low-grade/indolent lymphomas constituted 17%: 2% were the lymphocytic subtype and 10% were follicular lymphomas. Approximately one-third of the follicular lymphomas occurred in Indian patients. The largest group of high-grade lymphoma was diffuse large B-cell type (46%), followed by peripheral T/NK-cell (18%). A predominance of NK/T-cell lymphomas occurred in Chinese (5/7), and all were EBV associated. Burkitt's lymphoma accounted for 5% (eight cases), all were Chinese males, with a 38% EBV-association rate. The frequency of EBV-associated B-cell lymphoma is three times more common in Chinese than Malays. The EBV positivity rate among lymphomas in ethnic Malay, Chinese and Indian patients was 5%, 15% and 22%, respectively, and in T- and B-cell lymphomas was 36% and 7%, respectively.

CONCLUSIONS

This Malaysian series reveals differences in the subtype frequencies of non-Hodgkin's lymphomas and EBV association rate amongst patients of various ethnic groups residing in the same environment.

Primary non-Hodgkin's lymphoma of the jaws: immunohistochemical and genetic review of 10 cases

PURPOSE

Non-Hodgkin's lymphoma (NHL) comprises a group of malignant lymphoproliferative diseases characterized by clonal expansion of lymphocytes at various levels of ontogenetic development. The aim of this study was to review the immunohistochemical and cytogenetic features of 10 cases of NLH of the jaws to determine their respective derivation.

PATIENTS AND METHODS

Histopathologic and immunohistochemical review of 10 cases of large-cell lymphomas of the jaws, together with Southern blot analysis of 2 of the cases, was performed and results compared with the findings in the literature.

RESULTS

In the 10 cases studied, the average age of onset of the NHL was 51 years, with a male-to-female ratio of 3:2. Tumefaction was the first clinical sign of disease. Eight of 10 cases were high-grade, large-cell NHLs, centroblastic type. Two cases were high-grade, large-cell NHL, immunoblastic type.

CONCLUSION

The immunohistochemical and Southern blot data remain the principal laboratory aids in the diagnosis and characterization of NHL, and they provide critical information for guiding clinicians to the appropriate treatment protocol for these malignancies.

A predictive model for life-threatening neutropenia and febrile neutropenia after the first course of CHOP chemotherapy in patients with aggressive non-Hodgkin's lymphoma

The purpose of this study was to develop a model for predicting the occurrence of life-threatening neutropenia (LN, ANC < or = 0.5 x 10(9)/l) and febrile neutropenia (FN, an ANC < 0.5x10(9)/l in association with a body temperature of > or = 38.3 degrees C) after the first cycle of CHOP therapy in patients newly diagnosed with aggressive NHL. One hundred and forty-five patients, aged > or = 15 years, with newly diagnosed diffuse mixed, diffuse large-cell or large-cell immunoblastic lymphoma (IWF categories, F, G, H), who had been treated with CHOP at King Chulalongkorn Memorial Hospital between June 1994 and December 1998, were entered into the study. The criteria for eligibility included complete work-up for baseline evaluation, treatment with standard CHOP chemotherapy, at least one complete blood count performed during days 8-14 post-treatment or if at any time the patients experienced a BT of > or = 38.3 degrees C and were not treated with any colony-stimulating factors (CSFs). The median age of the patients was 47 years (range, 17-78). Forty-eight percent of the patients were in stage III/IV, 36% had ECOG performance status (PS) II-IV, 30% had > or = 2 extranodal diseases, 59% had serum LDH > 1 x normal and 23% had bone marrow involvement. The frequencies of patients in the low-, low-intermediate, high-intermediate and high risk groups according to the international index were 29%, 28%, 17% and 26%, respectively. Thirty-nine percent of the patients had LN at nadir and 33% developed FN after the first course of CHOP. By using stepwise logistic regression analysis, the pretreatment variables independently predictive of the LN at nadir and the FN were serum albumin concentration of < or = 3.5 g/dl, serum LDH > 1 x normal and whether there was bone marrow involvement of lymphoma at presentation. The model, based on the incorporation of these three factors, identified three risk groups of patients with a predicted probability of developing LN at nadir of 81.5% (95% CI, 68.5-90.7) (high risk), 23.9% (95% CI, 12.6-38.8) (intermediate risk) and 4.4% (95% CI, 0.5-15.1) (low risk). The predicted rate of FN in the three groups were 72.2% (95% CI, 58.4-83.5), 17.4% (95% CI, 7.8-31.4) and 2.2% (95% CI, 0.05-11.8), respectively. In conclusion, our model could be used as a means to identify patients with newly diagnosed aggressive NHL, treated with CHOP, who are at high risk (> or = 50% probability) of developing post-first course LN and FN, in whom CSF and/or antibiotic prophylaxis might be indicated.

Non-Hodgkin's lymphomas in Mexico. A clinicopathological and molecular analysis

It is now well established that the clinical and histopathological characteristics of non-Hodgkin's lymphomas may vary significantly throughout the world. However, only a few reports have been published in Latin American countries. In this work, the clinical and pathologic findings of 264 patients with non-Hodgkin's lymphomas in Mexico City were analyzed. Diffuse large (14%) and diffuse mixed cell types (20%) predominated among nodal lymphomas. Within the group of patients with high grade malignancies, immunoblastic sarcomas were the most common (40/48). It is important to mention that follicular lymphomas were sporadic (4.5%). Among extranodal lymphomas the most commonly involved site was the gastrointestinal tract (11.3%), followed by the midline (6%). Molecular analysis of 65 cases with immunoglobulin and T-cell receptor gene probes showed that most lymphomas were of B-cell lineage (66%). The remaining group was composed of T-cell (25%) and bigenotypic malignancies (9%). All attempts to establish a correlation between the clinical stage and histopathological types with the genetic findings were not successful. However, pre-B and bigenotypic lymphomas were observed mainly in patients over 60 years of age. This study highlights some relevant characteristics of non-Hodgkin's lymphomas in Mexico.

The association between Epstein-Barr virus and Chinese Hodgkin's disease

Epstein-Barr virus (EBV) can be detected in Hodgkin and Reed-Sternberg (HRS) cells in about one-half of cases of Hodgkin's disease (HD) in Western countries. To determine whether EBV is also associated with HD in a developing country such as China, we studied paraffin sections from 28 Chinese cases of HD for expression of latent membrane protein-I (LMP-I) and EBV-encoded small RNA (EBER-I), using immuno-histology and RNA/RNA in situ hybridization respectively. The cases were selected from a large series of Chinese lymphomas following histological and immunophenotypical revision. EBV gene expression was found in HRS cells in 17/28 cases, and was related to histological sub-type, being present in 10/11 of mixed cellularity, 6/14 nodular sclerosis, 0/1 lymphocytic predominance, 0/1 lymphocytic depletion, and 1/1 unclassified HD. The 2 methods for detecting EBV gene expression gave similar results, except in one case of nodular sclerosis, in which HRS cells were negative for EBER-I, but weakly positive for LMP-I. In 5/12 cases with EBER-negative HRS cells, rare small or medium-sized lymphocytes expressed EBER-I but not LMP-I. These results suggest that (i) Chinese HD is frequently associated with EBV; (ii) the proportional frequency and sub-type distribution of EBV-positive HD are similar in China and in the West; (iii) both LMP-I immunohistology and EBER in situ hybridization reliably detect EBV in HRS cells in routine biopsies, but the former is simpler and less resource-consuming to perform.

Malignant lymphomas in Gabon (equatorial Africa): a morphologic study of 72 cases

A retrospective morphologic analysis was conducted on 72 malignant lymphomas collected in Gabon, a country of the equatorial area in Africa. Non-Hodgkin's lymphomas (NHLs) were by far the most frequent type of lymphoma, representing 67 cases (93%); only five patients (7%) had Hodgkin's disease. Non-Hodgkin's lymphomas were classified according to two modern systems (Kiel and Working Formulation). The age distribution of NHL patients was bimodal, with the highest peak in the 0 to 14 years age group (these cases were almost exclusively associated with Burkitt's lymphomas), and with the second highest peak in the 55 to 64 years age group. The male to female ratio was 2.5:1, and the overall median age was 44 years. According to the Working Formulation, the NHL cases were composed of one follicular lymphoma (1.5%), 55 diffuse lymphomas (82%), and 11 miscellaneous lymphomas (16.5%). Burkitt's lymphoma was the most frequent NHL (17 cases; 25.4%), followed by diffuse large cell lymphoma (15 cases; 22.4%) and immunoblastic lymphoma (nine cases; 13.4%). Consequently, high-grade NHL formed the largest group (28 cases; 42%), intermediate-grade NHL formed the next largest group (21 cases; 31.3%), and low-grade NHL formed the smallest group (seven cases; 10.4%). These data are compared with series from developed and developing countries, and the observed differences in distribution of the histologic subtypes of malignant lymphoma are discussed.

Environmental epidemiology of non-Hodgkin's lymphoma in eastern Nebraska

The incidence of non-Hodgkin's lymphoma (NHL) is increased in many counties in eastern Nebraska. Histologic analysis has revealed a twofold increase in the clinically aggressive, diffuse large cell subtype of NHL. To investigate the possible association between NHL and agricultural exposures, a population-based case-control study was conducted in eastern Nebraska in 1985. Telephone interviews were conducted with 201 men having histologically confirmed NHL and 725 controls. Among men, the use of the herbicide 2,4-D was associated with a 50% increased risk of NHL (OR 1.5, 95% CI 0.9, 2.4). Personal exposure to 2,4-D more than 20 days per year increased the risk threefold (OR 3.3, 95% CI 0.5, 22.1). Several classes of insecticides were also associated with increased risk: organophosphates (OR 1.9, 95% CI 1.1, 3.1), carbamates (OR 1.8, 95% CI 1.0, 3.2), and chlorinated hydrocarbons (OR 1.4, 95% CI 0.8, 2.3). As a result of intense agrichemical use, extensive contamination of shallow groundwater by nitrate and atrazine has also occurred in eastern Nebraska. A twofold increased incidence of NHL is present in counties with greater than 20% of the wells contaminated by nitrate (greater than 10 ppm) and in counties with intense fertilizer use. These findings suggest that NHL in eastern Nebraska may be related to the use of pesticides and nitrogen fertilizers.

A specialist leukaemia/lymphoma registry in the UK. Part 1: Incidence and geographical distribution of Hodgkin's disease. Leukaemia Research Fund Data Collection Study Group

This paper describes the epidemiology of Hodgkin's disease occurring in parts of the United Kingdom between 1984 and 1986. The cases were carefully diagnosed and the data rigorously cross-checked as part of the larger Leukaemia Research Fund Data Collection Survey of all lymphoid and haematogenous malignancies. The age-specific rates show the lack of an older adult second peak. Spatial variation is examined in some detail. At county and district levels there is little heterogeneity in the distribution of cases. However, at the electoral ward level there were real differences for the younger age group (0-34).