Primary nasal and nasopharyngeal lymphomas: a comparative study of clinical presentation and treatment outcome

The Expression Levels of CD20 as a Prognostic Value in Feline B-Cell Nasal Lymphoma: A Pilot Study

The effect of the semi-quantitative expression of CD20 in the prognosis of feline nasal lymphoma has not been described. This study investigated the prognostic significance of CD20 expression, clinicopathological characterization, and treatment outcomes in cats with nasal lymphoma. Clinical data from cats diagnosed with nasal lymphoma were retrospectively collected, including signalment, clinical signs, clinicopathological variables, treatment outcomes, and survival times. Using ImageJ software, CD20 expression was semi-quantitatively measured based on the proportion of CD20-positive areas. Correlations between laboratory findings, immunohistochemical expressions, and survival outcomes were investigated. All cats included in the study exhibited the B-cell immunophenotype. During treatment, a reduction in PCV was noted in the cats at the second and sixth weeks (p = 0.01 and p = 0.01, respectively). The cats with low CD20 expression exhibited a significantly shorter MST (91 days; 95% CI, 41-141) than those with high CD20 expression (MST, 214 days; 95% CI, 76-351) (p = 0.01). Stage T1 cats displayed a higher MST (143 days; 95% CI, 144-172) than those in other stages > T1 (120 days, 95% CI, 71-169 days) (p = 0.04). Anemia, a common adverse effect in feline nasal lymphoma, did not impact MST. T1 clinical staging and high CD20 expression showed a trend for better MST.

Angioimmunoblastic T-cell lymphoma involving the nasopharynx: An easily misdiagnosed disease with atypical histopathological features

OBJECTIVES

To explore the clinicopathologic features, treatment, and survival outcomes of angioimmunoblastic T-cell lymphoma (AITL) involving the nasopharynx.

METHODS

We retrospectively analyzed 73 cases of AITL. Among them, 64 cases with complete pre-treatment 18F-FDG positron emission tomography/computed tomography (PET/CT) images were integrated into the analysis of clinical characteristics and PET/CT findings of AITL involving the nasopharynx; 14 cases with both biopsies from lymph node and nasopharynx were included in the comparison of pathological characteristics of AITL in the two areas. Forty-six of the 73 patients who received first-line systemic treatment at our institute were included in the treatment efficacy and survival analyses.

RESULTS

Nasopharyngeal involvement was seen in 44/64 (68.8%) patients. Histologically, lymph node and nasopharyngeal biopsies in 14 patients both showed small to medium-sized tumor cells, complex inflammatory infiltration, and Reed-Sternberg-like cells or B immunoblasts. However, tumor cells with clear cytoplasm, significant high endothelial venule (HEV) hyperplasia, and perivascular infiltration were observed in 5/14, 3/14, and 2/14 nasopharyngeal biopsies, respectively, but in all fourteen lymph node biopsies (P < 0.05). Immunophenotypic profiles and gene rearrangements were highly concordant. Treatment efficacy and survival were similar between patients with nasopharyngeal involvement and those without (P > 0.05), indicating nasopharyngeal involvement is not a prognostic factor for AITL patients.

CONCLUSIONS

Nasopharyngeal involvement is common in AITL but can be easily misdiagnosed because of its atypical pathologic pattern, especially when a lymph node biopsy is unavailable. However, the patient's clinical presentation, PET/CT manifestations, the typical immunophenotype, and gene rearrangements help the diagnosis.

Low-grade malt lymphoma of the nasopharynx in young adults: Successful treatment of a rare diagnosis at a rare site by radiotherapy

INTRODUCTION

Mucosa Associated Lymphoid Tissue (MALT) lymphoma is the third most common subgroup of Non-Hodgkin's lymphoma and is the most common type of primary extranodal lymphoma. They are rarely found in the nasopharyngeal region and their mean age at presentation is the sixth decade of life.

MATERIALS AND METHODS

We present the clinical, pathological, treatment and 5-year follow-up data of 5 cases of nasopharyngeal MALT lymphoma treated with definitive radiotherapy at our hospital, between 2009 and 2011.

RESULTS

The average age of diagnosis was 27 years which is more than a decade earlier than what has been reported previously. Clinical symptoms included nasal obstruction, tinnitus and hearing loss. All five patients had locoregional disease. They were treated by definitive radiotherapy to a dose between 30 to 40 Gy. At 5 years of follow-up, 4 patients were in complete remission while one had disease relapse.

CONCLUSION

The younger age of presentation compared to older reports in this rare subsite was an interesting finding in our study. The authors speculate that rising levels of particulate air pollution may have played a part in the etiology in this younger population. Our series shows that despite the younger age, the disease displays an indolent course and responds well to radiotherapy alone as the primary treatment. Recurrence or disseminated disease is also highly treatable with systemic chemotherapy.

Comparison of Primary B/NKT Non-Hodgkin Lymphomas in Nasopharynx, Nasal Cavity, and Paranasal Sinuses

OBJECTIVE

We aimed to compare clinical and survival differences between B-cell (B-NHL) and NKT-cell non-Hodgkin lymphomas (NKT-NHL) located in the nasal cavity (NC), nasopharynx, and paranasal sinuses, which are always categorized as one sinonasal type.

STUDY DESIGN

Patients diagnosed with primary B-NHL and NKT-NHL in the nasal cavity, nasopharynx, and paranasal sinuses from Surveillance, Epidemiology, and End Results (SEER) database were included (1975-2017).

SETTING

Population-based cohort study.

METHODS

We conducted univariate and multivariate Cox regressions and Kaplan-Meier analysis to examine survival outcomes of B/NKT-NHL in the nasal cavity, nasopharynx, and paranasal sinuses, respectively.

RESULTS

Overall, most B-NHL cases originated from the nasopharynx, while the majority of NKT-NHL cases occurred in the nasal cavity. Notably, the cancer-special survival (CSS) outcomes improved significantly in all sinonasal B-NHL cases over time, whereas no such improvement trend was observed in each sinonasal NKT-NHL type. Additionally, increasing age was linked with an elevated risk of death in B-NHL, particularly in the nasal cavity (Hazard ratio [HR]: 3.37), rather than in NKT-NHL. Compared with B-NHL, the adverse effect of a higher stage on CSS was more evident in NKT-NHL, particularly in its nasopharynx site (HR: 5.12). Furthermore, radiotherapy was beneficial for survival in patients with sinonasal B-NHL and NKT-NHL, except in the nasopharynx NKT-NHL. However, chemotherapy has only been beneficial for CSS in patients with paranasal sinuses B-NHL (HR: 0.42) since 2010, rather than in other types of B/NKT-NHL.

CONCLUSION

Although B-NHL and NKT-NHL in the nasal cavity, nasopharynx and paranasal sinuses have similar anatomical locations, their clinicodemographics and prognoses are largely different and should be treated and studied as distinct diseases.

Prognostic Indicators of Survival in Sinonasal Diffuse Large B-Cell Lymphoma: A National Cancer Database Analysis

OBJECTIVES/HYPOTHESIS

This study offers an update on the epidemiologic and prognostic factors and treatment-specific outcomes in patients diagnosed with sinonasal diffuse large B-cell lymphoma (DLBCL).

STUDY DESIGN

Retrospective cohort study.

METHODS

National Cancer Database was queried from 2004 to 2016 for patients with sinonasal DLBCL. Univariate Kaplan-Meier and multivariate Cox-regression analyses were performed to evaluate the association of suspected prognostic factors with overall survival (OS).

RESULTS

A total of 2,222 patients with sinonasal DLBCL were analyzed. OS was 62% at 5 years and 42% at 10 years. Prognostic factors associated with increased survival included African-American race (HR: 0.48, 95% CI: 0.33-0.70), chemotherapy (HR: 0.30, CI: 0.25-0.35), and radiation (HR: 0.80, CI: 0.69-0.93). Prognostic factors associated with decreased survival included patients with Charlson-Deyo scores of 1 (HR: 1.51, CI: 1.25-1.84), 2 (HR: 2.25, CI: 1.67-3.03), and 3 (HR: 2.36, CI: 1.49-3.74) and patients with Lugano stage III (HR: 1.69, CI: 1.09-2.62) and IV (HR: 1.96, CI: 1.46-2.64) disease. Stage-based split multivariate analysis was performed and revealed chemotherapy was independently associated with increased OS in patients with stage I (HR: 0.24, CI: 0.19-0.30), II (HR: 0.17, CI: 0.11-0.28), and IV (HR: 0.41, CI: 0.26-0.64) disease. Radiotherapy was independently associated with increased OS in patients with stage I disease only (HR: 0.67, CI: 0.55-0.83), while immunotherapy was an independent prognostic factor in patients with stage IV disease only (HR: 0.60, CI: 0.37-0.98).

CONCLUSION

This study is the largest to date to analyze the association of demographic features and treatment modalities with OS in patients with sinonasal DLBCL. It is the first to investigate the association of immunotherapy with OS in this population. A combination treatment of immunochemotherapy or radioimmunochemotherapy confers increased survival, particularly in patients with advanced disease.

LEVEL OF EVIDENCE

IV Laryngoscope, 2021.

Treatment Modalities and Survival Outcomes for Sinonasal Diffuse Large B-Cell Lymphoma

OBJECTIVES/HYPOTHESIS

This study utilizes a large population national database to comprehensively analyze prognosticators and overall survival (OS) outcomes of varying treatment modalities in a large cohort of sinonasal diffuse large B-cell lymphoma (SN-DLBCL) patients.

STUDY DESIGN

Retrospective database study.

METHODS

The National Cancer Database was queried for all SN-DLBCL cases diagnosed from 2004 to 2015. Kaplan-Meier log-rank test determined differences in OS based on clinical covariates. Cox proportional-hazards analysis was used to determine clinical and sociodemographic covariates predictive of mortality.

RESULTS

A total of 2,073 SN-DLBCL patients were included, consisting of 48% female with a mean age of 66.0 ± 16.2 years. Overall, 82% of patients were Caucasian, 74% had early-stage disease, and 49% had primary tumors in the paranasal sinuses. Early-stage patients were more likely to receive multi-agent chemoradiotherapy compared to multi-agent chemotherapy alone (P < .001). Multivariable Cox proportional-hazards analysis revealed chemoradiotherapy to confer significantly greater OS improvements than chemotherapy alone (hazard ratio [HR]: 0.61; P < .001). However, subset analysis of late-stage patients demonstrated no significant differences in OS between these treatment modalities (P = .245). On multivariable analysis of chemotherapy patients treated post-2012, immunotherapy (HR = 0.51; P = .024) demonstrated significant OS benefits. However, subset analysis showed no significant advantage in OS with administering immunotherapy for late-stage patients (P = .326). Lastly, for all patients treated post-2012, those receiving immunotherapy had significantly improved OS compared to those not receiving immunotherapy (P < .001).

CONCLUSIONS

Treatment protocol selection differs between early- and late-stage SN-DLBCL patients. Early-stage patients receiving chemotherapy may benefit from immunotherapy as part of their treatment paradigm.

LEVEL OF EVIDENCE

III Laryngoscope, 2021.

Nasopharyngeal B-cell lymphoma with pan-hypopituitarism and oculomotor nerve palsy: a case report and review of the literature

BACKGROUND

Primary nasopharyngeal lymphoma (NPL) is a very rare tumor of Waldeyer ring (WR) lymphoid tissue. It is challenging to differentiate lymphoma infiltration of pituitary from a pituitary adenoma, meningioma infiltration, and other sellar lesions to plan a suitable treatment strategy. We presented for the first time a unique case of NPL with an unusual presentation of oculomotor nerve palsy associated with pan-pituitary involvement in a diabetic patient.

CASE PRESENTATION

A 64-year old diabetic woman with no previous history of malignancy presented with intermittent diplopia for about the last nine months. Severe headache, left eye ptosis and hypoglycemic episodes were added to her symptoms after a while. Further complaints include generalized weakness, loss of appetite, generalized musculoskeletal pain, and 6-7 kg weight loss within six months. Her family history was unremarkable. Physical examinations of eyes indicated left eye 3rd, 4th, and 6th nerve palsy. But, she was not anisocoric, and the pupillary reflexes were normal on both eyes. No lymphadenopathy, organomegaly and other abnormalities were found. Magnetic resonance imaging (MRI) showed a heterogeneous enhancement in the seller and suprasellar regions, enlargement of the stalk, parasellar dural enhancement and thickening of the sphenoid sinus without bone erosion. Also, both cavernous sinuses were infiltrated and both internal carotid arteries were encased by the neoplastic lesion. It suggested an infiltrative neoplastic lesion which compressed the cranial nerves. Pituitary hormone levels assessment indicated a pan-hypopituitarism. Following nasopharyngeal mucosal biopsy, the immunohistochemistry (IHC) findings revealed a low-grade non-Hodgkin's B-cell lymphoma. Systemic workup, including cerebrospinal fluid (CSF) studies, bone marrow aspiration, chest and abdominopelvic high-resolution computed tomography (HRCT) indicated no other involvement by the lymphoma. After chemotherapy courses, central adrenal insufficiency, partial central diabetes incipidious (CDI) and central hypothyroidism have been resolved. To our best knowledge, we found 17 cases of NPL with cranial nerve palsy, 1 case of NPL with pan-hypopituitarism and no NPL case with both cranial nerve palsy and pituitary dysfunction.

CONCLUSIONS

The incidence of cranial neuropathy in patients with diabetes should not merely be attributed to diabetic neuropathy without further evaluation.

Nasal Lymphoma Presenting With Contralateral Proptosis and Vision Changes: A Case Report and Literature Review

Non-Hodgkin lymphoma (NHL) is a hematological malignancy that can sometimes originate from the nasal cavities and paranasal sinuses. Patients who present with these tumors typically report sinonasal symptoms. However, a diagnostic challenge can arise when a patient’s primary complaints include unique complex symptoms limited to the contralateral side of the tumor. This report describes the case of an 83-year-old man who presented to our center with a left-sided mass and right-sided proptosis with vision loss. After a nasal biopsy was taken, the patient was referred to the ophthalmology department to diagnose the cause of his ocular symptoms, which were not believed to be related to the mass. When biopsy results later returned as diffuse large B-cell lymphoma (DLBCL), an emergent repeat biopsy following lymphoma protocol was performed to confirm the diagnosis. A CT scan of the head and orbits showed generalized enlargement of the right optic nerve and extraocular muscles, and a positron emission tomography (PET) scan showed increased 18F-fluorodeoxyglucose (FDG) uptake in the right ethmoid sinus and orbit. The left-sided mass and right-sided symptoms resolved simultaneously with chemotherapy. This is the first documented case of a sinonasal mass causing ocular symptoms exclusively on the contralateral side. The presented diagnostic challenge highlights the importance of thorough investigations.

Nasopharyngeal Lymphoma: A 22-Year Review of 35 Cases

Nasopharyngeal (NP) lymphoma is a rare primary malignancy of the head and neck and represents a minority of malignancies originating from the nasopharynx. For this reason, there are limited data regarding epidemiologic and treatment outcomes. This is a retrospective review of patients diagnosed with NP lymphoma from 1995 to 2017 at a tertiary medical center. The patients’ demographic data, clinical presentations, treatment modalities, Epstein–Barr virus (EBV)-encoded small RNA (EBER) staining, and outcomes were investigated. We considered a total of 35 patients, including 20 males and 15 females, diagnosed with NP lymphoma. The age ranged from 17 to 88 years (mean = 59.6). The common presentations were nasal obstruction, epistaxis, and neck mass. In our study, the most common pathological diagnosis of NP lymphoma was diffuse large B cell lymphoma (DLBCL) (n = 17), followed by NK/T cell lymphoma (NKTCL) (n = 9). Other pathologic diagnoses included extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALToma), small lymphocytic lymphoma, mantle cell lymphoma. There were 13 cases showing EBER positivity, including 7 cases of NKTCL, 5 cases of DLBCL, and 1 case of post-transplant lymphoproliferative disorder (PTLD). Most patients received chemotherapy alone, while some patients received both chemotherapy and radiotherapy. Seven patients had local recurrence, and fewer than half of the patients (n = 16) were alive at the time of the study (mean follow-up duration: 54.4 months). The five-year overall survival was 50.4%. NP lymphoma is very rare, and the most common pathologic type is DLBCL. EBER positivity is found in both NKTCL and DLBCL. Identifying more effective therapeutic agents is extremely important to improve patients’ survival.

Primary nasal diffuse large B-cell lymphoma with synchronous pulmonary involvement: A case report

RATIONALE

Diffuse large B-cell lymphoma (DLBCL) is the most commonly occurring type of non-Hodgkin's lymphoma, which may be found at various extranodal sites. The nose is not a common site for DLBCL as compared with natural killer/T-cell lymphoma, and synchronous pulmonary involvement is even rarer. We report a case of primary nasal DLBCL who presented with a mass in the left lower lobe, mimicking primary lung carcinoma.

PATIENT CONCERNS

A 62-year-old Chinese female visited the Ear-Nose-Throat Department of our hospital with nasal congestion and rhinorrhea for 2 months.

DIAGNOSIS

Computed tomography scan revealed a mass with soft tissue density in the left vestibule and nasal cavity. Histopathological examination revealed a large number of lymphoma cells, and immunohistochemistry confirmed the diagnosis of DLBCL.

INTERVENTIONS

The patient was treated with 6 cycles of R-CHOP (cyclophosphamide, adriamycin, vincristine, prednisone, and rituximab).

OUTCOMES

The treatment was well tolerated and led to complete remission for the patient. There was no sign of relapse over the 3-year close follow-up LESSONS:: DLBCL can be present at various extranodal sites and clinicians irrespective of their specialty must be vigilant for the synchronous mode of presentation of such lesions. Immunohistochemical techniques play a vital role in the diagnosis, because clinical characteristics may be misleading.

Epidemiologic, prognostic, and treatment factors in sinonasal diffuse large B -cell lymphoma

OBJECTIVES

To further characterize the epidemiology, prognostic disease-specific factors, and treatment outcomes-including newly available chemotherapy data-for patients with sinonasal diffuse large B-cell lymphoma (DLBCL).

METHODS

The Surveillance, Epidemiology, and End Results registry was queried from 1973 to 2015 for patients with DLBCL of the nasal cavity and paranasal sinuses. Demographic and disease parameters were collected. Prognostic disease-specific survival and overall survival factors were evaluated with univariate Kaplan-Meier analysis. Significant variables were analyzed with multivariate Cox regression analysis.

RESULTS

A total of 1,273 cases of DLBCL of the sinonasal tract were identified. Significant differences in age of diagnosis between men (65.3) and women (71.1) existed (P < .01). Most common primary sites of DLBCL were maxillary sinus (36.1%) and nasal cavity (34.5%), with nasal cavity more common among Asian/Pacific Islands (43.4%) and maxillary sinus more common for Caucasians (36.3%) and African Americans (42.1%). Overall survival was 70% at 2 years, 54% at 5 years, and 38% at 10 years. Disease-specific survival was 81%, 73%, and 67%, respectively. Chemotherapy (hazard ratio [HR]: 0.551; P < .001) and radiation therapy (HR: 0.818; P = .012) were associated with improved prognosis, whereas higher Ann Arbor stage worsened prognosis (HR: 1.21; P < .001). Surgical intervention did not significantly impact survival.

CONCLUSION

This is the first study to include chemoradiation therapy in population-based analysis of sinonasal DLBCL. Chemotherapy and radiation therapy use significantly improve survival in these patients, whereas Ann Arbor staging is significantly associated with poorer outcomes. The mainstay of treatment for DLBCL should remain combination chemoradiation.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:1259-1264, 2019.

Oropharyngeal lymphoma: A US population based analysis

OBJECTIVES

To describe the epidemiology and analyze factors determinant of survival in patients with oropharyngeal lymphoma, using the Surveillance Epidemiology and End Results (SEER) database.

METHODS

2504 patients with oropharyngeal lymphoma were identified using the most recent SEER database entry from 1976 to 2016. Demographic information, Ann Arbor stage, tumor histopathology and location were collected. Multivariate analysis was used to analyze patient and tumor characteristics associated with survival.

RESULTS

The mean age of the patients studied was 60.5years, 58.4% of the subjects were male and 81% were white. Diffuse large B cell lymphoma (DLBCL) was the most common histologic subtype involving 56.9% of cases. The most common subsite of origin was the tonsil, with 71% of lymphomas originating from there. The association of survival with stage, age, tumor location, presence of B symptoms, tumor pathology, gender and race was analyzed using multivariate regression. Decreased survival was significantly associated with patient age p<0.0001, Ann Arbor staging p=0.005, the presence of B symptoms p=0.003 and tumor histopathology (T cell tumors) p=0.01. Patients with tumors originating from the soft palate were significantly more likely to die asa result of their disease p=0.03.

CONCLUSION

Oropharyngeal lymphoma most commonly originates from the tonsil. DLBCL is the most common subtype and has a good prognosis. The presence of B symptoms, tumors originating from the soft palate and patients with T cell tumors have the worst prognosis. This information can potentially be of great utility to the head and neck surgeon discussing prognosis with patients suffering from oropharyngeal lymphoma.

Epidemiology of Nasopharyngeal Lymphoma in the United States: A Population-Based Analysis of 1119 Cases

Objectives To describe the incidence and determinants of survival of patients with nasopharyngeal lymphoma (NPL) between 1973 and 2012 using the Surveillance, Epidemiology, and End Results (SEER) database. Study Design Retrospective cohort study using a national database. Methods The SEER registry was used to calculate survival trends for patients with NPL between 1973 and 2012. Patient data were then analyzed with respect to histopathology, age, sex, race, histologic subtype, Ann Arbor stage, and whether radiation therapy was given. Overall survival (OS) and disease-specific survival (DSS) were calculated. Results A total of 1119 cases of NPL were identified. The cohort was composed of 58.8% males. The mean age at diagnosis was 59.3 years. The median OS was 8.2 years. B-cell non-Hodgkin's lymphomas (NHLs) accounted for most cases (77.5%), with natural killer (NK)/T-cell lymphomas comprising 6.0% of cases. A total of 41.5% patients received radiation therapy. OS at 2, 5, and 10 years was 70%, 57%, and 45%, respectively. On multivariate analysis, advanced age and NK/T-cell NHL histologic subtype were associated with worse OS and DSS, while radiation therapy was associated with improved OS and DSS (all P < .05). Conclusion With the exception of NK/T-cell NHL subtypes, NPL is associated with a fair prognosis, with younger age, low Ann Arbor stage, and radiation therapy being independent positive prognosticators for survival.

Natural Killer T-Cell Lymphoma of the Tongue

Lymphoma, which represents about 5.4% of all neoplasms and, more significantly, 19% to 28% of malignant neoplasms, is the most common nonepithelial malignancy of the head and neck area in Koreans. Natural killer T-cell (NK/T-cell) lymphoma is a lymphoma of putative natural killer cell lineage. NK/T-cell neoplasms are generally rare, but they are more common in people of East Asian, Mexican, or South American descent. These neoplasms are highly aggressive and show a strong association with Epstein-Barr virus. The preferential site of extranodal NK/T-cell lymphoma is the nasal cavity, and there has been no report of NK/T-cell lymphoma developing from the tongue. We encountered a rare case of NK/T-cell lymphoma of the tongue, which we report with a review of the literature.

T-cell lymphoma in the nasal cavity of a Brown Swiss heifer

Background

Tumours of the upper respiratory tract are relatively common in cattle, but to our knowledge, there have been no reports of lymphoma of the nasal cavity. This case report describes the findings in a 22-month-old Brown Swiss heifer with T-cell lymphoma of the nasal cavity.

Case presentation

The main clinical findings were lacrimation and swelling of the head above and below the right eye, mild exophthalmos, third eyelid prolapse, purulent ocular discharge and congestion of scleral blood vessels. An endoscope could only be introduced a few centimetres into the right nasal cavity because of an obstructing mass in the nasal passage. Radiographs showed a mass in the right nasal cavity and maxillary sinus. A tentative diagnosis of neoplasia of the right nasal cavity was made and the heifer was euthanased and necropsied. A firm, tan mass measuring 10 by 13 by 15 cm in the right half of the head occupied the entire right nasal cavity. A final diagnosis of high-grade, malignant, small-sized T-cell lymphoma was made based on histological and immunohistochemical evaluation. A distinction between αβ T-cell or γδ T-cell lymphoma was not made.

Conclusions

This report on T-cell lymphoma in the nasal cavity of a cow suggests that nasal lymphoma should be included in the list of differential diagnosis of conditions associated with dyspnoea and stertorous breathing in cattle.

Feline upper respiratory tract lymphoma: site, cyto-histology, phenotype, FeLV expression, and prognosis

Lymphoma is the most common feline upper respiratory tract (URT) tumor. Primary nasal and nasopharyngeal lymphomas have been evaluated as distinct pathological entities; however, data on their differing clinical behavior are missing. A total of 164 endoscopic- guided URT pinch biopsies were formalin fixed and routinely processed. Imprint cytological specimens were stained with May Grünwald-Giemsa. Immunohistochemistry for anti-CD20, CD3, FeLVp27, and FeLVgp70 was performed. Prognostic significance of clinicopathological variables was investigated by univariate and multivariate analysis. Lymphoma was diagnosed in 39 cats (24%). Most cats with lymphoma were domestic shorthair (32 [82%]), were male (F/M = 0.56), and had a mean age of 10.3 years (range, 1-16 years). Lymphomas were primary nasal in 26 cats (67%), nasopharyngeal in 6 (15%), and in both locations (combined lymphomas) in 7 cats (18%). Neoplastic growth pattern was diffuse in 35 cases (90%) and nodular in 4 (10%). Epitheliotropism was observed in 10 cases (26%). Tumor cells were large in 15 cases, were small and medium in 11 cases each, and 2 had mixed cell size. Submucosal lymphoplasmacytic inflammation was observed in 23 cases (59%). Cytology was diagnostic for lymphoma in 12 of 25 cases (48%). A B-cell origin prevailed (34 [87%]). Feline leukemia virus (FeLV) p27 or gp70 antigen was detected in 21 lymphomas (54%). URT lymphomas were aggressive, with survival varying from 0 to 301 days (mean, 53 days). Epitheliotropism in 8 B-cell lymphomas (80%) and in 2 T-cell lymphomas (20%) correlated with prolonged survival. Age younger or older than 10 years had a negative prognostic value. Lymphoplasmacytic inflammation and FeLV infection may represent favoring factors for URT lymphoma development.

Clinical behavior and treatment outcome of primary nasal diffuse large B-cell lymphoma

BACKGROUND

Nasal diffuse large B-cell lymphoma (DLBCL) is rare. The objective of this study was to evaluate the clinical features and treatment outcomes of patients with nasal DLBCL.

METHODS

Twenty-five patients were included in the study. All patients received combination chemotherapy with or without radiotherapy.

RESULTS

Patients with nasal DLBCL usually were older and were predominantly men with early stage disease, low frequency of B symptoms and elevated lactate dehydrogenase (LDH), good performance status, and a low-risk international prognostic index (IPI) score. The overall response rate after initial treatment was 76%, the 3-year overall survival (OS) rate for the whole group was 44%, and the median OS was 35 months. Performance status and IPI were significant prognostic factors for OS. For patients with IPI scores of 0 or 1, the 3-year OS rate was 54%, and the median OS was 52 months compared with 17% and 11 months, respectively, for patients with IPI scores of 2 or 3 (P = .033). The prognosis for patients who achieved a complete response (CR) was significantly better than that for patients who did not achieve a CR. Extranodal spread was the primary pattern of failure.

CONCLUSIONS

The current results indicated that primary nasal DLBCL appears to have distinct clinical features; its poor outcome and propensity for extranodal failure illustrate the need for innovative therapies.

[Non-Hodgkin lymphoma of the nasopharynx: a report of four cases]

We report four cases of non-Hodgkin lymphoma involving the nasopharynx. Clinical, radiological, histological and treatment modalities are described. The four patients were male and aged 20, 42, 71 and 77 years. The symptoms were nasal obstruction with epistaxis in three cases and a cervical node in the fourth case. The histological type was a non-Hodgkin lymphoma of phenotype B with large cells CD20+ in the four cases. The treatment consisted in radiotherapy and chemotherapy.

Primary Nasopharyngeal non-Hodgkin lymphomas: a retrospective review of 26 Moroccan patients

Background

Nasopharyngeal non-Hodgkin lymphomas (NNHL) are extremely rare. In this study, we will report the progress achieved in the management of this disease in our institute.

Methods

We retrospectively reviewed the records of 26 patients having primary NNHL who were managed between January 1997 and December 2008, to evaluate and compare their clinical characteristics and treatment outcome. Clinical variables, including age, sex, stage, and treatment modality, were assessed. Disease free survival and overall survival were measured. Survival curves were constructed using the KaplanMeier method. The log-rank test was used to compare them.

Results

Median age of our patients was 52.7 years. Nasal obstruction, nasal discharge and epistaxis were the frequent symptoms in NNHL patients. Histology of NNHL were mainly large B-cell and follicular lymphoma. Four patients (15.4%) were at stage I, 15 (57.6%) at stage II, and 7 (27%) were at stage III/IV. The patients were treated with chemotherapy alone (27%) or chemotherapy plus radiotherapy (73%). At early stage (stage I/II), the patients were managed with chemo-radiotherapy. When the whole treatment was completed, 18 patients (69.2%) achieved complete response and remained disease free. After 25.9 months median follow-up, overall survival at 1 year was 87% and disease free survival at 1 year was 71%. The difference in term of overall and disease free survival between stage I, II, III and IV was significant (Log rank test: p = 0.02 for overall survival and p = 0.01 for disease free survival).

Conclusion

From our study, we conclude that histological characteristics, principle of treatment and outcome of primary NNHL patients are particular and more studies have to be directed.

Lack of Correlation Between P-glycoprotein and Chemotherapy Resistance in Nasal NK/T-cell Lymphomas

Thirty patients with nasal natural killer (NK)/T-cell lymphoma, who underwent systemic chemotherapy with or without involved-field radiotherapy between 1993 and 1998, were retrospectively reviewed to determine the clinical significance of P-glycoprotein immunohistochemically identified in tumor specimens. Eighty percent of previously untreated patients expressed P-glycoprotein. According to P-glycoprotein immunoreactivity, all patients with nasal NK/T-cell lymphoma were divided into 2 groups; (a) P-glycoprotein-negative group (N = 6) and (b) P-glycoprotein-positive group (N = 24). There was no significant difference in clinical profiles between both groups. Regardless of the P-glycoprotein expressions, Epstein-Barr virus genomes were almost identically detected in patients of the 2 groups. Contrary to our expectations, however, P-glycoprotein expressions were not found to be a strong predictor of chemotherapy resistance. Although 2 (33%) of 6 P-glycoprotein-negative patients and 10 (42%) of the 24 P-glycoprotein-positive patients showed a favorable response to systemic chemotherapy, 4 (67%) of 6 P-glycoprotein-negative patients did not achieve complete response (CR) to chemotherapy, which led to an early death, whereas 4 (17%) of the 24 P-glycoprotein-positive patients achieved CR to chemotherapy despite positive P-glycoprotein immunoreactivity. Overall, there were no significant differences in either CR rate or the response rate of patients in the two groups. Overall 5-year actuarial survival and disease-free survival for all patients were 44% and 47%, respectively, but no differences in survival rates were observed between 2 groups. (5-year actuarial survival rate: 33% for the P-glycoprotein-negative, 50% for the P-glycoprotein-positive) (P = 0.7093, log-rank). On univariate and multivariate analyses, P-glycoprotein expressions by immunohistochemical study were not found to be an important prognostic factor. Given these observations, we conclude that the molecular mechanisms of resistance to chemotherapy in nasal NK/T-cell lymphoma patients are not entirely dependent on P-glycoprotein, and that other complex mechanisms of drug action and resistance may be likely to be involved.

The value of [(18)F]fluorodeoxyglucose positron emission tomography/computed tomography in extranodal natural killer/T-cell lymphoma

PURPOSE

To our knowledge, there are no published data pertinent to the use of [(18F)]fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) in patients with natural killer (NK)/T-cell lymphoma. The purpose of this study was to assess the value of FDG PET/CT in this aggressive type of non-Hodgkin lymphoma.

PATIENTS AND METHODS

All patients with NK/T-cell lymphoma referred for FDG PET/CT at our institution from July 2001 to July 2006 were retrospectively studied. PET/CT examinations were blindly reviewed by 2 experienced readers. The results were compared with the status of the disease, which was determined after evaluation of biopsy, laboratory, clinical and conventional imaging examination, and follow-up results. PET/CT results were thereby classified as true-positive, true-negative, false-positive, or false-negative. The degree of FDG uptake in the positive lesions was semiquantified using maximum standard uptake value (SUV(max)).

RESULTS

Twenty-one PET/CT examinations were performed in 10 patients with NK/T-cell lymphoma. For nasal disease, PET/CT was true-positive in 5 cases, true-negative in 15 cases, and positive but unconfirmed in 1 case. For extranasal disease, PET/CT was true-positive in 3 cases, true-negative in 16 cases, and false-negative in 2 cases. The mean SUV(max) in PET-positive lesions in nasal cavities or paranasal sinuses was 16 gm/mL (range, 5-25 gm/mL; median, 19.3 gm/mL). In extranasal disease, the mean SUV(max) was 10.9 gm/mL (range, 4.6-34.1 gm/mL; median, 5.6 gm/mL).

CONCLUSION

Viable NK/T-cell lymphoma is intensely FDG hypermetabolic. PET/CT appears to be sensitive for the detection of disease in the nasopharynx and, to a lesser extent, in extranasal sites.

Nasal and nasopharyngeal lymphoma in cats: 50 cases (1989-2005)

Lymphoma is the most common nasal cavity tumor in cats, yet few reports specifically address the anatomic, immunohistologic, and cytologic features of this neoplasm. Fifty cats were diagnosed with lymphoma at necropsy, via biopsy or by cytology alone. Ten cats displayed multiorgan involvement, and in 2 of these the involvement was limited to the cerebellum and frontal cortex, respectively. Of the tumors, 41 of 50 (82%) were classified as nasal lymphoma, 5 of 50 (10%) were classified as nasopharyngeal lymphoma, and 4 of 50 (8%) involved both nasal and nasopharyngeal tissue. Histologically, all were considered diffuse lymphoid neoplasms and no cats displayed features of follicular lymphoma. Of the 44 cases available for slide review by the pathologist, 40 of 44 (91%) were classified as immunoblastic lymphoma, 2 of 44 (5%) as diffuse large cell, and 1 as diffuse mixed; 1 was unclassified. Of the 45 cats for which immunohistochemical stains were available, 32 were uniformly positive for CD79a, 7 were uniformly CD3 positive, and 6 had a mixed population of CD79a and CD3 cells. Epithelioptropism was exhibited in 4 of 5 (80%) cats in which there was sufficient epithelium present for evaluation. Of those 4, 3 were B-cell and 1 was a granulated T-cell lymphoma. In the 21 cats which nasal cytology was performed, 15 were cytologically diagnosed with lymphoma; the diagnoses in the remaining five cats were inflammatory (n = 4), normal lymphoid tissue (n = 1), or nondiagnostic (n = 1). The most common biochemical abnormalities were panhyperproteinemia in 26/46 (57%) of cats and hypocholesterolemia in 11/46 (24%) of cats.

Clinical significance of cyclooxygenase-2 expression in extranodal natural killer (NK)/T-cell lymphoma, nasal type

PURPOSE

To determine whether there are any differences in therapeutic response, patterns of systemic recurrence, and prognosis of patients with extranodal natural killer (NK)/T-cell lymphoma, nasal type, by the cyclooxygenase-2 (COX-2) expression.

PATIENTS AND METHODS

Thirty-four patients with Ann Arbor Stage I and II extranodal NK/T-cell lymphoma who underwent chemotherapy or radiotherapy, or both, were retrospectively reviewed. These patients were divided into two groups according to their immunohistochemical staining for COX-2 expressions: a COX-2-negative group (n = 10 patients) and a COX-2-positive group (n = 24 patients). The treatment response, patterns of treatment failure, and survival data for the patients were compared between the COX-2-positive and negative groups.

RESULTS

There was no significant difference in the clinical profiles between the COX-2-negative and COX-2-positive groups. All patients (100%) in the COX-2-negative group achieved complete response after initial treatment, whereas only 14 patients (58%) in the COX-2-positive group achieved complete response (p = 0.03). Compared with the patients in the COX-2-negative group, those in the COX-2-positive group had a significantly lower 2-year systemic recurrence-free survival rate (100% for the COX-2-negative group vs. 54% for the COX-2-positive group) (p = 0.02) and a decreased 5-year overall survival rate (70% for the COX-2-negative group vs. 32% for the COX-2-positive group) (p = 0.06).

CONCLUSION

Cyclooxygenase-2 expression can serve as a predictive factor for poor treatment response, higher systemic recurrence, and unfavorable prognosis in patients with extranodal NK/T-cell lymphoma, nasal type.

Outcome of patients with nasal natural killer (NK)/T-cell lymphoma treated with radiotherapy, with or without chemotherapy

BACKGROUND

This study reviews the outcome of patients with nasal natural killer (NK)/T-cell lymphoma treated at the Therapeutic Radiology Department, National Cancer Centre, Singapore, from 1997 to 2003.

METHODS

Twenty-one consecutive patients treated with radiotherapy, with or without chemotherapy, were retrospectively reviewed.

RESULTS

The median age was 44 years (range, 27-86 years). Thirteen patients had stage I disease, five had stage II disease, and three had stage IV disease. Immunophenotyping was CD 56+ in 18 patients. Median follow-up for patients still alive was 23.4 months (range, 8.9-78.5 months). A median dose of 50 Gy (range, 35-56 Gy) was delivered. Sixteen patients also received chemotherapy. Two-year overall survival was 52.8%. Five patients had rapidly progressive disease, with a median survival of 89 days from diagnosis. The other 16 patients had complete remission, after which four relapsed. There were two local relapses.

CONCLUSIONS

This disease often carries a poor prognosis, despite multimodality treatment. Radiotherapy may contribute to local control in some patients.

Natural killer-cell malignancies: diagnosis and treatment

Natural killer (NK)-cell malignancies are uncommon diseases. Previously known as polymorphic reticulosis or angiocentric T-cell lymphomas, they are classified by the World Health Organization as NK/T-cell lymphoma, nasal type and aggressive NK-cell leukemia. They are prevalent in Asia and South America, but exceptionally rare in western countries. Pathologically, NK-cell lymphomas show a polymorphic neoplastic infiltrate with an angioinvasive and angiodestructive pattern. Lymphoma cells are characteristically CD2+, CD56+ and cytoplasmic CD3epsilon+. T-cell receptor gene is germline, and clonal Epstein-Barr virus (EBV) infection is almost invariably. Clinically, they can be divided into nasal, non-nasal, and aggressive lymphoma/leukemia subtypes. Most nasal NK-cell lymphomas present with stage I/II disease, and frontline radiotherapy is the most important key to successful treatment. Many stage I/II patients treated with radiotherapy fail systemically, implying that concomitant chemotherapy may be needed. Chemotherapy is indicated for advanced nasal NK-cell lymphoma, and the non-nasal and aggressive subtypes. However, treatment results are unsatisfactory. High-dose chemotherapy with hematopoietic stem cell transplantation may be beneficial to selected patients. The International Prognostic Index and presentation EBV DNA load is of prognostic significance and may be useful in the stratification of patients for various treatment modalities.

Localised extranodal lymphoma of the head and neck: the Sheffield Lymphoma Group experience (1971-2000)

AIMS

Over the 30-year period from 1971-2000, 3750 cases of lymphoma were referred to the Sheffield Lymphoma Group for investigation and treatment. Of these, 580 were extranodal presentations and, of these, 190 (33%) were localised to the head and neck region. The aim of this lymphoma database review was to evaluate the patient characteristics and survival rates for these patients.

MATERIALS AND METHODS

The sample included 98 women and 92 men, with a median age at presentation of 65 years.

RESULTS

The most common site affected was tonsil (34%), followed by salivary glands (16%). Other common sites were the thyroid, orbit and nasopharynx. The most frequent presenting feature was a swelling or mass, with pain, dysphagia and nasal obstruction also comprising large groups. All cases were non-Hodgkin's lymphoma. Fifty-five cases were histological grade 1; 132 were grade 2. Diffuse large B cell was the most common histological subtype. The overall 5- and 10-year survival rates were 55% (95% CI 47-62) and 44%, (95% CI 36-53), respectively, with a median survival of 92 months (95% CI 56-128). Stage and grade were both found to influence survival.

CONCLUSION

This data concords with and extends information available from previous studies. More detail is now required on specific head and neck sites.

Primary nasal natural killer cell lymphoma: long-term treatment outcome and relationship with the International Prognostic Index

Nasal natural killer (NK) cell lymphoma is rare, so that its optimal therapy, long-term outcome, and prognostic factors are unclear. Data on 52 men and 15 women with well-characterized nasal NK cell lymphomas were analyzed retrospectively to define the impact of primary therapy on remission and long-term outcome and the validity of the International Prognostic Index (IPI). Most (84%) had stage I/II disease with an IPI score of 1 or less (52%). Seven patients received radiotherapy only; 47 patients received anthracycline-containing chemotherapy plus consolidation radiotherapy; and 12 patients received nonanthracycline-containing chemotherapy plus radiotherapy. The overall complete remission (CR) rate was 64.2%; the 20-year overall survival (OS) and disease-free survival (DFS) rates were 37.1% and 33.5%, respectively. Front-line radiotherapy was apparently better than chemotherapy for CR (100% versus 59%, P =.04) and OS (83.3% versus 32.0%, P =.03). Relapses occurred in 4 radiotherapy-treated (all local) and 14 chemotherapy-treated patients (9 local, 4 systemic). Among these, 5 late relapses (4 local, 1 systemic) occurred at 170 months (range, 92-348 months) from CR. The IPI score was of prognostic significance for the whole group (IPI <or= 1 superior to IPI >or= 2 for 20-year OS: 57.4% versus 27.6%, P = 0.012), as well as for patients treated with chemotherapy/radiotherapy (IPI <or= 1 superior to IPI >or= 2 for CR: 76.7% versus 35.7%, P =.017; and 10-year OS: 63.8% versus 26.8%, P =.003).

Natural killer cell neoplasms: a distinctive group of highly aggressive lymphomas/leukemias

Natural killer (NK) cell neoplasms, which include extranodal NK/T-cell lymphoma (nasal and extranasal) and aggressive NK cell leukemia, are generally rare, but they are more common in people of Oriental, Mexican and South American descent. These neoplasms are highly aggressive, and show a strong association with Epstein-Barr virus. Extranodal NK/T-cell lymphoma most commonly affects the nasal cavity and other mucosal sites of the upper aerodigestive tract. Patients present with nasal obstruction or midfacial destruction. Despite the early stage of disease at presentation, overall survival is poor. Patients with the extranasal form of the lymphoma often present with high-stage disease, commonly involving the skin, gastrointestinal tract, testis, and soft tissue, and the prognosis is even worse. Histologically, the lymphoma can show a broad cytologic spectrum, but apoptosis, necrosis, and angioinvasion are common. The most common immunophenotype is CD2(+), surface CD3(-), cytoplasmic CD3(+), CD56(+). Based on currently available data, treatment of nasal NK/T-cell lymphoma should consist of radiotherapy, with or without multiagent chemotherapy. More research is required to ascertain the role of high-dose chemotherapy with stem cell rescue and that of non-multidrug resistance-related chemotherapeutic agents. Aggressive NK cell leukemia affects younger patients, who present with poor general condition, fever, and disseminated disease; they often die within a short time from systemic disease or complications such as multi-organ failure. The peripheral blood and bone marrow show atypical large granular lymphocytes, which exhibit an immunophenotype similar to that of extranodal NK/T-cell lymphoma. Aggressive NK cell leukemia must be distinguished from T-cell large granular lymphocyte leukemia and indolent NK cell lymphoproliferative disorder, both of which are indolent.

Early stage nasal NK/T-cell lymphoma: clinical outcome, prognostic factors, and the effect of treatment modality

PURPOSE

To determine the clinical outcome, prognostic factors, and effect of adding combination chemotherapy to radiation therapy on disease control and survival in early stage nasal natural killer (NK)/T-cell lymphoma.

METHODS AND MATERIALS

A retrospective "intent to treat" analysis was carried out on 79 patients treated consecutively with curative intent between 1977 and June 2001. They all had early stage (Ann Arbor Stage I(E): 63, II(E):16) nasal NK/T-cell lymphoma. Sixty-one were planned for combined modality treatment (CMT); radiotherapy alone (RT) was intended for 18. Three to 6 cycles of anthracycline-containing regimens were aimed at for patients intended for CMT. Patients selected for RT were generally older or treated during the earlier part of the study period.

RESULTS

The overall complete response (CR) rate was 68.4% (54/79), of whom 44.4% (24/54) relapsed after 54.9 months median follow-up of the survivors. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 35.5% and 37.9%, respectively. On multivariate analysis, good performance status (Eastern Cooperative Oncology Group [ECOG] <2) was shown to be a significant favorable factor for DFS (p = 0.011), whereas good performance status (ECOG <2) and Ann Arbor Stage I(E) disease were shown to be significant favorable factors for OS (p = 0.001 and p = 0.013, respectively). The type of intended treatment was not a significant factor for DFS (5-year DFS CMT vs. RT = 35.8% vs. 30.5%, p = 0.795) or OS (5-year OS CMT vs. RT = 40.3% vs. 29.8%, p = 0.693) though only 2 of the 16 Stage II(E) patients were intended for RT alone. Resistance to treatment, especially to chemotherapy, was common. Of 61 patients intended to be given CMT, 31 showed disease progression while receiving chemotherapy, of whom 17 progressed locoregionally. Nine of the latter group were rendered CR by salvage radiotherapy.

CONCLUSIONS

The overall outcome in early stage nasal NK/T-cell lymphoma is poor. Performance status and Ann Arbor stage are significant factors influencing DFS and OS. The addition of anthracycline-containing chemotherapy to radiotherapy does not appear to confer any survival benefit in Stage I(E) patients. Therefore, radiation therapy remains the mainstay of treatment for this lymphoma type.

p53 Mutations in nasal natural killer/T-cell lymphoma from Mexico: association with large cell morphology and advanced disease

Nasal NK/T-cell lymphoma is a unique form of lymphoma highly associated with Epstein-Barr virus, and with a characteristic geographic distribution. Recently, we showed that p53 is overexpressed in a high percentage of nasal NK/T-cell lymphomas. The aim of this study was to analyze the status of the p53 gene, and correlate it with the expression of p53 protein and its downstream target, the cyclin-dependent kinase inhibitor p21, in a series of 25 cases of well-characterized nasal NK/T-cell lymphoma from Mexico. The highly conserved exons 5 to 8 of the p53 gene were amplified by polymerase chain reaction and screened for mutations by denaturing high-pressure liquid chromatography. Abnormal polymerase chain reaction products detected by denaturing high-pressure liquid chromatography and additional selected cases were sequenced. In addition, the incidence of loss of heterozygosity at the p53 locus was analyzed in 12 cases. Of the 25 patients, 17 were male and 8 female (M:F ratio, 2.1:1), with a median age of 43 years (range, 21 to 93 years). Morphologically, most of the cases were composed of a mixture of medium-sized cells and large transformed cells (21 cases), and four cases were composed exclusively of large transformed cells. Three different groups determined by p53 gene status and expression of p53 protein were identified: group 1 was p53 +/p53 mutated (five cases, all with p53 missense mutations). Morphologically, three of the five cases were composed of large cells. All five cases revealed overexpression of p53 in the majority of the tumor cells with a mean of 86%. Unexpectedly, three of these cases also showed overexpression of p21. Four of the five patients presented with clinical stage IVB and died with disease. Group 2 was p53+/p53 wild-type (10 cases). Histologically, nine cases were of the mixed type, and one of the large cell type. The percentage of p53 overexpressing cells was lower than in the previous group with a mean of 23%. p21 was positive in 7 of the 10 cases. Six patients in this group presented with clinical stages I to II and four patients with advanced disease (stage III and IV). Five patients are alive 12 to 120 months later (mean, 24 months), three with no evidence of disease. Group 3 was p53-/p53 wild-type (10 cases). All cases showed mixed cell morphology. p21 was positive in 5 of 10 cases. Four patients presented with clinical stage I to II and six patients with advanced disease. Four patients are alive with no evidence of disease 9 to 60 months later (mean, 10 months). Overall, p53 mutations were present in 24% (5 of 21) of the evaluable cases, all of them overexpressing p53 in the majority of tumor cells. Cases with p53 mutations were associated with large cell morphology (P = 0.0162) and presented more often with advanced stage disease. Loss of heterozygosity at chromosome 17p was found only in 2 of the 12 (17%) cases investigated, both cases showed p53 mutations of the remaining allele. P21 overexpression (60% of cases) is frequent in nasal NK/T-cell lymphoma and seems to be independent of p53 gene status. The overexpression of p53 and p21, independent of p53 mutations, although as yet not clear, might be the result of Epstein-Barr virus infection, and warrants further investigation.