Clinicopathologic features and treatment outcome of mature T-cell and natural killer-cell lymphomas diagnosed according to the World Health Organization classification scheme: a single center experience of 10 years

A differential diagnosis method for systemic CAEBV and the prospect of EBV-related immune cell markers via flow cytometry

Chronic active Epstein-Barr virus (CAEBV) infection of the T-cell or Natural killer (NK)-cell type, systemic form (systemic CAEBV or sCAEBV) was defined by the WHO in 2017 as an EBV-related lymphoproliferative disorder and is listed as an EBV-positive T-cell and NK-cell proliferation. The clinical manifestations and prognoses are heterogeneous. This makes systemic CAEBV indistinguishable from other EBV-positive T-cell and NK-cell proliferations. Early diagnosis of systemic CAEBV and early hematopoietic stem cell transplantation can improve patient prognosis. At present, the diagnosis of systemic CAEBV relies mainly on age, clinical manifestations, and cell lineage, incurring missed diagnosis, misdiagnosis, long diagnosis time, and inability to identify high-risk systemic CAEBV early. The diagnostic methods for systemic CAEBV are complicated and lack systematic description. The recent development of diagnostic procedures, including molecular biological and immunological techniques such as flow cytometry, has provided us with the ability to better understand the proliferation of other EBV-positive T cells and NK cells, but there is no definitive review of their value in diagnosing systemic CAEBV. This article summarizes the recent progress in systemic CAEBV differential diagnosis and the prospects of flow cytometry.

Lymphoma-associated hemophagocytic lymphohistiocytosis (LA-HLH): a scoping review unveils clinical and diagnostic patterns of a lymphoma subgroup with poor prognosis

Hemophagocytic lymphohistiocytosis (HLH) is a severe hyperinflammatory syndrome driven by pathologic activation of cytotoxic T-lymphocytes and macrophages. Despite advances in diagnostics and management, adult patients with lymphoma-associated HLH (LA-HLH) harbor particularly poor prognosis and optimal treatment remains challenging. As systematic data on LA-HLH are scarce, we aimed to synthesize research evidence by thorough analysis of the published literature in PubMed (MEDLINE-database) within the context of a scoping review. Of 595 search results, 132 articles providing information on 542 patients were reviewed and analyzed. Median patient age was 60 years (range, 18-98) with male predominance (62.7%). B- and T-NHL were equally represented (45.6% and 45.2%), Hodgkin's lymphoma was reported in 8.9% of the cases. The majority of patients (91.6%) presented in Ann-Arbor-Stages III and IV, and bone marrow infiltration was observed in a significant proportion of patients (61.5%). Soluble CD25 levels were markedly elevated (median 10,000 U/ml), with levels beyond 10,000 U/ml indicating unfavorable prognosis for 30-day and overall survival. 66.8% of the patients died after median 5.1 months. LA-HLH remains a clinical challenge requiring specialized management. Timely diagnosis and appropriate lymphoma-specific treatment are of utmost importance to enhance patient outcomes.

A case of extranodal NK/T-cell lymphoma, nasal type, diagnosed by scraping cytology of the maxillary gingiva

Extranodal NK/T-cell lymphoma (ENKTL), nasal type, is often seen in the head and neck region, but there have been rare instances of this disease with initial presentation as a lesion in the oral mucosa. The patient, a woman in her seventh decade of life, presented with an ulcer in the maxillary gingiva, and scraping cytology and biopsy were performed. Cytological specimens showed solitary or small aggregating cells with marked atypia in a necrotic background. Tumor cells were detected that had various nuclear shapes and azure granules in the cytoplasm. Biopsy showed that the tumor cells had diffusely infiltrated or interdigitated into the subepithelium. Immunohistochemistry revealed that the tumor cells had T- and NK cell phenotypes and were Epstein-Barr virus-encoded small RNA (EBER) positive, leading to a diagnosis of ENKTL. Thus, when nonepithelial tumor cells in a necrotic background and prominent atypia are found, as in this case, it is important to carefully observe for azurophil granules in the cytoplasm for differential diagnosis considerations.

Hydroa Vacciniforme Lymphoproliferative Disorder in a Young Spanish Woman: An Infrequent Case With Fatal Outcome

ABSTRACT

Hydroa vacciniforme (HV) lymphoproliferative disorder is a rare NK/T-cell lymphoma mainly affecting children and with a clinical resemblance to HV, which is mostly reported in Latin American and some Asian countries. Overall, the mature T cell and NK-cell neoplasms are now grouped into 9 families based on diverse concepts: cell of origin/differentiation state, clinical scenario, disease localization, and cytomorphology. HV lymphoproliferative disorder is listed within the group of Ebstein Barr Virus-positive T-cell and NK-cell lymphoid proliferations and lymphomas of childhood according to the fifth edition of the World Health Organization Classification of mature lymphoid neoplasms. We report the extraordinary case of a 22-year-old white woman, native of Spain, first presented in 2016 when she started suffering from recurrent facial edema. Four years later, the disease progressed with lymph node spreading and a fatal outcome. Here, we describe the clinical and histological presentation of the lymphoma throughout its evolution. Cases like this can be difficult to classify posing a real challenge to clinicians and pathologists. So, it is vital to be aware of the rare presentation of this disease to be able to identify the clinical and histological picture to make a correct diagnosis and establish an early treatment.

Multimodality imaging evaluation of primary testicular extranodal natural killer/T-cell lymphoma: two case reports

Background

Extranodal natural killer/T-cell lymphoma (ENKTCL) is a distinct pathological entity and accounts for ~10% of T-cell lymphomas. The histological features of ENKTCL include angiodestruction and coagulative necrosis and the association with EBV infection. ENKTCL is typically aggressive and mainly affects the nasal cavity and nasopharyngeal region. However, some patients can present with distant nodal or extranodal involvement such as the Waldeyer ring, gastrointestinal tract, genitourinary organs, lung, thyroid, skin, and testes. Compared to ENKTCL of nasal type, primary testicular ENKTCL is very rare and has a lower age of onset and faster clinical progression, with tumor cell dissemination occurring early in the disease.

Case report

Case 1: A 23-year-old man presented with 1 month of right testicular pain and swelling. Enhancement CT revealed increased density in the right testis, uneven increased enhancement, discontinuity of the local envelope, and multiple trophoblastic vessels in the arterial phase. Testicular ENKTCL was diagnosed by post-operative pathology. The patient underwent a follow-up ¹⁸F-FDG PET/CT imaging 1 month later and found elevated metabolism in the bilateral nasal, left testicular, and right inguinal lymph nodes. Unfortunately, the patient received no further treatment and died 6 months later. Case 2: A 2-year-old male child presented with an enlarged right testicle, MRI showed a mass in the right epididymis and testicular area, which showed low signal on T1WI, high signal on T2WI and DWI, and low signal on ADC. Meanwhile, CT showed soft tissue in the lower lobe of the left lung and multiple high-density nodules of varying sizes in both lungs. Based on the post-operative pathology, the lesion was diagnosed with primary testicular ENKTCL. The pulmonary lesion was diagnosed as hemophagocytic lymphohistiocytosis associated with EBV infection. The child was given SMILE chemotherapy, but pancreatitis was induced during chemotherapy, then he died 5 months later after chemotherapy.

Conclusion

Primary testicular ENKTCL is very rare in clinical practice, typically presenting as a painful testicular mass, which can mimic inflammatory lesions and cause diagnostic challenges. ¹⁸F-FDG PET/CT plays pivotal roles in the diagnosis, staging, evaluation of treatment outcomes and prognosis evaluation in patients with testicular ENKTCL, and it is helpful to assist clinical practice to better formulate individualized treatment plans.

Genomic profiling identifies distinct genetic subtypes in extra-nodal natural killer/T-cell lymphoma

Extra-nodal NK/T-cell lymphoma, nasal type (ENKTCL) is a highly aggressive Epstein-Barr virus associated lymphoma, typically presenting in the nasal and paranasal areas. We assembled a large series of ENKTCL (n = 209) for comprehensive genomic analysis and correlative clinical study. The International Lymphoma Prognostic Index (IPI), site of disease, stage, lymphadenopathy, and hepatomegaly were associated with overall survival. Genetic analysis revealed frequent oncogenic activation of the JAK/STAT3 pathway and alterations in tumor suppressor genes (TSGs) and genes associated with epigenomic regulation. Integrated genomic analysis including recurrent mutations and genomic copy number alterations using consensus clustering identified seven distinct genetic clusters that were associated with different clinical outcomes, thus constituting previously unrecognized risk groups. The genetic profiles of ENTKCLs from Asian and Hispanic ethnic groups showed striking similarity, indicating shared pathogenetic mechanism and tumor evolution. Interestingly, we discovered a novel functional cooperation between activating STAT3 mutations and loss of the TSG, PRDM1, in promoting NK-cell growth and survival. This study provides a genetic roadmap for further analysis and facilitates investigation of actionable therapeutic opportunities in this aggressive lymphoma.

Rhino-Orbital-Cerebral Mycosis and Extranodal Natural Killer or/and T-Cell Lymphoma, Nasal Type

Background

Extranodal natural killer/T-cell lymphoma, nasal type is a syndrome of middle face destruction with an association to Epstein-Barr virus. Fungi have been recovered from the diseased tissue now and then but were often seen as a lymphoma-associated secondary infection. However, there are ENKTL-NT cases with the recoveries of fungi and complete recovery with antifungal therapy, which are quite similar to rhino-orbital-cerebral mycosis (ROCM) that often confuses the physicians.

Methods

We searched Medline for English-language manuscripts limited to “human” and “case reports,” “letters,” “reviews,” and “clinical conferences” from 1966 to 2022. We used MeSH terms “lymphoma, extranodal nk-t-cell” [MeSH Terms] or “lethal midline granuloma” [MeSH Terms], in combination with MeSH terms “microbiology” [subheading] or “microbiology” [all fields] or “fungi” [all fields] or “fungi” [MeSH Terms] for ENKTL-NT with infections. We used MeSH terms “Mycoses” in combination with “Nose” [Mesh] OR “Orbital Diseases” [Mesh] for rhino-orbital-cerebral fungal infections.

Results

We appraised 149 included articles and extracted references related to ENKTL-NT and/or ROCM. Themes and subcategories were subsequently derived. Our findings revealed that ROCM and ENKTL-NT are characterized by progressive and destructive ulcers in the midline face or rhino-orbital structures. ROCM is mainly caused by fungi in the order of Mucorales, and ENKTL-NT is usually associated with Epstein-Barr virus and sometimes fungi. Radiologically, both are characterized by non-specific features of sinusitis, soft tissue infection, and necrosis. Pathologically, ROCM and ENKTL-NT share the same characteristics of inflammation, necrosis, and granuloma. ROCM is characterized by the detection of fungi in tissue, while ENKTL-NT is typically positive for NK/T-cell markers and cytotoxic granule-associated proteins, proliferation, and vascular damage of angioinvasion, which could be incited by Mucor irregularis and Rhizopus arrhizus in patients and mice.

Conclusion

ENKTL-NT and ROCM share many similarities in clinical presentations, radiology, and histopathology, and might have the same etiology. This may explain why the two diseases are tangled together in the reported cases, and suggests the role that the fungi may play in the development of these ENKTL-NT/ROCM diseases. The reason why ENKTL-NT and ROCM are sometimes confused is that the main pathogens of ROCM, Mucor irregularis and Rhizopus arrhizus, are the fungal causative agents of ENKTL-NT.

Cellular Origins and Pathogenesis of Gastrointestinal NK- and T-Cell Lymphoproliferative Disorders

The intestinal immune system, which must ensure appropriate immune responses to both pathogens and commensal microflora, comprises innate lymphoid cells and various T-cell subsets, including intra-epithelial lymphocytes (IELs). An example of innate lymphoid cells is natural killer cells, which may be classified into tissue-resident, CD56bright NK-cells that serve a regulatory function and more mature, circulating CD56dim NK-cells with effector cytolytic properties. CD56bright NK-cells in the gastrointestinal tract give rise to indolent NK-cell enteropathy and lymphomatoid gastropathy, as well as the aggressive extranodal NK/T cell lymphoma, the latter following activation by EBV infection and neoplastic transformation. Conventional CD4+ TCRαβ+ and CD8αβ+ TCRαβ+ T-cells are located in the lamina propria and the intraepithelial compartment of intestinal mucosa as type 'a' IELs. They are the putative cells of origin for CD4+ and CD8+ indolent T-cell lymphoproliferative disorders of the gastrointestinal tract and intestinal T-cell lymphoma, NOS. In addition to such conventional T-cells, there are non-conventional T-cells in the intra-epithelial compartment that express CD8αα and innate lymphoid cells that lack TCRs. The central feature of type 'b' IELs is the expression of CD8αα homodimers, seen in monomorphic epitheliotropic intestinal T-cell lymphoma (MEITL), which primarily arises from both CD8αα+ TCRαβ+ and CD8αα+ TCRγδ+ IELs. EATL is the other epitheliotropic T-cell lymphoma in the GI tract, a subset of which arises from the expansion and reprograming of intracytoplasmic CD3+ innate lymphoid cells, driven by IL15 and mutations of the JAK-STAT pathway.

Extranodal nasal-type natural killer/T-cell lymphoma with nasal septal perforation

There are very few reports of extranodal nasal-type NKTL with septal perforation, as seen in our patient. In addition, extranodal nasal-type NKTL is often diagnosed as chronic inflammation on histopathological examination. Therefore, if nasal septal perforation does not improve with appropriate conservative treatment, clinicians should consider a malignant disease such as extranodal nasal-type NKTL.

Comparison of Chemotherapy Combined With Chidamide Versus Chemotherapy in the Frontline Treatment for Peripheral T-Cell Lymphoma

Background

Peripheral T-cell lymphoma (PTCL) is featured with a poor survival outcome. China has approved chidamide, an oral novel histone deacetylase inhibitor, for patients diagnosed with relapsed or refractory PTCL.

Objective

We compared the benefit of traditional chemotherapy alone and a combination of chidamide and traditional chemotherapy against newly diagnosed PTCL. Prognostic factors related to progression and survival in patients diagnosed with untreated PTCL were also investigated.

Methods

104 patients with newly diagnosed PTCL were enrolled and divided into chemotherapy (ChT) group and chemotherapy combined with chidamide (ChT+C) group. Survival curves were plotted by the Kaplan-Meier method. Univariate and multivariate analysis were conducted with Log-rank test and Cox’s proportional hazard regression. Subgroup analysis and interaction tests were conducted to evaluate factors associated with prognostic differences between ChT and ChT+C groups.

Results

Compared with patients in ChT group, those in ChT+C group had superior progression-free survival (PFS) (p=0.047). However, there was no significantly statistical difference observed between the two groups in overall survival (OS) (p=0.212). High IPI scores have a negative relationship with survival. Multivariate analysis revealed that the type of frontline treatment regimen is an independent factor associated with PFS of PTCL patients (p=0.045). In the subgroup of patients with high international prognostic index scores (3-5), the HR value for PFS comparing ChT with ChT+C was 4.675. A test of interaction between IPI and treatment showed statistical significance (p = 0.037), implying that the benefits of ChT+C are higher for patients with high IPI scores.

Conclusions

In summary, the combination of ChT and chidamide may provide a promising prospect for patients with newly diagnosed PTCL.

Epigenetic Silencing of Tumor Suppressor lncRNA NKILA: Implication on NF-κB Signaling in Non-Hodgkin’s Lymphoma

The long non-coding RNA (lncRNA) NKILA, localized to 20q13.31, is a negative regulator of NF-κB signaling implicated in carcinogenesis. As a CpG island is embedded in the promoter region of NKILA, it is hypothesized as a tumor suppressor lncRNA silenced by promoter DNA methylation in non-Hodgkin’s lymphoma (NHL). By pyrosequencing-verified methylation-specific PCR, NKILA methylation was detected in 1/10 (10%) NHL cell lines, but not in normal peripheral blood buffy coats or tonsils. NKILA methylation correlated with the repression of NKILA in cell lines. Hypomethylation treatment with 5-Aza-2′-deoxycytidine resulted in promoter demethylation and the re-expression of NKILA. In 102 NHL primary samples, NKILA was methylated in 29 (51.79%) diffuse large B-cell lymphoma (DLBCL) and 4 (20%) peripheral T-cell lymphoma cases, but unmethylated in all 26 mantle cell lymphoma cases. Mechanistically, the knockdown of NKILA resulted in promoting IkBα phosphorylation, associated with nucleus translocation of total p65 and phosphorylated p65 in SU-DHL-1 cells, hence constitutive NF-κB activation. Functionally, the knockdown of NKILA in SU-DHL-1 cells led to decreased cell death and increased cellular proliferation. Collectively, NKILA was a tumor suppressor lncRNA frequently hypermethylated in DLBCL. Promoter DNA methylation-mediated NKILA silencing resulted in increased cellular proliferation and decreased cell death via the repression of NF-κB signaling in NHL.

What Effect Does Epstein-Barr Virus Have on Extranodal Natural Killer/T-Cell Lymphoma Prognosis? A Review of 153 Reported Cases

The primary aim of this review is to identify the relationship between Epstein-Barr virus (EBV) and prognosis in extranodal natural killer/T-cell lymphoma (ENKTL). Additionally, a literature review of ENKTL was carried out. The investigators designed and implemented a 21-year literature review using the online databases PubMed and Google Scholar. The total number of cases analyzed was 153 (64 case reports; one comparative study; one systematic review). Information related to ENKTL from July 1999 to February 2021 was included in the study. Study variables included: patient demographics, tumor classification, screening modalities, tumor characteristics, symptomatology, treatment, and prognosis. The average age at diagnosis was 50.9 years (range: 4-90 years). Patients of Asian ethnicity were most commonly affected, and there was a 1.6:1 male to female ratio. ENKTL was most frequently detected in the head and neck region, and 53.1% of cases metastasized. Of all head and neck cases, the nose was the most affected location. Immunohistochemistry positivity included: EBV (32.0%), CD2 (96.6%), CD3ϵ (81.7%), CD43 (91.7%), CD56 (86.4%), Granzyme (97.1%), Perforin (90.9%), TIA-1 (97.8%), p53 (33.3%). The most frequently employed single treatment modality was chemotherapy alone, and 34.2% of patients expired within five years of diagnosis. The average follow-up period was 16.51 months (range: 0.25-66 months). EBV was significantly associated with metastatic ENKTL (χ² = 4.36; CV = 3.84; p = 0.037). We found no association between EBV and ENKTL prognosis (χ² = 17.2; CV = 21.0; p = 0.14).

Comparison of chidamide-contained treatment modalities versus chemotherapy in the second-line treatment for relapsed or refractory peripheral T-cell lymphoma

Peripheral T-cell lymphoma (PTCL) is characterized by an aggressive clinical behavior. Chidamide has been approved for the treatment of relapsed/refractory (R/R) PTCL in China. We compared the efficacy of chidamide-contained regimens with chemotherapy (ChT) in R/R PTCL. Based on the second-line treatments, patients were divided into three groups, including ChT, ChT combined with chidamide (chidamide + ChT) and chidamide combined with or without other targeted agents (targeted therapy) group. Chidamide + ChT group had a better progression-free survival (PFS) compared with targeted therapy group (p = 0.013), and showed a trend towards superior PFS compared with ChT group (p = 0.079). Among patients with high second-line International Prognostic Index (IPI) (3-5), chidamide+ChT group had a longer PFS than ChT group(p = 0.018), and PFS in targeted therapy group was not inferior to that in chidamide+ChT group (p = 0.200). Among patients younger than 60 years, chidamide+ChT group demonstrated a PFS benefit over targeted therapy group (p = 0.010). Among CD30-negative patients, PFS was superior in the chidamide+ChT group compared with ChT group (p < 0.001). Conversely, results observed above were absent in patients with low second-line IPI or patients older than 60 years or CD30-positive patients. Overall, the combination of chidamide and ChT may be an effective treatment strategy for R/R PTCL.

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

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

Primary cutaneous T-cell lymphomas other than Mycosis Fungoides and Sezary Syndrome - Part I: Clinical and histologic features and diagnosis

Primary cutaneous T-cell lymphomas (CTCLs) are defined as lymphomas with a T-cell phenotype that present in the skin without evidence of systemic or extracutaneous disease at initial presentation. CTCLs other than Mycosis Fungoides (MF) and Sézary syndrome (SS) account for approximately one-third of CTCLs and encompass a heterogenous group of non-Hodgkin lymphomas ranging from indolent lymphoproliferative disorders to aggressive malignancies with a poor prognosis. The spectrum of CTCLs continues to broaden as new provisional entities are classified. Given the morphologic and histologic overlap among CTCLs and other diagnoses, a thorough clinical history, physical evaluation, and clinicopathologic correlation are essential in the workup and diagnosis of these rare entities. This article will summarize the epidemiologic, clinical, pathologic, and diagnostic features of CTCLs other than MF and SS.

Extranodal NK/T cell lymphoma, nasal type: An updated overview

Extranodal NK/T-cell lymphoma, nasal type (ENKTCL-NT) is an aggressive malignancy associated with Epstein-Barr virus infection, with a geographic and racial predilection for some Asian and Latin American countries. ENKTCL-NT manifests as a necrotic process affecting nasal or upper aerodigestive structures and, rarely, extranasal sites such as skin, and the gastrointestinal tract. ENKTCL-NT was characterized by its poor prognosis irrespective of clinical stage and therapy. However, during the last two decades, advances in its clinicopathologic, genetic and molecular characterization have been achieved, as have changes in the chemotherapy regimens that, in combination with radiotherapy, are significantly improving the survival of these patients, especially in initial stages. For these reasons, we present an overview of the historical background of ENKTCL-NT along with an updated review of its potential etiological factors, clinicopathologic and molecular features, as well as its prognostic models, current treatment protocols, and future directions on potential promising therapeutic approaches.

Dynamic evaluation of the prognostic value of 18F-FDG PET/CT in extranodal NK/T-cell lymphoma, nasal type

Extranodal natural killer/T-cell lymphoma, nasal-type (ENKTL) is a type of rare and distinct entity of non-Hodgkin lymphoma with poor prognosis. It is important to evaluate the early treatment response accurately to decide further treatment strategy. ¹⁸F-FDG PET/CT plays an important role in response evaluation and prognostic prediction in some kinds of lymphomas. However, data available regarding patients with ENKTL are limited. Thus, in this prospective study, we analyzed the prognostic value of ¹⁸F-FDG PET/CT in ENKTL. Thirty-four patients with newly diagnosed ENKTL were enrolled in this phase 2 study (NCT02825147, July 7, 2016). The patients received pre-, mid-, and end-treatment ¹⁸F-FDG PET/CT scans. Deauville score (DS), maximal standardized uptake values (SUVmax), and the change in SUVmax (ΔSUVmax) were recorded for response assessment. The median follow-up period was 42.2 months. The 2-year overall survival (OS) and progression-free survival (PFS) were 82.4% and 73.5%, respectively. Univariate analysis revealed that Ann Arbor stage (P < 0.002), mid-treatment DS (P = 0.005), mid-SUVmax (P = 0.001), mid-∆SUVmax (P = 0.004), end-treatment DS (P < 0.001), and end-SUVmax (P = 0.014) were prognostic factors for OS. Ann Arbor stage (P = 0.001), mid-treatment DS (P = 0.008), mid-SUVmax (P = 0.029), mid-∆SUVmax (P < 0.001), and end-treatment DS (P =0.021) were of prognostic significance for PFS. Multivariate analysis showed that mid-SUVmax (P = 0.042) and DS at the middle (P = 0.050) and end (P = 0.044) of treatment were significant independent predictors of PFS. ¹⁸F-FDG PET/CT is useful for predicting the prognosis of ENKTL.

Weakly supervised deep learning for determining the prognostic value of 18F-FDG PET/CT in extranodal natural killer/T cell lymphoma, nasal type

Purpose

To develop a weakly supervised deep learning (WSDL) method that could utilize incomplete/missing survival data to predict the prognosis of extranodal natural killer/T cell lymphoma, nasal type (ENKTL) based on pretreatment ¹⁸F-FDG PET/CT results.

Methods

One hundred and sixty-seven patients with ENKTL who underwent pretreatment ¹⁸F-FDG PET/CT were retrospectively collected. Eighty-four patients were followed up for at least 2 years (training set = 64, test set = 20). A WSDL method was developed to enable the integration of the remaining 83 patients with incomplete/missing follow-up information in the training set. To test generalization, these data were derived from three types of scanners. Prediction similarity index (PSI) was derived from deep learning features of images. Its discriminative ability was calculated and compared with that of a conventional deep learning (CDL) method. Univariate and multivariate analyses helped explore the significance of PSI and clinical features.

Results

PSI achieved area under the curve scores of 0.9858 and 0.9946 (training set) and 0.8750 and 0.7344 (test set) in the prediction of progression-free survival (PFS) with the WSDL and CDL methods, respectively. PSI threshold of 1.0 could significantly differentiate the prognosis. In the test set, WSDL and CDL achieved prediction sensitivity, specificity, and accuracy of 87.50% and 62.50%, 83.33% and 83.33%, and 85.00% and 75.00%, respectively. Multivariate analysis confirmed PSI to be an independent significant predictor of PFS in both the methods.

Conclusion

The WSDL-based framework was more effective for extracting ¹⁸F-FDG PET/CT features and predicting the prognosis of ENKTL than the CDL method.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00259-021-05232-3.

Application of high-throughput gene sequencing in lymphoma

As a malignant tumor originating from the lymphoid hematopoietic tissues, lymphoma has an increased incidence in recent years and has ranked among the top ten malignant tumors in the world. But until now, due to the multiple pathological subtypes and the unclear molecular mechanism, it's still difficult to make rapid diagnosis and accurate prognosis assessment for lymphoma patients. Recently, the development of high-throughput gene sequencing technology has provided the possibility to solve these clinical problems. This technology has realized large-scale screening of specific markers for lymphoma at the molecular biology level, followed by discovery of prognostic indicators and biological targets for new drug research. In this paper, we summarize the results of large-scale high-throughput gene sequencing research, and introduce the genetic changes associated with occurrence and prognosis of lymphomas with different pathological subtypes, hoping to further promote the application of this technology in clinical research of lymphoma.

Comparison of Nasopharyngeal MR, 18 F-FDG PET/CT, and 18 F-FDG PET/MR for Local Detection of Natural Killer/T-Cell Lymphoma, Nasal Type

Objectives

The present study aims to compare the diagnostic efficacy of MR, ¹⁸F-FDG PET/CT, and ¹⁸F-FDG PET/MR for the local detection of early-stage extranodal natural killer/T-cell lymphoma, nasal type (ENKTL).

Patients and Methods

Thirty-six patients with histologically proven early-stage ENKTL were enrolled from a phase 2 study (Cohort A). Eight nasopharyngeal anatomical regions from each patient were imaged using ¹⁸F-FDG PET/CT and MR. A further nine patients were prospectively enrolled from a multicenter, phase 3 study; these patients underwent ¹⁸F-FDG PET/CT and PET/MR after a single ¹⁸F-FDG injection (Cohort B). Region-based sensitivity and specificity were calculated. The standardized uptake values (SUV) obtained from PET/CT and PET/MR were compared, and the relationship between the SUV and apparent diffusion coefficients (ADC) of PET/MR were analyzed.

Results

In Cohort A, of the 288 anatomic regions, 86 demonstrated lymphoma involvement. All lesions were detected by ¹⁸F-FDG PET/CT, while only 70 were detected by MR. ¹⁸F-FDG PET/CT exhibited a higher sensitivity than MR (100% vs. 81.4%, χ² = 17.641, P < 0.001) for local detection of malignancies. The specificity of ¹⁸F-FDG PET/CT and MR were 98.5 and 97.5%, respectively (χ² = 0.510, P = 0.475). The accuracy of ¹⁸F-FDG PET/CT was 99.0% and the accuracy of MR was 92.7% (χ² = 14.087, P < 0.001). In Cohort B, 72 anatomical regions were analyzed. PET/CT and PET/MR have a sensitivity of 100% and a specificity of 92.5%. The two methods were consistent (κ = 0.833, P < 0.001). There was a significant correlation between PET/MR SUVmax and PET/CT SUVmax (r = 0.711, P < 0.001), and SUVmean (r = 0.685, P < 0.001). No correlation was observed between the SUV and the ADC.

Conclusion

In early-stage ENKTL, nasopharyngeal MR showed a lower sensitivity and a similar specificity when compared with ¹⁸F-FDG PET/CT. PET/MR showed similar performance compared with PET/CT.

Epidemiology of Cutaneous T-Cell Lymphomas: A Systematic Review and Meta-Analysis of 16,953 Patients

Simple Summary

Cutaneous T-cell lymphomas (CTCL) are rare malignant diseases. In this study we have compared the cutaneous lymphoma registries of different countries, which included information on at least 100 patients. The frequencies of each CTCL subtype were compared within and between continents. We found that the registries differed importantly in terms of size and quality. Some rare CTCL subtypes, such as NK/T-cell lymphoma or subcutaneous panniculitis-like lymphomas, were more frequent in Asian countries, while others were evenly distributed. We discuss possible reasons for this and provide suggestions on how to build future CTCL registries.

Abstract

Cutaneous T-cell lymphomas (CTCL) are a heterogenous group of rare diseases. Many studies have reported on local epidemiology or geographic clustering, however we lack information from a global perspective. A systematic review and meta-analysis was conducted in Medline and the Cochrane Library based on a previously registered protocol and according to the preferred reporting of items for systematic reviews and meta-analyses (PRISMA). We selected publications that enrolled at least 100 patients with primary cutaneous lymphomas according to the current classifications. The relative frequencies (proportions) of subtypes were compared between studies and geographic regions in a meta-analysis. In total, 26 studies met our inclusion criteria, reporting on altogether 16,953 patients. Within primary cutaneous lymphomas, CTCL appeared to be 15% more frequent in Asian populations. Mycosis fungoides (MF) accounted for 62% of CTCL, with an important heterogeneity in frequencies between studies and continents. The proportion of Sézary syndrome (SS) was 3%, stable worldwide. Rare CTCL, such as NK/T-cell lymphoma or subcutaneous panniculitis-like lymphoma, were more frequent in Asian studies. This global meta-analysis of CTCL confirmed the predominance of CTCL among primary cutaneous lymphomas (83% on average) in the three analyzed continents, most of which were MF cases. It revealed the same proportions of SS across continents, and the heterogeneity of MF frequencies, suggesting the possible role of environmental factors in the pathophysiology of the latter. Registration number: CRD42020148295 (PROSPERO).

Baseline SUVmax of 18F-FDG PET-CT indicates prognosis of extranodal natural killer/T-cell lymphoma

To evaluate the prognostic value of the baseline SUVmax of F-FDG PET-CT in extranodal natural killer/T-cell lymphoma (NKTCL) patients.From January 2010 to December 2015, 141 extranodal NKTCL patients with staging F-FDG PET-CT scan were divided into two group based on SUVmax cutoff value obtained from operating characteristic (ROC) curves. All the patients received radiotherapy, chemotherapy or chemoradiation. Survival analysis was performed on the basis of SUVmax.The median baseline SUVmax of the tumors was 11.67 (range 2.6-34.6). The ROC curves showed that the optimal cutoff of the baseline SUVmax was 9.65. The patients were divided into two groups: low SUV group (SUVmax < 9.65) and high SUV group (SUVmax ≥ 9.65). Patients in high SUV group were more likely to have invasive disease outside the nasal cavity (P < .001), poorer ECOG scores (P = .012) and higher LDH levels (P = .034). The univariate survival analyses indicated that high SUVmax was a poor prognostic factor for overall survival (OS, P = .038), progression free survival (PFS, P = .006) and distant relapse free survival (DRFS, P = .001), but not for local recurrence free survival (LRFS, P > .05). These results were consistent with that of the survival analyses using the Kaplan-Meier method. The multivariate survival analyses showed that the baseline SUVmax was no longer a prognostic factor for OS (HR 1.99, 95% CI 0.81-4.88, P = .135), but it still indicated worse PFS (HR 2.6, 95% CI 1.24-5.46, P = .012) and DRFS (HR 4.58, 95% CI 1.83-11.46, P = .001) independent of other variables.For extranodal NKTCL patients, a higher baseline SUVmax of F-FDG PET-CT was associated with more aggressive clinical features. An SUVmax ≥ 9.65 was an independent poor prognostic factor for DRFS and PFS. Thus, the baseline SUVmax may be a valuable tool to help identify patients with a high risk of disease progression.

Oncogenic Network and Hub Genes for Natural Killer/T-Cell Lymphoma Utilizing WGCNA

Natural killer (NK)/T-cell lymphoma (NKTCL) is a subtype of non-Hodgkin lymphoma with aggressive progression and poor prognosis. The molecular mechanisms of NKTCL have not been well-studied. Herein, we revealed the lymphoma-associated dysregulated genes and signaling pathways or biological processes in NKTCL. We characterized that the extracellular matrix (ECM) receptor interaction pathway and T-cell receptor signaling pathway were the main dysregulated pathways in NKTCL by Gene Ontology (GO) analysis and pathway enrichment analysis. By using weighted gene co-expression network analysis (WGCNA), the gene co-expression network of NKTCL (SRP049695) was constructed, and hub genes (LMO3, GRB14) were identified. In addition, another Gene Expression Omnibus (GEO) dataset (GSE69406) was used to validate these hub genes. Furthermore, these hub genes were identified and validated by survival analysis (GSE90597). These results provided novel insights into the pathogenesis of NKTCL. Of particular interest, LMO3 and GRB14 might be potential oncoproteins and biomarkers for the diagnosis and treatment of NKTCL.

Changing trends in lymphoid neoplasm distribution in South Korea: analysis of 8615 cases from a single institute, 1997-2016: An observational study

The purpose of this study was to evaluate changes in the proportion of lymphoid neoplasm subtypes in South Korea. A total of 8615 cases of lymphoid neoplasms diagnosed in 1997-2016 at Samsung Medical Center in South Korea were classified according to the 2008 World Health Organization system. The total number and proportion of lymphoid neoplasms were compared between these two decades, with data from nationwide studies, and with other countries. To evaluate changes in the proportion of subtypes, crude rate of each subtype per 100 lymphoma patients during each decade and age adjusted rate were calculated. There were 3024 patients with lymphoid neoplasm in 1997-2006, and 5591 in 2007-2016, which represents an average increase of 1.85 times over the 20-year study period. Crude rate and age adjusted rate were increased in Hodgkin's lymphoma and mature B cell lymphoma while precursor lymphoid neoplasms and mature T cell lymphoma were decreased. Among B cell neoplasms, age adjusted rate of plasma cell neoplasm, follicular lymphoma, mantle cell lymphoma increased while there was no significant change in extranodal marginal zone lymphoma and Burkitt lymphoma. The increase in follicular lymphoma was due to the increases in nodal follicular lymphoma of low grade and duodenal-type follicular lymphoma. These results are consistent with the dynamics of causative factors, including socioeconomic factors, in Korea.

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

BACKGROUND

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

PATIENTS AND METHODS

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

DISCUSSION

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

Prognostic significance of locally invaded sites and tissue types in patients with nasal extranodal natural-killer/T-cell lymphoma: a single-center retrospective analysis

Background:

Extranodal natural killer/T-cell lymphoma (ENKTL), nasal type, is an aggressive entity within the World Health Organization classification of lymphoid tumors. The International Prognostic Index is reported to be prognostically meaningful for ENKTL, but lacks discriminatory power for stage I/II ENKTL with extensive local invasion. This study aimed to evaluate the prognostic effects of local invasion by site and tissue type in patients with ENKTL.

Methods:

We retrospectively analyzed data of 86 patients who were diagnosed with ENKTL by the Department of Pathology of Beijing Tongren Hospital from June 2002 to April 2016, and ascertained tumor infiltration of adjacent structures (AS), bone, and soft tissue for each patient, using physical findings and imaging scans. We used univariate and multivariate analysis to assess the association of each involved tissue or site with patients’ overall survival (OS).

Results:

Of the 86 patients, 71 (82.6%) experienced invasion of AS, 22 (25.6%) of soft tissue, and 26 (30.2%) had bone involvement. Overall, patients with AS involvement did not show significantly shorter survival than those without AS involvement (Log rank χ² = 1.177, P = 0.278); however, patients who had involved eyeballs or brains showed significantly lower 2-year OS rates than those without eyeball involvement (Log rank χ² = 4.105, P = 0.043) or brain involvement (Log rank χ² = 7.126, P = 0.008). Patients with involved local soft tissue or bones, respectively, showed lower 2-year OS rates than those without involved local soft tissue (Log rank χ² = 10.390, P = 0.001) or bones (Log rank χ² = 8.993, P = 0.003). Multivariate analysis showed that involvement of the cheek or facial muscles (hazard ratio, HR = 5.471, 95% confidence interval [CI]: 1.466–20.416, P = 0.011) and the maxilla bone (HR = 6.120, 95% CI: 1.517–24.694, P = 0.011) were significantly independent predictors of lower 2-year OS rates.

Conclusions:

Imaging can accurately detect ENKTL invasion of AS, soft tissue, and bone. Involvement of local soft tissue or bone was significantly associated with lower 2-year OS rates. Involvements of the cheek or facial muscle, as well as maxilla bone, are independent predictors of lower 2-year OS rates in ENKTL patients.

Extranodal natural killer/T-cell lymphoma (nasal type) presenting as a perianal abscess: A case report

BACKGROUND

Extranodal natural killer (NK) T-cell lymphoma (ENKTL), nasal type is a rare subtype of extranodal non-Hodgkin lymphoma characterized by vascular damage and necrosis. The lesions usually present in the nasal cavity and adjacent tissues, however, the disease originates from the gastrointestinal or genitourinary tract in 25% of cases. Since rectal involvement in ENKTL is rare, rectal symptoms in the course of ENKTL are often misdiagnosed and considered to be related to benign diseases such as rectal fistula or perianal abscess.

CASE SUMMARY

We report the case of a 24-year-old Han Chinese female who initially presented with a perianal abscess that was subsequently diagnosed as nasal type ENKTL. Due to typical perianal pain, perianal abscess was diagnosed and surgical incision and drainage were performed. After recurrent, severe anal hemorrhages leading to hypovolemic shock and multiple surgeries, a diagnosis of ENKTL was made. The patient’s condition gradually deteriorated, and she died shortly after initiation of chemotherapy.

CONCLUSION

Systemic and neoplastic diseases should be included in the differential diagnosis of any potentially benign perianal abscess complicated with recurrent hemorrhages.

Total nasal reconstruction for nasal defect after treatment for extranodal natural killer/T cell lymphoma, nasal-type: A case report

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Total nasal defect after chemoradiation was complex and difficult to rebuild.

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The surgery was divided into 3 stages with each stage to prepare for the next stage.

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With the multiple facial unit defects, reconstruction is based on aesthetic unit.

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After using multiple local flaps to reconstruct the defect, the result was improved.

Introduction

Nasal-type extranodal natural killer (NK)/T-cell lymphomas are a rare type of clinical condition. Reconstruction of the complex nasal defect after chemoradiation is extremely challenging for plastic surgeons.

Presentation of case

Here we present the case of a 56-year old female with the condition of a nasal-type NK/T-cell lymphoma which had caused complex nasal disfigurement. The patient had undergone chemoradiotherapy. Lesions after treatment were present all over the nasal defect (nasal septum, mucosa, support frame and skin) and the left cheek medial subunit. The surgery was subdivided into 3 stages. First, we removed the infectious tissue and restored the wall of nasal cavity by the left forehead – scalp flap. Second, we used the pedicle of the left forehead flap to rebuild the nasal mucosa defect, the rotational flap to rebuild the cheek defect, and the right forehead flap to recovered skin defect of the nose. Finally, we divided the pedicle of right forehead flap.

Discussion

The complex nasal defect is difficult to reconstruct and has a higher risk of failure in patient who received chemoradiotherapy. It is crucial to choose the right materials and have a confident plan in order to achieve successful results for the sake of the patient.

Conclusion

Our case report shows that the nasal defect caused by a nasal-type NK/T-cell lymphoma is complex. After our 3 stages plan for the surgery, as well as using multiple flaps for reconstruction from the forehead skin, the result was significant reduction in the disfiguration of the patient’s nose.

Extranodal NK/T-Cell Lymphoma, Nasal Type in Guatemala: An 86-Case Series Emphasizing Clinical Presentation and Microscopic Characteristics

Extranodal NK/T-cell lymphoma, nasal type (ENKTCL-NT) is a lymphoid malignancy that mainly affects the nasopharynx and is associated with the Epstein-Barr virus (EBV). Increased incidence is seen in some Latin American and Asian countries. In this study, we describe a case series of 86 Guatemalan patients with ENKTCL-NT from a single diagnostic head and neck center. We emphasize the distinctive clinical, microscopic, and immunohistochemical (IHC) features, as well as EBV positivity by in situ hybridization (ISH). Most of the patients (90.6%) were of Mayan descent and low socioeconomic status (SES). Males were more often affected than females, comprising 68.3% of cases. Patient age ranged from 8 to 71, with a mean of 34.7 years. All cases arose in the upper aerodigestive tract and mainly presented as a rapidly progressive, necrotizing midfacial process affecting the nasal, nasopharyngeal, sinonasal, palatal, and oropharyngeal structures. Microscopically, ENKTCL-NT showed a diffuse polymorphic and atypical lymphoid infiltrate. Angiocentric and angiodestructive growth patterns were present with associated necrosis. Peripheral hyaline necrosis of blood vessels was a histologic hallmark. The ISH and IHC profiles included positivity of EBV, LCA, CD3, CD45RO, CD30 (focal in 39.2%), granzyme-B, TIA-1, perforin (in 82.3%), and CD56 (in 83.7%). CD20 was negative, and the Ki-67 index ranged from 70 to 90%. In Guatemala, this lymphoma is strongly associated with people of low SES and indigenous ethnicity. When affected, the palatal mucosa provides the best site to obtain a representative biopsy. Since ENKTCL-NT is highly aggressive, it is extremely important to recognize the spectrum of clinical presentations and microscopic features in order to avoid misdiagnosis and treatment delay.

Prognostic Value of Baseline and Interim Total Metabolic Tumor Volume and Total Lesion Glycolysis Measured on 18F-FDG PET-CT in Patients with Follicular Lymphoma

Purpose

The purpose of this study was to investigate the prognostic significance of total metabolic tumor volume (TMTV) and total lesion glycolysis (TLG) in patients with follicular lymphoma (FL) at baseline and mid-treatment with ¹⁸F-fluorodeoxyglucose positron emission tomography-computed tomography (PET-CT) scans.

Methods

The study analyzed data from 48 patients with FL who were treated in Jiangsu Province Hospital and reviewed their baseline PET-CT scans. TMTV and TLG were computed by using the absolute value of 2.0, 2.5, and 3.0 thresholding method, respectively.

Results

Median age was 53 years, 75.0% of patients had stage III to IV disease, 43.8% had a Follicular Lymphoma International Prognostic Index 1 (FLIPI1) score of 3 to 5 and 20.8% had a FLIPI2 score of 3 to 5. Receiver operating characteristic (ROC) curve analysis showed the optimal cut-off values for TMTV3.0 and TLG3.0 were 476.4 (sensitivity, 85.7%; specificity, 78.0%; area under the curve [AUC], 0.760; p=0.003) and 2,676.9 (sensitivity, 71.4%; specificity, 78.0%; AUC, 0.760; p=0.003). On multivariable analysis, TMTV3.0 and TLG3.0 were independent predictors of both progression-free survival (PFS) (hazard ratio [HR], 5.406; 95% confidence interval [CI], 1.326 to 22.040; p=0.019 and HR, 6.502; 95% CI, 1.079 to 39.182; p=0.042) and overall survival (OS) (HR, 4.111; 95% CI, 1.125 to 15.027; p=0.033 and HR, 5.885; 95% CI, 1.014 to 34.148; p=0.049). ROC curve analysis showed the optimal cut-off values for ΔTMTV3.0 and ΔTLG3.0 were 66.3% (sensitivity, 85.7%; specificity, 63.4%; AUC, 0.774; p < 0.001) and 64.5% (sensitivity, 85.7%; specificity, 65.9%; AUC, 0.777; p < 0.001).

Conclusion

Baseline TMTV and TLG are strong predictors of PFS and OS in FL. Furthermore, interim TMTV (ΔTMTV > 66.3%) and TLG (ΔTLG > 64.5%) reduction are valuable tools for early treatment response assessment in FL patients.

[Prognostic significance of NCCN-International Prognostic Index (NCCN-IPI) for patients with peripheral T-cell lymphoma treated with CHOP-based chemotherapy]

目的

明确美国国家综合癌症网络国际预后指数（NCCN-IPI）对外周T细胞淋巴瘤（PTCL）患者化疗后的预后评估价值。

方法

回顾性分析2003年1月至2013年5月接受CHOP或CHOP样方案化疗的162例初治PTCL患者的临床资料，采用国际预后指数（IPI）和NCCN-IPI进行危险分层和预后评估。

结果

①162例患者预期5年总生存（OS）和无进展生存（PFS）率分别为33%和20%，中位OS和PFS时间分别为17.0和9.2个月。②多因素分析提示美国东部肿瘤协作组体能状态评分（ECOG评分）≥2分（PFS：HR＝2.418，95%CI 1.535～3.809，P<0.001；OS：HR＝2.347，95%CI 1.435～3.839，P＝0.001）和存在特定的结外病变部位（PFS：HR＝1.800，95%CI 1.216～2.665，P＝0.003；OS：HR＝1.608，95%CI 1.054～2.454，P＝0.027）是影响患者PFS和OS的独立危险因素；ALK⁺是影响间变性大细胞淋巴瘤患者PFS（HR＝0.424，95%CI 0.184～0.975，P＝0.043）及OS（HR＝0.276，95%CI 0.087～0.877，P＝0.029）的独立预后良好因素。③NCCN-IPI低危组患者的生存率显著高于IPI低危组患者（5年OS率74%对54%，χ²＝5.041，P＝0.025；5年PFS率50%对38%，χ²＝5.295，P＝0.021），差异均有统计学意义。

结论

NCCN-IPI较IPI对低危PTCL患者具有更好的预后判断意义，可作为PTCL患者有效的预后分层工具。

Extranodal NK/T-cell lymphoma in adolescents: imaging findings of a consecutive 7-year case series

Objectives

Extranodal NK/T-cell lymphoma is reportedly a rare but emerging type of lymphoma in adolescents. The present study was performed to specify its imaging characteristics.

Methods

Our hospital’s picture archiving and communication systems were searched from January 2009 to December 2016. We identified 13 patients aged <18 years with pathologically confirmed extranodal NK/T-cell lymphoma in the head and neck region. The computed tomography and magnetic resonance images were reviewed to summarize the imaging characteristics of extranodal NK/T-cell lymphoma in adolescents.

Results

The mean age at onset was 15.2 ± 1.46 years (range, 12–17 years) with a male:female ratio of 1.17:1.00. Most of the patients (n = 10) displayed nasal cavity and/or paranasal involvement. The tumor was homogeneous in both computed tomography and magnetic resonance images and showed slight enhancement. No calcification or liquefactive necrosis was observed. Adjacent structures were usually involved.

Conclusion

Suggestive imaging characteristics could acquaint specialists with extranodal NK/T-cell lymphoma in adolescents, facilitating improved early recognition of the diagnosis and helping to improve the patient’s outcome.

Pegaspargase, gemcitabine, dexamethasone, and cisplatin (P-GDP) combined chemotherapy is effective for newly diagnosed extranodal NK/T-cell lymphoma: a retrospective study

Purpose

l-asparaginase or pegaspargase-based chemotherapies have shown promising results in the treatment of extranodal NK/T-cell lymphoma. A retrospective study was conducted to determine the efficacy and safety of pegaspargase, gemcitabine, dexamethasone, and cisplatin (P-GDP) combined chemotherapy in patients with newly diagnosed extranodal NK/T-cell lymphoma.

Patients and methods

From September 2013 to November 2016, 57 patients with newly diagnosed, stages I to IV, extranodal NK/T-cell lymphoma received P-GDP chemotherapy. Clinical data from these patients were collected and analyzed to evaluate the efficacy and safety of P-GDP.

Results

All patients were subjected to 1-6 cycles of P-GDP chemotherapy, and the median number of cycles of P-GDP regimen administered was 3. The overall response rate was 89.5% (51/57), including a complete response rate of 70.2% (40/59) and a partial response rate of 19.3% (11/57). The median follow-up time was 28 months (range 2-54 months). The 2-year overall survival and progression-free survival (PFS) rates were 82.9% and 75.9%, respectively. For stage I/II patients and stage III/IV patients, 2-year PFS were 80.8% and 66.7%, respectively. The most common grade 3/4 adverse events were neutropenia (42.1%), thrombocytopenia (38.6%), and hypofibrinogenemia (26.3%). No treatment-related deaths were observed.

Conclusion

P-GDP combination chemotherapy is highly effective and safe for newly diagnosed patients with extranodal NK/T-cell lymphoma, nasal type. Additional large sample prospective trials are required to confirm these results.

Specific Soft-Tissue Invasion and LMP1 Expression Are Potential Indicators of Extranodal NK/T Cell Lymphoma, Nasal Type

BACKGROUND Extranodal NK/T cell lymphoma, nasal type (ENKTL-NT) is difficult to distinguish from nasal polyps and inverted papilloma, leading to its high misdiagnosis ratio. The aim of this study was to investigate its potential prognostic indicators. MATERIAL AND METHODS Kaplan-Meier method was used to calculate overall survival (OS) rate. Cox proportional hazards regression was used to analyze risk ratios (ORs) with 95% confidence intervals (CIs). RESULTS Nasal ala infiltration and nasal floor thickness >2.0 mm or nasal septum thickness >2.5 mm were potential prognostic factors for OS (p=0.0323 and 0.0072, respectively). Cox proportional-hazards regression indicated that high LMP1 expression and the nasal floor thickness >2.0 mm or nasal septum thickness >2.5 mm were the independent risk factors for poor OS of ENKTL-NT (HR=3.0655, p=0.028; HR=2.3650, p=0.0452, respectively). In the subgroup analysis, the OS rate was lower when the nasal floor thickness >2.0 mm or nasal septum thickness >2.5 mm in the patients who had high expression of LMP1 (p=0.0651), whereas high LMP1 expression increased the risk of worse prognostic outcome in patients with deep infiltration thickness. Thus, high LMP1 expression may contribute to the tissue invasion of ENKTL-NT. CONCLUSIONS Any patient with nasal ala soft-tissue invasion, nasal floor thickness >2.0 mm/nasal septum thickness >2.5 mm on CT imaging or high LMP1 expression should prompt immediate histopathologic diagnosis to rule out ENKTL-NT in clinical practice.

[Nasal NK/T-cell lymphoma: about two rare cases]

Le lymphome T/NK est une affection grave et rare en Afrique et en Europe. Le traitement repose sur la radiothérapie et la chimiothérapie. Les auteurs rapportent deux observations de patients âgés respectivement de 55 et 52 ans, qui présentent une obstruction nasale bilatérale avec une rhinorrhée purulente, chez eux l'examen clinique a mis en évidence la présence d'une fente palatine. Le diagnostic n'a pu être posé qu'après une étude immuno-histochimique des biopsies. Les 2 patients ont bénéficié d'une chimiothérapie type CHOEP suivi d'une cure de radiothérapie. Le lymphome T/NK nasal est une forme agressive de lymphome non hodgkinien comportant des caractéristiques clinicopathologiques qui lui sont spécifiques. L'association de la chimiothérapie pour les stades avancés ne semble pas améliorer la survie par rapport à la radiothérapie seule qui reste le traitement de choix surtout pour les stades localisés. La localisation nasal du lymphome T /NK est rare. Le diagnostic repose sur l'étude immunohistochimique. Le traitement comprend chimiothérapie et radiothérapie. Ce type lymphome est de mauvais pronostic globalement, y compris sous traitement.

A phase II prospective study of the "Sandwich" protocol, L-asparaginase, cisplatin, dexamethasone and etoposide chemotherapy combined with concurrent radiation and cisplatin, in newly diagnosed, I/II stage, nasal type, extranodal natural killer/T-cell lymphoma

Nasal-type, extranodal NK/T cell lymphoma (ENKTCL) is a special type of lymphomas with geographic and racial specificity. Up to now, the standard first-line treatment is still not unified. In our previous report, the "sandwich" protocol produced good results. Continuing to use the "sandwich" mode, a new chemotherapy composed of L-asparaginase, cisplatin, etoposide and dexamethasone (LVDP) plus concurrent chemoradiotherapy (CCRT) was conducted in more patients with newly diagnosed, I/II stage ENKTCL. The results showed that 66 patients were enrolled. Overall response rate was 86.4% including 83.3% complete response and 3.0% partial remission. With the median follow-up of 23.5 months, 3-year overall survival and 3-year progression-free survival were 70.1% and 67.4%, respectively. The survival rate in stage II and extra-cavity stage I was significantly less than that in limited stage I (p < 0.05). Therefore, we thought that the "sandwich" mode was worthy of being generalized and LVDP combined with CCRT was an effective protocol for I/II stage ENKTCL. But this regimen was not suitable for all stage I/II patients and warrants larger sample and layering investigation. This study was a registered clinical trial with number ChiCTR-TNC-12002353.

Prognostic value of baseline, interim and end-of-treatment 18F-FDG PET/CT parameters in extranodal natural killer/T-cell lymphoma: A meta-analysis

METHODS

We searched the PubMed, EMBASE, Cochrane Library and Medline databases for eligible articles. SUVmax, MTV, and TLG on B-PET/CT, DS on I-PET/CT and DS on E-PET/CT were regarded as efficacy data. Combined hazard ratios (HRs) for progression-free survival (PFS) and overall survival (OS) were estimated using RevMan 5.3 software.

RESULTS

Nine trials with a total of 535 ENKTL patients were included. SUVmax, MTV and TLG on B-PET/CT were significantly associated with PFS with HRs of 2.78 (95%CI 1.54-5.03), 3.61 (95%CI 1.96-6.65) and 5.62 (95%CI 1.94-16.33), respectively, and with OS with HRs of 4.78 (95%CI 2.29-9.96), 3.20 (95%CI 1.55-6.60) and 7.76 (95%CI 1.79-33.58), respectively. For the DS on I-PET/CT, the HRs for PFS and OS were 5.15 (95%CI 2.71-9.80) and 5.80 (95%CI 2.28-14.73), respectively. Similarly, the DS on E-PET/CT was a significant predictor of PFS and OS with HRs of 3.65 (95%CI 2.13-6.26) and 3.32 (95%CI 1.79-6.15), respectively.

CONCLUSION

Our results suggest that SUVmax, MTV, TLG on B-PET/CT, DS on I-PET/CT and DS on E-PET/CT may be significant prognostic indicators for PFS and OS in ENKTL patients. Moreover, TLG tends to be superior to SUVmax and MTV on B-PET/CT for predicting survival of ENKTL patients. Therefore, response monitoring and prognostication assessments based on multiple PET/CT parameters should be considered in the management of ENKTL patients.

The DDGP (cisplatin, dexamethasone, gemcitabine, and pegaspargase) regimen for treatment of extranodal natural killer (NK)/T-cell lymphoma, nasal type

Extranodal natural killer/T cell lymphoma (ENKL) is a high invasive disease with poor prognosis. Since there is no consensus on standard chemotherapy, we developed an original chemotherapeutic DDGP (cisplatin, dexamethasone, gemcitabine, and pegaspargase) regimen. We retrospectively analyzed 80 patients who received DDGP chemotherapy. The primary end point was progression-free survival (PFS) and secondary end points were overall survival (OS), complete response rate (CRR), and overall response rate (ORR). The one-year PFS and OS rates were 86.0% and 88.6%, and the 2-year PFS and OS rates were 81.40% and 87.1%, respectively. The ORR and CRR of DDGP chemotherapy were 91.3% and 60.0%. The major adverse events were myelosuppression, digestive tract toxicities, and coagulation disorder. No treatment-related deaths were observed. Our results suggest that the DDGP regimen is a high effective and safe treatment for ENKL.

Therapeutic effect of chidamide on relapsed refractory angioimmunoblastic T-cell lymphoma: A case report and literature review

INTRODUCTION

Angioimmunoblastic T-cell lymphoma (AITL) is a kind of rare peripheral T cell lymphoma, which usually has acute onset at old age.

MATERIALS AND METHODS

Here we report a case of relapsed refractory AITL, which has achieved obvious curative effect after treatment with chidamide.

RESULTS

Initially, the patient received 7 courses of treatment with recombinant human endostatin (endostar)+CHOP. The patient achieved complete remission, but suffered from recurrence later. After changing chemotherapy regimens, the outcome was still not satisfactory, and the patient developed systemic skin infiltration and rashes. After 2 courses of chemotherapy with chidamide (30 mg) twice a week + intravenous injections with cyclophosphamide (0.1 g) twice every other day + thalidomide (50 mg) every night, the patient began with the oral intake of chidamide, and the therapeutic effect was satisfactory, with diminishing systemic rashes and shrunken lymph nodes.

DISCUSSION AND CONCLUSIONS

Chidamide has good therapeutic effect in the treatment of AITL, which provides a novel therapeutic strategy for relapsed refractory AITL. However, more cases are still needed to further validate its efficacy.

Epstein-Barr virus-associated lymphomas

Epstein-Barr virus (EBV), originally discovered through its association with Burkitt lymphoma, is now aetiologically linked to a remarkably wide range of lymphoproliferative lesions and malignant lymphomas of B-, T- and NK-cell origin. Some occur as rare accidents of virus persistence in the B lymphoid system, while others arise as a result of viral entry into unnatural target cells. The early finding that EBV is a potent B-cell growth transforming agent hinted at a simple oncogenic mechanism by which this virus could promote lymphomagenesis. In reality, the pathogenesis of EBV-associated lymphomas involves a complex interplay between different patterns of viral gene expression and cellular genetic changes. Here we review recent developments in our understanding of EBV-associated lymphomagenesis in both the immunocompetent and immunocompromised host.This article is part of the themed issue 'Human oncogenic viruses'.

T-cell Lymphoma Epidemiology: the Known and Unknown

T-cell lymphoma, a collection of subtypes of Non-Hodgkin lymphoma, is a rare malignancy. The low prevalence of this disease has made it challenging to identify subtype-specific risk factors. Potential risk factors could enable us to identify high-risk patients and predict patient outcomes. Here, we report on the current epidemiologic and prognostic factors data associated with the individual subtypes both of peripheral T-cell lymphoma (PTCL) and cutaneous T-cell lymphoma (CTCL) found in large cohort and case studies. Additionally, with recent findings, as well as updates in the new World Health Organization (WHO) classification of lymphoid neoplasms, we consider what this could do to change our approach to this group of diseases.

Extranodal natural killer/T-cell lymphoma in Malawi: a report of three cases

Background

Extranodal NK/T-cell lymphoma (ENKTCL) reports from sub-Saharan Africa (SSA) are remarkably rare, despite early childhood acquisition and high prevalence of the causative infectious agent, Epstein-Barr virus (EBV), and frequent occurrence of other lymphoproliferative disorders causally associated with EBV.

Case presentations

At a national teaching hospital in Malawi, three patients of African descent were seen with ENKTCL between 2013 and 2014. Patients were aged between 29 and 60 years, two with craniofacial involvement and one with a primary abdominal tumor, and all were HIV-negative. All had systemic B symptoms, and two severely impaired performance status. On histologic review, morphology and immunophenotyping demonstrated classical ENKTCL features in all cases, including diffuse proliferations of intermediate-to-large atypical lymphocytes with high mitotic activity and extensive background necrosis, positivity for CD3 and CD56, and negativity for CD20. By in situ hybridization, all three tumors were positive for EBV-encoded RNA (EBER). Baseline plasma EBV DNA was also markedly elevated for all three patients. Due to radiotherapy and chemotherapy limitations, patients were treated with CHOP (cyclophosphamide, doxorubicin, vincristine, prednisone) with rapid disease progression. All three patients died from progressive lymphoma within 3 months of initial diagnosis.

Conclusions

Our experience with these three patients in Malawi can highlight that ENKTCL does indeed occur in SSA, increase familiarity with ENKTCL among clinicians and pathologists throughout the region, and emphasize the need for better diagnosis and treatment for this neglected population.

The Diagnosis, Management, and Role of Hematopoietic Stem Cell Transplantation in Aggressive Peripheral T-Cell Neoplasms

Background

Peripheral T-cell neoplasms (PTCNs) comprise a group of uncommon and heterogeneous lymphoid malignancies. They are more difficult to diagnose and treat and have a worse prognosis than B-cell lymphomas. Although PTCNs initially show a significant degree of chemosensitivity, the outcome of treatment with conventional dose chemotherapy remains poor.

Methods

We reviewed the literature on the diagnosis, treatment, and collective transplant reports regarding PTCNs.

Results

The correct diagnosis of peripheral T-cell lymphoma requires a combination of clinical presentation, morphology, immunophenotype, and molecular study. While no specific treatment other than conventional dose chemotherapy is currently available for aggressive PTCN, histone acetylase inhibitors and monoclonal antibodies such as anti-CD7 and anti-CD52 are being studied in T-cell malignancies. The role of autologous and allogeneic transplantation is being investigated for high-risk, relapsed, and refractory PTCNs with some promising results.

Conclusions

Access to hematopathology expertise in a tertiary care setting may lead to earlier and more accurate diagnoses of these diseases. PTCNs comprise a heterogeneous group of diseases with no widely accepted standard of care, and accurate determination of their histologic subtypes correlates with prognosis. Patients in first complete remission with poor risk features and patients with relapsed and refractory disease should be considered for bone marrow transplant due to the poor outcomes obtained with conventional chemotherapy.