Immune thrombocytopenic purpura as the presenting feature of gastric MALT lymphoma

Gastric cancer with severe immune thrombocytopenia: A case report

BACKGROUND

Primary immune thrombocytopenia (ITP) is a rare autoimmune disease associated with a high bleeding risk. For those patients with gastric cancer, surgical treatment may be the only option for therapy. Here, we present the first case of gastric cancer with severe and medically refractory ITP treated by radical resection of the gastric cancer and splenectomy.

CASE SUMMARY

A 54-year-old female patient was admitted to our surgical department with a 2 mo history of decreased appetite, nausea, vomiting, and weight loss, which progressed to difficulty in feeding 3 d prior to her visit. According to her medical history, she was diagnosed with refractory ITP [platelets (PLT), 3000-8000/μL] 10 years ago. After admission, the patient underwent a splenectomy and a distal subtotal gastrectomy (D2 radical resection) with Roux-en-Y reconstruction simultaneously. She had an uneventful postoperative course with a slight increase in her PLT count. This case is unique in terms of the patient's complication of severe and medically refractory ITP.

CONCLUSION

Simultaneous splenectomy, preoperative PLT transfusion, and early enteral nutrition were important treatment methods for helping this patient recover.

Successful treatment of non-Hodgkin lymphoma associated immune thrombocytopenia with involved field radiotherapy

Immune thrombocytopenia complicates the course and impacts the outcome of non-Hodgkin lymphoma (NHL-ITP, non-Hodgkin lymphoma-immune thrombocytopenic purpura). The response to corticosteroids and/or intravenous immune globulins is usually short lasting, but NHL-ITP usually responds to anti-lymphoma chemotherapy. It is not clear if this success is due to the elimination of the lymphomatous tissue or to the immunosuppressor/immunomodulator effect of chemotherapy. Myelosuppressive anti-lymphoma chemotherapy carries the risk of severe thrombocytopenia that may not respond adequately to platelet transfusion support. We report on a patient with recurrent diffuse large B-cell lymphoma that coincided with immune thrombocytopenia. Both diseases completely responded to involved field radiation therapy. This supports the hypothesis that at least in some cases of NHL-ITP, the lymphomatous clone secretes the anti-platelet antibodies. This supports the therapeutic decision making for these patients.

Autoimmune phenomena in untreated and treated marginal zone lymphoma

INTRODUCTION

Current literature suggests an association between various autoimmune conditions and marginal zone lymphoma (MZL). However, these autoimmune conditions have not been comprehensively systematized to date. As a result, their clinical implications remain largely unknown.

AREAS COVERED

The authors provide a comprehensive review of the existing literature on various autoimmune abnormalities documented in the course of MZL, as well as on autoimmune alterations induced by certain MZL therapies.

EXPERT OPINION

The course of MZL is accompanied by a variety of hematologic and non-hematologic autoimmune disorders. Whereas some of them could be secondary and related to the course of the MZL, others may be primary and might even favor the development of MZL itself. In addition, authentic autoimmune conditions have been documented with the use of rituximab as a single agent and the nucleoside analogs. Therefore, we believe caution should be exerted with the use of these agents in MZL patients with evidence of autoimmune disorders, as exacerbation of autoimmune phenomena can be anticipated. While the heterogeneity of the MZL subtypes represents an inherent limitation, integration of emerging information from immunology research laboratories and clinical practice could translate into improved outcomes of this disease spectrum.

Resolution of immune thrombocytopenic purpura associated with extranodal B-cell lymphoma of the petroclival region after radiotherapy

Background:

Secondary immune thrombocytopenic purpura (ITP) associated with extranodal B-cell non-Hodgkin’s lymphoma (NHL) is extremely rare. The optimal management is not established. We report a first case of ITP in association with extranodal B-cell NHL originating in the lower petroclival region, successfully managed by local tumor control using conventional radiotherapy.

Case Description:

A 75-year-old man presented with a two-month history of hearing loss, hoarseness, and dysphagia. Neuroimaging revealed a large enhanced lesion in the left lower petroclival bone near the jugular foramen. Isolated unilateral parotid lymphadenopathy was also noted. Preoperative laboratory findings were normal, except for elevation of serum soluble interleukin-2 receptor level. A suboccipital craniotomy was performed and a biopsy sample was taken. Histological and immunohistochemical examination confirmed small B-cell lymphoma with plasmacytic differentiation. After initiation of radiotherapy, thrombocytopenia (24,000/µl) rapidly developed. Serological and bone marrow examination confirmed ITP. Prednisone was given at 1 mg/kg/day and radiation therapy was continued. After more than 32Gy, platelet count rapidly normalized. Radiotherapy to the tumor site achieved local tumor control and ITP was resolved. No evidence of recurrence and normal platelet count were confirmed at the two-year follow-up examination.

Conclusion:

Local control of the tumor was considered important in the resolution of secondary ITP in association with extranodal NHL of the skull base region.

Immune thrombocytopenia in lymphoproliferative disorders

Lymphoproliferative disorders are recognized as a common cause of secondary immune thrombocytopenia (ITP). The mechanisms involved in the pathogenesis of ITP associated with lymphoproliferative disorders are heterogeneous and often linked to the presence and activity of the malignant clone. A better understanding of the responsible mechanisms leading to ITP in each disease may allow for targeted treatment decisions, avoiding unwarranted immunosuppression and bleeding complications.

Primary pulmonary mucosa-associated lymphoid tissue lymphoma combined with idiopathic thrombocytopenic purpura and amyloidoma in the lung

Three abnormal shadows were detected in the right lung on chest X-ray films and computed tomography in a 75-year-old woman during follow-up for idiopathic thrombocytopenic purpura. Because a definitive diagnosis was not obtained through general examinations, exploratory thoracotomy was performed for diagnosis and treatment. The main lesion in the right middle lobe was diagnosed as mucosa-associated lymphoid tissue (MALT) lymphoma according to histopathological findings, cytogenic studies and reverse transcriptase-polymerase chain reaction analysis, and nodular lesions in S(3) and S(7) were diagnosed with Congo-red staining as local deposition of amyloid. The patient had no recurrence of the MALT lymphoma of the lung or other organs for 4 years after surgery. To our knowledge, this is the first reported case of primary pulmonary MALT lymphoma combined with idiopathic thrombocytopenic purpura/lung amyloidoma.

MALTOMA Presenting With Thrombocytopenia

Immune thrombocytopenia of malignancy is most frequently associated with lymphoproliferative disorders. Thrombocytopenia generally does not develop in MALT subtype of lymphoma (MALTOMA) unless the tumor has infiltrated the bone marrow. Cytopenias resulting from immunologic causes in patients with MALT lymphoma were rarely reported in the literature. In this report, a woman was diagnosed with stage IIE gastrointestinal MALTOMA. Bone marrow infiltration was not present. Patient also had thrombocytopenia, which did not improve after intravenous steroid treatment. Thrombocyte count increased after a single gamma-globulin infusion, and 6 cycles of chemotherapy were given every 21 days. The patient has remained in complete remission.

[Auto-immune manifestations in Non-Hodgkin's lymphoma]

PURPOSE

A wide spectrum of auto-immune manifestations is frequently reported in non-Hodgkin's lymphoma (NHL). The purpose of the review is to describe the immune manifestations observed in NHL, according to their histological subtype and to discuss the current physiopathological hypothesis with their therapeutic relevance.

CURRENT KNOWLEDGE AND KEY POINTS

Most of the organs can be targeted by an immune process due to the lymphoproliferative disease: they include skin diseases (paraneoplastic pemphigus, vasculitis, urticaria, acrosyndromes), peripheral and central nervous system involvement (polyneuropathy, multifocal neuropathy), haematological manifestations (immune cytopenia, acquired bleeding disorders), rheumatologic diseases (arthritis, systemic vasculitis, myositis) and renal lesion (cryoglobulinemia, glomerulopathies). A higher prevalence of autoantibodies, such as antinuclear antibodies, Antiphospholipid antibodies, or endomysium antibodies, is observed in NHL but usually without clinical manifestations. In B-cell NHL, clinical and biological immune manifestations are more frequently observed in indolent lymphoma than in aggressive NHL. In T-cell NHL, immune manifestations are frequent and polymorphous, preceding usually the diagnosis of lymphoma. The prognosis value of the immune manifestations in NHL is unclear. Immune manifestations can be also be related to the treatment procedure, including fludarabine, Interferon, autograft or Rituximab. The physiopathology of the immune manifestations may involve auto-antibodies production by natural CD5+ autoreactive B-cell from which is issue the proliferation, a lost of immune tolerance, an abnormality in the Fas/Fas Ligand pathway or a chronic antigenic stimulation.

FUTURE PROSPECTS AND PROJECTS

As observed in T-cell lymphoma cases, immunosuppressive treatment can control both immune manifestations and lymphoproliferation, suggesting that lymphoma and auto-immunity may be the two aspects of the same process. The monoclonal antibody anti-CD20 (rituximab), able to suppress the tumoral cells and change the B-cell repertoire is the most promising treatment to cure immune disorders related to NHL. So far, rituximab has been successfully used in mixed cryoglobulinemia and cold agglutinins secondary to NHL.