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Musanhu E, Sharma RK, Attygalle A, Wotherspoon A, Chau I, Cunningham D, Dearden C, El-Sharkawi D, Iyengar S, Sharma B. Chronic lymphocytic leukaemia and Richter's transformation: multimodal review and new imaging paradigms. Clin Radiol 2021; 76:789-800. [PMID: 34217434 DOI: 10.1016/j.crad.2021.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 06/01/2021] [Indexed: 12/15/2022]
Abstract
Chronic lymphocytic leukaemia (CLL) is the most common leukaemia in adults. It is a malignancy of CD5 B-cells characterised by small, mature-appearing lymphocytes accumulating in the blood, bone marrow, and lymphoid tissues. Richer transformation (RT) is an important adverse complication. Detection of RT is critical to allow initiation of appropriate therapy. CLL staging and response evaluation is complicated and nuanced. From our extensive tertiary centre experience of several hundred CLL cases over the last decade, we detail key computed tomography (CT) and positron-emission tomography (PET) imaging features of the natural history of CLL. The authors present an original imaging-based patient-management paradigm for the investigation of potential RT, which will inform global practice. Potential applications of whole-body diffusion weighted imaging, novel PET radiotracers, minimal residual disease, and ct-DNA are addressed.
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Affiliation(s)
- E Musanhu
- Radiology Department, Royal Marsden Hospital, London, UK
| | - R K Sharma
- University of Exeter Medical School, Exeter, UK
| | - A Attygalle
- Pathology Department, Royal Marsden Hospital, UK
| | - A Wotherspoon
- Clinical Oncology Department, Royal Marsden Hospital, UK
| | - I Chau
- Clinical Oncology Department, Royal Marsden Hospital, UK
| | - D Cunningham
- Clinical Oncology Department, Royal Marsden Hospital, UK
| | - C Dearden
- Clinical Oncology Department, Royal Marsden Hospital, UK
| | - D El-Sharkawi
- Clinical Oncology Department, Royal Marsden Hospital, UK
| | - S Iyengar
- The Institute of Cancer Research, London, UK
| | - B Sharma
- Radiology Department, Royal Marsden Hospital, London, UK.
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Douglas AP, Atarod M, Prince HM. FDG-PET/CT findings, the vital clue to rare diagnosis of herpes simplex virus lymphadenitis simulating Richter transformation. Pathology 2018; 51:102-104. [PMID: 30471841 DOI: 10.1016/j.pathol.2018.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 08/12/2018] [Accepted: 08/17/2018] [Indexed: 01/30/2023]
MESH Headings
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Leukemia, Lymphocytic, Chronic, B-Cell/virology
- Lymphadenitis/diagnosis
- Lymphadenitis/virology
- Lymphoma, Large B-Cell, Diffuse/diagnosis
- Lymphoma, Large B-Cell, Diffuse/virology
- Male
- Middle Aged
- Positron Emission Tomography Computed Tomography/methods
- Simplexvirus/pathogenicity
- Tomography, X-Ray Computed/methods
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Affiliation(s)
- Abby P Douglas
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Vic, Australia; Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia; The National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Vic, Australia; Epworth Healthcare, Melbourne, Vic, Australia.
| | - Mohammad Atarod
- Anatomical Pathology, Melbourne Pathology, Melbourne, Vic, Australia
| | - H Miles Prince
- Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic, Australia; Epworth Healthcare, Melbourne, Vic, Australia; Department of Haematology, Peter MacCallum Cancer Centre, Melbourne, Vic, Australia
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3
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Joffe M, Wagner SD, Tang JW. Case report: a fatal case of disseminated adenovirus infection in a non-transplant adult haematology patient. BMC Infect Dis 2018; 18:58. [PMID: 29374466 PMCID: PMC5787257 DOI: 10.1186/s12879-018-2962-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 01/16/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We report a fatal case of disseminated adenovirus infection in a non-transplant haematology adult patient with chronic lymphocytic leukaemia who had completed combination chemoimmunotherapy a few months before developing respiratory symptoms. In such non-transplant patients, monitoring for adenovirus in the blood is not routine. However, with adenoviruses, when there is a more peripheral (i.e. non-blood) site of infection such as the chest, serial adenovirus monitoring in blood for the duration of that illness may be warranted. CASE PRESENTATION This case started with an initial bacterial chest infection that responded to treatment, followed by an adenovirus pneumonitis that disseminated to his blood a week later with levels of up to 92 million adenovirus DNA copies/ml. Despite prompt treatment with cidofovir, his respiratory function continued to deteriorate over the next two weeks and he was moved to intensive care. Intravenous immunoglobulin and ribavirin were subsequently added to his treatment. However, he died soon after this with a final adenovirus load of 20 million copies/ml in his blood. CONCLUSIONS We recommend that even in non-transplant haematology patients, where such patients present with an acute respiratory adenovirus infection, teams should consider checking the blood for adenovirus to check for signs of disseminated infection. The earlier this can be tested, the earlier treatment can be initiated (if adenovirus positive), which may produce more successful clinical outcomes.
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Affiliation(s)
- Michael Joffe
- Department of Haematology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Simon D Wagner
- Department of Haematology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Julian W Tang
- Clinical Microbiology, Leicester Royal Infirmary, University Hospitals of Leicester NHS Trust, Level 5 Sandringham Building, Leicester Royal Infirmary, Infirmary Square, Leicester, LE1 5WW, UK. .,Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, UK.
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Pemmaraju N, Jain P, Jeffrey Medeiros L, Jorgenson JL, Jain N, Willis J, Kontoyiannis DP, Estrov Z, Wierda WG. PET-positive lymphadenopathy in CLL-Not always Richter transformation. Am J Hematol 2017; 92:405-406. [PMID: 27677095 DOI: 10.1002/ajh.24566] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 09/17/2016] [Accepted: 09/20/2016] [Indexed: 11/06/2022]
Affiliation(s)
- Naveen Pemmaraju
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Preetesh Jain
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - L. Jeffrey Medeiros
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jeffrey L. Jorgenson
- Department of Hematopathology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Nitin Jain
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Jason Willis
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | | | - Zeev Estrov
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - William G. Wierda
- Department of Leukemia; The University of Texas MD Anderson Cancer Center; Houston Texas
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Salem A, Loghavi S, Khoury JD, Agbay RLMC, Jorgensen JL, Medeiros LJ. Herpes simplex infection simulating Richter transformation: a series of four cases and review of the literature. Histopathology 2016; 70:821-831. [PMID: 27905140 DOI: 10.1111/his.13137] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Accepted: 11/26/2016] [Indexed: 12/27/2022]
Abstract
AIMS Richter transformation (RT) occurs in 5-10% of patients with chronic lymphocytic leukaemia/small lymphocytic lymphoma (CLL/SLL), and is associated with a poor outcome. The histological manifestations of RT are variable, and include an increase in the proportion of prolymphocytes, immunoblasts, and other pleomorphic cells, along with an increased proliferation rate and often necrosis. Rarely, superimposed herpes simplex virus (HSV) infection involving lymph nodes in patients with CLL/SLL may mimic RT clinically and histologically. In this study, we describe four cases of CLL/SLL with superimposed HSV lymphadenitis, and we review the literature. METHODS AND RESULTS We describe the clinicopathological and immunophenotypic findings of four cases of CLL/SLL with superimposed HSV infection. The patients presented with B-type symptoms, and laboratory and imaging findings suggested progression of lymphoma. Histologically, there were geographical areas of necrosis and increased numbers of prolymphocytes and immunoblasts, in some areas forming sheets, with increased mitotic figures and a high proliferation (Ki67) rate. However, the necrotic regions were associated with acute inflammatory cells and larger cells, mostly necrotic, showing viral cytopathic effects. Therapy with antiviral agents resulted in improvement of clinical symptoms and laboratory and imaging findings. Additionally, we identified 11 cases of CLL/SLL with superimposed HSV infection described in the English-language literature, and integrated the cases that we report here into this wider context. CONCLUSIONS Herpes simplex virus infection of lymph nodes in patients with CLL/SLL results in clinicopathological and radiological findings that may mimic RT. It is essential to refrain from misclassifying these cases as RT, as patients can respond remarkably well to antiviral therapy.
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Affiliation(s)
- Alireza Salem
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Sanam Loghavi
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Joseph D Khoury
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Rose Lou Marie C Agbay
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffrey L Jorgensen
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
| | - L Jeffrey Medeiros
- Department of Hematopathology, The University of Texas, MD Anderson Cancer Center, Houston, TX, USA
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Di Bernardo A, Mussetti A, Aiello A, De Paoli E, Cabras AD. Alternate clonal dominance in richter transformation presenting as extranodal diffuse large B-cell lymphoma and synchronous classic Hodgkin lymphoma. Am J Clin Pathol 2014; 142:227-32. [PMID: 25015865 DOI: 10.1309/ajcp4t9rpxytxqde] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES Richter transformation (RT) represents the rare occurrence of a secondary aggressive lymphoma in the setting of chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). METHODS Here we describe the peculiar case of a patient with trisomy 12+ and atypical (CD5+, CD23-) CLL/SLL who developed a two-step RT with complex morphologic and molecular features. RESULTS Molecular analysis of a CLL/SLL population detected two different immunoglobulin rearrangement patterns corresponding to a main peak and a minor peak. Transformation took place both as gastric diffuse large B-cell lymphoma and as a synchronous bone marrow classic Hodgkin lymphoma with the same immunoglobulin rearrangement pattern corresponding to the minor peak detected in CLL/SLL at diagnosis. During chemotherapy, progression occurred as axillary nodal involvement by a CD5+ high-grade lymphoma with an immunoglobulin rearrangement pattern corresponding to the main CLL peak. CONCLUSIONS In this case, the elaborate clinical and molecular picture may be correlated to an alternate dominance of two distinct clonal populations probably influenced by therapeutic and environmental factors.
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Affiliation(s)
- Andrea Di Bernardo
- Department of Anatomic Pathology, Orthopaedic Institute G. Pini, Milan, Italy
| | - Alberto Mussetti
- Department of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
- Università degli Studi di Milano, Milan, Italy
| | - Antonella Aiello
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Elena De Paoli
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
| | - Antonello Domenico Cabras
- Department of Pathology and Laboratory Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Milan, Italy
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Bowen DA, Rabe KG, Schwager SM, Slager SL, Call TG, Viswanatha DS, Zent CS. Infectious lymphadenitis in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma: a rare, but important, complication. Leuk Lymphoma 2014; 56:311-4. [PMID: 24738974 DOI: 10.3109/10428194.2014.914202] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The differential diagnosis of rapidly progressive or symptomatic lymphadenopathy in patients with chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL) includes infectious lymphadenitis. We studied 286 (9%) of 3040 patients with CLL seen between 2003 and 2012 at Mayo Clinic Rochester who had 356 diagnostic lymph node biopsies to evaluate rapidly progressive or symptomatic lymphadenopathy. Most (85.4%) biopsies showed progressive CLL, 8.9% a second lymphoid malignancy, 3.9% infectious lymphadenitis, 1.1% reactive adenitis and 0.6% non-hematological malignancies. Of the 12 patients (14 biopsies) with infectious lymphadenitis, five patients had never been treated for their CLL, and seven had a specific microbiological diagnosis (herpes simplex n=3, Cryptococcus neoformans n=1, Mycobacterium n=1, coagulase negative Staphylococcus n=2). We conclude that infectious lymphadenitis is a rare complication of CLL with clinical characteristics similar to progressive CLL and transformation to a more aggressive lymphoma. Early recognition and antimicrobial therapy treatment of infectious lymphadenitis can be highly effective in these patients.
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Michelis FV, Kourti G, Skertsou M, Karmiris T, Rontogianni DP, Harhalakis N. Richter transformation of chronic lymphocytic leukemia into composite diffuse large B-cell and Hodgkin lymphoma. Leuk Lymphoma 2012; 53:2302-3. [DOI: 10.3109/10428194.2012.676172] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kastenbaum HA, Khalbuss WE, Felgar RE, Stoller R, Monaco SE. The spectrum of coincident entities with small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) diagnosed by cytology. Cytojournal 2010; 7:20. [PMID: 20976208 PMCID: PMC2955352 DOI: 10.4103/1742-6413.70966] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Accepted: 07/06/2010] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND The cytologic diagnosis of Small lymphocytic lymphoma/chronic lymphocytic leukemia (SLL/CLL) often relies on finding a small lymphoid population with the characteristic immunoprofile by ancillary testing. There are only a few reports of other processes identified with SLL/CLL. The aim of this study was to review the fine needle aspiration (FNA) and touch prep (TP) diagnoses of SLL/CLL in order to identify any coincident entities. MATERIALS AND METHODS We retrospectively reviewed all FNA and TP cytology cases between January 2005 and May 2009 with a diagnosis of SLL/CLL to determine the presence of any coincident process. RESULTS We identified 29 cases, including 23 FNAs and six TPs, from 23 patients. Ancillary studies were utilized in 97% of the cases, including flow cytometry (FC, 79%), immunohistochemistry (IHC, 55%), fluorescent in situ hybridization studies (24%) and special stains (7%). Coincident entities were identified in nine cases (31%) and included seven (28%) neoplastic entities (Hodgkin lymphoma [HL], adenocarcinoma, squamous cell carcinoma, seminoma) and two (7%) non-neoplastic entities (infection and immunoglobulin containing cells). Six cases (21%) suspicious for large cell transformation were also identified. CONCLUSION In our review of SLL/CLL, coincident entities were present in 31% of the cases and included a spectrum of non-neoplastic and neoplastic processes. FC was the most frequently utilized ancillary test, but IHC provided important information by excluding a mantle cell lymphoma or confirming a coincident process. Thus, cytomorphologic evaluation in these patients is important due to the high risk of a coincident process that may not be apparent by FC alone and may require clinical management.
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Affiliation(s)
- Hannah A Kastenbaum
- Department of Pathology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Kleinberg M. Viruses. MANAGING INFECTIONS IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2009. [PMCID: PMC7114983 DOI: 10.1007/978-1-59745-415-5_2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Viral infections are an important and often unrecognized component of disease in immunocompromised patients. The diagnosis and management of viral infections have expanded largely because of new quantitative molecular diagnostic assays. Well-recognized pathogens such as herpes simplex virus (HSV), cytomegalovirus (CMV), and respiratory viruses have been joined by newly recognized pathogens such as BK virus, human herpesvirus-6 (HHV-6), and human metapneumovirus in this highly susceptible patient population. The role of Epstein-Barr virus (EBV) and Human herpesvirus-8 (HHV-8) in lymphoproliferative diseases also continue to be clarified. As a result, the management of viral infections in patients with hematologic malignancies continues to be a growing challenge for the clinician.
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Affiliation(s)
- Michael Kleinberg
- School of Medicine, University of Maryland, S. Greene St. 22, Baltimore, 21201 U.S.A
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Gattenlohner S, Etschmann B, Lippert BM, Rumpelt HJ, Einsele H, Müller-Hermelink HK. Concomitant Herpes simplex and Epstein-Barr virus lymphadenitis with simultaneous lymph node metastases of an occult squamous cell carcinoma in a patient with chronic lymphocytic leukemia. Leuk Lymphoma 2008; 49:2390-2. [PMID: 19052994 DOI: 10.1080/10428190802491680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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