NK-cell intravascular lymphomatosis--a mini-review

Cutaneous Intravascular Hematolymphoid Entities: A Review

Intravascular lymphomas are rare disease conditions that exhibit neoplastic lymphoid cells that are confined mainly to the lumens of small capillaries and medium-sized vessels. The majority of the intravascular lymphomas are of B-cell origin, but they can include NK/T-cell and CD30+ immunophenotypes. In the histologic differential diagnosis are benign proliferations such as intralymphatic histiocytosis and intravascular atypical CD30+ T-cell proliferation. In this review, we discuss the clinical, histopathologic, and molecular findings of intravascular B-cell lymphoma, intravascular NK/T-cell lymphoma, intralymphatic histiocytosis, and benign atypical intravascular CD30+ T-cell proliferation.

Intravascular NK/T-cell lymphoma: a case report and literature review

Intravascular lymphoma is characterized by an exclusively intravascular distribution of tumor cells. Intravascular natural killer/T-cell lymphoma (IVNKTL) is extremely rare, highly aggressive, commonly Epstein-Barr virus (EBV)-positive, and predominantly affects the skin and central nervous system. Here we report a case of IVNKTL diagnosed in a 67-year-old female, presenting with persistent intermittent fever and skin rashes throughout the body. Incisional biopsy of an erythematous lesion on the chest exhibited aggregation of medium to large-sized atypical lymphoid cells confined to the lumen of small vessels that were positive for CD3, granzyme B, and CD56 on immunohistochemistry and EBV-encoded RNA in situ hybridization. EBV DNA was also detected in serum after diagnosis. With a review of 26 cases of IVNKTL to date, we suggest that active biopsy based on EBV DNA detection may facilitate early diagnosis of IVNKTL.

Intravascular NK/T-Cell Lymphoma: What We Know about This Diagnostically Challenging, Aggressive Disease

Intravascular lymphoma is a form of lymphoid malignancy characterized by neoplastic cells growing almost exclusively within the lumina of small- to medium-sized blood vessels. Most cases are of B-cell origin with rare cases of natural killer or T-cell lineage. Extranodal sites are affected, mainly the skin and central nervous system, although any organ may be involved. Intravascular NK/T-cell lymphoma deserves special attention because of its clinicopathologic features and the need for adequate immunophenotyping combined with clonality test for a proper diagnosis. Moreover, intravascular NK/T-cell lymphoma is strongly linked to Epstein-Barr virus (EBV), which is considered to play a role in tumorigenesis and to be responsible for the aggressive behavior of the disease. In this paper, we review the current knowledge on this rare lymphoma and, in particular, the most recent advances about its molecular landscape. The main distinguishing features with other EBV-related entities, such as extranodal NK/T-cell lymphoma, EBV-positive primary nodal T/NK-cell lymphoma, and aggressive NK-cell leukemia, are discussed to help pathologists obtain the correct diagnosis and consequently develop an adequate and prompt therapy response.

[Clinicopathological features of intravascular peripheral T-cell lymphoma]

Objective: To summarize the clinical and pathological features of intravascular NK and T cell lymphoma for better understanding of such disease to reduce misdiagnosis and miss-diagnosis. Methods: Clinical and pathological features were analyzed retrospectively in one case of intravascular peripheral T-cell lymphoma, not otherwise specified (IVPTCL, NOS) , with literatures review. Results: The case presented in this study was a 66-year-old man. PET/CT scan showed multiple lymph nodes enlargement throughout the body. Normal lymph node structure could not be observed by tissue biopsy, while lymph follicles were partially disrupted. High-power light microscope revealed a large number of blood vessels with diffuse proliferation and dilation, where atypical lymphoid cell mass was restricted in the lumen and partially infiltrated the large blood vessel wall. These tumor cells were medium to large with moderate cytoplasm. The nucleus was irregular, single or multiple nucleoli could be seen, chromatin was condensed, some were empty and bright, and mitotic figures could be seen. Immunohistochemical staining showed that the neoplastic cells were positive for expression of CD3, CD43, CD8, GrB, TIA-1 and perforin. EBER in situ hybridization result was negative. Polymerase chain reaction test identified a clonal gene rearrangement of T-cell receptor γ. The patient was treated with CHOP in combination with chidamide, but died of infection and cardiopulmonary failure within 2 months. 56 cases of intravascular NK/T cell lymphoma with definite classification were collected from relevant literatures, including 47 cases with nasal type of extranodal NK/T cell lymphoma (27 were male and 20 were female) , 8 cases with anaplastic large cell lymphoma (3 males and 5 females) , and only one case with de nova IVPTCL, NOS in brain. We report the second case of IVPTCL,NOS, and notably originated from lymph node for the first time. Conclusions: Intravascular NK/T cell lymphoma is a highly aggressive disease with no effective treatment at present. Involvement of Lymph node has rarely been reported, and further studies on more cases are necessary.

Case of Extranodal Natural Killer/T-Cell Lymphoma, Nasal Type, Presenting With Intravascular Localization of Tumor Cells in Skin Biopsies From Both Plaque and Normal-Appearing Skin: A Case Report and Literature Review

Extranodal natural killer/T-cell lymphoma, nasal type (ENKTL-NT), is a rare subtype of non-Hodgkin lymphoma associated with Epstein-Barr virus. This type of lymphoma is rare in Western countries but is more frequent in East Asia and Latin America. ENKTL-NT mostly occurs in the nose and paranasal area, including the upper aerodigestive tract. The skin is the second-most commonly involved organ. ENKTL-ET is characterized by an angiocentric, angiodestructive pattern of growth with ulceration and necrosis evident on histopathological examination. We provide the first description of ENKTL-NT presenting with intravascular localization of tumor cells in skin biopsies from both plaque and normal-appearing skin. Random skin biopsy might thus be useful for early diagnosis, staging, and estimation of prognosis in ENKTL-NT. Moreover, the current case indicates that ENKTL-NT and intravascular natural killer/T-cell lymphoma may represent related diseases.

Cytogenetic complexity and heterogeneity in intravascular lymphoma

AIMS

To characterise the karyotypic abnormalities and heterogeneities in intravascular lymphoma (IVL).

METHODS

G-banded karyotyping was performed on biopsy specimens from a single-centre IVL cohort comprising intravascular large B-cell lymphoma (IVLBCL, n=12) and NK/T-cell lymphoma (IVNKTCL, n=1).

RESULTS

Five IVLBCL cases and one IVNKTCL case (total 46%) were found to have normal karyotypes, and the cytogenetic abnormalities observed in the other seven IVLBCL cases (54%) were investigated further. These seven karyotypes were uniformly complex with an average of 13 aberrations. The seven cases all had abnormalities involving chromosome 6, with 57% involving structural abnormalities at 6q13, and chromosome 8, with 43% involving abnormalities at 8p11.2. In addition, 71% had aberrations at 19q13. On average, 4.4 chromosomal gains and losses were detected per case. Cytogenetic heterogeneities were observed in six cases (86%) and tetraploidy in three cases (43%). There was no significant difference in progression-free survival (p=0.92) and overall survival (p=0.61) between the IVLBCL cases with complex and normal karyotypes.

CONCLUSION

Approximately half of IVLBCL cases had a highly heterogeneous pattern of karyotypes with different clonal numerical and structural chromosome aberrations.

Intravascular NK/T-cell lymphoma, Epstein-Barr virus positive with multiorgan involvement: a clinical dilemma

Background

Intravascular lymphoma is a rare type of non-Hodgkin lymphoma mostly of B-cell lineage. A few cases of intravascular lymphoma have been found to be of NK/T-cell origin, mainly affecting the skin and central nervous system.

Case presentation

A 54-year-old Caucasian man sought care because of a 2 weeks history of jaundice and intermittent fever, not responsive to antibiotics and antipyretics. Laboratory tests showed low blood oxygen concentration and pancytopenia. Serum microbiological tests were negative. Computerized tomography (CT) scan revealed hepatosplenomegaly and diffuse ground-glass opacities in both lungs without interlobular septal thickening. Despite oxygen therapy, the clinical conditions rapidly deteriorated leading to death 3 days after admission. Autopsy revealed a multiorgan involvement by an Epstein-Barr virus positive NK/T-cell lymphoma, strikingly growing within the blood vessel lumina, in absence of skin lesions.

Conclusions

The current case highlights the pathological features of this rare entity, the protean clinical presentation of which is often misleading, resulting in delayed diagnosis and treatment.

[Aggressive primary cutaneous B-cell lymphomas and novel EBV+ entities]

Primary cutaneous large B‑cell lymphomas (PCBLT), EBV-positive large B‑cell lymphomas, not otherwise specified (EBV+ DLBCL, NOS), and primary cutaneous intravascular large B‑cell lymphomas (PCIVLBL) are recognized as cutaneous lymphomas with intermediate to poor prognosis. Differentiation from indolent B‑cell lymphomas or other pathologies of the skin can be complex, both clinically and histologically, but vital for the outcome of the patient. The combination of immunotherapy and polychemotherapy regimens, such as R‑CHOP, has led to significant improvements in prognosis, especially in diffuse large B‑cell lymphomas. Therapeutic decisions need to be individually made for each patient, ideally within an interdisciplinary tumor conference. Immunosenescence may be an important factor in the pathogenesis of EBV+ DLBCL, NOS in elderly individuals. Their prognosis is less favorable than that of patients with EBV-negative PCBLT, whereby this has been observed particularly in elderly patients. One third of patients with PCIVLBL progress to systemic disease. The occurrence of nodal manifestation is rarely observed. Symptoms may vary depending on the organ system involved. Currently there are no evidence-based therapy recommendations due to the rarity of the disease. EBV-positive mucocutaneous ulcer is a new provisional category in the current WHO classification for lymphoid neoplasms. It has been segregated from EBV+ DLBCL, NOS due to its self-limiting course and good response to conservative therapy.

Cutaneous Intravascular NK/T-cell lymphoma mimic panniculitis clinically, case report and literature brief review

Intravascular large cell lymphoma is a rare subtype of extranodal large cell lymphoma characterized by the presence of neoplastic cells within the lumina of small vessels. Most cases of intravascular large cell lymphoma have a B-cell phenotype. To date, 12 cases of intravascular natural killer (NK/)/T–cell lymphoma (IVNKL) have been reported. Our case is A 47-year-old female presented with erythematous patches and plaques on the lower extremities mimicking panniculitis clinically. A skin biopsy revealed intravascular lymphoma (IVL) with a NK/T cell phenotype (positive for CD3, and granzyme B and negative for CD20, CD4, CD8, CD5). The lymphoma cells were also positive for Epstein-Barr virus by Epstein-Barr virus-encoded RNA in situ hybridization test. Because this type of lymphoma is extremely rare, our case is documented and compared with the previously reported cases.

Intravascular NK-cell lymphoma: a case report and review of the literature

Background

Intravascular NK-cell lymphoma (IVNKL) is an extremely rare variant of non-Hodgkin lymphoma. To our knowledge, there are only a few cases reported in the English literature. Here, a case of a 29-year-old male with IVNKL involving the skin of the trunk and 4 extremities and liver is presented. A comprehensive literature review is undertaken to summarize the clinical and pathological features of this disorder.

Findings

In our case, large neoplastic lymphoid cells are restricted to the lumen of small vessels and exhibit the phenotype of a true NK cell. The morphology and immunophenotype, positivity of EBER and NK-cell origin are similar to other IVNKL cases. In addition, some cases including ours carry a poor prognosis as multiple systems or vital organs are involved.

Conclusion

In summary, we report a case of an unusual intravascular lymphoma of NK-cell lineage that displays both clinical and pathological features and compare it with other differential diagnoses. It is important to recognize this rare entity to make an appropriate diagnosis and achieve a better understanding regarding the treatment and prognosis.

Intravascular proliferating anaplastic lymphoma kinase-positive anaplastic large-cell lymphoma

An 82-year-old Japanese man visited our emergency unit complaining of dyspnea. Laboratory data showed 15% atypical lymphocytes in peripheral blood which expressed the T-cell phenotype. Chest/abdominal computed tomography depicted hepatosplenomegaly and swelling of systemic lymph nodes. The patient died of advanced respiratory failure 5 d after the first occurrence of his dyspnea. At autopsy, the pathological features revealed a diffuse infiltration of large atypical lymphocytes to systemic organs including the spleen and lung. In immunohistochemical staining, these cells expressed CD30, TIA-1, anaplastic lymphoma kinase (ALK), CD5 and CD3. An advanced surface molecule analysis revealed a lack of CD54 (intercellular cell adhesion molecule-1) and CD56 (neural cell adhesion molecule). We observed the proliferation and infiltration of these lymphoma cells specifically at the intravascular lesions similar to intravascular lymphoma (IVL). T-cell IVL is not established as an independent clinical entity in the World Health Organization classification, and our patient’s ALK-positive T-IVL in lung appears to be the first reported case.

Cutaneous intravascular natural killer-cell lymphoma: a case report and review of the literature

OBJECTIVES

To our knowledge, since 2003, there have been 11 reported cases of intravascular natural killer (NK)-cell lymphoma (IVNKL). Herein we describe the 12th case.

METHODS

H&E and Envision immunohistochemical stains as well as in situ hybridization were used to study this disease in combination with review of the literature.

RESULTS

Half of the cases reported to date are from China and Taipei. The clinical manifestation of IVNKL is erythema in the limbs and trunk, although patients' conditions have varied notably from each other. One-year survival rate is about 40%.

CONCLUSIONS

IVNKL should be distinguished from extranodal NK/T-cell lymphoma (nasal type) and aggressive NK-cell leukemia. These three diseases have a similar phenotype and are all related to Epstein-Barr virus infection. However, the pathogenesis of similarities and differences needs further study. In particular, IVNKL is quite unusual. The treatment of IVNKL is difficult, and the prognosis is poor. Currently, IVNKL is not included in the World Health Organization classification subtypes and has been classified into NK/T-cell lymphoma (nasal type). However, in view of the unique characteristics of this disease, we propose that the diagnosis be independent, since this will facilitate further study of this disease.

Canine intravascular lymphoma with overt leukemia

A 6-year-old spayed Labrador Retriever Mix dog was evaluated for a 2-week history of progressive generalized weakness and reluctance to stand. Physical examination revealed severe weakness with obtunded mentation, head tilt, bilateral nystagmus, and decreased vision. CBC findings included mild nonregenerative anemia, marked thrombocytopenia, and a few atypical mononuclear cells on the blood film. The cells were 15-30 μm in diameter and had round to oval to reniform centrally placed nuclei with stippled chromatin, prominent nucleoli, and abundant basophilic cytoplasm with numerous discrete vacuoles and, occasionally, small azurophilic granules. Similar cells were found in bone marrow. On histologic examination of tissues collected at necropsy, neoplastic cells were detected in bone marrow, hepatic sinusoids, cerebral and meningeal vessels, and in capillaries of the heart, renal interstitium, small intestinal submucosa, and muscularis, and alveolar septa. A small discrete mass in the right atrium consisted of similar neoplastic cells, and the spleen was diffusely infiltrated. Tissue distribution was suggestive of intravascular lymphoma. Neoplastic cells in tissue sections were immunoreactive for vimentin, CD18, CD45, and granzyme B and lacked immunoreactivity for cytokeratin. Neoplastic cells on bone marrow aspirate smears and blood films lacked immunoreactivity for CD3, CD79a, CD1c, CD11b, CD11c, CD11d, and E-cadherin. In the absence of immunophenotypic evidence for the neoplastic cells being derived from B-cell, T-cell, or histocytic/dendritic lineages and the lack of clonal antigen receptor gene rearrangement(s), along with positive immunoreactivity for granzyme B, a tumor of NK cells was considered likely. Based on current knowledge, this is the first report of canine intravascular lymphoma, of probable NK cell origin, with peripheral blood involvement.

Cutaneous intravascular anaplastic large cell lymphoma

Intravascular lymphoma (IL) is a rare variant of non-Hodgkin lymphoma with a predilection for skin. Most reported cases are large B cell lymphomas. Intravascular anaplastic large cell lymphoma (IALCL) is extremely rare. Retrospective analysis of a case of cutaneous IALCL was performed. Hematoxylin and eosin stained sections and immunohistochemical staining results were analyzed. The patient was a 47-year-old woman who had developed multiple erythematous patches and plaques on her back. The lesions responded well to CHOP (cyclophosphamide, hydroxydoxorubicin, oncovin, prednisone) chemotherapy, but relapsed shortly after therapy. The patient was surviving with the disease for eight years but was ultimately lost to follow up. Histopathologically, the neoplasm evolved from IL to extravascular lymphoma. This was showed in biopsies obtained at different stages of the disease. The lymphoma cells stained positively for CD30, CD45, CD3, CD4, CD5 and Ki67, and lacked expression of anaplastic lymphoma kinase (ALK), CD8, CD45RA, CD45RO, CD20, CD79, CD56, perforin and granzyme B. Our results suggest that IALCL represents a distinct subtype of IL and is histopathologically and biologically different from IL with B, NK or T cell phenotype.