Analysis of 142 Northern Chinese patients with peripheral T/NK-Cell lymphomas: subtype distribution, clinicopathologic features, and prognosis

Brentuxinmab vedotin, alone or combine with bendamustine in the treatment of natural killer T cell lymphoma

Natural killer (NK)/T cell lymphoma is a highly aggressive subtype of non-Hodgkin lymphoma. The prognosis of patients with natural killer T cell lymphoma (NKTCL) remains poor. More potent treatment strategies are urgently needed to improve the survival of these patients with R/R NKTCL. CD30 expression has been reported to occur in about 40% of NK/T cell lymphoma. Brentuximab vedotin (BV), a monomethyl auristatin E conjugated CD30 antibody, targets CD30 to kill cancer cells. Therapeutic combination of BV and bendamustine has been shown to be highly effective in Hodgkin lymphoma. We investigated efficacy of BV in treating NKTCL as a single therapy, and in combination with bendamustine in vitro and in vivo. We determined CD30 expression levels in 6 NKTCL cell lines. The efficiency of lymphoma cell inhibition by BV correlates with CD30 expression. We also determined the efficacy of BV in combination with bendamustine and found synergistic effects with bendamustine in NKTCL. Combined BV and bendamustine treatment exerted synergistic antiproliferation effect and enhanced cell apoptotic in vitro and in vivo. Brentuximab vedotin and bendamustine synergistically arrested cell cycle at the G2/M phase in NKTCL cell lines. The combination of BV and bendamustine was demonstrated to synergistically damage DNA in NKTCL. This study provides a reference for possible application on using BV for the treatment of NKTCL, either as a single agent or in combination with bendamustine.

Extranodal Natural Killer/T-Cell Lymphomas: Current Approaches and Future Directions

Extranodal natural killer/T(NK/T)-cell lymphoma (ENKTL) is a rare subtype of non-Hodgkin lymphoma that typically presents with an isolated nasal mass, but a sizeable minority present with advanced stage disease and have a significantly poorer prognosis. Those with limited disease are standardly treated with chemotherapy and radiation while those with advanced stage disease are treated with L-asparaginase containing chemotherapy regimens. The addition of modern radiation therapy techniques and the incorporation of L-asparaginase into chemotherapy regimens have significantly improved outcomes in this disease, but relapses and death from relapsed disease remain frequent. Given the high rate of relapse, several novel therapies have been evaluated for the treatment of this disease. In this review, we explore the current standard of care for ENKTL as well as novel therapies that have been evaluated for its treatment and the biologic understanding behind these therapies.

Extranodal NK/T-cell lymphoma, nasal type without evidence of EBV infection

Extranodal natural killer/T cell lymphoma-nasal type (EN-NK/T-NT) is extremely rare in Western countries; however, it is the most common subtype of peripheral T cell lymphoma in China. Despite this, there are a limited number of clinicopathological research studies on Epstein-Barr virus (EBV)-negative EN-NK/T-NTs. EBV-negative EN-NK/T-NT is a rare disease type, which has not been fully investigated. If other diagnostic criteria are met, such as the lesions being located predominantly in the upper aerodigestive tract, the presence of angiocentricity or angioinvasion, necrosis and expression of NK/T-cell phenotype, EN-NK/T-NT may be diagnosed, even if EBV is negative. In the present study, 99 cases of EN-NK/T-NTs were analyzed retrospectively, among which seven cases were EBV-negative EN-NK/T-NTs and selected for further investigation. In addition, the present study reviewed previously published research into EN-NK/T-NT, highlighting that EBV-negative EN-NK/T-NT is rare and that its geographical distribution is mainly in countries in Asia, Central America and South America. Patients with EBV-negative EN-NK/T-NT were all of Chinese ethnicity, with a median age of 32 years and primarily female. Furthermore, these patients shared similar clinicopathological characteristics (such as the tumor occurring mainly in the upper aerodigestive tract, the presence of vascular destruction, necrosis and cytotoxic phenotypes) to patients with EBV-positive EN-NK/T-NT. Immunohistochemistry and molecular analysis results indicated that tumor cells were primarily of NK or cytotoxic T origin; however, EBV-encoded small RNAs were not detected in any of these cases. Among the immunochemistry markers, T-bet was statistical significantly different between EBV-positive and -negative cases. Fluorescence in situ hybridization was also performed in two EBV-negative cases, including one case with a co-deletion of 6q21 and PR/SET domain 1 genes. There was only available follow-up data in 3/5 patients who survived for 37–113 months (median, 40 months). As EN-NK/T-NT can be diagnosed, even when EBV is negative, awareness of this subtype may prevent misdiagnosis or delayed diagnosis.

Reproducing the molecular subclassification of peripheral T-cell lymphoma-NOS by immunohistochemistry

Peripheral T-cell lymphoma (PTCL) is a heterogeneous group of mature T-cell malignancies; approximately one-third of cases are designated as PTCL-not otherwise specified (PTCL-NOS). Using gene-expression profiling (GEP), we have previously defined 2 major molecular subtypes of PTCL-NOS, PTCL-GATA3 and PTCL-TBX21, which have distinct biological differences in oncogenic pathways and prognosis. In the current study, we generated an immunohistochemistry (IHC) algorithm to identify the 2 subtypes in paraffin tissue using antibodies to key transcriptional factors (GATA3 and TBX21) and their target proteins (CCR4 and CXCR3). In a training cohort of 49 cases of PTCL-NOS with corresponding GEP data, the 2 subtypes identified by the IHC algorithm matched the GEP results with high sensitivity (85%) and showed a significant difference in overall survival (OS) (P = .03). The IHC algorithm classification showed high interobserver reproducibility among pathologists and was validated in a second PTCL-NOS cohort (n = 124), where a significant difference in OS between the PTCL-GATA3 and PTCL-TBX21 subtypes was confirmed (P = .003). In multivariate analysis, a high International Prognostic Index score (3-5) and the PTCL-GATA3 subtype identified by IHC were independent adverse predictors of OS (P = .0015). Additionally, the 2 IHC-defined subtypes were significantly associated with distinct morphological features (P < .001), and there was a significant enrichment of an activated CD8+ cytotoxic phenotype in the PTCL-TBX21 subtype (P = .03). The IHC algorithm will aid in identifying the 2 subtypes in clinical practice, which will aid the future clinical management of patients and facilitate risk stratification in clinical trials.

Extranodal NK/T-cell lymphoma in Tunisia: clinicopathological features, immunophenotype and EBV infection

BACKGROUND

Extranodal NK/T-cell lymphomas (ENKTL) are rare non-Hodgkin's lymphomas with aggressive clinical behavior. ENKTL are frequently associated with the Epstein-Barr virus (EBV). Data on ENKTL in Africa and Arab world are extremely limited. The study investigated the clinicopathological characteristics, EBV infection, and immunophenotype of ENKTL in Tunisia. We conducted a retrospective study of ENKTL. Main clinicopathological features were reported. The expression of CD3, CD4, CD5, CD8, CD20, CD56, CD57, and Granzyme B were analyzed by immunohistochemistry. EBV infection was detected by IHC (LMP-1) and Epstein-Barr encoding region (EBER1/2) in situ hybridization.

RESULTS

A total of nine ENKTL were identified (mean age of 48 years and male-to-female ratio of 8:1). There were five nasal ENKTL, and the remaining four cases had extranasal involvement (palate, sub-mandibular gland, skin, and soft tissues of the ankle). The histopathology showed a lymphoid and pleomorphic proliferation characterized by images of angiocentrism. Strong and diffuse CD3 expression was observed in all cases. Tumor cells exhibited an expression of CD5 (two cases), CD8 (three cases), CD56 (six cases), CD57 (three cases), and Granzyme B (eight cases). All ENKTL cases were EBV-associated. Overall 5-year survival rate was 57%. Although six ENKTL were diagnosed at early clinical stages, the prognosis was unfavorable and associated with patient death in three cases.

CONCLUSIONS

ENKTL are exceptional in Tunisia with unfavorable outcome. Histopathological diagnosis remains challenging in clinical practice. However, a careful histopathological examination combined with a correct interpretation of immunohistochemistry and in situ hybridization results refines the ENKTL diagnosis.

Characteristics, Prognostic Factors, and Survival of Patients with NK/T-Cell Lymphoma of Non-upper Aerodigestive Tract: A 17-Year Single-Center Experience

Purpose

The extranodal natural killer (NK)/T-cell lymphoma (NKTCL) of non-upper aerodigestive tract (NUAT) was found to have clinical heterogeneity compared with NKTCL of the upper aerodigestive tract (UAT) in small scale studies. We conducted this study in a much larger cohort to analyze the clinical characteristics, prognostic factors, treatment modality, and clinical outcomes of patients with NUAT-NKTCL.

Materials and Methods

From January 2001 to December 2017, a total of 757 NKTCL patients were identified and included in this study, including 92 NUAT-NKTCL patients (12.2%) and 665 UAT-NKTCLpatients (87.8%).

Results

NUAT-NKTCL patients had relatively poorer performance status, more unfavorable prognostic factors, and more advanced stage, compared with UAT-NKTCL patients. The 5-year overall survival (OS) was 34.7% for NUAT-NKTCL, which was significantly worse than UAT-NKTCL (64.2%, p<0.001). The median OS duration was 30.9 months for NUAT-NKTCL. Multivariate analysis showed that presence with B symptoms and elevated serum lactate dehydrogenase independently predicted worse OS. International prognostic index score and prognostic index of natural killer lymphoma score still had prognostic values in NUAT-NKTCL, while the Ann Arbor system could not accurately predict the OS.

Conclusion

NUAT-NKTCL is a distinctive subtype of NKTCL in many aspects. Patients with NUAT-NKTCL have relatively poorer performance status, more unfavorable prognostic factors, more advanced stage, and poorer prognosis.

CD30-positive cutaneous extranodal natural killer/T-cell lymphoma: clinicopathological features and survival outcomes

BACKGROUND

The prognostic value of CD30 expression in cutaneous extranodal natural killer/T-cell lymphoma is controversial.

METHODS

Clinicopathological features, survival outcomes, and prognostic implications of CD30 were retrospectively analyzed in 55 patients with cutaneous extranodal natural killer/T-cell lymphoma. We classified patients into (i) primary cutaneous extranodal natural killer/T-cell lymphoma and (ii) cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease depending on the primary tumor site.

RESULTS

CD30+ cutaneous extranodal natural killer/T-cell lymphoma was more common in patients with cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease than in those with primary cutaneous disease. CD30+ cases were more likely to present nodular lesions or cellulitis-like swelling than CD30- cases. Histologically, CD30+ cutaneous extranodal natural killer/T-cell lymphoma predominantly comprised large tumor cells compared with CD30- cases. However, the clinical morphology and tumor cell size were not associated with survival outcomes. CD30 expression was associated with better survival outcomes in patients with cutaneous extranodal natural killer/T-cell lymphoma secondary to nasal disease.

CONCLUSION

CD30+ cutaneous extranodal natural killer/T-cell lymphoma presented peculiar clinicopathological features and had more favorable disease course in patients with cutaneous dissemination from nasal disease.

GATA3 expression correlates with poor prognosis and tumor-associated macrophage infiltration in peripheral T cell lymphoma

Peripheral T cell lymphoma (PTCL) is an aggressive form of non-Hodgkin's lymphoma characterized by a poor prognosis. In this study, we examined the prognostic value of two T-cell-specific transcription factors, GATA3 and T-bet, in PTCL, uncovered the pathogenesis of PTCL, and investigated new PTCL therapeutic targets. Samples from 109 PTCL patients were examined for expression of GATA3, T-bet and CD68. High GATA3 expression correlated with poor survival in PTCL patients and with tumor-associated macrophage (TAM) infiltration, as indicated by the presence of CD68-positive cells. Multivariate analysis further confirmed that high GATA3 expression and Eastern Cooperative Oncology Group (ECOG) scores higher than 2 were independent predictors of patient survival. Using lentiviral transfection to induce stable GATA3 knockdown in a PTCL cell line, we observed that GATA-3 knockdown in Hut78 cells decreased levels of IL4, IL5, IL13 and VEGF mRNA and reduced the number of co-cultured U937 cells that differentiated towards the M2 phenotype. These results suggest that high GATA3 expression is a predictor of a poor prognosis in PTCL, and that T lymphoma cells promote M2-type macrophage differentiation through a GATA3-dependent mechanism.

CD30 expression in extranodal natural killer/T-cell lymphoma, nasal type among 622 cases of mature T-cell and natural killer-cell lymphoma at a single institution in South China

Background

Mature T-cell and natural killer (NK)-cell lymphomas compose a heterogeneous group of non-Hodgkin lymphomas, and extranodal NK/T-cell lymphoma, nasal type (ENKTL) is an aggressive subtype with sporadic CD30 expression. However, the significance of CD30 expression in ENKTL is controversial. We aimed to classify a large cohort of patients with mature T-cell and NK-cell lymphomas according to the 2016 World Health Organization (WHO) classification guidelines and to study the association between CD30 expression and prognosis of patients with ENKTL.

Methods

We selected consecutive patients with mature T-cell and NK-cell lymphomas who attended our institution between September 1, 2009 and August 31, 2013. We classified the lymphomas according to the 2016 revision of the WHO classification of lymphoid neoplasms, analyzed the associations between CD30 expression and clinicopathologic features of ENKTL patients, and evaluated the prognostic implications of CD30 expression.

Results

We identified 622 consecutive patients with mature T-cell and NK-cell lymphomas, including 317 (51.0%) patients with ENKTL. In addition, CD30 expression was detected in 43 (47.3%) of a subset of 91 patients with ENKTL. No clinicopathologic features were associated with CD30 expression, and CD30 positivity showed no prognostic significance in patients with ENKTL.

Conclusions

ENKTL is the most common type of mature T-cell and NK-cell lymphoma diagnosed at our institution. CD30 is frequently expressed in ENKTL and represents a therapeutic target; however, it may not be a prognostic marker.

Hypermethylation of PRDM1/Blimp-1 promoter in extranodal NK/T-cell lymphoma, nasal type: an evidence of predominant role in its downregulation

The loss of PRDM1 expression is common in extranodal NK/T-cell lymphoma, nasal type (EN-NK/T-NT), but the role of promoter methylation in silencing PRDM1 expression remains unclear. Hence, we performed pyrosequencing analysis to evaluate the promoter methylation of PRDM1 gene in vivo and in vitro, to analyze the association between methylation and its expression, and to assess cellular effects of PRDM1 reexpression. The promoter hypermethylation of PRDM1 gene was detected in 11 of 25 EN-NK/T-NT cases (44.0%) and NK92 and NKL cells. The promoter hypermethylation of PRDM1 was significantly correlated with PRDM1 expression in vivo and in vitro, predominantly contributing to the loss of PRDM1 expression compared with genetic deletion and aberrant expression of miR-223 in EN-NK/T-NT. PRDM1 expression was significantly restored by demethylation treatment, which induced cell proliferation suppression, cell cycle arrest, and apoptosis increase. We also found that PRDM1 reexpression could downregulate the expression of Ets-1, T-bet, granzyme B, and c-myc. Our findings demonstrated that the promoter hypermethylation of PRDM1 harbored a predominant role in the downregulation of PRDM1 expression, significantly affecting the biological behavior of tumor cells in EN-NK/T-NT.

[T-bet in peripheral T-cell lymphoma]

目的

观察转录因子T-bet (T-box expressed in T cells）在外周T细胞淋巴瘤（PTCL）患者中的表达并分析其与预后的相关性。

方法

收集2007年至2013年间由北京协和医院病理科诊断的109例初治PTCL患者的石蜡包埋病理标本及临床资料。对患者标本进行免疫组化染色，观察转录因子T-bet的表达并分析其与患者临床特征及预后的关系。

结果

109例初治PTCL患者中PTCL非特指型（PTCL-NOS）60例，NK-T细胞淋巴瘤（NKT) 18例，血管免疫母细胞性T细胞淋巴瘤11例，ALK阳性及阴性间变大细胞淋巴瘤各4例，其他12例。109例患者中T-bet总体阳性率为42.2%，在PTCL-NOS组患者中为43.3%，在NKT组患者中为44.4%。Kaplan-Meier生存曲线法结果显示，T-bet表达水平与PTCL患者总生存期无相关性（P=0.586）。病理亚型分层研究发现，T-bet表达水平与PTCL-NOS组患者总生存期无相关性（P=0.309），与NKT组患者总生存期呈正相关（P=0.004）。多因素分析提示ECOG评分≥2分为影响PTCL患者预后的独立危险因素（HR=5.907，95%CI 2.399~14.549，P<0.001）。

结论

转录因子T-bet在几类PTCL病理亚型患者中均有阳性表达，其表达水平与NKT患者总生存期呈正相关。

The Genetic Deletion of 6q21 and PRDM1 and Clinical Implications in Extranodal NK/T Cell Lymphoma, Nasal Type

6q21 genetic deletion has been frequently detected in extranodal NK/T cell lymphoma, nasal type (EN-NK/T-NT), and PRDM1 is considered as candidate gene. However, direct detection of PRDM1 deletion has not been well documented. We investigated genetic alterations of 6q21 and PRDM1 in 43 cases of EN-NK/T-NT and cell lines by FISH. PRDM1 expression was evaluated by immunohistochemistry and Western blot. The correlation between genetic alteration and PRDM1 expression and the significance in clinic-pathologic were analyzed. Heterozygous deletion of 6q21 and/or PRDM1 was observed in 24 of 43 cases (55.81%) of EN-NK/T-NT including 16 cases (37.21%) for 6q21 deletion and 19 cases (44.19%) for PRDM1 deletion. Similarly, heterozygous codeletion of 6q21 and PRDM1 was identified in NK92 and NKL cells. The heterozygous deletion of 6q21 and/or PRDM1 was correlated with PRDM1 expression. However, genetic deletion of 6q21 and/or PRDM1 was not correlated with clinicopathological features of EN-NK/T-NT, while PRDM1 expression showed positive effect on the outcome of patients as those as disease site, B symptom, and clinical stage. Thus, heterozygous deletion of 6q21 and/or PRDM1 was frequently detected in EN-NK/T-NT and correlated with downregulation of PRDM1. But the prognostic role of genetic deletion needs to be further evaluated in larger cohort.

The downregulation of PRDM1/Blimp-1 is associated with aberrant expression of miR-223 in extranodal NK/T-cell lymphoma, nasal type

BACKGROUND

The mechanism for inactivation of positive regulatory domain containing I (PRDM1), a newly identified tumour suppressor gene in extranodal NK/T-cell lymphoma, nasal type (EN-NK/T-NT) has not been well defined. The aim of the present study was to investigate the expression of PRDM1 in EN-NK/T-NT and analyse its downregulation by miRNAs.

METHODS

PRDM1 and miRNA expression were evaluated in EN-NK/T-NT samples by immunohistochemical analysis, qRT-PCR, and in situ hybridisation. Luciferase assays were performed to verify the direct binding of miR-223 to the 3'-untranslated region of PRDM1 mRNA. In addition, the effect of miR-223 on PRDM1 expression was assessed in NK/T lymphoma cell lines by transfecting a miR-223 mimic or inhibitor to increase or decrease the effective expression of miR-223. Overall survival and failure-free survival in EN-NK/T-NT patients were analysed using Kaplan-Meier single-factor analysis and the log-rank test.

RESULTS

Investigation of the downregulation of PRDM1 in EN-NK/T-NT cases revealed that PRDM1-positive staining might be a favourable predictor of overall survival and failure-free survival in EN-NK/T-NT patients. However, the negative staining of PRDM1 usually presented transcripts, suggesting a possible post-transcriptional regulation. miR-223 and its putative target gene, PRDM1, exhibited opposite patterns of expression in EN-NK/T-NT tissues and cell lines. Moreover, PRDM1 was identified as a direct target gene of miR-223 by luciferase assays. The ectopic expression of miR-223 led to the downregulation of the PRDM1 protein in the NK/T-cell lymphoma cell line, whereas a decrease in miR-223 restored the level of PRDM1 protein.

CONCLUSIONS

Our findings reveal that the downregulation of the tumour suppressor PRDM1 in EN-NK/T-NT samples is mediated by miR-223 and that PRDM1-positive staining might have prognostic value for evaluating the clinical outcome of EN-NK/T-NT patients.

Extranodal natural killer/T-Cell lymphoma: A population-based comparison of sinonasal and extranasal disease

OBJECTIVES/HYPOTHESIS

Extranodal natural killer/T-cell Lymphoma (ENKTL) is a rare, aggressive malignancy that preferentially affects the paranasal region. This study analyzes the demographic, clinicopathologic, incidence, and survival characteristics of sinonasal ENKTL (SN-ENKTL) and extranasal ENKTL (EN-ENKTL) in a comparative fashion.

STUDY DESIGN

Retrospective analysis.

METHODS

The Surveillance, Epidemiology, and End Results database was queried; 528 cases were available for frequency and incidence analysis, and 473 for survival analysis. Data were examined according to age, gender, race, histology, the presence of systemic (or B) symptoms, treatment, and Ann Arbor stage.

RESULTS

Extranasal disease was a poor prognostic factor (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.30-2.19, P < .05). Patients with EN-ENKTL were older (mean 53.8 vs. 49.9 years, P < .05), most were male (72.5% vs. 59.8%, P < .05), and they were more likely to present with stage IIIE/IV disease (38.33% vs. 18.26%, P < .05). B symptoms were present in 38.41% of the EN-ENKTL group (vs. 22.86%, P < .05), and were a poor prognostic factor in this group only (HR = 1.6593, 95% CI = 1.05-2.62, P < .05). Radiation therapy demonstrated a survival advantage among both groups, especially in early stage disease.

CONCLUSIONS

SN-ENKTL carries a significantly better prognosis than EN-ENKTL, which presents at more advanced stages. Radiation therapy was associated with increased survival in both groups, especially in cases of localized disease.

LEVEL OF EVIDENCE

2b.

Increased expression of Trop2 correlates with poor survival in extranodal NK/T cell lymphoma, nasal type

Human trophoblastic cell surface antigen 2 (Trop2) has been suggested to play an important role in the development of solid tumors. However, the expression of Trop2 in extranodal NK/T cell lymphoma, nasal type (ENKTL) and the relationship with the clinical characteristics of this disease remain poorly understood. In this study, one-step quantitative PCR reverse transcription-polymerase chain reaction and immunohistochemical staining with tissue sections were employed to evaluate the expression of Trop2 in ENKTL. Furthermore, the relationship between Trop2 expression and prognosis of ENKTL was investigated. Expression of Trop2 mRNA and protein was significantly higher in ENKTL tissue than in corresponding non-lymphomatous tissue (p = 0.04 and p < 0.001, respectively). Expression of Trop2 protein in ENKTL was associated with lymph node involvement and poor overall survival (p = 0.045 and p = 0.018, respectively). Kaplan-Meier analysis and the logrank test indicated that lymph node involvement (p = 0.0481), single therapy strategy (p = 0.0037), and high expression of Trop2 (p = 0.0042) are significantly correlated with poor prognosis of ENKTL patients. The data suggest that Trop2 expression reflects a more malignant phenotype and may serve as an unfavorable prognostic factor for ENKTL.

Clinical manifestation of angioimmunoblastic T-cell lymphoma with exuberant plasmacytosis

Angioimmunoblastic T-cell lymphoma (AITL) is a rare subtype of non-Hodgkin lymphoma characterized by aggressive symptoms and various abnormal laboratory test results. One of the rare immunologic abnormalities in AITL is exuberant polyclonal plasmacytosis, but its clinical significance has not been evaluated. This report concerns three AITL cases with exuberant polyclonal plasmacytosis and investigates its clinical impact by comparison with 12 patients without plasmacytosis. Our study found that the performance status (PS) of the former was significantly worse and their serum immunoglobulin levels were significantly higher. All other parameters, including B symptoms, various prognostic scores, blood cell counts other than plasmacyte, and serum levels of lactate dehydrogenase, C-reactive protein and soluble interleukin-2 receptor, showed no significant differences. More importantly, although the diagnosis of AITL with plasmacytosis was not straightforward in our series, outcomes of treatment with conventional chemotherapy or immunosuppressive therapy with cyclosporine A were favorable. To conclude, AITL should be considered a candidate underlying disease of exuberant polyclonal plasmacytosis. Provided a correct diagnosis is made early and is followed by adequate treatment, the prognosis for AITL with plasmacytosis may not be worse than that for those without plasmacytosis despite the severe exhaustion at first presentation.