Burkitt lymphoma in adolescents and young adults: management challenges

Long-term outcomes in patients with Burkitt lymphoma older than 65 years: an analysis of the Texas Cancer Registry

Burkitt lymphoma (BL) is an extremely aggressive but curable subtype of non-Hodgkin lymphoma. While younger patients have excellent outcomes in response to aggressive chemoimmunotherapy, the rarity of this disease in older patients and limitations caused by age, comorbidities, and performance status may negate survival advantages. This analysis assessed outcomes of older adults with BL through data provided by the Texas Cancer Registry (TCR). Patients ≥65 years with BL were assessed. Patients were dichotomized into 1997-2007 and 2008-2018. Median overall survival (OS) and disease-specific survival (DSS) were assessed using Kaplan-Meier methodology, and covariates including age, race, sex, stage, primary site, and poverty index were analyzed using Pearson Chi-squared analysis. Odds ratio (OR) with 95% confidence intervals (CI) was used to assess factors contributing to patients not offered systemic therapy. P value <0.05 was considered statistically significant. Non-BL mortality events were also categorized. There were 325 adults, 167 in 1997-2007 and 158 in 2008-2018; 106 (63.5%) and 121 (76.6%) received systemic therapy, a trend that increased with time (p = 0.010). Median OS for 1997-2007 and 2008-2018 was 5 months (95% CI 2.469, 7.531) and 9 months (95% CI 0.000, 19.154) (p = 0.013), and DSS was 72 months (95% CI 56.397, 87.603) (p = 0.604) and not reached, respectively. For patients that received systemic therapy, median OS was 8 months (95% CI 1.278, 14.722) and 26 months (95% CI 5.824, 46.176) (p = 0.072), respectively, and DSS was 79 months (95% CI: 56.416, 101.584) and not reached, respectively (p = 0.607). Age ≥75 years (HR 1.39 [95% CI 1.078, 1.791], p = 0.011) and non-Hispanic whites (HR 1.407 [95% CI 1.024, 1.935], p = 0.035) had poorer outcomes, and patients at the 20-100% poverty index (OR 0.387 [95% CI 0.163, 0.921], p = 0.032) and increasing age at diagnosis (OR 0.947 [95% CI 0.913, 0.983], p = 0.004) were less likely to receive systemic therapy. Of 259 (79.7%) deaths, 62 (23.9%) were non-BL deaths, and 6 (9.6%) of these were from a second cancer. This two-decade analysis of older Texas patients with BL indicates a significant improvement in OS over time. Although patients were more likely to receive systemic therapy over time, treatment disparities existed in patients residing in poverty-stricken regions of Texas and in advancing age. These statewide findings reflect an unmet national need to find a systemic therapeutic strategy that can be tolerated by and augment outcomes in the growing elderly population.

Genomic landscape of virus-associated cancers

It has been estimated that 15%-20% of human cancers are attributable to infections, mostly by carcinogenic viruses. The incidence varies worldwide, with a majority affecting developing countries. Here, we present a comparative analysis of virus-positive and virus-negative tumors in nine cancers linked to five viruses. We find that virus-positive tumors occur more frequently in males and show geographical disparities in incidence. Genomic analysis of 1,658 tumors reveals virus-positive tumors exhibit distinct mutation signatures and driver gene mutations and possess a lower somatic mutation burden compared to virus-negative tumors of the same cancer type. For example, compared to the respective virus-negative counterparts, virus-positive cases across different cancer histologies had less often mutations of TP53 and deletions of 9p21.3/ CDKN2 A- CDKN1A ; Epstein-Barr virus-positive (EBV+) gastric cancer had more frequent mutations of EIF4A1 and ARID1A and less marked mismatch repair deficiency signatures; and EBV-positive cHL had fewer somatic genetic lesions of JAK-STAT, NF-κB, PI3K-AKT and HLA-I genes and a less pronounced activity of the aberrant somatic hypermutation signature. In cHL, we also identify germline homozygosity in HLA class I as a potential risk factor for the development of EBV-positive Hodgkin lymphoma. Finally, an analysis of clinical trials of PD-(L)1 inhibitors in four virus-associated cancers suggested an association of viral infection with higher response rate in patients receiving such treatments, which was particularly evident in gastric cancer and head and neck squamous cell carcinoma. These results illustrate the epidemiological, genetic, prognostic, and therapeutic trends across virus-associated malignancies.

Genes associated with diagnosis and prognosis of Burkitt lymphoma

Burkitt lymphoma (BL) is one of the most aggressive forms of non-Hodgkin's lymphomas that affect children and young adults. The expression of genes and other molecular markers during carcinogenesis can be the basis for diagnosis, prognosis and the design of new and effective drugs for the management of cancers. The aim of this study was to identify genes that can serve as prognostic and therapeutic targets for BL. We analysed RNA-seq data of BL transcriptome sequencing projects in Africa using standard RNA-seq analyses pipeline. We performed pathway enrichment analyses, protein-protein interaction networks, gene co-expression and survival analyses. Gene and pathway enrichment analyses showed that the differentially expressed genes are involved in tube development, signalling receptor binding, viral protein interaction, cell migration, external stimuli response, serine hydrolase activity and PI3K-Akt signalling pathway. Protein-protein interaction network analyses revealed the genes to be highly interconnected, whereas module analyses revealed 25 genes to possess the highest interaction score. Overall survival analyses delineated six genes (ADAMTSL4, SEMA5B, ADAMTS15, THBS2, SPON1 and THBS1) that can serve as biomarkers for prognosis for BL management.

HIV/AIDS Associated Lymphoma: Review

Lymphoma is one of the hematologic malignancies that occur at a higher rate in human immunodeficiency virus-infected individuals. It is one of the most frequent neoplastic causes of death in those individuals. Non-Hodgkin's lymphoma and Hodgkin's lymphomas are acquired immunodeficiency syndrome defining lymphoma and non-acquired immunodeficiency syndrome defining lymphoma, respectively. Non-Hodgkin's lymphoma is the most common type of lymphoma in human immunodeficiency virus-positive people. The lymphoma that develops in patients infected with the human immunodeficiency virus/acquired immunodeficiency syndrome is heterogeneous in terms of morphology, pathogenesis pathways, and cellular derivation. A narrative review was conducted on the basis of relevant literature on the current topic to summarize the current epidemiology, pathogenesis, laboratory diagnosis, and treatment of lymphoma in human immunodeficiency virus-infected patients. The finding showed that although the incidence of non-Hodgkin's lymphoma has decreased after the advent of highly active antiretroviral therapy, it has remained higher in human immunodeficiency virus-infected people than in the general population. On the other hand, the incidence of Hodgkin's lymphoma has increased after the introduction of highly active antiretroviral therapy. Therefore, it is recommended that people living with human immunodeficiency virus/ acquired immunodeficiency syndrome be screened for the development of lymphoma to increase their survival time and quality of life, and further research is required regarding the pathogenesis, treatment, and laboratory diagnosis of human immunodeficiency virus/ acquired immunodeficiency syndrome-associated lymphoma.

Improved survival of Burkitt lymphoma/leukemia patients: observations from Poland, 1999-2020

The aim of this study was to estimate the survival of Polish Burkitt lymphoma/leukemia (BL) patients diagnosed between 1999 and 2017, considering multiple covariates and periods, to reflect changes in BL treatment. We identified all BL patients registered in the Polish National Cancer Registry in 1999-2017. Observed survival (OS) was evaluated deploying the life table method. Univariate and multivariate Cox proportional hazards regression models were fit to generate hazard ratios (HR) and the corresponding 95% confidence intervals (95% CI), describing the association between exposures (sex, age at the diagnosis, year of diagnosis, and region of residence) and time-to-event (death). Two-sided log-rank test was applied to assess the significance of exposures. Overall, 937 BL cases were included in the study (654 men and 283 women). Between the periods 1999-2005 and 2015-2017, the 3-year OS changed from 56.0% (95% CI 50.4 to 62.2%) to 73.8% (68.1 to 80.0%; P < 0.001), and the 5-year OS increased from 53.8% (48.2 to 60.0%) to 73.0% (67.1 to 79.3%; P < 0.001). The death HR was significantly higher in adolescents and young adults' (AYA) and adults' groups than in pediatric patients (HR = 3.00, 95% CI 2.05 to 4.39, P < 0.001, for AYA; and HR = 7.30, 5.14 to 10.3, P < 0.001, for adults). During the last two decades, the survival of Polish BL patients has been systematically improving. The death hazard ratio is most significantly associated with the patients' age at diagnosis and year of diagnosis, and not associated with sex or region of residence.

KRAS and RAS-MAPK Pathway Deregulation in Mature B Cell Lymphoproliferative Disorders

KRAS mutations account for the most frequent mutations in human cancers, and are generally correlated with disease aggressiveness, poor prognosis, and poor response to therapies. KRAS is required for adult hematopoiesis and plays a key role in B cell development and mature B cell proliferation and survival, proved to be critical for B cell receptor-induced ERK pathway activation. In mature B cell neoplasms, commonly seen in adults, KRAS and RAS-MAPK pathway aberrations occur in a relevant fraction of patients, reaching high recurrence in some specific subtypes like multiple myeloma and hairy cell leukemia. As inhibitors targeting the RAS-MAPK pathway are being developed and improved, it is of outmost importance to precisely identify all subgroups of patients that could potentially benefit from their use. Herein, we review the role of KRAS and RAS-MAPK signaling in malignant hematopoiesis, focusing on mature B cell lymphoproliferative disorders. We discuss KRAS and RAS-MAPK pathway aberrations describing type, incidence, mutual exclusion with other genetic abnormalities, and association with prognosis. We review the current therapeutic strategies applied in mature B cell neoplasms to counteract RAS-MAPK signaling in pre-clinical and clinical studies, including most promising combination therapies. We finally present an overview of genetically engineered mouse models bearing KRAS and RAS-MAPK pathway aberrations in the hematopoietic compartment, which are valuable tools in the understanding of cancer biology and etiology.

The Primary Outbreaks of Burkitt Lymphoma in the Oral Cavity. A Report of Two Cases, Review of the Literature and Dental Implications

Two cases of Sporadic Burkitt’s lymphoma in children aged 11 and 8 years with primary symptoms in the oral cavity are reported. The first symptoms of the disease appeared in the oral cavity and were initially misdiagnosed as an inflammatory condition in one case and incidental findings not associated with the primary reason for visiting the dentist’s office in the second case. Biopsies of the lesions revealed the actual cause of the observed changes and contributed to the prompt initiation of polychemotherapy treatment. A review of current literature presents the known symptoms of Burkitt’s Lymphoma in the oral cavity and the available diagnostic methods. The role of the primary care physicians—the pedodontist and paediatrician—in the diagnostic and therapeutic process is discussed.

Adult Nodal Burkitt Lymphoma Forming Nodular Architectures

In this report, we discuss a case of nodal Burkitt lymphoma seen in a 60-year-old Japanese male patient. Microscopic features of the biopsied 30 mm-sized cervical lymph node revealed nodular architectures with starry sky appearance surrounded by small mantle zone B-lymphocytes. Immunohistochemical and molecular studies demonstrated typical features of sporadic Burkitt lymphoma: the atypical cells were positive for CD20, CD79a, CD10, CD23, HLA-DR, bcl-6, PAX5, c-myc, and cytoplasmic IgM, but negative for CD3, CD5, CD15, CD30, CD34, TdT, bcl-2, and MUM1. The mantle zone B-cells were clearly positive for bcl-2 and IgD. In situhybridization (ISH) analysis for immunoglobulin light chains showed kappa-type monoclonality. A few nuclei were labeled for Epstein-Barr virus-encoded small nuclear RNA (EBER). Ki-67 labeling index was nearly 100%. Within the nodule, CD21, CD23, and CD35-positive follicular dendritic cells were scattered with a small number of CD3/CD5-positive small T-lymphocytes, indicating that the nodular architecture represented follicular colonization of Burkitt lymphoma cells. Karyotypic analysis revealed t(8;14)(q24;q32), and IGH-MYC fluorescence in situ hybridization (FISH) demonstrated IGH-MYC fusion signals. The presentation of follicular colonization was quite unique in Burkitt lymphoma in the present case. Differential diagnosis is also discussed.

Primary bilateral ovarian involvement in Burkitt's lymphoma with an adnexal Torsion-like manifestation: A case report

Burkitt's lymphoma (BL) is defined as a highly invasive B-cell lymphoma with a poor prognosis. Primary bilateral ovarian mass without involvement of other organs is a rare manifestation of BL. Our report was a case of an EBV positive Burkitt's lymphoma, which initially presented with ovarian mass and adnexal torsion.

Transcription factor 3 (TCF3) combined with histone deacetylase 3 (HDAC3) down-regulates microRNA-101 to promote Burkitt lymphoma cell proliferation and inhibit apoptosis

To explore the function of transcription factor 3 (TCF3) on the proliferation and apoptosis of Burkitt lymphoma cells and its mechanism. qRT-PCR was performed to determine the expression of TCF3, histone deacetylase 3 (HDAC3), and microRNA-101 (miR-101) in the Burkitt lymphoma (BL) tumor tissues and lymph node tissues with reactive lymph node hyperplasia (RLNH). We found that the expression of TCF3 and HDAC3 was up-regulated in BL tumor tissues and lymphoma cells, and the miR-101 expression was down-regulated. And TCF3 and HDAC3 were negatively correlated with the expression of miR-101, respectively. In addition, knockdown of TCF3 can inhibit BL cell proliferation, reduce cell viability and promote cell apoptosis, retain the cell cycle in the G0/G1 phase, and inhibit the expression of Akt/mTOR pathway-related proteins (p-Akt and p-mTOR). When miR-101 was overexpressed, the results were the same as when TCF3 was knocked down. Moreover, we used Co-immunoprecipitation (Co-IP) to detect the interaction between TCF3 and HDAC3, and performed the Chromatin immunoprecipitation (ChIP) experiment to detect the enrichment of TCF3 and HDAC3 in the promoter region of miR-101. We found that TCF3 can interact with HDAC3 and is enriched in the miR-101 promoter region. In conclusion, TCF3 combined with HDAC3 down-regulates the expression of miR-101, thereby promoting the proliferation of BL cells and inhibiting their apoptosis.

A rare case of the superior vena cava obstruction in a 16-year-old boy with Burkitt's lymphoma: A case report

Burkitt's lymphoma (BL) is an aggressive non-Hodgkin B-cell lymphoma. Superior vena cava obstruction (SVCO) is considered a rare presentation of BL and it is usually associated with other types of non-Hodgkin lymphoma such as diffuse large-cell. We report a rare case of sporadic BL with SVCO in a 16-year-old boy with nasopharyngeal, mediastinal, and adrenal masses. The patient presented with a two-month history of left upper neck swelling that increased with time and was not associated with other symptoms. The patient tested positive for COVID-19 on the second day after admission. On examination, he had enlarged solitary lateral cervical and bilateral posterior auricular lymph nodes. There were no signs or symptoms of SVCO regardless of the findings suggested by the computed tomography of the chest. The patient was treated with hyper-CVAD chemotherapy and showed a remarkable resolution of the nasopharyngeal and mediastinal masses with a mild response of his adrenal mass. There were no complications detected during this patient's management.

Triclosan induces apoptosis in Burkitt lymphoma-derived BJAB cells through caspase and JNK/MAPK pathways

Burkitt's lymphoma (BL) is the fastest growing human tumor. Current treatment consists of a multiagent regimen of cytotoxic drugs with serious side effjects including tumor lysis, cardiotoxicity, hepatic impairment, neuropathy, myelosuppression, increased susceptibility to malignancy, and death. Furthermore, therapeutic interventions in areas of BL prevalence are not as feasible as in high-income countries. Therefore, there exists an urgent need to identify new therapies with a safer profile and improved accessibility. Triclosan (TCS), an antimicrobial used in personal care products and surgical scrubs, has gained considerable interest as an antitumor agent due to its interference with fatty acid synthesis. Here, we investigate the antitumor properties and associated molecular mechanisms of TCS in BL-derived BJAB cells. Dose-dependent cell death was observed following treatment with 10-100 µM TCS for 24 h, which was associated with membrane phospholipid scrambling, compromised permeability, and cell shrinkage. TCS-induced cell death was accompanied by elevated intracellular calcium, perturbed redox balance, chromatin condensation, and DNA fragmentation. TCS upregulated Bad expression and downregulated that of Bcl2. Moreover, caspase and JNK MAPK signaling were required for the full apoptotic activity of TCS. In conclusion, this report identifies TCS as an antitumor agent and provides new insights into the molecular mechanisms governing TCS-induced apoptosis in BL cells.

Neurological Nuance: Sporadic Burkitt's Lymphoma Presenting with Guillain–Barre Syndrome

Burkitt's lymphoma (BL) is a high-grade mature B cell neoplasm. Primary lymphoma of the central nervous system (CNS) is very rare. In contrast, BL can be localized in any part of the body and may spread to the CNS. Peripheral nervous system impairment caused by BL has been thoroughly described. However, Guillain–Barre syndrome (GBS) does not commonly appear as an initial manifestation of BL. We presented the case of a young child with sporadic BL with neuromeningeal involvement and spinal cord compression whose first clinical manifestation was the appearance of GBS. Lymphoma should be taken into account, especially in children presenting with the clinical features of acute polyradiculoneuropathy.

Burkitt and Burkitt-Like Lymphomas: a Systematic Review

PURPOSE OF REVIEW

Burkitt's lymphoma and its leukemic form (Burkitt cell acute lymphoblastic leukemia) are a highly aggressive disease. We review the classification, clinical presentation, histology, cytogenetics, and the treatment of the disease.

RECENT FINDINGS

Burkitt's lymphoma might be associated with tumor lysis syndrome which is a potentially fatal complication that occurs spontaneously or upon initiation of chemotherapy. Major improvements were made in the treatment of pediatric and adults population using short-course dose-intensive chemotherapy regimens, usually 1 week after a prephase induction. Addition of Rituximab to chemotherapy has become a standard of care. Relapsed/refractory disease has a very poor prognosis and the benefit from autologous/allogeneic hematopoietic stem cell transplant remains uncertain. Rituximab-based short-course dose-intensive chemotherapy is the standard of care of Burkitt's lymphoma even in the immunodeficiency-related form.

Endemic Burkitt lymphoma - an aggressive childhood cancer linked to Plasmodium falciparum exposure, but not to exposure to other malaria parasites

Burkitt lymphoma (BL) is an aggressive non-Hodgkin lymphoma. The prevalence of BL is ten-fold higher in areas with stable transmission of Plasmodium falciparum malaria, where it is the most common childhood cancer, and is referred to as endemic BL (eBL). In addition to its association with exposure to P. falciparum infection, eBL is strongly associated with Epstein-Barr virus (EBV) infection (>90%). This is in contrast to BL as it occurs outside P. falciparum-endemic areas (sporadic BL), where only a minority of the tumours are EBV-positive. Although the striking geographical overlap in the distribution of eBL and P. falciparum was noted shortly after the first detailed description of eBL in 1958, the molecular details of the interaction between malaria and eBL remain unresolved. It is furthermore unexplained why exposure to P. falciparum appears to be essentially a prerequisite to the development of eBL, whereas other types of malaria parasites that infect humans have no impact. In this brief review, we summarize how malaria exposure may precipitate the malignant transformation of a B-cell clone that leads to eBL, and propose an explanation for why P. falciparum uniquely has this capacity.

Serine Biosynthesis Pathway Supports MYC-miR-494-EZH2 Feed-Forward Circuit Necessary to Maintain Metabolic and Epigenetic Reprogramming of Burkitt Lymphoma Cells

Burkitt lymphoma (BL) is a rapidly growing tumor, characterized by high anabolic requirements. The MYC oncogene plays a central role in the pathogenesis of this malignancy, controlling genes involved in apoptosis, proliferation, and cellular metabolism. Serine biosynthesis pathway (SBP) couples glycolysis to folate and methionine cycles, supporting biosynthesis of certain amino acids, nucleotides, glutathione, and a methyl group donor, S-adenosylmethionine (SAM). We report that BLs overexpress SBP enzymes, phosphoglycerate dehydrogenase (PHGDH) and phosphoserine aminotransferase 1 (PSAT1). Both genes are controlled by the MYC-dependent ATF4 transcription factor. Genetic ablation of PHGDH/PSAT1 or chemical PHGDH inhibition with NCT-503 decreased BL cell lines proliferation and clonogenicity. NCT-503 reduced glutathione level, increased reactive oxygen species abundance, and induced apoptosis. Consistent with the role of SAM as a methyl donor, NCT-503 decreased DNA and histone methylation, and led to the re-expression of ID4, KLF4, CDKN2B and TXNIP tumor suppressors. High H3K27me3 level is known to repress the MYC negative regulator miR-494. NCT-503 decreased H3K27me3 abundance, increased the miR-494 level, and reduced the expression of MYC and MYC-dependent histone methyltransferase, EZH2. Surprisingly, chemical/genetic disruption of SBP did not delay BL and breast cancer xenografts growth, suggesting the existence of mechanisms compensating the PHGDH/PSAT1 absence in vivo.

The snoring 2-year-old boy: a case of primary nasopharyngeal Burkitt's lymphoma

Sporadic Burkitt's lymphoma affecting the nasopharyngeal region is an extremely rare disease, especially in infants. We describe the case of a 2-year-old boy who presented to the ear, nose and throat department with a history of snoring, blood-stained rhinorrhoea and symptoms consistent with upper respiratory tract infections. Physical examination revealed massive cervical lymphadenopathy. MRI of the head and neck showed a mass lesion in the nasopharynx with bilateral lymph node enlargement. Debulking of the mass was performed and biopsies were sent for histology, which confirmed Burkitt's lymphoma. The patient was treated with complex chemotherapy and had a good clinical response. The patient remains in remission after 6 years.

Design, Synthesis and Biochemical Evaluation of Novel Ethanoanthracenes and Related Compounds to Target Burkitt's Lymphoma

Lymphomas (cancers of the lymphatic system) account for 12% of malignant diseases worldwide. Burkitt’s lymphoma (BL) is a rare form of non-Hodgkin’s lymphoma in which the cancer starts in the immune B-cells. We report the synthesis and preliminary studies on the antiproliferative activity of a library of 9,10-dihydro-9,10-ethanoanthracene based compounds structurally related to the antidepressant drug maprotiline against BL cell lines MUTU-1 and DG-75. Structural modifications were achieved by Diels-Alder reaction of the core 9-(2-nitrovinyl)anthracene with number of dienophiles including maleic anhydride, maleimides, acrylonitrile and benzyne. The antiproliferative activity of these compounds was evaluated in BL cell lines EBV⁻ MUTU-1 and EBV⁺ DG-75 (chemoresistant). The most potent compounds 13j, 15, 16a, 16b, 16c, 16d and 19a displayed IC₅₀ values in the range 0.17–0.38 μM against the BL cell line EBV⁻ MUTU-1 and IC₅₀ values in the range 0.45–0.78 μM against the chemoresistant BL cell line EBV⁺ DG-75. Compounds 15, 16b and 16c demonstrated potent ROS dependent apoptotic effects on the BL cell lines which were superior to the control drug taxol and showed minimal cytotoxicity to peripheral blood mononuclear cells (PBMCs). The results suggest that this class of compounds merits further investigation as antiproliferative agents for BL.

Status and prognostic nomogram of patients with Burkitt lymphoma

The purpose of the present study was to evaluate the newest status of patients diagnosed Burkitt lymphoma (BL), an aggressive lymphoma subset with a high cure rate. Furthermore, the study aimed to create prognostic nomograms to consider various prognostic factors and estimate patient survival, paving the way for clinical decision-making. A total of 4,600 patients diagnosed with BL between 1983 and 2015 were investigated, via data collected from the SEER database. The overall status of the patients was analyzed through several aspects, including incidence and survival analysis of the previous three decades using the log-rank test and the Kaplan-Meier method. In order to construct and validate the nomograms, the patient diagnosed during 2005-2015 were randomly assigned to the training cohort and validation cohort. Univariate and multivariate analyses were applied to identify independent factors that were further included in the nomograms, predicting 3- and 5-year overall survival (OS) and cancer-specific survival (CSS). The data of the training cohort were used for internal validation and validation cohort used to external validation. C-index and calibration plots were used to validate the nomograms, comparing predicted values with actual outcomes. The incidence of BL was gradually increased from 1984 and reached its peak in 2009, at a rate of 0.491 per 100,000 [95% confidence interval (CI), 0.412-0.581]. From 2009, the incidence slowly declined year by year and dropped to 0.280 per 100,000 (95% CI, 0.224-0.346). The OS and CSS rates of patients diagnosed between 2005 and 2015 were increased, in contrast with those of patients diagnosed from 1983-1993 and 1994-2004. A total of five variables, including age, race, chemotherapy, primary site and stage, proved to be the prognostic factors of BL and were used to construct the nomograms predicting 3- and 5-year OS and CSS. The internal and external calibration plots for the probability of 3- and 5-year OS and CSS were consistent between nomogram prediction and observed outcomes. The slow decline in incidence and the significantly improved cure rate make BL a disease that is no longer an urgent problem. Effective nomograms were developed to predict the OS and CSS of patients with BL.

An update on Burkitt lymphoma: a review of pathogenesis and multimodality imaging assessment of disease presentation, treatment response, and recurrence

Burkitt lymphoma (BL) is a highly aggressive, rapidly growing B cell non-Hodgkin lymphoma, which manifests in several subtypes including sporadic, endemic, and immunodeficiency-associated forms. Pathologically, BL is classically characterized by translocations of chromosomes 8 and 14 resulting in upregulation of the c-myc protein transcription factor with upregulation of cell proliferation. BL affects nearly every organ system, most commonly the abdomen and pelvis in the sporadic form. Imaging using a multimodality approach plays a crucial role in the management of BL from diagnosis, staging, and evaluation of treatment response to therapy-related complications with ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography playing roles. In this article, we review the pathobiology and classification of BL, illustrate a multimodality imaging approach in evaluating common and uncommon sites of involvement within the trunk and head and neck, and review common therapies and treatment-related complications.

Adult Burkitt lymphoma- an Island between lymphomas and leukemias

Background: Burkitt lymphoma is a rare, aggressive and rapidly fatal, B-cell non-Hodgkin’s lymphoma. It has an incidence of 0.4/100,000 age-adjusted to the USA standard population. Here we describe the case of a 77-year-old patient who presented with Burkitt lymphoma.

Case: A 77-year-old male presented to his primary care physician with fatigue and listlessness and was referred to the hospital with a white blood cell count (WBC)-23.7 K/uL (neutrophils 37%, lymphocyte 11%, blasts 9%) and platelets-19 K/uL. During his stay in the hospital, repeat investigations revealed WBC-29.9 K/uL (neutrophils 22%, lymphocyte 27%, atypical lymphocytes 5%, blasts 20%) and platelets-10 K/uL with no evidence of mucosal bleeds, neck or abdominal masses or generalized lymphadenopathy. Bone marrow aspirate revealed the presence of MYC rearrangements (8q24) on flow cytometry and fluorescent in-situ hybridization (FISH), indicative but not typical of BL. He was transfused with platelets due to a rapidly deteriorating platelet count and episodes of epistaxis. He was discharged after four days with a plan of outpatient chemotherapy over a period of 4 months. An Ommaya reservoir was placed in the right ventricle for intrathecal chemotherapy. After four months of chemotherapy, computerized tomography of the chest, abdomen, and pelvis confirmed remission. A magnetic resonance imaging of the brain a month after completion of chemotherapy revealed metastatic lymphoma in the temporal, parietal and occipital lobes. He was discharged to hospice for palliative care.

Conclusion: Unconventional presentations, as seen in our case of a leukemia-like picture in the absence of a bulky disease, are the quagmire that might delay aggressive management and result in poorer outcomes.

Burkitt Lymphoma Presenting as Menorrhagia and a Vaginal Mass in an Adolescent

BACKGROUND

Menorrhagia is a common gynecologic complaint among adolescents, which rarely is secondary to malignancy. Burkitt lymphoma can mimic gynecologic malignancy, however it is rarely seen in adolescents. Burkitt lymphoma of the gynecologic tract requires early diagnosis and intervention for optimal outcomes.

CASE

We report a case of a 15-year-old adolescent who had multiple admissions for menorrhagia that was thought to be secondary to anovulatory bleeding until pelvic ultrasound revealed a large 8-cm vaginal/cervical mass. Histologic examination of the biopsy specimen revealed Burkitt lymphoma, which was treated with chemotherapy leading to resolution of her menorrhagia.

SUMMARY AND CONCLUSION

Burkitt lymphoma presenting as a vaginal/cervical mass is exceedingly rare, especially in the adolescent patient. Burkitt lymphoma is generally highly responsive to chemotherapy, and symptoms rapidly improve after initiation of treatment.

HIV-related non-Hodgkin Lymphoma. Case report and review of the literature

Background: HIV-related Burkitt’s lymphoma with initial oropharyngeal presentation is rarely reported. The aim of this paper is to report the clinical findings of an unusual case of a patient with extranodal oropharyngeal Burkitt’s lymphoma as presenting disease of an unknown HIV positivity and acquired immunodeficiency syndrome. Methods: We reported the case of a hispanic patient with extranodal oropharyngeal Burkitt’s lymphoma as presenting disease of an unknown HIV positivity and acquired immunodeficiency syndrome. We describe the diagnostic work-up and treatment of this rare case of extranodal oropharyngeal Burkitt’s lymphoma. Results: Histological exam on oropharyngeal incision biopsy documented a Burkitt’s lymphoma. The patient underwent highly active antiretroviral therapy and chemotherapy. After two years of follow-up the patient shows no signs of recurrence from disease. Conclusions: HIV-related Burkitt’s lymphoma presenting with primary oropharyngeal involvement is rare, with rapidly progressing dysphagia, and does not respond to antibiotherapy. Patients should undergo incision biopsy to rule out a malignancy. In young adults, diagnosis of Burkitt’s lymphoma should suggest HIV infection. The importance of a prompt diagnosis in such cases is essential to correctly adequately staging the disease to start highly active antiretroviral therapy and chemotherapy as soon as possible. (www.actabiomedica.it)

Burkitt's Lymphoma of the Gastrohepatic Omentum: A Malignant Presentation of Pseudoachalasia

Achalasia is an intrinsic disorder of the esophagus that results from loss of ganglion cells in the lower esophageal sphincter. Clinically it is manifested by dysphagia to solids and liquids, weight loss, regurgitation, and chest pain. Pseudoachalasia, in contrast, is a rare entity that causes identical symptoms, but has a divergent underlying pathogenesis. The symptomology in these cases oftentimes occurs secondary to extrinsic compression of the esophagus, mostly attributable to malignancy. Although many cases of extrinsic esophageal compression have been reported in the literature, rarely has this occurred secondary to Burkitt's lymphoma in an adult. Here, we present a case of Burkitt's lymphoma resulting in pseudoachalasia in a 70-year-old female. The concurrence of these two entities in one patient makes this case presentation especially rare.

HIV-related Malignancies and Mimics: Imaging Findings and Management

The risk of developing malignancy is higher in patients with human immunodeficiency virus (HIV) infection than in non-HIV-infected patients. Several factors including immunosuppression, viral coinfection, and high-risk lifestyle choices lead to higher rates of cancer in the HIV-infected population. A subset of HIV-related malignancies are considered to be acquired immunodeficiency syndrome (AIDS)-defining malignancies, as their presence confirms the diagnosis of AIDS in an HIV-infected patient. The introduction of highly active antiretroviral therapy (HAART) has led to a significant drop in the rate of AIDS-defining malignancies, including Kaposi sarcoma, non-Hodgkin lymphoma, and invasive cervical carcinoma. However, non-AIDS-defining malignancies (eg, Hodgkin lymphoma, lung cancer, hepatocellular carcinoma, and head and neck cancers) now account for an increasing number of cancer cases diagnosed in HIV-infected patients. Although the number has decreased, AIDS-defining malignancies account for 15%-19% of all deaths in HIV-infected patients in the post-HAART era. Most HIV-related malignancies in HIV-infected patients manifest at an earlier age with a more aggressive course than that of non-HIV-related malignancies. Understanding common HIV-related malignancies and their specific imaging features is crucial for making an accurate and early diagnosis, which impacts management. Owing to the weakened immune system of HIV-infected patients, other entities such as various infections, particularly opportunistic infections, are prevalent in these patients. These processes can have confounding clinical and imaging manifestations that mimic malignancy. This article reviews the most common AIDS-defining and non-AIDS-defining malignancies, the role of imaging in their diagnosis, and the imaging mimics of malignancies in HIV-infected patients. ^©RSNA, 2018.

Case Report: Sporadic Burkitt lymphoma misdiagnosed as dental abscess in a 15-year-old girl

Background: Burkitt lymphoma (BL) is a non-Hodgkin’s B-cell tumor that can be classified into three variants, based on clinical characteristics and epidemiology: endemic, human immunodeficiency-related and sporadic. Oral sporadic BL is quite an unusual entity, with the gastrointestinal trait being often the first site of appearance.

Clinical finding: A 15-year-old patient that presented a symptomatic swelling of the right maxilla, unsuccessfully treated as a primary endodontic disease, displaying solid tissue on CT scan, “starry sky” pattern on oral biopsy, multifocal bone and lymph node uptake on PET.

Diagnoses, interventions, and outcomes: A diagnosis of stage IV BL was formulated; Rituximab was then administered for three months according to Inter-B-NHL ritux 2010 protocol and CYM (cytarabine and methotrexate) chemotherapy. The patient was followed-up for three years, with no recurrence.

Conclusion: It is important for general dental practitioners to suspect a malignancy in the differential diagnosis of unresponsive odontogenic infections in young healthy patients.

New Approaches to the Management of Adult Acute Lymphoblastic Leukemia

Traditional treatment regimens for adult acute lymphoblastic leukemia, including allogeneic hematopoietic cell transplantation, result in an overall survival of approximately 40%, a figure hardly comparable with the extraordinary 80% to 90% cure rate currently reported in children. When translated to the adult setting, modern pediatric-type regimens improve the survival to approximately 60% in young adults. The addition of tyrosine kinase inhibitors for patients with Philadelphia chromosome-positive disease and the measurement of minimal residual disease to guide risk stratification and postremission approaches has led to additional improvements in outcomes. Relapsed disease and treatment toxicity-sparing no patient but representing a major concern especially in the elderly-are the most critical current issues awaiting further therapeutic advancement. Recently, there has been considerable progress in understanding the disease biology, specifically the Philadelphia-like signature, as well as other high-risk subgroups. In addition, there are several new agents that will undoubtedly contribute to additional improvement in the current outcomes. The most promising agents are monoclonal antibodies, immunomodulators, and chimeric antigen receptor T cells, and, to a lesser extent, several new drugs targeting key molecular pathways involved in leukemic cell growth and proliferation. This review examines the evidence supporting the increasing role of the new therapeutic tools and treatment options in different disease subgroups, including frontline and relapsed or refractory disease. It is now possible to define the best individual approach on the basis of the emerging concepts of precision medicine.

β-elemene against Burkitt's lymphoma via activation of PUMA mediated apoptotic pathway

Burkitt's lymphoma is a type of highly aggressive Non-Hodgkin's lymphoma. Although advanced Burkitt's lymphoma is responsive to high-intensity chemotherapy regimens, increasing systemic toxicity, tumor recurrence and metastasis significantly reduce the patient survival. Thus, it is important to investigate novel antitumor agents with safety and effectiveness. β-elemene shows anti-proliferative effect on cancer cells by triggering apoptosis through regulating several molecular signaling pathways. However, its role in the suppression of Burkitt's lymphoma has not yet been fully elucidated. The inhibitory effect of β-elemene in Burkitt's lymphoma was studied in vitro and in vivo, as well as the involved molecular mechanism. The results demonstrated that β-elemene effectively inhibited the growth and induced the apoptosis of Burkitt's lymphoma cells through upregulation of PUMA expression and modulating PUMA related apoptotic signaling pathway. The in vivo data confirmed the anti-tumor effect of β-elemene in the xenografts, suggesting that β-elemene is associated with PUMA activation, leading to Bax and caspase induction and onset of mitochondrial apoptosis.

Non-Hodgkin lymphoma, diagnostic, and prognostic particularities in children - a series of case reports and a review of the literature (CARE compliant)

RATIONALE

Non-Hodgkin lymphoma remains an unpredictable condition in pediatric patients.

PATIENT CONCERNS

Our first case describes an 8-year-old boy with a history of iron deficiency anemia, admitted in our clinic for recurrent abdominal pain, weight loss, loss of appetite, diarrheic stools, and fever. The second case also describes an 8-year-old boy admitted for abdominal pain and vomiting. The 3rd case refers to a 4 years and 10 months old boy admitted in our clinic with abdominal pain and loss of appetite, who was initially admitted in the Pediatrics Surgery Clinic with the suspicion of appendicitis. Our 4th patient was a 5-year-old boy admitted in our clinic for abdominal pain and intermittent diarrheic stools.

DIAGNOSES

In the first case, the laboratory tests showed anemia, thrombocytosis, elevated inflammatory biomarkers, a low level of iron, and hypoproteinemia. The abdominal ultrasound and CT exam revealed an abdominal mass, and the histopathological exam established the diagnosis of diffuse large B-cell lymphoma of the bowel. In the second case, the laboratory tests pointed out anemia, elevated ESR and lactate dehydrogenase level, while both abdominal ultrasound and CT exams showed an abdominal mass. The histopathological exam confirmed the diagnosis of Burkitt lymphoma. Regarding our 3rd case, the laboratory findings revealed leukocytosis, anemia, thrombocytosis, increased inflammatory biomarkers, elevated LDH, and a low level of iron. The abdominal ultrasound and the CT scan revealed an abdominal mass which, according to the histopathological exam, was a Burkitt lymphoma. Due to the cranial CT findings the patient was diagnosed with IV stage Burkitt lymphoma with central nervous system metastases. In our 4th patients we found leukocytosis, anemia, mildly increased inflammatory biomarkers, a high level of LDH, hypoproteinemia, and a low level of serum Ir. Both ultrasound and abdominal CT exams were negative, but the exploratory laparotomy identified an abdominal mass, and according to the histopathological exam the patient was diagnosed with Burkitt lymphoma.

INTERVENTIONS

All the patients followed chemotherapy (B-NHL BFM 04 protocol) and supportive treatment.

OUTCOMES

The first patient died approximately 4 months after the completion of chemotherapy due to tumor relapse, the second patient died after the first cure of chemotherapy and the fourth patient died at approximately 2 years after the diagnosis. The third patient is recurrence-free after 2 years.

LESSONS

Despite the advances in the management, NHL remains a fatal condition in pediatrics.

Relapsed/refractory Burkitt lymphoma and HIV infection

The care of patients with HIV and Burkitt lymphoma poses a challenge to clinicians. Due to the limited treatment options that exist for relapsed/refractory Burkitt lymphoma, there is a need for the development of new therapies. This review aims to discuss evidence for current management strategies including chemotherapy and stem cell transplant, and highlight gaps in knowledge that will need to be addressed in the future.

Influence of health insurance status on paediatric non-Hodgkin's lymphoma treatment in Kenya

OBJECTIVE

Non-Hodgkin's lymphoma (NHL) is the most common childhood malignancy in sub-Saharan Africa. Survival rates for NHL are higher than 80% in high-income countries.This study explores treatment outcomes of children with NHL in Kenya, a sub-Saharan low-income country, and the association between health insurance status at diagnosis and treatment outcomes.

DESIGN

This was a retrospective medical records study. All children diagnosed with NHL in 2010, 2011 and 2012 were included. Data on treatment outcomes and health insurance status at diagnosis were collected.

RESULTS

Of all 63 patients with NHL, 35% abandoned treatment, 22% had progressive or relapsed disease, 14% died and 29% had event-free survival. Most patients (73%) had no health insurance at diagnosis. Treatment outcomes in children with or without health insurance at diagnosis differed significantly (p=0.005). The most likely treatment outcome in children with health insurance at diagnosis was event-free survival (53%), whereas in children without health insurance at diagnosis it was abandonment of treatment (44%). Crude HR for treatment failure was 3.1 (95% CI 1.41 to 6.60, p=0.005) for uninsured versus insured children. The event-free survival estimate was significantly higher in children with health insurance at diagnosis than in patients without health insurance at diagnosis (p=0.003). Stage of disease at diagnosis was identified as a confounder of this association (adjusted HR=2.4, 95% CI 0.95 to 6.12, p=0.063).

CONCLUSIONS

Survival of children with NHL in Kenya is much lower compared with high-income countries. Abandonment of treatment is the most common cause of treatment failure. Health insurance at diagnosis was associated with better treatment outcomes and survival.

Primary ovarian Burkitt's lymphoma: a rare oncological problem in gynaecology: a review of literature

Purpose

This review presents the information about epidemiology, clinical manifestation, diagnosis and treatment of primary ovarian Burkitt’s lymphoma (BL), including a literature search of available BL cases. The purpose of this review is to draw clinicians’ attention to the possibility of ovarian BL occurrence, which may be important in the differential diagnosis of ovarian tumours.

Methods

PubMed and Web of Science databases were searched using the keywords ‘‘Burkitt’s’’, ‘‘Lymphoma’’, ‘‘Ovarian’’, ‘‘Primary’’, ‘‘Burkitt’s lymphoma’’. Only cases with histopathologically confirmed diagnosis of primary ovarian BL were included in this review.

Results

Fifty articles, reporting cases with an ovarian manifestation of primary non-Hodgkin’s lymphoma, were found. Twenty-one cases with a histopathologically confirmed BL were evaluated to compare various manifestations, treatment and prognosis in ovarian BL.

Conclusions

Primary ovarian BL is a rare condition, included in the entity of non-Hodgkin lymphoma. The tumour can occur uni- or bilaterally in the ovaries with major symptoms such as abdominal pain or a large abdominal mass. Differential diagnosis, based on imaging features and pathological examination of the specimens, is essential for further treatment due to various aetiology of ovarian tumours. Although most of the patients suffering from ovarian BL underwent surgery after the ovarian tumour had been detected, surgical treatment is not the treatment of choice in patients with ovarian lymphoma. The mainstay of therapy is chemotherapy without further surgery. The prognosis is better if the chemotherapy protocol is more aggressive and followed by prophylactic central nervous system chemotherapy. Nowadays, multiagent protocols are administered, which improves the survival rate.

Single-cell genomic analysis of head and neck squamous cell carcinoma

Head and neck squamous cell carcinoma (HNSCC) incidence or rates have increased dramatically recently with little improvement in patient outcomes. There is an unmet need in HNSCC to develop reliable molecular markers capable of evaluating patient risks and advising treatments. This review focuses on recent developments in single-cell molecular analysis of cancer, and its applications for HNSCC diagnosis and treatments. For proof of concept, we examined gene expression levels of 62 patients with HNSCC, and correlate the gene expression profiles to single-cell gene expression profiles obtained from a pilot single-cell study of CCR5-positive breast carcinoma cells. The single-cell molecular analyses complemented the lysate data and reveals heterogeneity of oncogenesis pathways with the cancer cell population. Our single-cell molecular analysis indicated that molecular heterogeneity exists in HNSCC and should be addressed in treatment strategy of HNSCC. Single-cell molecular technology can have significant impact on diagnosis, therapeutic decision making, and prognosis of HNSCC.