Isolated uterine relapse of nasal T/Nk cell lymphoma

The diagnosis and management of NK/T-cell lymphomas

Extranodal natural killer (NK)/T-cell lymphoma is an aggressive malignancy of putative NK-cell origin, with a minority deriving from the T-cell lineage. Pathologically, the malignancy occurs in two forms, extranodal NK/T-cell lymphoma, nasal type; and aggressive NK-cell leukaemia. Lymphoma occur most commonly (80%) in the nose and upper aerodigestive tract, less commonly (20%) in non-nasal areas (skin, gastrointestinal tract, testis, salivary gland), and rarely as disseminated disease with a leukemic phase. Genetic analysis showed mutations of genes involved in the JAK/STAT pathway, RNA assembly, epigenetic regulation, and tumor suppression. In initial clinical evaluation, positron emission tomography computed tomography, and quantification of plasma EBV DNA are mandatory as they are useful for response monitoring and prognostication. In stage I/II diseases, combined chemotherapy and radiotherapy (sequentially or concurrently) is the best approach. Conventional anthracycline-containing regimens are ineffective and should be replaced by non-anthracycline-containing regimens, preferably including L-asparaginase. Radiotherapy alone is associated with high systemic relapse rates and should be avoided. In stage III/IV diseases, non-anthracycline-regimens-containing L-asparaginase are the standard. In relapsed/refractory cases, blockade of the programmed death protein 1 has recently shown promising results with high response rates. In the era of effective non-anthracycline-containing regimens, autologous haematopoietic stem cell transplantation (HSCT) has not been shown to be beneficial. However, allogeneic HSCT may be considered for high-risk or advanced-stage patients in remission or relapsed/refractory patients responding to salvage therapy. Prognostic models taking into account presentation, interim, and end-of-treatment parameters are useful in triaging patients to different treatment strategies.

Diagnosis and management of extranodal NK/T cell lymphoma nasal type

INTRODUCTION

Extranodal NK/T-cell lymphoma nasal type is a distinct clinicopathologic entity. The most common initial site of presentation is the nasopharyngeal area, but non-nasals sites including the skin and the gastrointestinal tract may be affected.

AREAS COVERED

The diagnosis and management of NK/T-cell lymphoma is discussed, based on a literature search on PubMed. NK/T-cell lymphoma are typically positive for CD3 (cytoplasmic), CD56, cytotoxic markers (granzyme B, TIA1) and Epstein Barr virus (EBV). Plasma EBV DNA is an accurate surrogate biomarker for lymphoma load. For stage I/II nasal lymphoma, a combination of chemotherapy and radiotherapy yields the best results. Concomitant chemoradiotherapy and sequential chemotherapy and radiotherapy give similar response rates and survivals. For stage III/IV nasal lymphoma and non-nasal lymphomas, chemotherapy is the mainstay of treatment. Conventional anthracycline-based regimens are ineffective. Recommended chemotherapy protocols are based on the use of L-asparaginase combined with other effective drugs. Durable remission can be expected in at least 60% of patients irrespective of stage. Prognostically models based on clinicopathologic parameters and EBV DNA load are useful in stratification of patients for therapy. Expert commentary: Current treatment leads to long-term survival in a significant proportion of patients. For relapsed patients, novel strategies are needed.

Advances in the management and monitoring of extranodal NK/T-cell lymphoma, nasal type

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, has a unique geographic distribution. Its pathology is characterized by marked angio-invasion and tissue necrosis. A typical NK-cell phenotype is usually present: CD2(+), CD3 epsilon+, CD56(+), cytotoxic molecules+ and Epstein-Barr virus (EBV)+. Magnetic Resonance Imaging helps to clearly define the local involvement. Positron Emission Tomography helps to demonstrate system spread. Various prognostic variables (International Prognostic Index or the Korean Prognostic Index) should be documented. This may include quantification of plasma EBV DNA. For localized nasal disease, radiotherapy is important, although chemotherapy is often added. Sustainable remission is observed in over half of these patients. For extra-nasal or disseminated disease, systemic chemotherapy becomes the mainstay and the prognosis is usually poor. Doxorubicin-containing regimens are not entirely satisfactory and L-asparaginase containing regimens are being investigated. Patients with poor prognostic features may be considered for an early autologous haematopoietic stem cell transplant. Allogeneic transplantation is efficacious but is associated with high transplant-related mortality.

Primary extranodal NK/T cell lymphoma ("nasal type") of the endometrium: report of an unusual case diagnosed at autopsy

Primary natural killer (NK)/T cell lymphoma of the female genital tract is extremely rare. We here report the case of a "nasal type" NK/T cell lymphoma arising in the uterus. The diagnosis was established only at autopsy.

Natural killer-cell malignancies: diagnosis and treatment

Natural killer (NK)-cell malignancies are uncommon diseases. Previously known as polymorphic reticulosis or angiocentric T-cell lymphomas, they are classified by the World Health Organization as NK/T-cell lymphoma, nasal type and aggressive NK-cell leukemia. They are prevalent in Asia and South America, but exceptionally rare in western countries. Pathologically, NK-cell lymphomas show a polymorphic neoplastic infiltrate with an angioinvasive and angiodestructive pattern. Lymphoma cells are characteristically CD2+, CD56+ and cytoplasmic CD3epsilon+. T-cell receptor gene is germline, and clonal Epstein-Barr virus (EBV) infection is almost invariably. Clinically, they can be divided into nasal, non-nasal, and aggressive lymphoma/leukemia subtypes. Most nasal NK-cell lymphomas present with stage I/II disease, and frontline radiotherapy is the most important key to successful treatment. Many stage I/II patients treated with radiotherapy fail systemically, implying that concomitant chemotherapy may be needed. Chemotherapy is indicated for advanced nasal NK-cell lymphoma, and the non-nasal and aggressive subtypes. However, treatment results are unsatisfactory. High-dose chemotherapy with hematopoietic stem cell transplantation may be beneficial to selected patients. The International Prognostic Index and presentation EBV DNA load is of prognostic significance and may be useful in the stratification of patients for various treatment modalities.

Nasal NK-cell lymphoma followed by relapse in the uterine cervix

We report a case of nasal natural killer (NK)-cell lymphoma in a 51-year-old Japanese woman who showed a later relapse in the uterine cervix. The nasal NK-cell lymphoma regressed after local radiation therapy. Six months after the diagnosis while the patient was being treated with chemotherapy for a subclinical tumor, a mass lesion of the uterine cervix was noticed by follow-up computed tomography. Giemsa-stained vaginal smear showed lymphoid tumor cells with large azurophilic granules, leading to a rapid diagnosis of cervical involvement by NK-cell lymphoma. The chemotherapy regimens were immediately changed, but the patient died 2 months after the relapse with an overall survival of 8 months. This case may be of value in elucidating the biological behavior and natural history of NK-cell lymphoma.

Primary CD56 positive lymphomas of the gastrointestinal tract

BACKGROUND

Primary CD56 positive lymphoma of the gastrointestinal (GI) tract is rare. Genotypically, these tumors can be classified into natural killer (NK)-like T-cell lymphoma or NK cell lymphoma by the presence or absence of T-cell receptor (TCR) gene rearrangement. However, they have a considerable degree of morphologic and immunophenotypic overlap, making a definitive diagnosis difficult.

METHODS

The clinicopathologic features of three patients with primary CD56 positive lymphoma of the small and large bowel are presented. This is followed by a review of the English literature from 1966 to the present.

RESULTS

All patients had CD56 positive/CD3epsilon positive disease on paraffin section. Two patients were positive for Epstein-Barr virus-encoded early nuclear RNAs (EBER) according to in situ histochemistry results and were negative for TCR gene rearrangement, consistent with primary NK lymphoma of the GI tract. The other patient was EBER negative with rearranged TCR, consistent with NK-like T-cell lymphoma. There was no clinical or histologic evidence of enteropathy in any of the patients. The major presenting symptoms included fever, weight loss, and intestinal perforation. All patients died between 1 week and 6 months after diagnosis despite undergoing surgery and intensive chemotherapy.

CONCLUSIONS

These results, together with a literature review, suggest that primary NK cell lymphoma of the GI tract may be considered a distinct clinicopathologic entity. Both primary NK and NK-like T-cell lymphoma pursue an aggressive clinical course. EBER and TCR gene rearrangement are useful in distinguishing NK cell lymphoma from NK-like T-cell lymphoma, particularly when frozen tissue is not available for immunophenotyping.

Diagnosis and management of primary nasal lymphoma of T-cell or NK-cell origin

The primary nasal natural killer cell (NK/T cell) lymphoma is histologically characterized by angiocentricity with invasion of blood vessels and blockage of blood vessels by lymphoma cells, resulting in marked ischemic necrosis of the normal and neoplastic tissues. The cytological appearances of the neoplastic cells are highly variable and accompanied by a mixture of inflammatory cells. On immunophenotyping, the diagnostic features are surface CD3(-), cytoplasmic CD3 epsilon(+), and CD56(+). For the majority of the cases, T-cell receptor gene rearrangement is absent, confirming an NK-cell origin of the tumor cells. Clonal proliferation of Epstein-Barr virus (EBV) is usually present in the tumor cells and is a useful diagnostic marker. Patients commonly present with nasal symptoms: mass, obstruction, or bleeding. The tumor is locally invasive and may infiltrate surrounding tissues and organs, such as the orbits, nasopharynx, oropharynx, and palate. The cranial nerves are sometimes affected. The tumor may also disseminate to skin, gastrointestinal tract, and the testis at the time of progression. Occasionally, other organ sites such as the skin are involved, sparing the nose, and it is then called the non-nasal type. A high index of suspicion is required for the diagnosis of this disease. Because of the small size of the specimen and the necrotic nature of the tumor, biopsy of the nasal tissue may not be easy to interpret. Repeated biopsies are often required. The special stain for EBV in the tumor cells may also be helpful in making the correct diagnosis. Response of primary nasal T-/NK-cell lymphoma to local treatment such as radiotherapy is often not satisfactory. Combined chemotherapy and radiotherapy has been used and appears to be more effective.