Intravascular lymphomatosis of the T cell type presenting as interstitial lung disease--a case report

Intravascular cytotoxic T-cell lymphoma in a young immunocompetent woman

Intravascular lymphoma (IVL) is a rare disorder characterized by the presence of large neoplastic lymphoid cells restricted to the lumens of small vessels with a predilection for the skin and the central nervous system. While the vast majority of cases involving IVL are of B-cell lineage, the disease rarely affects the T-cell, the histiocytes, and the natural killer cells. We report a case of intravascular T-cell lymphoma (IVTL) associated with Epstein-Barr virus (EBV). A 23-year-old healthy woman presented with tender indurated erythematous patches with overlying telangiectasia on her right breast, abdomen, both the upper and the lower extremities and the back for 3 months. The pathology revealed an infiltration of dermal and subcutaneous vessels by large and atypical lymphoid cells with immunohistochemical features of the T-cell lineage with a cytotoxic phenotype (CD3+, CD8+, granzyme B+, TIA-1+, CD4-, CD5-, CD20-, CD56-). Interestingly, the DNA extracted from the skin biopsies demonstrated evidence of a monoclonal immunoglobulin heavy chain gene rearrangement, but no T-cell receptor gene rearrangement was found. In situ hybridization study for EBV-encoded RNA was positive. She was diagnosed with an EBV-associated IVTL. The patient's skin lesions were refractory to the combination of chemotherapy and autologous stem cell transplant, and she expired. The findings in the present case may highlight the unique clinicopathologic aspects of EBV-associated cytotoxic IVTL that occurred in a young, immunocompetent woman.

Clinical features and treatment outcomes of intravascular large B-cell lymphoma: a single-center experience in Korea

BACKGROUND

Clinical features and treatment outcomes of intravascular large B-cell lymphoma (IVLBCL) have rarely been reviewed due to its rarity and pathologic obscurity.

METHODS

We analyzed 20 patients who were pathologically diagnosed with IVLBCL at the Samsung Medical Center.

RESULTS

Initial manifestations were nonspecific, such as fever with cytopenia, elevated serum lactate dehydrogenase and hypoalbuminemia. Hemophagocytosis was frequent and bone marrow was the most common site of pathologic diagnosis in our series. Hepatosplenomegaly, pleural effusion and ground-glass opacity in the lungs were also commonly found, and positron emission tomography imaging showed increased (18)F-fluorodeoxyglucose uptake in the involved organs. All patients received CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) or rituximab-CHOP. The median overall survival (OS) was 38.9 months (95% confidence interval 6.7-71.1). Rituximab-containing chemotherapy compared to chemotherapy alone resulted in higher 3-year OS (71.4 and 25.0%; p = 0.027). Patients with hemophagocytosis had a poorer 3-year OS compared to patients without hemophagocytosis (29.6 and 75%; p = 0.046). Prognostic factor analysis showed the association of pleural effusion with worse OS (p = 0.002).

CONCLUSIONS

Treatment with rituximab-containing chemotherapy can improve the treatment outcome of IVLBCL. Pleural effusion may be a poor prognostic factor in patients with IVLBCL.

A rare case of intravascular large T-cell lymphoma with an unusual T helper phenotype

Although most cases of intravascular large cell lymphoma exhibit a B-cell phenotype, less than 50 cases in the literature describe a T-cell or natural killer cell phenotype and, of these, the majority are CD3+, CD4-, CD5-, CD30-, CD56+, TIA-1+, and EBER+. We present a case of a rare intravascular large T-cell lymphoma in a 59-year-old man with an unusual CD3+, CD4+, CD5-, CD30+, CD56-, TIA-1-negative and EBER-negative phenotype. This T helper or CD30 phenotype is particularly uncommon. To our knowledge, it has only been described once before and never in the absence of the cytotoxic marker TIA-1. This case exemplifies the particular diagnostic challenges raised by intravascular large cell lymphomas generally and should encourage the use of endothelial immunohistochemical staining in questionable cases. While evaluating skin punch biopsies, it is critical to keep this rare entity on the differential diagnosis along with the relatively more common intravascular large B-cell lymphoma and epithelial malignancies. Additionally, our understanding of intravascular large natural killer/T-cell lymphoma as a heterogeneous phenotypic entity continues to evolve. This case demonstrates that the degree of this phenotypic heterogeneity may be even greater than previously thought.

NK-cell intravascular lymphomatosis--a mini-review

The majority of cases of intravascular lymphomatosis (IVL) is derived from B cells. However, IVL may also arise from T cells, or more rarely NK cells. The clinicopathological findings in six cases of NK-cell IVL (NK-IVL), including one new case, were summarised and compared with B-cell IVL (B-IVL) and T-cell IVL (T-IVL). Earlier onset of disease and female predominance were found in NK-IVL. NK-IVL was typically Epstein-Barr virus (EBV)-positive, whereas EBV was rarely detected in B-IVL. Cutaneous manifestations were common in NK-IVL with constant EBV infection. B-IVL showed a more favourable prognosis than T- or NK-IVL. Irrespective of immunophenotype, however, IVL showed a less favourable prognosis than ordinary lymphomas within the same immunophenotype. In summary, IVL of the B-, T- and NK-cell phenotypes is clinicopathologically distinct and shows similarities to their more common counterparts, i.e. diffuse large B-cell lymphoma, peripheral T-cell lymphoma, unspecified and extranodal NK/T-cell lymphoma, nasal type.

Skin manifestations of intravascular lymphoma mimic inflammatory diseases of the skin

BACKGROUND

Intravascular lymphoma (IVL) is fatal when it is diagnosed late in the course. Sometimes skin lesions enable early diagnosis, but criteria for diagnosis are not well established.

OBJECTIVES

To demonstrate the clinical spectrum of skin lesions of IVL and to correlate it with clinical outcome; to identify features differentiating between B-cell and T-cell IVL with skin involvement.

METHODS

Review of 97 articles reporting on total of 224 patients with IVL.

RESULTS

Skin lesions were mentioned in 90 of 224 patients. They were nodules and/or plaques (49%) or macules (22.5%) of red (31%) or blue to livid (19%) colour on the leg (35%), the thigh (41%) and the trunk (31%). Telangiectases were present in only 20% of the patients. Oedema (27.5%) of the legs and pain (24%) were often accompanying. No criteria enabled distinction between lesions restricted to the skin and skin lesions concurrent with IVL in other organs, but when the disease was restricted to the skin, the prognosis was favourable (10% vs. 85% fatal outcome). Skin lesions of T-cell IVL are indistinguishable from those of B-cell IVL.

CONCLUSIONS

Forty per cent of all patients with IVL have skin lesions, these being red, sometimes painful plaques located typically on the lower extremities, accompanied by oedema. A clinician risks misinterpreting these changes as thrombophlebitis, erythema nodosum or erysipelas. Neither clinical course nor differentiation of the lymphoma can be predicted from the morphology of skin lesions, but involvement of other organs at the time of diagnosis indicates a poor prognosis.

Intravascular large T-cell lymphoma: a case report of CD30-positive and ALK-negative anaplastic type with cytotoxic molecule expression

We reported a case of intravascular T-cell lymphoma (T-IVL) with anaplastic large cell morphology, the hemophagocytic syndrome, and an aggressive clinical course. Phenotypic analysis of the tumor cells revealed CD2+, CD3-, CD4+, CD5-, CD8-, CD30+, CD56-, T-cell receptor alpha/beta-, ALK-, TIA1+, granzyme B+, and perforin+. No association with Epstein-Barr virus was found by in situ hybridization. A review revealed that 25 cases of T-IVL have been reported in the available literature, only two of which were of CD30+ anaplastic large cell or cytotoxic T-cell type. The findings in the present case may highlight the unique clinicopathologic aspects of a subset of CD30-positive T-IVLs with an ALK-negative cytotoxic phenotype.

Intravascular T-cell lymphoma with bowel involvement: case report and literature review

Intravascular lymphoma (IVL) is a rare form of non-Hodgkin lymphoma characterized by massive proliferation of large, neoplastic cells in small- and medium-sized blood vessels. Most cases of IVL are of B-cell immunophenotype; fewer than 15 cases of T-cell IVL have been reported. A 23-year-old male presented with acute abdominal pain, fever, and tender lower abdomen. Pathology at laparotomy revealed infiltration of colonic vessels with large lymphoid cells compatible with IVL. We reviewed all cases of IVL diagnosed at the Queen Elizabeth II Health Sciences Centre in Halifax, Nova Scotia, from August 1992 to August 2002. A literature review was also performed. Five additional cases of IVL were identified at this institution during a 10-year period. Three patients presented with neurological symptoms, and two with abdominal pain. In 4 of 5 cases, patients died of lymphoma within 3 months of presentation; one patient experienced a 10-month remission. While visceral involvement with IVL is common at autopsy, IVL presenting as an acute abdomen in an immunocompetent patient has not previously been described. Among the 15 cases of T-cell IVL reported in the literature, only two occurred in people under age 30. Given the rarity of T-cell IVL, it is remarkable that three cases of T-cell IVL have been diagnosed at our institution during a 10-year period.