Extranodal NK/T-cell lymphoma, nasal type (angiocentric T-cell lymphoma): A review about the terminology

Rhino-Orbital-Cerebral Mycosis and Extranodal Natural Killer or/and T-Cell Lymphoma, Nasal Type

Background

Extranodal natural killer/T-cell lymphoma, nasal type is a syndrome of middle face destruction with an association to Epstein-Barr virus. Fungi have been recovered from the diseased tissue now and then but were often seen as a lymphoma-associated secondary infection. However, there are ENKTL-NT cases with the recoveries of fungi and complete recovery with antifungal therapy, which are quite similar to rhino-orbital-cerebral mycosis (ROCM) that often confuses the physicians.

Methods

We searched Medline for English-language manuscripts limited to “human” and “case reports,” “letters,” “reviews,” and “clinical conferences” from 1966 to 2022. We used MeSH terms “lymphoma, extranodal nk-t-cell” [MeSH Terms] or “lethal midline granuloma” [MeSH Terms], in combination with MeSH terms “microbiology” [subheading] or “microbiology” [all fields] or “fungi” [all fields] or “fungi” [MeSH Terms] for ENKTL-NT with infections. We used MeSH terms “Mycoses” in combination with “Nose” [Mesh] OR “Orbital Diseases” [Mesh] for rhino-orbital-cerebral fungal infections.

Results

We appraised 149 included articles and extracted references related to ENKTL-NT and/or ROCM. Themes and subcategories were subsequently derived. Our findings revealed that ROCM and ENKTL-NT are characterized by progressive and destructive ulcers in the midline face or rhino-orbital structures. ROCM is mainly caused by fungi in the order of Mucorales, and ENKTL-NT is usually associated with Epstein-Barr virus and sometimes fungi. Radiologically, both are characterized by non-specific features of sinusitis, soft tissue infection, and necrosis. Pathologically, ROCM and ENKTL-NT share the same characteristics of inflammation, necrosis, and granuloma. ROCM is characterized by the detection of fungi in tissue, while ENKTL-NT is typically positive for NK/T-cell markers and cytotoxic granule-associated proteins, proliferation, and vascular damage of angioinvasion, which could be incited by Mucor irregularis and Rhizopus arrhizus in patients and mice.

Conclusion

ENKTL-NT and ROCM share many similarities in clinical presentations, radiology, and histopathology, and might have the same etiology. This may explain why the two diseases are tangled together in the reported cases, and suggests the role that the fungi may play in the development of these ENKTL-NT/ROCM diseases. The reason why ENKTL-NT and ROCM are sometimes confused is that the main pathogens of ROCM, Mucor irregularis and Rhizopus arrhizus, are the fungal causative agents of ENKTL-NT.

Case Report: Rhizopus arrhizus Rhino-Orbital-Cerebral Mycosis and Lethal Midline Granuloma: Another Fungal Etiological Agent

Objective: Both rhino-orbital-cerebral mycosis and lethal midline granuloma (LMG) may result in midline destruction. LMG has now been generally considered as a natural killer/T cell lymphoma, nasal type (ENKTL-NT) with an association of EBV. Fungi have been detected from the diseased tissues now and then but are often considered as lymphoma-associated infections. We previously reported an ENKTL-NT case with Mucor irregularis, which played a causal role in the disease and was involved in the overexpression of Ki67 and CD56 in the mouse experiment. The present study describes a chronic Rhizopus arrhizus infection with immunological parameters that are closely similar to LMG. We aim to explore the relationship of another Mucorales fungus, R. arrhizus, and LMG in a patient and in mice. Methods: Case study and mouse infection modules were designed for our observation. A 35-year-old man with midline face ulcers which was clinically suspected as LMG was selected. Biopsy specimens were sent for lymphoma diagnosis and microbiological detection. The isolated fungus was tested in an ICR mouse model for mycological and histological analyses. Results: Five tissue samples yielded Rhizopus arrhizus. In the pathology, characteristic inflammation, necrosis, and granulation with thin-walled hyphae are observed. Immunohistochemistry showed NK/T cell infiltration (CD3+, CD8+, TIA1+, GZMB+, PRF+, individual CD56+) with hyperplasia (Ki67+) and angioinvasion. The patient recovered completely with amphotericin B. In the murine experiment, R. arrhizus caused angioinvasion with NK/T cell infiltration (CD3+, CD56+, TIA1+, GZMB +, PRF+) with proliferation (Ki67+) and was re-isolated from the infected host. Conclusions: We here describe a mid-face destruction patient, which was diagnosed by the top pathologists in China according to the current criteria of NK/T cell lymphoma, with a negative result for EBV and positive result for R. arrhizus. With a then developed mouse experiment, the R. arrhizus in the diseased lesions was responsible for the NK/T cell infiltration (CD3+, CD8+, CD56+, TIA1+, GZMB+, PRF+), proliferation (Ki67+), and angioinvasion, suggesting another fungal etiological agent for LMG, which could be eradicated with amphotericin B. Limitations: The sample size is not sufficient for statistical analysis. However, our findings are suggestive for the role fungus plays in LMG.

An Unusual Source of Sinonasal Disease in an Immunocompromised Patient: A Case Report of the Clinical Presentation, Diagnosis, and Treatment of Acanthamoeba Rhinosinusitis

Chronic nasal crusting is a commonly encountered entity in an otolaryngology office. Progressive, extensive nasal crusting with erosion is relatively unusual, however. We present the case a 58-year-old renal transplant patient with a history of vasculitis and immunosuppression who presents with subjective headache and facial pain, nasal crusting, and isolated left ethmoid sinusitis. She developed extensive intranasal necrosis and underwent multiple endoscopic sinus surgeries with intraoperative biopsies, which played a critical role in her workup and eventual diagnosis of Acanthamoeba rhinosinusitis. Although she endured a difficult course, proper diagnosis and treatment allowed for her recovery over time. The differential diagnosis for intranasal necrosis is often broad. This case highlights the wide range of etiologies to be considered in a patient with extensive nasal crusting and erosion/necrosis, and the importance of thorough diagnostic evaluation in these patients, especially those in an immunocompromised state.

Differential diagnosis of sinonasal extranodal NK/T cell lymphoma and diffuse large B cell lymphoma on MRI

Purpose

To evaluate whether imaging features on conventional magnetic resonance imaging (MRI) can differentiate sinonasal extranodal natural killer/T cell lymphomas (ENKTL) from diffuse large B cell lymphoma (DLBCL).

Methods

Consecutively, pathology-proven 59 patients with ENKTL and 27 patients with DLBCL in the sinonasal region were included in this study. Imaging features included tumor side, location, margin, pre-contrast T1 and T2 signal intensity and homogeneity, post-contrast enhancement degree and homogeneity, septal enhancement pattern, internal necrosis, mass effect, and adjacent involvements. These imaging features for each ENKTL or DLBCL on total 86 MRI scans were indicated independently by two experienced head and neck radiologists. The MRI-based performance in differential diagnosis of the two types of lymphomas was evaluated by multivariate logistic regression analysis.

Results

All ENKTLs were located in the nasal cavity, with ill-defined margin, heterogeneous signal intensity, internal necrosis, marked enhancement of solid component on MRI, whereas DLBCLs were more often located in the paranasal sinuses, with MR homogenous intensity, mild enhancement, septal enhancement pattern, and intracranial or orbital involvements (all P < 0.05). Using a combination of location, internal necrosis and septal enhancement pattern of the tumor in multivariate logistic regression analysis, sensitivity, specificity, and accuracy in differential diagnosis of ENKTL and DLBCL were 100%, 79.4%, and 91.9%, respectively, for radiologist 1, and were 98.3%, 81.5%, and 93.0%, respectively, for radiologist 2.

Conclusion

MRI can effectively differentiate ENKTL from DLBCL in the sinonasal region with a high diagnostic accuracy.

Down-regulation of intracellular reactive oxygen species attenuates P-glycoprotein-associated chemoresistance in Epstein-Barr virus-positive NK/T-cell lymphoma

Epstein-Barr virus (EBV)-positive extranodal NK/T-cell lymphoma is a rare and highly aggressive disease with a poor prognosis and strong resistance to anti-cancer drugs. Reactive oxygen species (ROS) are closely related to tumorigenesis and P-glycoprotein (P-gp) is highly expressed in various cancers. However, the exact relationship between ROS and P-gp in EBV-positive lymphoma remains unclear. In this study, we demonstrated that EBV latent infection induced intracellular ROS production and increased ROS levels triggered elevated P-gp expression, which resulted in strong resistance to existing anti-cancer drugs in EBV-positive lymphoma cell lines and in patients' tissue samples. We also verified that regulation of intracellular ROS reduced P-gp expression and function via inhibition of STAT1 phosphorylation. These results indicate that treatment with a ROS scavenger is a potential therapeutic strategy to overcome resistance to anti-cancer drugs by downregulating the expression of P-gp in EBV-positive NK/T-cell lymphoma.

Nasal NK/T-cell Lymphoma Presenting as Acute Inflammation of Nasal Vestibule

Extra nodal nasal NK/T cell lymphoma is relatively a rare type of non-Hodgkin lymphoma. Variable clinical presentation with rapidly progressive necrosis of the cartilaginous and bony wall of the nose and upper respiratory passages leads to delayed diagnosis and treatment. A 43-years-old patient presented with right nasal pain and furuncle-like swelling. The swelling progressed rapidly to cellulitis to the face up to the right eye. Within 2 months, it had advanced to necrosis of the lateral vestibular cartilage, medial maxillary wall, turbinate and nasal septal cartilage. Biopsy reported as non-Hodgkin diffuse T cell (angiocentric T cell) lymphoma.

Tip of nose tuberculosis: A rare presentation of extra pulmonary tuberculosis

Tuberculosis is notorious that it affects various sites of the human body and presents in different ways. One of the uncommon or rather rare presentation of extra pulmonary tuberculosis is nasal tuberculosis. The nose apart from its physiological functions also contributes to facial aesthetics and gives a defined appearance and its deformity imparts cosmetic disfigurement and unsightly appearance. Both primary and secondary forms of nasal tuberculosis are rare but should be considered in the differential diagnosis of ulcerative or crusting lesions of the nose. Here we report such a case of nasal tuberculosis, which presented as an ulcerative and crusting lesion over the tip of the nose in a female child. The patient was given antituberculous chemotherapy after establishing the diagnosis and responded well to treatment.

Successful Treatment of Genetically Profiled Pediatric Extranodal NK/T-Cell Lymphoma Targeting Oncogenic STAT3 Mutation

Extranodal natural killer (NK)/T-cell lymphoma (ENKTCL) is a distinct type of non-Hodgkin lymphoma predominantly observed in Asian and Latin American adult males. A 12-year-old Hispanic female diagnosed with ENKTCL was enrolled in our genomic profiling research protocol. We identified specific somatic alterations consistent with diagnosis of ENKTCL as well as oncogenic mutations in MAP2K1 and STAT3. To our knowledge, this is the first report of an immunophenotypically confirmed and genetically profiled case of ENKTCL in a female pediatric patient in the United States, including its unique treatment and favorable outcome.

Osteonecrosis of the Jaw in Association With Chemotherapy in the Setting of Cutaneous T-Cell Lymphoma

T-cell lymphomas (TCLs) account for approximately 15 to 20% of all non-Hodgkin lymphomas in the United States. The most common form of TCL is cutaneous TCL (CTCL), with Sézary syndrome and mycosis fungoides being the most prevalent subtypes. Sézary syndrome is the more aggressive form and often is referred to as a late-stage variant of mycosis fungoides. Clinically, it is characterized by diffuse erythroderma, cutaneous edema, pruritus, nonhealing cutaneous ulcers, and lymphadenopathy. Patients also can present with changes to their nails, hyperpigmentation, alopecia, palmoplantar keratoderma, ectropion, and hepatosplenomegaly. The overall prognosis for patients with Sézary syndrome is poor. The literature regarding oral manifestations of CTCL mostly report those of mycosis fungoides because it is the most common subtype of CTCL. Currently, there are only 2 reports in the scientific literature of intraoral manifestations of Sézary syndrome. This case report describes a patient with Sézary syndrome who presented with rapidly progressing erythematous lesions of the gingiva and multifocal osteonecrosis of the maxilla and mandible. This is the third reported case of an intraoral manifestation of Sézary syndrome and the first reported case of osteonecrosis in the setting of CTCL.

A comparative population-based analysis of sinonasal diffuse large B-cell and extranodal NK/T-cell lymphomas

OBJECTIVE/HYPOTHESIS

Diffuse large B-cell lymphoma (DLBCL) and extranodal natural killer/T-cell lymphoma (ENKTL) are aggressive tumors. ENTKL is very rare in the United States and often affects the nasal cavity and paranasal sinuses; DLBCL, although more common, rarely occurs in these locations. Our study aims to compare incidence and survival of these lymphomas in the sinonasal cavity.

STUDY DESIGN

Retrospective analysis of the United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry.

METHODS

The SEER database was searched for patients diagnosed with sinonasal ENKTL and DLBCL between 1973 and 2011. Data analyzed included patient demographics, incidence, treatment modality, and survival.

RESULTS

Three hundred and twenty-eight sinonasal ENKTL (SN-ENKTL) cases and 1,054 sinonasal DLBCL (SN-DLBCL) cases were identified. The mean ages at diagnosis for SN-ENKTL and SN-DLBCL were 51.7 and 67.8 years, respectively (P = 0.0001). Overall 1-, 5-, and 10-year disease-specific survival (DSS) rates for SN-DLBCL were 85.5%, 63.5%, and 44.0%, compared to 66.4%, 30.9%, and 9.2% for SN-ENKTL, respectively (P < 0.0001). For patients matched for stage, age, and treatment modality, the 1-, 5-, and 10-year DSS for the SN-DLBCL group was 94.4%, 72.8%, and 46.8%, respectively, whereas the respective survival rates for the SN-ENKTL group were 77.6%, 38.4%, and 13.9%, respectively (P < 0.0001 at each time interval).

CONCLUSIONS

To our knowledge, this study represents the only population-based comparison between SN-DLBCL and SN-ENKTL. SN-DLBCL has a better prognosis regardless of gender, stage, treatment modality, and age.

LEVEL OF EVIDENCE

2b.

The significance of combining radiotherapy with chemotherapy for early stage extranodal natural killer/T-cell lymphoma, nasal type: a systematic review and meta-analysis

Abstract Radiotherapy is regarded as a primary treatment for early stage extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKTL). However, whether combined modality treatment (CMT) comprising radiotherapy and chemotherapy is necessary remains controversial. A systematic review and meta-analysis of studies was performed to evaluate the significance of combining radiotherapy with chemotherapy for early stage ENKTL. Comparison of CMT and radiotherapy alone (RT) showed no significant difference by the measurement of complete response (CR) (odds ratio [OR] 1.07; 95% confidence interval [CI] 0.73-1.58; p = 0.73), 5-year overall survival rate (OS) (HR 0.73; 95% CI 0.45-1.19; p = 0.21) and progression-free survival rate (PFS) (HR 0.76; 95% CI 0.50-1.17; p = 0.21). Additional chemotherapy did not decrease systemic failure (OR 1.52; 95% CI 0.97-2.40; p = 0.07), as well as locoregional failure (OR 0.94; 95% CI 0.52-1.73; p = 0.85). The results may support the assertion that the combination of radiotherapy with chemotherapy cannot improve treatment outcomes, but rather it increases adverse effects and financial costs. However, these results should be interpreted with caution.

Natural killer/T-cell lymphoma, nasal type, masquerading as recalcitrant periodontitis in a patient with a diagnosis of Wegener's granulomatosis

Extranodal natural killer (NK)/T-cell lymphoma, nasal type, is a rare type of non-Hodgkin's lymphoma with similar presentation to various benign inflammatory diseases. Adequate biopsy is required for a diagnosis because this lymphoma frequently coexists with large amount of necrosis and inflammation. In this study, a case of a 49-year-old woman presenting with a 3-week history of right maxillary alveolar ridge pain with a subsequent diagnosis of periodontitis is described. The patient's clinical condition deteriorated over a period of 6 weeks. Computed tomography delineated involvement of the right maxillary sinus, posterior part of the right pharynx and right nasal cavity. Immunohistopathology initially revealed Wegener's granulomatosis, followed by extranodal nasal-type NK/T-cell lymphoma. Severe refractory periodontitis in a background of Wegener's granulomatosis may be the initial presentation of extranodal NK/T-cell lymphoma, nasal type. In addition to careful examination, radiographic and laboratory testing, multiple large biopsies should be taken for immunohistochemical analysis to obtain an appropriate diagnosis.

Lethal midline granuloma

Lethal midline granuloma is a relatively rare disease characterized by destruction and mutilation of the nose and other structures of respiratory passages. The nonspecificity of symptoms obscures the correct diagnosis and is responsible for the delay in treatment which can be detrimental as this grave disease calls for urgent intervention. We present a case report of this disease in a 35 year old male who gave a short two month history of the clinical symptoms.

Immunomorphologic profile and Epstein-Barr virus status of a cohort of 35 cases of extranodal natural killer/T-cell lymphoma, nasal type of upper aerodigestive tract from a tertiary care center in South India

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (EN-NK/T-NT) is a lymphoma of NK-cell or cytotoxic T-cell origin, which occurs most commonly in the upper aerodigestive tract. We have studied the immunomorphologic profile and Epstein-Barr virus (EBV) status of a cohort of 35 cases of EN-NK/T-NT of the upper aerodigestive tract (UADT) diagnosed in our institution during the period May 2002 to April 2012. At our institution these lymphomas constitute 0.7% of total non-Hodgkin lymphomas (NHLs) and 5.1% of total peripheral T-cell lymphomas (PTCLs). The median age at diagnosis was 40 years with a male-to-female ratio of 4:1, and the most common site of involvement was the nasal cavity. Morphologically, the neoplastic cells were predominantly medium sized in most cases. Necrosis and angiocentricity were common histologic features. Thirty cases (85.7%) showed NK-cell immunophenotype, CD3+ (29/30, 96.7%), CD56+ (30/30, 100%) and TIA1/Granzyme B+ (30/30, 100%). Five cases (14.3%) showed cytotoxic T-cell immunophenotype, CD3+ (5/5, 100%), CD56- (5/5, 100%) and TIA1/Granzyme B+ (5/5, 100%). EBV-encoded RNA-in situ hybridization (EBER-ISH) was positive in all 35 cases, whereas EBV latent membrane protein-1 (EBVLMP1) was positive in only 19/35 (54.3%) of cases. In conclusion, this is the first large study from India to report the immunomorphologic profile and EBV association of EN-NK/T-NT, which is known to have geographic variation. The frequency of these lymphomas in our study is comparable to that of Western and European countries and much less than that of Far Eastern countries.

Retrospective analysis of treatment outcomes for extranodal NK/T-cell lymphoma (ENKL), nasal type, stage I-IIE: single institute experience of combined modality treatment for early localized nasal extranodal NK/T-cell lymphoma (ENKL)

Extranodal natural killer/T-cell lymphoma (ENKL) is a very aggressive disease frequently involving the nasal cavity and upper aerodigestive tract. We retrospectively reviewed the treatment outcomes and treatment-associated complications of the patients with stage I-II early localized ENKL. A total of 24 patients were included. All patients were treated with combined chemoradiotherapy. Three, sixteen, and five patients were initially treated with radiation therapy, chemotherapy, and surgical procedures, respectively. Nine patients underwent hematopoietic stem cell transplantation (HSCT), and four patients administered immunotherapy with pegylated-interferon alpha. The mean observation time was 71.6 months (range, 29.7-183.6 months). Twenty patients achieved complete remission; thus, the overall response rate was 83.3 %. The 5-year overall survival (OS) and relapse-free survival (RFS) rates were 70.3 % and 62.2 %, respectively. In univariate analysis, HSCT was a significant prognostic indicator for OS and RFS. By combining HSCT, the 5-year OS and RFS rates were 100.0 % vs. 52.5 % (p = 0.018) and 88.9 % vs. 45.7 % (p = 0.045), respectively. Also, absence of B symptoms was a good prognostic factor for RFS, the 5-year RFS rate, 75.0 % vs. 25.0 % (p = 0.010), and B symptoms were significant for RFS in multivariate analysis (odds ratio = 7.4, confidence interval = 1.6~34.1, p = 0.011). However, a total of four cases of grade 3 toxicities were reported. Radiation dose range (≤4,500 vs. >4,500 cGy) was significantly correlated with late complications, as more severe complications occurred more frequently with a radiation dose >4,500 cGy (p = 0.026, in multivariate analysis). For more efficient treatment of ENKL, chemotherapy, HSCT, and/or immunotherapy can be combined with radiation therapy to prolong long-term survival and achieve good local control. Also, lower radiation dose could be administered to avoid severe late complications.