Analysis of prognostic factors in diffuse large B-cell lymphoma associated with rheumatic diseases

Objective

The risk of developing diffuse large B-cell lymphoma (DLBCL) is increased in many rheumatic diseases (RDs). It is possible that RD-associated DLBCL is a distinct subset within the category of ‘DLBCL’, exhibiting characteristic biological features and clinical behaviour. However, information on RD-associated DLBCL is limited.

Methods

We searched the V.A. Nasonova Research Institute of Rheumatology (Russia) database from 1996 to 2021 for patients with RDs and coexisting DLBCL. Prognostic factors including the International Prognostic Index (IPI), bulk disease and c-MYC/8q24 gene rearrangements were analysed. Furthermore, we stratified DLBCLs as germinal centre B-cell (GCB) subtype and non-GCB subtype based on Hans’ immunohistochemical algorithm and also examined Epstein-Barr virus (EBV) status.

Results

Twenty-seven patients with RD-associated DLBCL were identified. Twenty patients had primary Sjogren’s syndrome, three had systemic lupus erythematosus, two had rheumatoid arthritis and two had systemic sclerosis. Secondary Sjogren’s syndrome was found in four patients. The median age at the time of diagnosis of DLBCL was 59 years with a female predominance (26:1). Based on IPI, 16 patients were assigned to the intermediate-high and high-risk groups. Bulk disease was detected in 29% of patients. Of the 20 examined cases, 4 (20%) were classified as the GCB subtype and 16 (80%) were classified as the non-GCB subtype. EBV was detected in 2 of the 21 tested cases (10%), and the c-MYC/8q24 gene rearrangement was not found in any of the 19 examined cases. After the lymphoma diagnosis, the median overall survival (OS) was 10 months (range: 0–238 months).

Conclusions

Except for the more common non-GCB subtype, we did not identify any other prognostic factor that could influence the prognosis of patients with RD-associated DLBCL. We believe that short OS in our patients was predominantly associated with decreased tolerance to lymphoma treatment.

The non-leukemic T cell large granular lymphocytic leukemia variant with marked splenomegaly and neutropenia in the setting of rheumatoid arthritis - Felty syndrome and hepatosplenic T cell lymphoma mask

T cell large granular lymphocytic (T-LGL) leukemia is a rare type of mature T cell neoplasm. The typical features of T-LGL leukemia include an increased number of large granular lymphocytes in the peripheral blood, cytopenia (most commonly neutropenia), and mild-to-moderate splenomegaly. Up to 28% of patients with T-LGL leukemia have rheumatoid arthritis (RA). This study reports ten atypical cases (seven women and three men, median age 60.5 years) of RA-associated T-LGL leukemia presenting with lymphopenia, severe neutropenia, and marked splenomegaly. The weight of the spleens ranged from 892 to 2100 g (median 1100 g). Bone marrow histology and differential counts of bone marrow aspirates revealed no peculiarities in nine of ten cases. The red pulp of the spleen was expanded and showed moderate to strong infiltration by medium-sized slightly pleomorphic lymphocytes in nine cases and subtle infiltration in one. Although lymphocytic infiltration involved both cords and sinusoids, it was more apparent within the splenic cords. The white pulp was preserved and contained prominent germinal centers in eight patients and was atrophic in two patients. Immunohistochemically, malignant lymphocytes were CD3+, CD43+, and CD4- in all cases and TIA-1+ in nine out of ten. TCRαβ positivity and TCRγδ positivity was observed in six and four cases out of ten, respectively. All ten patients had T cell clonality in the spleen tissue, but in three cases it was absent in both blood and bone marrow. STAT3 mutations in the spleen tissue were detected in three of ten cases. In all eight cases studied, neither isochromosome 7q nor trisomy 8 was detected in the spleen tissue. Cases of RA-associated T-LGL leukemia with low LGL count in the peripheral blood, neutropenia, and marked splenomegaly present a diagnostic challenge and can be misdiagnosed as Felty's syndrome or hepatosplenic T cell lymphoma.

AB0757 ON THE ISSUE OF DIFFERENTIAL DIAGNOSIS OF PANNICULITIS

Background:

Diagnosis of panniculitis (Pn) is associated with significant difficulties due to the variety of etiological factors, which include panniculitis-like T-cell lymphoma (PLTСL) – a rare variant of non-Hodgkin lymphoma.

Objectives:

to study clinical and laboratory features of PLTСL in rheumatology.

Methods:

Over 8 years PLTСL was diagnosed in 10 patients (9 women and 1 man, average age 37.2 ± 7.4) who were referred to V.A. Nasonova Research Institute of Rheumatology with a diagnosis of erythema nodosum or panniculitis. In addition to general clinical study, serum concentrations of α-1 antitrypsin, amylase, lipase, ferritin, creatine phosphokinase, immunological parameters (ANF-Hep2, dsDNA, C3 and C4 complements, CRP, ANCA, Scl-70, antibodies to cardiolipins G and M) were determined, and positron emission tomography combined with computed tomography (PET-CT), histological and immunohistochemical examination (IHC) of the biopsy sample of skin with subcutaneous fat from the affected areas were performed.

Results:

The clinical picture of PLTСL was characterized by generalized red-crimson moderately painful (VAS pain intensity 45mm) subcutaneous nodes on the upper limbs and trunk (100%), face (60%) and lower extremities (75%), without ulceration and oily fluid leakage. A “trembling saucer” symptom was evident in 75% of the observed cases. All patients had febrile fever. No enlargement of the lymph nodes of the liver and spleen was observed. The blood test revealed leukopenia (up to 2.0·x 109 /l) in 50% of cases, an increase in ESR and CRP by three or more times in 100% of cases. The biochemical blood test demonstrated an increase in LDH activity by two or more times in all patients. PET-CT in 100% of cases revealed an intense accumulation of 18F-FDG in the nodes which correlated with a high proliferative activity index. The morphological picture resembled lobular panniculitis without vasculitis. Tumor lymphocytes had an immunophenotype of cytotoxic T-lymphocytes: CD3+, CD8+, granzyme B+. To confirm the tumor nature of the infiltrate the rearrangements of the T-cell receptor genes were studied. Glucocorticoid therapy (23.5±9.6 mg/day) was ineffective which required polychemotherapy in most patients.

Conclusion:

PLTСL presents a complex diagnostic task that requires a multidisciplinary approach to verify the diagnosis and treatment tactics.

Disclosure of Interests:

None declared