[Lymphoma with signet ring morphology: pathology with distinctive differential diagnoses]

BACKGROUND

Signet-ring cell lymphoma is a rare entity that simulates epithelial neoplasms, sarcomas and reactive histiocytes conditions. It represents a morphological variant of non-Hodgkin's lymphomas, its diagnosis can represent a challenge, therefore it should be considered in complementary studies.

OBJECTIVE

The aim of this work is to show a case with a very rare morphology and to emphasize the importance of awareness this entity and avoid mistakes in its diagnosis.

CLINICAL CASE

We present the case of a 67-year-old man, who developed lymph node growths in the right armpit, neck, right groin, and submandibular region, with apparent involvement of the lungs and spleen; was diagnosed as diffuse large B cell lymphoma with signet-ring morphology, originated in the germinal center. Transmission electron microscopy study was carried out for a more precise characterization of the morphology. Unfortunately, the patient did not return for a follow-up consultation, so he did not start treatment and died 6 months after diagnosis.

CONCLUSIONS

Lymphoma with the signet-ring phenotype is rare, and can occur in any type of non-Hodgkin lymphoma; however, this morphology is more commonly associated with carcinomas and, less frequently, with sarcomas, melanomas or reactive histiocytes conditions, therefore should be considered this entity together with the appropriate use of complementary studies for proper diagnosis.

Intravascular large B-cell lymphoma presenting with fever and refractory acidosis

Intravascular large B-cell lymphoma (IVLBCL) is a rare form of diffuse large B-cell lymphoma, characterized by malignant B-cells primarily localized to the lumina of small- and medium-sized blood vessels without lymphadenopathy. Two patients initially presented with fever of unknown origin and persistent lactic acidosis without evidence of tissue hypoxia. Neither patient had an identifiable source of infection and both underwent peripheral blood smear demonstrating leukocytosis with a neutrophilic predominance and thrombocytopenia without evidence of hematologic malignancy. One had previously had a bone marrow biopsy which was unremarkable. Both patients’ condition deteriorated rapidly, progressing to multiorgan failure requiring pressors and mechanical ventilation, which ultimately resulted in cardiopulmonary arrest. At autopsy, each patient demonstrated malignant lymphocytoid cells, staining positive for CD20, localized to the lumina of small- and medium-sized vessels in multiple organs, including the lungs, liver, spleen, and kidneys, among others, allowing for the diagnosis of IVLBCL. IVLBCL is exceedingly rare, which in combination with significant variability in presentation, can make identification and diagnosis challenging. Diagnosis requires biopsy, therefore a high index of suspicion is needed to obtain an adequate tissue sample, whether pre- or postmortem. In the presented cases, both patients exhibited type B lactic acidosis with an unknown etiology that was ultimately determined at autopsy.

Unusual Presentation of a Testicular Lymphoma Mimicking a Missed Testicular Torsion: A Case Report

Testicular lymphoma is an uncommon testicular tumor that usually presents as a painless mass. It usually shows hypervascularity on color Doppler ultrasound (US) and a mild enhancement on enhanced CT or MRI. We present an unusual case of a testicular lymphoma mimicking a missed testicular torsion in a 67-year-old male patient with right scrotal swelling and intermittent pain for 2 months. Color Doppler US demonstrated the absence of vascularity in the enlarged right testis, and the initial diagnosis was a missed testicular torsion. CT demonstrated a poorly enhancing mass rather than a missed testicular torsion with enhanced small nodular foci at the periphery. The final pathological diagnosis was testicular lymphoma.

Extranodal NK/T-cell lymphoma, nasal type with extensive cardiopulmonary involvement

Extranodal NK/T-cell lymphoma, nasal type (ENKTL-NT) is a rare type of Non-Hodgkin’s lymphoma, which usually presents with extranodal involvement and affects the nasal/upper aerodigestive tract in the classical presentation. Herein, we report the case of a 31-year-old, previously healthy, male patient diagnosed with ENKTL-NT with the involvement of the lung parenchyma and heart. Unfortunately, due to the rapid disease progression, the diagnosis was performed only at the autopsy. The authors highlight the rare clinical presentation of this type of lymphoma, as well as the challenging anatomopathological diagnosis in necrotic samples.

[Expression of PD-1, TIM-3, LAG-3 and BTLA in diffuse large B-cell lymphoma and its effect on prognosis]

Objective: To investigate the expression levels of programmed death protein 1 (PD-1)、T cell immunoglobulin domain and mucin domain 3(TIM-3)、lymphocyte activating gene 3 (LAG-3) and B and T lymphocyte attenuator (BTLA) in Diffuse large B-cell lymphoma, not otherwise specified (DLBCL, NOS) and their effects on prognosis. Methods: The paraffin specimens of 30 patients with DLBCL, NOS newly diagnosed in People's Hospital of Zhengzhou University were stained with immunohistochemistry. The effects of single positive and co-expression of the above molecules on progression-free survival (PFS) phase and overall survival (OS) phase were analyzed. Results: There was no significant difference in prognosis between PD-1, TIM-3, LAG3, BTLA single positive group and single negative group. The median PFS phase of PD-1 and TIM-3 co-expression group and TIM3 and BTLA co-expression group were 26 and 24 months respectively, which were both lower than the 54 months (P=0.021) and 47 months (P=0.037) in non-co-expression group. The median PFS phase and OS phase of PD-1, TIM-3 and LAG-3 co-expression group were 17 and 25 months respectively, which were significantly lower than the 41 months (P=0.024) and 60 months (P=0.015) of non-co-expression group. The median PFS phase and OS phase of PD-1, TIM-3, LAG-3 and BTLA co-expression group were 18 and 26 months respectively, which were significantly lower than the 40 months (P=0.038) and 57 months (P=0.041) of non-co-expression group. Conclusions: In patients with DLBCL, NOS, those with PD-1 and TIM-3 co-expression as well as those with TIM-3 and BTLA co-expression have poor PFS phase. Patients with PD-1, TIM-3 and LAG-3 co-expression and patients with PD-1, TIM-3, LAG-3 and BTLA co-expression have poor PFS and OS phase.

Multiple osteolytic lesions due to Double-Expressor Primary non-Hodgkin Lymphoma of the Bone

Primary non-Hodgkin lymphoma of the bone (PLB) is a rare type of non-Hodgkin’s lymphoma (NHL) that affects the skeletal system with or without regional lymph node involvement. We present the case of a 74-year-old female patient with pain due to multifocal osteolytic lesions. The diagnosis of diffuse large B-cells (non-GCB) phenotype was made by clinical, laboratory, histopathological examination accompanied by an extensive immunohistochemical profile of one of the skeletal lesions.

[Coexistence of mycosis fungoides and essential thrombocythemia with JAK2V617F]

BACKGROUND

The coexistence of myeloproliferative neoplasms (MPNs), specifically essential thrombocythemia and lymphoproliferative neoplasms, are a very rare finding with a frequency < 1%.

CASE REPORT

We present the case of a woman with diagnosis of mycosis fungoides early stage IB, of 5 months of evolution, she received systemic treatment based on methotrexate orally for 4 months; after this, she started with important thrombocythemia reaching up to 1 200 000/mm3 platelets and leukocytosis ranging from 10 000 - 13000/mL. A study protocol for chronic myeloproliferative disease was performed, reporting 90% cellular bone biopsy, erythroid myeloid ratio 5:1, 25 megakaryocytes per mm3, some with hyperlobed nuclei, and giant nuclei. Karyotype: 46XX. PCR without expression of BCR/ABL. JAK 2 positive. The diagnosis of essential thrombocythemia was concluded.

CONCLUSIONS

There are several hypotheses seeking to elucidate the etiopathogenesis of the coexistence of myeloproliferative and lymphoproliferative neoplasms, some claim that they are precursors of the same multipotential stem cell, while others support that they are the result of a coincidence. More molecular studies are required to elucidate this unknown.

High-grade B-Cell lymphoma with MYC and BCL6 rearrangements associated with Richter transformation of chronic lymphocytic leukemia

Richter transformation (RT), or Richter syndrome, is defined as the transformation of chronic lymphocytic leukemia (CLL) to an aggressive B-cell lymphoma. The vast majority, up to 99%, transform into diffuse large B-cell lymphoma (DLBCL), with a small subset (<1%) becoming classical Hodgkin lymphoma. Approximately half of RT cases progress through a pathway involving dysregulation of C-MYC. High-grade B-cell lymphoma (HGBL) is a recent diagnostic category of aggressive B-cell lymphomas set forth in the updated 2017 WHO Classification of Hematopoietic and Lymphoid Tissues. HGBL with MYC and BCL2 and/or BCL6 rearrangements, formerly “double-hit” and “triple-hit” lymphomas, comprise the majority of HGBL cases. Patients with HGBL have a worse prognosis than those with diffuse large B-cell lymphoma. We present a case of RT with rearrangements of MYC and BCL6. To our knowledge, there are no reported cases of RT with a “double-hit” lymphoma genotype.

Nasopharyngeal Mantle Cell Lymphoma: An Extremely Rare Entity

Mantle cell lymphoma (MCL) is a rare, aggressive subtype of non-Hodgkin lymphoma with a poor prognosis and high recurrence rate. It seldom affects the Waldeyer's ring let alone the nasopharynx. Patients usually present at late stages of the disease leading to poor failure-free and overall survival rates. Intensive chemotherapy regimes and autologous stem cell transplantation have reported increased survival rates. We report a relapsed case of nasopharyngeal MCL, which previously occurred in the gastrointestinal tract. The patient had undergone a hemicolectomy for colon intussusception secondary to the intraluminal lymphoma mass. He was unable to complete the treatment regime for MCL due to the adverse side effects. Oropharyngeal mass was discovered during routine outpatient follow-up, which was confirmed as nasopharyngeal MCL. We discuss the prognosis, disease progression, and possible treatments.

Mortality trend for tumor correlated immune system in hyperendemic area of HCV infection in southern Italy: joinpoint analysis

BACKGROUND

In many regions of southern Italy, hepatitis C virus (HCV) infection represents a major health problem (with a prevalence rate between 6% and 13%). HCV is associated with different kinds of neoplasms such as non-Hodgkin lymphomas (NHL), and with auto-immune diseases (cryoglobulinemia), which develop after the virus has caused immune system alterations.

OBJECTIVES

To provide updated information on trends in mortality in a major metropolitan area of southern Italy from NHL, multiple myeloma and Hodgkin disease we analyzed cancer mortality data from 1988 to 2009.

MATERIALS AND METHODS

Mortality data were extracted from National death certificates by age groups, gender, residence and cause of death by the Italian national institute of statistics (ISTAT). Age-standardized mortality rates (SMR) were computed applying the direct method and using the world standard population. To quantify the recent direction of temporal trends in older populations over time, truncated age-adjusted mortality rates were calculated for people aged 65 years and older. Cancer mortality trends were described using their estimated annual percent change (EAPC) and related 95% Confidence Interval (CI).

RESULTS

Statistically significant increasing EAPC was found among women for NHL (+2.0% / year), while statistically significant decrease was found among men and women for HD (-3.5% / year, -3.4% / year, respectively). No statistically significant EAPC was found for multiple myeloma.

CONCLUSIONS

The association between viral hepatitis and NHL in the area of interest might provide some degree of explanation to this finding. Our data confirm that due to epidemic infection of HCV in the area of Naples, a high mortality for NHL persists, moreover the adoption of standard therapeutic protocols administered in full accordance with an evidence-based approach and current guidelines explain reduced mortality from Hodgkin lymphomas.

Disseminated non-Hodgkin's lymphoma presenting as bilateral salivary gland enlargement: a case report

Non-Hodgkin's lymphoma (NHL) constitutes a group of malignancies those arises from cellular components of lymphoid or extranodal tissues. The head and neck is the most common area for the presentation of these lymphoproliferative disorders. Primary involvement of salivary glands is uncommon. This report described a case of a 73-year-old female patient who presented with involvement of both nodal and extranodal sites, with predominant involvement of salivary glands. The tumor staging worked up along with imaging, histopathological, and immunohistochemical findings were discussed. Computed tomographic images showed the involvement of Waldeyer's ring, larynx, orbit, and spleen. This report described imaging and prognostic tumor markers in diagnosing, treatment planning, and prognosis.

Comparison between presence of epstein barr virus in nodal and extra nodal diffuse large B cell lymphoma of head and neck, an Iranian experience

Background

Epstein Barr Virus (EBV) is one of the most common viral infections in human population. EBV has a significant role in pathogenesis of Hodgkin's lymphoma, Burkitt's lymphoma and nasopharyngeal carcinoma. The role of EBV in non-Hodgkin’s lymphoma, diffuse large B cell (NHL - DLBL) in the head and neck is controversial.

Objectives

The purpose of this study is to find out the difference between the presence of Epstein Barr virus in nodal and extra nodal lymphoma of head and neck.

Patients and Methods

A total of 30 cases of DLBL in two separate groups were collected from pathology department. The first group was consisted of 15 patients with DLBL of neck lymph node and the other was consisted of 15 patients with extra nodal DLBL of head and neck mainly in palatine tonsil. Both immune-histo-chemical (IHC) study and polymerase chain reaction (PCR) for detection of late membrane antigen (LMP) were performed on formalin fixed paraffin embedded tissue.

Results

All 30 cases were negative for EBV in IHC method. But in PCR method, 10% of patients were positive for LMP gene. There were 2 positive cases in nodal lymphoma and 1 positive case in extra nodal lymphoma group.

Conclusions

Compare with PCR method, it seems that IHC is not a sensitive method for detection of EBV. Overall, the finding of EBV in NHL depends on site, type of lymphoma and the detection method.

Clinical course and prognostic factors of children with Burkitt's lymphoma in a developing country: the experience of a single centre in Brazil

Objective:

Burkitt's lymphoma is the most common subtype of non-Hodgkin lymphoma in children. The aim of this study was to characterize the clinical course and prognostic factors of children and adolescents with Burkitt's lymphoma treated in the Hematology Unit of Hospital das Clínicas, Universidade Federal de Minas Gerais (UFMG).

Methods:

A retrospective cohort study was made of 50 consecutive cases of children and adolescents aged 16 years or less with Burkitt's lymphoma admitted between January 1981 and December 2007. Prognostic factors associated with death were evaluated using the Kaplan-Meier method and compared by the two-tailed log-rank test.

Results:

The median age at diagnosis was 4.7 years. Most patients had abdominal tumors (66.7%) and advanced disease (68.9%) at diagnosis. Thirty-eight patients (84.4%) achieved complete clinical remission and 33 (73.3%) were alive at the first remission. Twelve children (26.7%) died. The median follow-up was 35 months with the probability of overall survival being 73% (89.2% and 35.7% for patients with uric acid < 7 mg/dL and ≥ 7.0 mg/dL, respectively - p-value < 0.001). Uric acid was the only significant prognostic factor at diagnosis.

Conclusion:

Our findings confirm the favorable prognosis of children with Burkitt's lymphoma even when treated with intermediate doses of methotrexate (500 mg/m2). Survival was significantly lower for individuals with concentrations of uric acid > 7 mg/dL.

Enteropathy-associated T-cell lymphoma (type II): a Brazilian case report

Enteropathy-associated T-cell Lymphoma (EATL) is a rare form of aggressive T-cell lymphoma. It is more prevalent in men over 60 years and the prognosis is very poor. EATL is classified into two groups based on morphology, immunohistochemistry, and genetic profile. EATL type I is highly associated with celiac disease and is more common in Western countries. EATL type II predominates over type I in Asia, where celiac disease is uncommon. We report a case of a 78-year-old previously healthy white male who presented with a 2-month history of diarrhea, weight loss and edema. The abdomen was distended and painful, and a tumor mass was palpable in the hypogastrium. Laboratory tests showed hypoalbuminemia. Serological tests for HIV, viral hepatitis and HTLV-1 were negative. The chest radiography showed pneumoperitoneum, and an exploratory laparotomy revealed perforation of the small bowel. An advanced stage (Ann Arbor IV B/Lugano IIE2B) EATL type II was diagnosed. Four cycles of chemotherapy were interspersed with several complications (anthracycline-induced cardiotoxicity, chemotherapy-induced neutropenic fever and severe sepsis). Performance status progressively worsened and he died 6 months after the diagnosis. This is an illustrative report of a rare and aggressive primary intestinal lymphoma. To the best of our knowledge, this is the first report of EATL type II in Brazil.

Imaging characteristics of diffuse large cell extra nodal non-Hodgkin's lymphoma involving the palate and maxillary sinus: a case report

Non-Hodgkin's lymphomas are a group of highly diverse malignancies and have a strong tendency to affect organs and tissues that do not ordinarily contain lymphoid cells. Primary extra nodal lymphoma of the hard palate is rare. Here, we present a case of diffuse large B cell lymphoma in a 60-year-old male patient that manifested as slightly painful ulcerated growth on the edentulous right maxillary alveolar ridge extending onto the palate, closely resembling carcinoma of the alveolar ridge. Computed tomography images showed the involvement of the maxillary sinus and right nasal cavity, along with destruction of hard palate, superiorly extending into the orbit. This case report highlights the importance of imaging to evaluate the exact extent of such large malignant lesions, which is essential for treatment planning.

"Nutrothorax" complicating a misplaced nasogastric feeding tube in a severely ill patient

Introduction of nasogastric feeding tubes is usually blindly performed and is generally considered a safe procedure. However, the rate of complications of a blind insertion technique varies from 0.3 to 15%, and is usually related to inadvertent insertion of nasogastric tubes into the trachea and distal airways. The main predisposing factors related to tube malpositioning and complications are altered mental status with decreased cough or gag reflex, a preexisting endotracheal tube and severe illness. Complications include severe aspiration pneumonia, hydrothorax, hemothorax, empyema and pneumothorax. The mortality related to misplacement of a nasogastric tube is around 0.1-0.3% of the procedures. This 61-year old female had a history of poor appetite, weight loss, dyspnea and fever. A chest axial computerized tomography showed enlarged mediastinal lymph nodes. Laboratory showed hypercalcemia with normal PTH and hypokalemia. As the patient remained anorectic, a nasogastric feeding tube was placed, through which the administration of enteral diet, by continuous infusion pump, was started. After 12 -en.jpg-en.jpghours the patient developed dyspnea, hypoxemia and hypotension. During orotracheal intubation, it was disclosed the presence of the nasogastric tube in the trachea as well as the infused diet within the respiratory tract. Autopsy revealed an unusual complication of a nasogastric tube misplacement, which led to a massive collection of enteral nutrition fluid into the pleural space – a “nutrothorax”. Additionally, an underlying stage IV anaplastic large cell lymphoma with interstitial lung and bronchial mucosa involvement was diagnosed.