Quarter-Century PET/CT Transformation of Oncology: Lymphoma

The clinical landscape of lymphomas has changed dramatically over the last 2 decades, including significant progress made in the understanding and utilization of imaging modalities and the available treatment options for both indolent and aggressive lymphomas. Since the introduction of hybrid PET/CT scanners in 2001, the indications of 18F-fluorodeoxyglucose (FDG) PET/CT in the management of lymphomas have grown rapidly. In today's clinical practice, FDG PET/CT is used in successful management of the vast majority patients with lymphomas.

Autologous hematopoietic stem cell transplantation conditioning regimens and chimeric antigen receptor T cell therapy in various diseases

Conditioning regimens employed in autologous stem cell transplantation have been proven useful in various hematological disorders and underlying malig nancies; however, despite being efficacious in various instances, negative consequences have also been recorded. Multiple conditioning regimens were extracted from various literature searches from databases like PubMed, Google scholar, EMBASE, and Cochrane. Conditioning regimens for each disease were compared by using various end points such as overall survival (OS), progression free survival (PFS), and leukemia free survival (LFS). Variables were presented on graphs and analyzed to conclude a more efficacious conditioning regimen. In multiple myeloma, the most effective regimen was high dose melphalan (MEL) given at a dose of 200/mg/m2. The comparative results of acute myeloid leukemia were presented and the regimens that proved to be at an admirable position were busulfan (BU) + MEL regarding OS and BU + VP16 regarding LFS. In case of acute lymphoblastic leukemia (ALL), BU, fludarabine, and etoposide (BuFluVP) conferred good disease control not only with a paramount improvement in survival rate but also low risk of recurrence. However, for ALL, chimeric antigen receptor (CAR) T cell therapy was preferred in the context of better OS and LFS. With respect to Hodgkin's lymphoma, mitoxantrone (MITO)/MEL overtook carmustine, VP16, cytarabine, and MEL in view of PFS and vice versa regarding OS. Non-Hodgkin's lymphoma patients were administered MITO (60 mg/m2) and MEL (180 mg/m2) which showed promising results. Lastly, amyloidosis was considered, and the regimen that proved to be competent was MEL 200 (200 mg/m2). This review article demonstrates a comparison between various conditioning regimens employed in different diseases.

Children and adolescents with non-Hodgkin lymphoma in Brazil: A national survey identifies the challenges encountered and documents the diversity of care

INTRODUCTION

Brazil has many inequities in the healthcare provided nationwide. Therefore, in order to access challenges in treatment, available resources and current practices, to identify barriers in delivering a good quality of care among Brazilian centers treating children and adolescents with Non-Hodgkin Lymphoma (NHL) and to generate a future prospective guideline, a customized online survey was distributed to pediatric hematologists and oncologists across the country.

RESULTS

A total of 97 surveys were completed (35% response rate), from 47 cities in all Brazilian regions and 79 units of care, with a median of 1 answer by the center (range 1 - 5). Most respondents work at an institution supported exclusively by public/philanthropic resources (58%), with an average of 5 to 9 new cases/year (49%), and 41% have 4 to 6 oncologists/centers. Additionally, 22% have no easy access to the intensive care unit, 26% have no access to Rasburicase, 28% have no access to Rituximabe as front-line therapy and 41% have unreliable methotrexate monitoring levels. Those differences cannot be explained thoroughly by regional wealth variances, nor by the financing model. Regarding the pathology service, 70% consider having reasonable quality assistance, but the timeframe to deliver diagnosis is satisfactory to 46%. There is no uniform management of care, with the current guideline from the Sociedade Brasileira de Oncologia Pediátrica being adopted by 54 to 59%, depending on the NHL subtype.

CONCLUSION

This study provides insights into the heterogeneity of care among Brazilian centers. Recognizing those diversities will support the design of effective strategies and collaboration nationwide.

Anal lymphoma: a tumor with insufficient attention

BACKGROUND

Anal lymphomas are extremely rare. There are no relevant descriptions in professional books, and there are only a few case reports in the literature. Here, we report a new case and review the literature to summarize the clinical and pathological features of anal lymphoma.

METHODS

We described a case of anal lymphoma confirmed by pathological diagnosis, then searched the PubMed database, and finally selected 12 reported cases to be included in the study. We described the clinical and pathological characteristics of the patients.

RESULTS

Thirteen patients with anal lymphoma were confirmed. Seven men and six women with a median age of 50. There were four cases of HIV- and EBV-infected patients. The size of the tumor was 1-13 cm, all of which were diagnosed as B-cell lymphoma, and 61.5% were diffuse large B-cell lymphomas. Among the 13 patients, eight received chemotherapy or immunochemotherapy, two received radiotherapy, one received chemotherapy combined with radiotherapy, one received surgery, and one gave up treatment. Three patients died, and only 2 of 10 surviving patients had complete remission.

CONCLUSION

Anal lymphoma is extremely rare. Patients with persistent abscess complicated with HIV or EBV infection should undergo pathological biopsy to exclude anal lymphoma.

Mediastinal Desmoid Tumor Presents as Lymphadenopathy in Patient with Lymphoma: A Case Report

Desmoid tumors are rare mesenchymal neoplasms that are rapidly growing but do not metastasize. We present a case of a 75-year-old man with a history of non-Hodgkin lymphoma in remission incidentally found to have an enlarging internal mammary lymph node on screening CT, subsequently diagnosed as a desmoid tumor via biopsy. The patient was deemed unfit for surgical resection and instead underwent urgent radiation and immunotherapy. This report highlights a unique case of desmoid tumor presenting as mediastinal lymphadenopathy.

A Rare Occurrence of Primarily Extranodal Spinal Epidural Lymphoma With Spinal Cord Compression and Invasion to the Thoracic Cavity

A 41-year-old man suffered from progressive radiculomyelopathy caused by spinal epidural mass primarily encasing the spinal cord at the cervicothoracic vertebrae that extended into the thoracic cavity through the neural foramen. An urgent decompressive laminectomy and epidural tumor resection were performed to prevent neurological deterioration and effective spinal cord decompression. The histopathologic diagnosis was diffuse large B-cell lymphoma. As first-line treatment for stage II extranodal lymphoma, he received 6 cycles of R-CHOP (rituximab/cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisone) chemotherapy. Consequently, follow-up positron-emission tomography CT and MR images demonstrated a complete metabolic response (Deauville score 1). This rare occurrence of primarily extranodal spinal epidural lymphoma with limited disease will be presented in a literature review.

Neurolymphomatosis in Recrudescent Diffuse Large B-cell Lymphoma

Neurolymphomatosis is an uncommon manifestation of lymphoma, often presenting with painful polyneuropathy or polyradiculopathy and concomitant distal extremity weakness. Differentiation from other etiologies resulting in similar neuropathic symptoms such as compressive or inflammatory pathologies can be difficult and often results in delayed diagnosis. Here we describe a case of neurolymphomatosis affecting a 64-year-old man with a history of diffuse large B-cell lymphoma (DLBCL) in remission presenting with a right-sided foot drop following a gunshot wound. MRI at that time demonstrated thickening and enhancement of the cauda equina nerve roots. Over the course of the subsequent eight months, he developed left lower extremity sensory symptoms, left-sided foot drop and signs of upper motor neuron involvement, including left facial weakness, dysphonia, and dysphagia. ¹⁸F-FDG PET/CT revealed intensely avid left lumbosacral nerve roots, bilateral lower extremity and left upper extremity neurovascular bundles. Left sural nerve biopsies showed infiltration of DLBCL and confirmed neurolymphomatosis. We highlight the role of ¹⁸F-FDG PET/CT, with histological verification, for the diagnosis of an extended course of neurolymphomatosis occurring in the absence of typical painful neuropathy but with cranial and peripheral neuropathies.

A phase I pharmacokinetic study of copanlisib in Chinese patients with relapsed indolent non-Hodgkin lymphoma

PURPOSE

Copanlisib, a pan-PI3K inhibitor, has previously shown clinical efficacy and a tolerable safety profile in patients with indolent non-Hodgkin lymphoma. However, the pharmacokinetics, safety, tolerability, and efficacy of copanlisib in Chinese patients have not been reported.

METHODS

This was a single-arm, open-label, phase I study of copanlisib in Chinese patients with relapsed or refractory indolent non-Hodgkin lymphoma (iNHL). Patients received a single intravenous 60 mg infusion of copanlisib over 1 h on days 1, 8, and 15 of a 28-day cycle, with 1 week of rest. Safety was monitored throughout the study, and plasma copanlisib levels were measured for pharmacokinetic analysis. Tumor response was determined by independent central radiologic review.

RESULTS

Sixteen patients were enrolled and 13 were treated with 60 mg of copanlisib for a median of 15.0 weeks. With a C_max of 566 μg/L and a AUC (0-24) of 1880 μg·h/L following single intravenous infusion, the pharmacokinetic parameters of copanlisib were consistent with that in previous studies, and no accumulation in plasma was observed. Treatment-emergent adverse events were reported for all 13 patients, the most common of which were hyperglycemia (100.0%), hypertension (76.9%), decreased neutrophil count (76.9%), and decreased white blood cell count (69.2%). Seven out of 12 evaluated patients achieved partial response, resulting in an overall response rate of 58.3% CONCLUSIONS: Copanlisib was well tolerated in Chinese patients with relapsed or refractory iNHL at the dose of 60 mg and demonstrated encouraging disease control, thus warranting further clinical investigation.

CLINICAL TRIAL REGISTRATION NUMBER

NCT03498430 (April 13, 2018).

Clinical Characteristics, Treatment and Evolution of Splenic and Nodal Marginal Zone Lymphomas-Retrospective and Multicentric Analysis of Portuguese Centers

INTRODUCTION

Treatment of Splenic (SMZL) and Nodal (NMZL) Marginal Zone Lymphoma is not consensual. Histologic transformation (HT) to aggressive lymphoma is a poorly understood event, with an unfavorable outcome.

OBJECTIVES

Describe the clinical characteristics, treatment, outcomes and incidence of HT.

METHODS

Characteristics of patients with SMZL and NMZL consecutively diagnosed in 8 Portuguese centers were retrospectively reviewed. Endpoints were overall survival (OS), time to first systemic treatment (TTFST), frequency of HT and time to transformation (TTT).

RESULTS

This study included 122 SMZL and 68 NMZL, most of them received systemic treatment: 55.4% and 76.5%, respectively. Splenectomy was performed in 58.7% of patients with SMZL. Different treatment protocols were used. OS or TTFST did not differ significantly according to treatments. Given the small sample size, no conclusion can be made concerning the role of Rituximab in the treatment of NMZL and SMZL based in these results. HT was documented in 18 patients, mainly in SMZL, with a cumulative incidence at 5 years of 4.2%. We confirmed that age is a prognostic factor.

CONCLUSION

Randomized prospective trials are needed to standardize treatment in MZL. Patients with HT did appear to have shorter OS in comparison with those who did not experience HT (OS 5 years of 68.4% vs. 80.4%), but the number of HT was too small to reach statistical significance.

Twenty-year Experience with Genitourinary Lymphoma at a Community Hospital

Introduction: Non-Hodgkin lymphoma is the seventh most common cancer in the United States. It may involve any extranodal organ, although involvement of the genitourinary (GU) tract accounts for <5% of all primary extranodal lymphomas. Published GU lymphoma literature is currently limited to small case series and case reports. The last substantial American series was published in 2009. Our objective was to characterize cases of GU lymphoma from our institution based on organ involved and to review relevant literature.Patients and Methods: After institutional review board approval, we retrospectively reviewed medical records of patients diagnosed with lymphoma involving the GU organs from 1995 through 2015. Patients with obstructive uropathy from retroperitoneal adenopathy without parenchymal involvement of a GU organ were excluded. We classified extranodal GU lymphomas as primary or secondary, based on involvement of other organs and distant lymphadenopathy.Results: Thirty-six patients had lymphoid neoplasms involving the kidney, ureters, bladder, testis, penile skin, or prostate in our health system during the study period. Of these, 15 (41.6%) were primary. Most patients initially sought consultation for GU-related symptoms, such as bladder obstruction, hematuria, testicular mass, or abdominal pain. Histological subtypes and flow cytometry findings varied broadly.Conclusion: Our series reports site-specific outcomes data and adds detail to findings from other published series. Although GU lymphomas are rare, our series confirms prior studies demonstrating presentation in urologic organs. They should be considered in the differential diagnosis in all patients, especially those with unusual findings on examination, cystoscopy, or computed tomography scan.

Primary ovarian Burkitt's lymphoma presentation in a young woman: A case report

INTRODUCTION AND IMPORTANCE

Burkitt's lymphoma is one of the fastest growing human cancers and it needs a rapid diagnosis.

CASE PRESENTATION

A young woman presented to our institution with acute abdominal pain, tenderness and constipation. Ultrasound reported a right ovarian mass; at laparoscopy, we discovered ascites, peritoneal carcinomatosis and a voluminous pelvic mass.

CLINICAL DISCUSSION

Diagnosis was confirmed as non-Hodgkin sporadic Burkitt's lymphoma: the careful workup was the key to initiate multiagent chemotherapy.

CONCLUSION

Primary ovarian Burkitt's lymphoma, in a young woman in a non-endemic zone, is a rarity that represents a strong diagnostic challenge, but rapid identification can lead the patient to appropriate therapies and improvement of prognosis.

Soluble programmed cell death protein 1 (sPD-1) and the soluble programmed cell death ligands 1 and 2 (sPD-L1 and sPD-L2) in lymphoid malignancies

BACKGROUND

The programmed cell death protein 1 (PD-1) and its ligand 1 and 2 (PD-L1/PD-L2) regulate the immune system, and the checkpoint pathway can be exploited by malignant cells to evade anti-tumor immune response. Soluble forms (sPD-1/sPD-L1/sPD-L2) exist in the peripheral blood, but their biological and clinical significance is unclear.

METHOD

Time-resolved immunofluorometric assay (TRIFMA) and enzyme-linked immunosorbent assay (ELISA) were used to measure sPD-1, sPD-L1, and sPD-L2 levels in serum from 131 lymphoma patients and 22 healthy individuals.

RESULTS

Patients had higher sPD-1 and sPD-L2 levels than healthy individuals. In diffuse large B-cell lymphoma, patients with high International Prognostic Index score had higher sPD-1 levels and sPD-L2 levels correlated with subtype according to cell of origin. Compared to other lymphoma types, follicular lymphoma displayed higher sPD-1 and lower sPD-L1 levels along with lower ligand/receptor ratios.

CONCLUSION

This is the first study to simultaneously characterize pretherapeutic sPD-1, sPD-L1, and sPD-L2 in a variety of lymphoma subtypes. The relation between higher sPD-1 levels and adverse prognostic factors suggests a possible biological role and potential clinical usefulness of sPD-1. Moreover, the reverse expression pattern in follicular lymphoma and T-cell lymphoma/leukemia may reflect biological information relevant for immunotherapy targeting the PD-1 pathway.

Imaging of primary testicular lymphoma with unusual intraabdominal spread along the spermatic cord and gonadal vein

Primary testicular lymphoma (PTL) is a rare Testicular neoplasm found in elderly patients. Imaging features in PTL presenting with contiguous involvement of spermatic cord and extension along gonadal vein have been rarely detailed before. We describe a case of a 50-year-old male who presented with complaints of scrotal swelling and abdominal discomfort. Imaging, which included Ultrasonography and contrast-enhanced computed tomography of chest-abdomen, showed features of aggressive-looking bilateral testicular mass lesions with the distinctive feature of contiguous spread along the spermatic cord and gonadal vein till retroperitoneum and disseminated chest and abdominal metastases. The distinctive feature of contiguous extension along the spermatic cord and gonadal vein can help suggest a diagnosis of PTL on imaging.

Malignant lymphoma with diffuse cardiac involvement and pulmonary stenosis

Lymphoma is one of the most common tumors with the risk of cardiac metastasis. The pattern of cardiac involvement is usually as focal masses. As early diagnosis of lymphoma plays a crucial role in its response to treatment and patient survival longevity, we report a rare case of cardiac lymphoma with diffuse cardiac involvement and acquired pulmonary stenosis. The patient was referred to our center for further evaluation because of dyspnea and systolic ejection murmur. In pericardial biopsy, T cell lymphoblastic lymphoma was reported. After a full course of chemotherapy and one-year follow up, symptoms had improved and echocardiography was normal except for small pericardial effusion. <Learning objective: Early diagnosis of lymphoma plays a crucial role in its response to treatment and introducing atypical presentation form could be helpful for early diagnosis.>.

The epidemiology of lymphoma in Jordan: A nationwide population study of 4189 cases according to World Health Organization classification system

OBJECTIVE/BACKGROUND

Lymphoma is a common human cancer that shows a variable geographic incidence worldwide. It is the fourth most common cancer in Jordan. Systemic reports of descriptive epidemiology on lymphoma from the Middle East are limited.

METHODS

A nationwide multi-institutional retrospective study was conducted covering all major hospitals and laboratories that provide diagnostic services. We collected data on all cases diagnosed with lymphoma between 2014 and 2019. The included variables were patients' age, gender, anatomic site, and the histologic type according to the World Health Organization classification system.

RESULTS

A total of 4189 cases were diagnosed with lymphoma. There was a statistically significant gender difference (p < .05), as 57.5% of patients were males. The peak incidence occurred at age 25-55 years. There were 1,652 (39%) cases of Hodgkin lymphoma (HL) and 2,537 (61%) of non-Hodgkin lymphoma (NHL), where nodular sclerosis (67%) and diffuse large B-cell lymphoma (53%) were the most common subtypes, respectively. The average age-adjusted incidence rates per 100,000 population were 8.01 for all lymphomas, 4.33 for NHL, and 3.16 for HL and all remained stable over the 6 years.

CONCLUSION

HL is the most common lymphoma in Jordan, with a percentage higher than most of reported studies in Asian and Western countries. It also shows a unimodal distribution of age-specific incidence rates, with a single peak in young adults. The incidence rate of HL is higher than Eastern countries but comparable to the West. In contrast, NHL demonstrates a lower incidence rate than Western countries but a similar distribution of subtypes, as mature T/natural killer-cell lymphomas were rare.

The epidemiology of lymphoma in Jordan: A nationwide population study of 4189 cases according to World Health Organization classification system

OBJECTIVE/BACKGROUND

Lymphoma is a common human cancer that shows a variable geographic incidence worldwide. It is the fourth most common cancer in Jordan. Systemic reports of descriptive epidemiology on lymphoma from the Middle East are limited.

METHODS

A nationwide multi-institutional retrospective study was conducted covering all major hospitals and laboratories that provide diagnostic services. We collected data on all cases diagnosed with lymphoma between 2014 and 2019. The included variables were patients' age, gender, anatomic site, and the histologic type according to the World Health Organization classification system.

RESULTS

A total of 4189 cases were diagnosed with lymphoma. There was a statistically significant gender difference (p < .05), as 57.5% of patients were males. The peak incidence occurred at age 25-55 years. There were 1,652 (39%) cases of Hodgkin lymphoma (HL) and 2,537 (61%) of non-Hodgkin lymphoma (NHL), where nodular sclerosis (67%) and diffuse large B-cell lymphoma (53%) were the most common subtypes, respectively. The average age-adjusted incidence rates per 100,000 population were 8.01 for all lymphomas, 4.33 for NHL, and 3.16 for HL and all remained stable over the 6 years.

CONCLUSION

HL is the most common lymphoma in Jordan, with a percentage higher than most of reported studies in Asian and Western countries. It also shows a unimodal distribution of age-specific incidence rates, with a single peak in young adults. The incidence rate of HL is higher than Eastern countries but comparable to the West. In contrast, NHL demonstrates a lower incidence rate than Western countries but a similar distribution of subtypes, as mature T/natural killer-cell lymphomas were rare.

Primary extra nodal Non-Hodgkin's lymphoma of urinary bladder presenting as a bladder tumor: A case report

Introduction

Primary non-Hodgkin's lymphoma (NHL) of urinary bladder is an exceedingly rare entity accounting for 0.2% of the primary neoplastic lesions. This tumor has female predominance; with most of the cases seen in middle-aged females. It primarily affects urinary bladder without involvement of the surrounding tissues and lymph nodes. The common presentations include hematuria, dysuria, urinary frequency, nocturia, and abdominal or back pain. The clinical, radiological and endoscopic signs are not very specific. It is diagnosed by its characteristic morphology and immunohistochemical characteristics. The various therapeutic options available are chemotherapy; radiotherapy and surgery used either alone or in combination. Presentation of Case: We hereby report a case of 40 years old man who presented with hematuria as the presenting symptom. On radiology, diffuse thickening of bladder wall was noted, which was biopsied. On histopathology, it was NHL, Diffuse large B cell type. He was treated with chemotherapy (6 cycles of CHOP) and radiotherapy for primary NHL of the bladder and now he is in complete remission.

Discussion

Primary lymphoma of the urinary bladder is exceedingly rare. Non-specific presentation and rarity of this disease pose a diagnostic challenge for both the clinician and the histopathologist. Diagnosis is based upon the characteristic morphology and is supported by immunohistochemical analysis.

Conclusion

All patients with extra-nodal lymphoma need thorough diagnostic work up like nodal lymphomas to arrive at exact staging of the disease to outline subsequent management.

•

Primary lymphomas of the urinary bladder are extremely rare.

•

Non-specific presentation and rarity of this disease pose a diagnostic challenge for both the clinician and the histopathologist.

•

Usually, the diagnosis is one of exclusion. It is made on biopsy with immunohistochemical study and after a negative study of disease extension.

[Burkitt’s lymphoma of the skull calotte: a case report]

Introduction

Burkitt’s lymphoma is a non- Hodgkin B-cell lymphoma whose cranial location is extremely rare.

Clinical case

The case of a 35-year-old Peruvian man with a progressive parietal left cranial tumor is described. A biopsy with immunohistochemistry was performed for the diagnostic confirmation of Burkitt’s lymphoma. First-line outpatient treatment with CODOX-M/IVAC was initiated, however, he stopped attending his treatment for 2 months. He returns, he is shown progression of the disease and is treated with rituximab, ifosfamide carboplatin and etoposide. Does not respond satisfactorily and dies.

Conclusions

Burkitt’s lymphoma is a very aggressive tumor that, if not treated in a timely manner, has high mortality, as happened with the patient in the case.

Disparities in Trace Metal Levels in Hodgkin/Non-Hodgkin Lymphoma Patients in Comparison with Controls

Lymphoma arises from cells of the immune system and trace metals augment the immune system and their imbalance may promote immunological disorders including tumorigenesis. The primary aim of the present investigation was to evaluate the levels of essential/toxic trace metals in the nails of non-Hodgkin and Hodgkin lymphomas patients in comparison with controls. The samples collected from patients and controls were digested in the mixture of HNO₃-HClO₄ and selected trace metals were analysed using flame atomic absorption spectrometry. The results showed that mean concentrations of some elements (Pb, Ni, Cd, Cu and Cr) in nails of non-Hodgkin lymphoma patients were significantly elevated (p < 0.05) than that of the controls whereas mean contents of Pb, Cu, Cd and Cr were observed to be significantly higher in the nails of Hodgkin lymphoma patients compared with healthy donors. Additionally, correlation study pointed out significantly diverse mutual associations of the trace metals among the patients and controls. The present results revealed noticeable disparities in the metal concentrations based on gender, food habits, tobacco use and types/stages of the donor's groups. Overall, the pathogenesis of disease significantly affected the trace metal balance in both patients' groups.

Panhypopituitarism and cranial mononeuropathy, manifestation of NK/T lymphoma that imitates meningeal tuberculosis

INTRODUCCIÓN

El linfoma extranodal derivado de células NK/T (LNK/T) es una variedad de linfoma no Hodgkin; el tipo nasal constituye la presentación más común. Nuestro objetivo es presentar un caso de LNK/T con afección del sistema nervioso central (SNC) que simuló una tuberculosis meningea.

CASO CLÍNICO

Varón de 31 años con sensación de obstrucción nasal, cefalea, fiebre, panhipopituitarismo y mononeuropatía craneal múltiple, con lesión hipofisaria por imagen de resonancia magnética y engrosamiento dural, que evolucionó con pancitopenia y úlcera en el paladar blando. El diagnóstico se realizó mediante biopsia de cornete nasal compatible con infiltración por linfoma de estirpe T maduro NK.

CONCLUSIONES

La afección del LNK/T al SNC es una forma rara de presentación. El diagnóstico de LNK/T se puede ver retrasado por la presencia de síntomas heterogéneos. En nuestra población, la infección por Mycobacterium debe ser considerada como diagnóstico diferencial.

BACKGROUND

Lymphoma of NK/T cells (LNK/T) is a variety of non-Hodgkin lymphoma; the nasal type is the most common presentation. The aim of this article is to present a case of LNK/T with affection to central nervous system that imitates meningeal tuberculosis.

CASE REPORT

31 years old man with nasal blockage feeling, headache, fever, panhypopituitarism and multiple cranial mononeuropathy, with a pituitary injury demonstrated by magnetic resonance image and meningeal thickening, that progress with pancytopenia and soft palate ulcer. The diagnosis was made by nasal concha biopsy compatible with lymphoma infiltration, of LNK/T cell linage.

CONCLUSIONS

The affectation of LNK/T cell lymphoma in central nervous system is a rare presentation. the diagnosis could be delayed for the presence of heterogeneous symptoms. Mycobacterium infection must be considered as a differential diagnosis in our population.

Two lymphomas in the same patient: A case report

INTRODUCCIÓN

La asociación de forma sincrónica de un linfoma Hodgkin y un linfoma no Hodgkin en un mismo paciente es muy rara.

CASO CLÍNICO

Varón de 68 años que comienza su padecimiento con adenomegalias cervicales y axilares. Se realiza biopsia escisional y se encuentra linfoma de Hodgkin de tipo celularidad mixta, por lo que se inicia quimioterapia. Durante el transcurso del tratamiento se observa la continuidad de lesiones refractarias en la piel y el músculo, por lo que el servicio de radiooncología decide hacer una nueva biopsia y se demuestra que se trata de una nueva afección, un linfoma no Hodgkin difuso de células B grandes.

CONCLUSIONES

Este caso ejemplifica que ante un paciente con un cuadro clínico típico y con una evolución tórpida hay que replantearse el diagnóstico e incluso repetir los estudios realizados para descartar diagnósticos alternos que puedan alterar el curso de la enfermedad.

BACKGROUND

The synchronous association of Hodgkin lymphoma and non-Hodgkin lymphoma in the same patient is very rare.

CASE REPORT

A 68 years old male patient who began his disease with cervical and axillary adenomegaly, it was performed an excisional biopsy and a mixed cell-type Hodgkin lymphoma was found. Chemotherapy with partial response was initiated. During the course of the treatment, refractory lesions were observed in skin and muscle. Radiation oncology service decided to make a second biopsy which confirms the presence of a large diffuse B cell non-Hodgkin ­lymphoma.

CONCLUSIONS

This case is an example of how when you have a patient with a typical clinical picture of bad prognosis, the diagnosis should be reconsidered and laboratory studies previously done must be repeated to rule out alternative diagnoses that may change the course of the disease.

Plasmablastic lymphoma: case report

INTRODUCCIÓN

El linfoma plasmablástico es un linfoma no Hodgkin de alto grado. Se describe en pacientes con infección por el virus de la inmunodeficiencia humana (VIH), en receptores de trasplantes y en pacientes de edad avanzada. Se presenta en la cuarta década de la vida, siendo la cavidad oral el sitio más común de afección. Sus células neoplásicas expresan marcadores de células plasmáticas como CD138 y CD38. En su patogenia se ha implicado al virus de Epstein-Barr. La consideración más desafiante en el diagnóstico diferencial es el mieloma múltiple, ya que las características morfológicas e inmunofenotípicas de estas dos enfermedades son muy similares. El régimen EPOCH (etopósido, epirubicina, vincristina, ciclofosfamida y prednisona) asociado a tratamiento antirretroviral es la opción más eficaz, mejorando la supervivencia a 17 meses.

CASO CLÍNICO

Varón de 35 años con VIH y síntomas de disfunción orgánica asociada a mieloma. Se realizó electroforesis de proteínas y aspirado de médula ósea, descartándose mieloma múltiple. Continuando con el abordaje diagnóstico y con la sospecha de neoplasia ósea, se realizó una biopsia ósea que reportó linfoma plasmablástico CD138+ y Ki-67 80%, Epstein-Barr positivo. El paciente recibió quimioterapia con EPOCH y tuvo una sobrevida de 6 meses.

CONCLUSIONES

La presencia de disfunción orgánica relacionada con mieloma motivó la búsqueda de dicha patología y se determinó la presencia de linfoma plasmablástico. La correlación clínica, bioquímica, inmunohistoquímica y radiográfica es esencial para el correcto diagnóstico.

BACKGROUND

Plasmablastic lymphoma is a high grade non-Hodgkin lymphoma. It is described in patients with HIV infection, post-transplant and advanced age. It appears in the fourth decade of life and the oral cavity is the most common site of affection. Its neoplastic cells express markers of plasma cells such as CD138, CD38. In its pathogenesis the Epstein-Barr virus has been implicated. The most challenging consideration in the differential diagnosis is with multiple myeloma, since the morphological and immunophenotypic characteristics of these two entities are very similar. Treatment with EPOCH (etoposide, epirubicin, vincristine, cyclophosphamide and prednisone) associated with antiretroviral treatment is the most effective option, improving survival to 17 months.

CASE REPORT

Male of 35 years with HIV and symptoms of organic dysfunction associated with myeloma. Protein electrophoresis and bone marrow aspiration were performed, ruling out multiple myeloma. Continuing with the diagnostic approach and with suspicion of bone neoplasia, a bone biopsy was performed with report of plasmablastic lymphoma CD 138+ and Ki-67 80%, Epstein-Barr positive. He received chemotherapy with EPOCH, with a six-month survival.

CONCLUSIONS

The presence of organic dysfunction related to myeloma motivated the search for said pathology and the presence of plasmablastic lymphoma was determined; clinical, biochemical, immunohistochemical, and radiographic correlation are essential for correct diagnosis.

Burden of lymphoma in China, 2006-2016: an analysis of the Global Burden of Disease Study 2016

Background

The accurate information about lymphoma burden at national and provincial levels remains unknown in China.

Methods

Following the general analytical strategy used in GBD 2016, the age-, sex-, and province-specific incidence, mortality, and prevalence of lymphoma in China were analyzed. Trends in the incidence, mortality, prevalence, and disability-adjusted life years (DALYs) due to Hodgkin’s lymphoma (HL) and non-Hodgkin’s lymphoma (NHL) were assessed from 2006 to 2016.

Results

It was estimated that there were 75,400 new cases and 40,500 deaths of lymphoma in 2016 in China, of which 6900 new cases and 2900 deaths were due to HL, while 68,500 new cases and 37,600 deaths were due to NHL. The age-standardized incidence rate (ASIR), mortality rate (ASMR), and prevalence rate (ASPR) per 100,000 were 0.46, 0.19, and 1.75 for HL, and 4.29, 2.45, and 14.9 for NHL, respectively. An upward trend with age in incidence and mortality was observed. Males had higher incidence and mortality rates than females in all age groups. Sociodemographic index had a correlation with the ASIR (r = 0.75), ASMR (r = − 0.74), ASPR (r = 0.84), and age-standardized DALYs (r = − 0.75) of HL, as well as with the ASIR (r = 0.80), ASPR (r = 0.83), and age-standardized DALYs (r = − 0.33) of NHL. From 2006 to 2016, the age-standardized DALYs of HL decreased significantly, while the age-standardized DALYs of NHL increased from 2006 to 2013 and remained stable from 2013 to 2016.

Conclusions

The burden of lymphoma in China showed unexpected patterns varied by sex, age, and provinces, with an increased trend of NHL and a decreased trend of HL from 2006 to 2016.

Electronic supplementary material

The online version of this article (10.1186/s13045-019-0785-7) contains supplementary material, which is available to authorized users.

Mediastinal Lymphoma Presenting in Cardiogenic Shock with Superior Vena Cava Syndrome in a Primigravida at Full Term: Salvage Resection after Prolonged Extracorporeal Life Support

Primary mediastinal large B-cell lymphoma (PMBCL) is a rare type of non-Hodgkin lymphoma that typically has a good response rate to first line chemotherapy regimens. There have been reports of successful chemotherapy, but with a residual mass from fibrosis. Here, we report the case of a 19-year-old primigravida presenting with cardiogenic shock and superior vena cava (SVC) syndrome at full term who was found to have a PMBCL. Following delivery via urgent cesarean section, she was put on veno-arterial extra corporeal membrane oxygenation (VA-ECMO) and once hemodynamically stable was started on chemotherapy. In view of limited change in tumor size on consecutive CT scans and questionable response to chemotherapy, there were multidisciplinary meetings wherein withdrawing support was discussed and put forward to the family. At that point, surgical debulking was offered on compassionate grounds to be able to wean her off the VA-ECMO. This case report highlights the role of salvage resection when there are no other options.

Multiple secondary cauda equina non-Hodgkin's lymphoma: a case report and literature review

Background

Secondary central nervous system involvement of non-Hodgkin’s lymphoma (NHL) is rare and with poor prognosis, the most common pathological type is diffuse large B cell lymphoma (DLBCL). Although it can occur in any part of central nervous system, it rarely directly infiltrates the spinal cord or cauda equina.

Case presentation

We present the case of 64-year-old immunocompetent man with a worsening pain of waist and left lower extremity, accompanied by numbness and paresis of bilateral lower extremity for 20 days. His previous medical history included a resection of painless mass in the left groin in another hospital 7 months ago, and the pathological diagnosis was non-Hodgkin small B cell lymphoma. Gd-enhanced MRI and F-18 FDG PET-CT scan demonstrated multiple infiltrations in the cauda equina. During the operation, we removed as many as 11 subdural-extramedullary bean-size lesions involving multiple nerve roots. The paralysis of his left leg recovered rapidly after the operation. During the follow-up period of more than one year, he underwent standard R-CHOP chemical therapy, no evidence of recurrence was noted until the 13th month, the patient died because of intracranial relapse.

Conclusions

Imaging examination is important in the diagnosis of multiple secondary cauda equina non-Hodgkin’s lymphoma, and we highlight the significance of gadolinium-enhanced MRI and F-18 FDG-PET/CT in preoperative diagnosis as well as the previous history.

Clinicopathological characteristics of diffuse large B-cell lymphoma involving small and large intestines: an analysis of 126 patients

We analyzed the clinicopathologic characteristics of 136 intestinal diffuse large B-cell lymphomas (DLBCLs) among 126 patients. The DLBCL sites were categorized as: duodenum (n = 23), ileocecal region (n = 63), other small intestine (n = 29), rectum (n = 7), and other large intestine (n = 14). Patients with DLBCLs of the ileocecal region or other small intestine frequently underwent surgery for ileus or perforations (P < 0.001), were predominantly male (P = 0.042), and had a higher incidence of limited-stage disease (P = 0.001), lower International Prognostic Index (P = 0.015), and lower incidence of lactate dehydrogenase elevation (P = 0.007) than those with DLBCLs of other regions. Half of the intestinal DLBCLs exhibited the germinal center B-cell phenotype. A low-grade B-cell lymphoma background was found in 21% of the cases; the prevalence was significantly lower in the ileocecal region (13%, P = 0.025), suggesting a higher incidence of de novo DLBCLs. Intestinal follicular lymphoma (FL) and mucosa-associated lymphoid tissue (MALT) lymphoma backgrounds were observed in 10% and 0% of the cases, respectively. Five percent (5/107) of intestinal DLBCL cases were Epstein-Barr virus-encoded RNA-1 positive. The clinicopathologic characteristics of the DLBCLs differed by region. Histologic transformation of intestinal FL was observed in around 10% of the intestinal DLBCL cases.

New/Revised Entities in Gastrointestinal Lymphoproliferative Disorders

The gastrointestinal tract is a common extranodal site of involvement by lymphomas. These may be diagnostically challenging because they can mimic a variety of benign conditions and may be difficult to subclassify when malignant. The classification of gastrointestinal lymphomas is an evolving area with some recent changes. Although some of these entities are rare, they are important to recognize because of the variable clinical presentations, comorbidities, and treatment implications. This article explores new and revised entities in gastrointestinal lymphoproliferative disorders.

Remission of Late-Onset Post-Liver Transplantation Non-Hodgkin Lymphoma

We describe the clinical course of a patient who developed high-grade lymphoma during immunosuppression treatment with cyclosporine A, following liver transplantation. After anti-neoplastic polychemotherapy treatment, the remission of lymphoma was confirmed and maintained for over four years. The patient, a 27 year old female had liver transplantation at the age of 17, due to acute liver failure, caused by non-diagnosed Wilson disease. Nearly seven years post-transplantation, the patient was diagnosed with non-Hodgkin B-cell lymphoma (NHBCL), potentially induced by Cephalosporin A therapy. After the treatment with rituximab and CHOP therapy (r-CHOP protocol), remission was determined using computer tomography. Remission is maintained to date. A review of reported cases of post-transplant lymphoproliferative disorders (PTLDs) in liver transplanted (LT) patients showed that the onset of PTLDs is the highest in the first year after transplantation. In addition, remission rates of NHBCL in LT patients are not much elaborated in the literature. It is our opinion that the presented case is rare, both from the aspect of timeline of occurrence of the PTLD and the achieved remission, using r-CHOP protocol.

Serum organochlorines and non-Hodgkin lymphoma: A case-control study in Israeli Jews and Palestinians

Associations of organochlorine (OC) pesticides and polychlorinated biphenyls (PCBs) with non-Hodgkin lymphoma are controversial. We compared serum levels of 6 OC pesticides and 38 PCBs in Israeli Jews (IJ) and Palestinian Arabs (PA) and assessed possible associations with B-cell non-Hodgkin lymphoma (B-NHL). Ninety B-NHL cases (50 IJ and 40 PA) and 120 controls (65 IJ and 55 PA) were included. Median concentrations of analytes in controls were compared across ethnic groups using quantile regression, adjusting for age and sex. We used logistic regression to derive odds ratios (OR) and 95% confidence intervals (CI) for detectable analytes and B-NHL, adjusting for age, ethnic group, faming and body mass index. Median values of PCBs and dichlorodiphenyldichloroethylene (DDE) were higher in IJ vs PA controls (P = 0.0007), as were several PCBs (74, 99, 118, 138, 146, 153, 156, 163, 170, and 180). Overall, OC pesticide and PCB exposures were comparable with reports from high-income countries. B-NHL was associated with PCB 146 (OR 1.70, 95% CI: 1.02, 2.83), PCB 156 (OR 1.75, 95% CI: 1.06, 2.89), and high-chlorinated PCBs (OR 1.55, 95% CI: 1.00, 2.40) in all study subjects. These associations were robust in quantile as well as sensitivity analyses. An association of DDE with B-NHL was noted in PA (OR 1.72, 95% CI: 1.07, 2.77), but not in IJ (OR 0.87, 95% CI: 0.59, 1.27). Although high-chlorinated PCB concentrations did not indicate high exposure levels, our findings indicate that B-NHL may be associated with this exposure.

Primary Lymphoma of the Skull Base in the Chinese: Clinical, Radiological, Pathological, and Therapeutic Experience in a Series of 8 Patients

BACKGROUND

Primary lymphoma of the skull base (PLSB) is an extremely rare neoplasm and not much is known regarding the clinical features of, treatment strategies for, and prognoses of these lesions. We investigated the manifestations and clinical outcomes of Chinese patients with PLSB.

METHODS

We retrospectively reviewed the data from 8 consecutive patients with PLSB who had been treated at our center from October 2008 to December 2016 and analyzed their clinical features, treatment strategies, and prognoses.

RESULTS

Of the 8 patients, 3 were men and 5 were women, with a male/female ratio of 0.6. The median age was 53.5 years. In most instances, the onset was characterized by headache, followed by dysfunction of the cranial nerves. The most frequently affected region was the cavernous sinus. On magnetic resonance imaging, the main characteristic was that the internal carotid artery was encased by the tumor without an obvious tendency to be deformed, dislocated, or narrowed. All patients underwent surgical biopsy via a transsphenoidal or sublabial-transmaxillary approach. The pathological diagnosis was non-Hodgkin lymphoma for all 8 patients, with diffuse large B-cell lymphoma in 7 patients. The patients underwent chemotherapy and involved-field radiotherapy. The median overall survival was 52 months, and the 1-year progression-free survival rate was 87.5%.

CONCLUSIONS

PLSB is a rare disease and a diagnostic challenge, with most cases in the Chinese due to diffuse large B-cell lymphoma. We found that the incidence peaked in middle and old age, and the cavernous sinus was usually affected. Multidisciplinary treatment involving surgical biopsy, chemotherapy, and radiotherapy was an effective therapeutic strategy.

18F-FDG PET/CT Findings of Non-Hodgkin Lymphoma Involving the Whole Genitourinary System

A sixty-two-year-old male patient underwent orchiectomy and was diagnosed with diffuse large B-cell lymphoma in the testicle and spermatic cord. ¹⁸F-FDG positron emission tomography/computed tomography (PET/CT) scanning was performed for initial staging. ¹⁸F-FDG PET/CT scan revealed multiple hyper-metabolic lymphadenopathies, lung lesions and mass lesions in the adrenal glands and kidneys. In addition, diffuse increased ¹⁸F-FDG uptake suggesting lymphomatous infiltration on the right testicle, prostate and left testicular veins were detected. The genitourinary system involvement is extremely rare in extra-nodal lymphomas and to the best of our knowledge this is the first case in the literature having ¹⁸F-FDG accumulating lesions in all genitourinary system structures.

Late-onset cardiomyopathy among survivors of childhood lymphoma treated with anthracyclines: a systematic review

Medical advances in pediatric oncology have led to increases in survival but the long-term adverse effects of treatment in childhood cancer survivors have not yet been examined in depth. In this systematic review, we aimed to study the prevalence and risk factors of late-onset cardiomyopathy (LOCM) among survivors of childhood lymphoma treated with anthracyclines. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines we searched Pubmed/Medline, abstracted data and rated studies on quality regarding late-onset (>1 year following treatment) cardiotoxicity of anthracyclines in survivors of childhood lymphoma. Across 22 identified studies, the prevalence of anthracycline-induced LOCM among survivors of childhood lymphoma ranges from 0 to 40%. Anthracycline dose, administration and dose of mediastinal radiation, patient's age and era of diagnosis and evaluation, follow-up duration as well as disease relapse have been reported as risk factors for LOCM, whereas administration of dexrazoxane seems to act protectively. There was significant between-study heterogeneity with regards to lymphoma subtypes, follow-up duration, definition of outcomes, and anthracycline-based treatment protocols. The rates of anthracycline-induced LOCM among survivors of childhood lymphoma are high and dependent on study design. Future studies should explore whether modifying risk factors and suggested supportive care could decrease its prevalence among childhood lymphoma survivors. Until then, lifelong follow-up of these patients aiming to determinate the earliest signs of cardiac dysfunction is the most important measure towards primordial prevention of LOCM.

Paraneoplastic immunoglobulin A nephropathy and associated focal segmental glomerulosclerosis in asymptomatic low volume B-cell lymphoma - a case report

Background

Paraneoplastic glomerulonephritis is rare in haematological malignancies and tends to manifest as minimal change disease, membranous glomerulonephritis or membranoproliferative glomerulonephritis. We present the first report of immunoglobulin A nephropathy and associated focal segmental glomerulosclerosis in a patient with asymptomatic low grade B-cell lymphoma.

Case presentation

A 53 year old gentleman presented with nephrotic range proteinuria (urine protein creatinine ratio of 662 mg/mmol) on a background of type 2 diabetes mellitus (glycosylated haemoglobin: < 6%), hypertension, obesity (body mass index: 47.6 kg/m²) and degenerative spine disease. Bone marrow biopsy diagnosed a low grade B-cell lymphoma and renal biopsy was consistent with immunoglobulin A nephropathy. Lymphoma treatment with six cycles of cyclophosphamide/ rituximab/ prednisolone led to normalisation of urinary protein excretion (urine protein creatinine ratio: 14 mg/mmol at 26 months post-chemotherapy).

Conclusion

Paraneoplastic immunoglobulin A nephropathy can occur with a broad range of haematological malignancies regardless of stage. This case illustrates the importance of meticulous haematological system work-up for patients presenting with immunoglobulin A nephropathy. Recognition of paraneoplastic immunoglobulin A nephropathy and early diagnosis of associated malignancy can be life-saving.

Marginal Zone Lymphoma: Clinicopathologic Variations and Approaches to Therapy

PURPOSE OF REVIEW

The purpose of the study is to summarize the current conundrums in the management of marginal zone lymphomas (MZL).

RECENT FINDINGS

In 2017, the US Food and Drug Administration (FDA) approved ibrutinib, a first in class Bruton Tyrosine Kinase inhibitor, for the treatment of relapsed/refractory MZL based on pivotal open-label phase II trial demonstrating an overall response rates of 48%. Clinical trials design utilizing chemotherapy-free regimens for relapsed/refractory disease are gaining popularity. Recent studies have identified multiple genetic biomarkers that helped characterize and prognosticate different subtypes of MZL. MZLs are heterogeneous, mostly indolent, malignancies derived from B lymphocytes. Three disease subtypes are recognized, extranodal, nodal, and splenic. The disease characteristics, clinical picture, and treatment algorithms vary considerably based on subtype and site of involvement. Recent discoveries have enhanced our knowledge of the pathogenesis of MZLs leading to development of more accurate prognostic models as well as novel targeted systemic therapies.

The degree of overlap between the follicular dendritic cell meshwork and tumor cells in mantle cell lymphoma is associated with prognosis

This study concerning mantle cell lymphoma (MCL) investigated retrospectively an association between patient prognosis and the percentage of the total number of lymphoma cells found in the follicular dendritic cell (FDC) meshwork, that is, the degree of overlap of lymphoma cells. Two hundred and nine MCL patients were apportioned to grades I-III, in which the CD21-positive FDC meshwork covered ≤50%, 51%-89%, and ≥90% of the tumor area, respectively. Significant differences among the grades (all, P < 0.01) were found in the following: duration of disease (from onset of clinical manifestation to diagnosis); clinical staging; extranodal involvement (non-lymphoid organs); histological subtype; and Ki-67 proliferation index (PI). After removing the aggressive variants, the overall survival rates of grade I (n = 92) and II (n = 57) patients were similar. The overall survival rates of grade III (n = 46) patients differed from that of grade I + II patients (P < 0.01). The grades negatively correlated with the Ki-67 PI value (r = -0.234, P = 0.001). At each grade the OSR of patients with Ki-67 PI ≤30% was similar to that of patients with Ki-67 >30%. In the Ki-67 PI ≤30% group, the OSRs of the patients differed significantly among the grades. In the Ki-67 >30% group the OSRs of the grades were similar. The results of multivariate Cox regression analysis showed that the degree of overlap, age and Ki-67 PI was the independent prognostic factors of the OSRs of MCL patients. Our data suggests that MCL patients in whom there was a high degree of overlap between the FDC meshwork and tumor area have a better clinical prognosis. The degree of overlap correlates well with the Ki-67 PI, which can be used to predict the prognosis of patients.

Systemic Non-Hodgkin T Cell Lymphomas Presenting in the Head and Neck Region: An Institutional Experience of a Rare Entity

T cell lymphoma (TCL) is a group of rare and aggressive diseases. TCL primary to head and neck organs often present as extranodal NK/T cell lymphoma, nasal type. Systemic TCL with initial head and neck presentation is extremely rare. Here we report our institutional experience. Clinicopathologic data was collected from patients diagnosed with TCL and treated at the University of Alabama at Birmingham between 2002 and 2012. Eleven cases of systemic TCL initially presented at head and neck region were identified. The median age was 54 years and male:female ratio was 1.8. The most common sites involved were sinonasal tissue, tonsil, tongue and larynx. Most patients presented with a mass lesion without systemic symptoms. The presentation of TCL primary to the head and neck region is often non-specific. A misdiagnosis of undifferentiated tumor or chronic inflammation due to ambiguous morphology is not uncommon. TCL should be considered in differential diagnosis and a thorough evaluation is warranted for accurate diagnosis.

Intestinal perforation that developed after chemotherapy in a patient diagnosed with non-Hodgkin lymphoma: A case report and review of literature

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Intestinal perforations are one of the most well-known complications of NHLs.

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The reasons of perforation in patients who receive chemotherapy were fast tumor necrosis, tumor lysis, and tissue impairment.

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Depending on the steroids given to the patient, perforation may develop, and the clinical symptoms may be masked.

Introduction

Non-Hodgkin Lymphomas (NHL) appear with the malign transformation of mature lymphocytes. Intestinal perforations are one of the most well-known complications of NHLs. In this review, a 29-year-old male patient who was diagnosed with NHL with gastrointestinal involvement that developed intestinal perforation after chemotherapy is presented.

Presentation of case

A 29-year-old male patient who received systemic chemotherapy in another healthcare center due to Major B-Cell Lymphoma was examined because he had stomachache after the treatment. The patient was urgently taken to operation. In the exploration, there were partly mass lesions in all small intestine segments. It was determined that one of the lesion was perforated. Small intestine resection was applied. The pathology report on resection material was reported as High Grade Major B-Cell Lymphoma.

Discussion

In the treatment of Lymphoma with intestinal B-Cells, there is no consensus because this disease is rarely observed. Perforation may appear as a complication of the chemotherapy. Depending on the steroids given to the patient, perforation may develop, and the clinical symptoms may be masked.

Conclusion

It must be born in mind that there may be intestinal involvement in patients diagnosed with NHL, and intestinal perforation may develop due to chemotherapy.

Surveillance Scans in Lymphoma: Friend or Foe?

OPINION STATEMENT

Advancements in the treatment of lymphoma over the last few decades have allowed more patients to achieve a remission after the completion of therapy. Due to the improvement in response rates, methods to detect recurrence early and accurately during follow-up, especially in patients with potential curable aggressive lymphomas, are a key. Observation has always involved close clinical follow-up with the use of physical exams and routine labs, but rapid changes in technology have allowed CT scans, PET scans, and MRIs to become an integral part of managing patients with lymphoma. While the utility of scans in initial staging and immediately after completion of therapy is well established, the use of these imaging modalities for monitoring recurrence in lymphoma patients is still controversial. Patient advocacy groups and other regulatory committees have questioned the frequency and in some cases even the need for these tests in patients without evidence of active disease given the concern for radiation-associated health risks. Additionally, the extent to which this form of testing impacts the psyche of our patients is not completely known. Given the numerous questions raised about the benefits, safety, and cost-effectiveness of CT imaging, firm guidelines are needed at this time in standard practice and within our clinical trials to limit the use of surveillance imaging. Such efforts are expected to improve the utility of these scans in asymptomatic patients, reduce healthcare costs, and reduce patient exposure to radiation.

Extranodal Non-Hodgkin's Lymphoma of the Oral Cavity: A Case Report

Lymphomas are solid malignant tumors having a wide spectrum of clinical and pathological features. Non-Hodgkin's lymphoma (NHL) is a subtype of lymphoma with two-thirds of the cases presenting as lymph node enlargement. The remaining one third of NHL cases has been reported in the extranodal sites, including the gastro intestinal tract, Waldeyer's ring, bone, skin, and brain. Intraoral non-Hodgkin's lymphoma is uncommon and may affect either the jaw bones or occur within the soft tissues of the oral cavity. Here we report a case of non-Hodgkin's lymphoma in a 65-year-old male patient who presented with a growth from the extraction socket. Non-Hodgkin's lymphoma presenting as a growth from the extraction socket is unusual. An orthopantamograph (OPG) was taken which revealed a diffuse radiolucent defect in relation to the extraction socket of the left lower molar region. Routine hemogram, urine analysis, and chest radiograph were normal. Incisional biopsy was performed and the tissue was subjected to histopathological examination. Histopathological and immunohistochemical analysis confirmed the diagnosis of B-cell lymphoma. The patient was referred to a regional cancer institute for further management, where chemotherapy was planned. However, prior to chemotherapy, the patient was diagnosed with brain metastasis and he expired in hospital within one month.

Lymphoma

Lymphomas may be broadly divided into non-Hodgkin (90%) and Hodgkin (10%) types. Most lymphomas (90%) are of B cell origin but can also be T cell or natural killer cell. Clinical management of indolent and aggressive lymphomas is different. Aggressive lymphomas are more dangerous if left untreated yet a higher cell proliferation rate also renders them more chemosensitive, so they are managed with curative intent. Indolent lymphomas are, for the most part, incurable, such that quality of life must be balanced against toxicity of treatment in deciding when and how to treat.

Primary osseous Burkitt lymphoma with nodal and intracardiac metastases in a child

Burkitt lymphoma (BL) is the most frequent non-Hodgkin lymphoma in pediatric patients, accounting for approximately 34% of the cases of lymphoma in children. This subtype of non-Hodgkin lymphoma was first described in 1958 as a monoclonal proliferation of B cell lymphocytes. Cardiac involvement of BL in association with osseous compromise and lymphadenopathy is rare and poorly documented. We report a case of femur primary BL in an 8-year-old boy with metastatic cardiac involvement, retroperitoneal and iliofemoral lymphadenopathy, and hepatosplenomegaly. We highlight the diagnostic challenge in a patient with clinical nonspecific findings and systemic disease.

A Study of Clinical Profile of Primary Extranodal Lymphomas in a Tertiary Care Institute in South India

Context:

Primary extranodal lymphoma (pENL) refers to group of disorders arising from tissues other than lymph nodes. The incidence of pENL is increasing and is probably due to better diagnostic immunophenotyping and imaging modalities. Hence, this study was undertaken to ascertain the incidence, distribution, and histological subtypes of extranodal non-Hodgkin lymphoma (NHL) in a tertiary care institute in South India.

Subjects and Methods:

This was a retrospective study of patients diagnosed to have histologically proven NHL. The demographic and clinical features, laboratory parameters, imaging findings, histopathology, and immunophenotyping were documented. The lymphomas were grouped as extranodal and nodal. The data were tabulated in a Microsoft Excel sheet, and descriptive analysis was done.

Results:

Primary extranodal NHLs constituted 35.96% (41/114) of all NHLs. The B symptoms were less common in pENL compared to nodal NHL. Gastrointestinal tract (GIT) constituted the most common extranodal site (19/41, 46.34%), and diffuse large B-cell lymphoma (DLBCL) was the most common histological subtype. Majority (40/41, 97%) of the patients with pENL were immunocompetent. 31/41 (75%) patients were in Stage I–II compared to 58/73 (79.4%) patients in Stage III–IV in nodal NHL.

Conclusions:

Primary extranodal NHL constituted about one-third of patients diagnosed to have NHL at our center with the GIT being the most common site of presentation and DLBCL being the most common histology. A strong suspicion of NHL at an extranodal site with appropriate pathological and immunophenotyping evidence is needed to establish the diagnosis of a pENL.

[Radiotherapy for localized gastric and orbital MALT lymphomas]

Primary gastric and orbital MALT lymphomas are both low grade (indolent) B-cell non-Hodgkin's lymphomas. Traditionally, these tumors are radiosensitive and have a good prognosis. In localized orbital and stages IE-IIE gastric MALT lymphomas without Helicobacter pylori infection or in case of persistent H. pylori infection after eradication therapy, several retrospective studies have shown that radiotherapy was an effective and well-tolerated treatment.

10 years of experience and follow-up

INTRODUCTION

Radioimmunotherapy (RIT) is one of the therapies directed against molecular targets in non-Hodgkin's lymphoma (NHL).

OBJECTIVE

To evaluate the positioning, safety, and effectiveness of RIT with 90Y-Ibritumomab in NHL patients.

METHOD

A retrospective study was conducted on patients with NHL who received RIT with 90Y-Ibritumomab. An evaluation was made of the concordance with clinical guidelines, toxicity as rated by the Common Terminology Criteria for Adverse Events (CTCAE), and effectiveness was assessed based on response to treatment, overall survival (OS), and progression-free survival (PFS).

RESULTS

RIT was requested in 26 patients, of whom 21 (11 women, mean age 56±10 years) were included in the study, with the following distribution: Follicular NHL, 67%, Mantle NHL, 14%, Diffuse large B-cell NHL, 9.5%, and Transformed NHL 9.5%. Twelve patients with refractory NHL, 7 for consolidation response, and 2 transplant conditioning, were treated. Adverse effects were observed in 71% of patients, which were usually manageable and transient, and with the most common being thrombocytopenia. At 3-4 months, overall response rate was 76.2% (71.4% complete and 4.8% partial response), and 19% had progression of disease. With a median follow up of 70 months, the OS was 96±8 months, and the PFS was 54±11 months.

CONCLUSION

RIT showed a moderate correlation with clinical guidelines, and is probably underused. Adverse effects were common, mild, and manageable. The data show a high complete response rate and an increase in the OS and PFS.

Predictive Efficacy of Interim Positron Emission Tomography/Computed Tomography (PET/CT) for the Treatment of Aggressive Lymphoma

The prognostic value of whole-body positron emission tomography/computed tomography (PET/CT) with ¹⁸F-fluoro-2-deoxy-D-glucose (FDG) shortly after the onset of induction chemotherapy or mid treatment could help to predict long-term clinical outcomes in patients with Hodgkin's or Non-Hodgkin's lymphoma. However, FDG is not a tumor-specific substance, and it may accumulate to the point of being detected in a variety of benign conditions or at physiologic anatomical sites, which may give rise to false-positive interpretation. In an attempt to standardize the reporting criteria for interim PET/CT, the First International Workshop on Interim PET in Lymphoma suggested visual response criteria with the Deauville five-point scale, and the standardized uptake value (SUV) has been investigated in comparison with this visual system. A quantitative approach using the measurement of maximal SUV (SUVmax) or the reduction rate of SUVmax (ΔSUVmax) might be more appropriate in early-response PET/CT for reducing false-positive rates or for decreasing interobserver variability in interpretation. In this review, the predictive efficacy of PET/CT is discussed for the treatment of aggressive lymphoma, especially in terms of an interim PET/CT-based prognostic model.

A Rare Case of Malignant Lymphoma Occurred at Spinal Epidural Space: A Case Report

The sacral spinal epidural space is an uncommon site for primary malignant lymphomas, presenting with symptoms associated with cauda equina compression. Especially, lumbo-sacral epidural lymphoma has been reported to be very rare. We present a rare case of 29-year-old male with sacral spinal epidural malignant lymphoma. The patient complained of tingling sensation in his buttocks that was radiating to his calf. The neurological examination was normal. Magnetic resonance imaging (MRI) with contrast showed a well-defined extradural mass lesion at the mid L5 to mid S2 level. The lesion was iso- to hypointense on T1 and T2 weighted images and showed homogenous enhancement and a focal enhancement in the L5 vertebral body on post-contrast images. The patient underwent a L5-S2 laminectomy and subtotal excision of the lesion. Intra-operatively, the lesion was extradural and not densely adherent to the dura; the lesion was friable, not firm, fleshy, brownish and hypervascular. The histologic diagnosis was grade 2 non-Hodgkin's follicular lymphoma. Even though the primary spinal epidural non-Hodgkin's lymphoma is a very rare disease, clinicians should take it into consideration in the differential diagnosis of patients with spinal epidural tumor.

Extranodal hematopoietic neoplasms and mimics in the head and neck: an update

The head and neck region is a common site for extranodal lymphomas, second only to the gastrointestinal tract; and 12% to 15% of all head and neck tumors are lymphomas. Non-Hodgkin lymphomas are most common, and Hodgkin lymphoma occurs rarely at extranodal sites in the head and neck. Most non-Hodgkin lymphomas of the head and neck region are of B-cell lineage, and the Waldeyer ring is the most common site. Head and neck lymphomas have distinctive epidemiological and clinicopathologic features, including an association with immunosuppression, infectious organisms, or autoimmune disorders; site-specific differences (eg, thyroid gland versus ocular adnexa) for common lymphomas, such as extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue; and genetic differences that provide insights into etiology. Furthermore, the diagnosis of non-Hodgkin lymphomas at extranodal sites implies differences in prognosis and therapeutic implications with lymphomas at nodal sites. In this review, we discuss various types of non-Hodgkin lymphomas and Hodgkin lymphoma, focusing on unique aspects related to the head and neck region. We also discuss a number of newer entities that are clinically indolent as well as mimics of lymphoma that can occur in the head and neck region, including infectious mononucleosis, Kikuchi-Fujimoto disease, Kimura disease, Castleman disease, and immunoglobulin G4-related disease.

[Bilateral primitive non-Hodgkin Lymphoma of the breast: about a case]

Les lymphomes malins non-hodgkiniens (LMNH) primitifs du sein sont des tumeurs rares. Leur symptomatologie clinique est polymorphe. L'imagerie médicale est non-spécifique. Le diagnostic peut être évoqué à l'examen cytologique, sa confirmation est toujours histologique. Il s'agit essentiellement de lymphomes de type B, ceux de type NK/T restant rares. Les plus fréquents sont les lymphomes diffus à grandes cellules présentant la particularité de donner des rechutes sous forme d'extension au système nerveux central. Nous rapportons un cas de LMNH primitif bilatéral du sein chez une patiente âgée de 33 ans, révélé par deux nodules mammaires bilatéraux. La mammographie et l'examen extemporané ont évoqué une tumeur phyllode. Le diagnostic du LMNH n'a été fait qu'après examen histologique définitif. Sous chimiothérapie, l’évolution était favorable avec un recul de 15 mois.