Purpose: Nasallymphoma created dosimetric challenges in radiotherapy due to the complex ana- tomical structures. This study was to evaluate the efficacy and toxicity of helical Tomotherapy (HT) in the treatment of nasalNK/T-celllymphoma (NKTCL) patients. Methods and Materials: Between August 2008 and April 2013, a total of 25 NKTCL patients were treated with HT in our department; Among them, three patients have not received chemotherapy, one patient has received concurrent chemo-radiation with CHOP plus L-ASP, two patients have received the sequential chemotherapy regimen following irradiation, and all the others have received 1 - 2 cycles of induction chemo- therapy followed by irradiation and then with sequential chemotherapy. CHOP-L with 1 - 7 cycles (median: 4 cycles) was utilized as the main chemotherapy regimen. As for HT, the gross tumor vo- lume (GTV) received target doses (TD) ranging from 50 to 56 Gy (median: 50 Gy) at 2 - 2.78 Gy per fraction; and the clinical target volume (CTV) from 36 to 50 Gy (median: 40 Gy) at 1.6 - 2 Gy per fraction. Results: For those patients who had received irradiation, thirteen achieved complete re- mission (CR), four partial responses (PR); four had progressive disease (PD), two were lost to fol- low-up, two died within one month after irradiation and were not followed. In 21 patients with follow-up records, the overall response (CR + PR) was 81.0% with the 3-year survival rate of 87.2%, and the mean survival time was 52.8 months [95% confidence interval (CI): 45.2 - 60.4 months]. After radiotherapy the majority of patients had dry mouth and taste changes in varying degrees, and a small portion of patients had compromised hearing or vision functions. No brain injury symptoms occurred during radiation radiotherapy. Conclusions: As compared with conven- tional three-dimensional conformal radiotherapy (3D-CRT) and intensity modulated radiation therapy (IMRT) performed with HT, HT appears to have more favorable efficacy and toxicity pro- files in the treatment of NKTCL. Further systematic and randomized clinical research is under in- vestigation.
the testis. All 14 cases exhibited the same immunophenotype resembling that of nasalNK/T-celllymphoma. Immunohistochemistry (IHC) showed that 14 cases were positive for CD3, CD56, and cytotoxic proteins including perforin, granzyme B and TIA-1, and negative for CD20 and CD79α. The Ki-67 proliferation indices were approximately 70-100% which denoted active proliferation of the neoplastic cells. In situ hybridization for EBER was positive in 13 cases. In our case, the immunohisto- chemical features and EBER in situ hybridiza- tion (ISH) results supported the diagnosis of IVNKTL. Among 14 previous reported cases, 1 case was without treatment, 2 cases of treat- ment was unknown, the other 11 cases were treated with CHOP or modified CHOP chemo- therapy, and 2 cases among the 11 cases received stem cell transplantation (SCT) thera- py meanwhile. Two cases were died at 14 and 15 days after diagnosis respectively because of the rapid progress of the disease. Eight cases were died during 4 to 17 months follow- up. Four cases were free of disease during 3 to 12 months follow-up. In the present case, the patient received three courses of CHOP chemo- therapy and remained disease free after 22 months, and is undergoing follow-up.
often fatal clinical course . Our case presen- tation may be concordant with the hypothesis that aggressive NK-cell leukemia may represent the leukemic counterpart of nasalNK/Tcelllymphoma similar to the relationship between lymphoblastic lymphoma and acute lymphoblas- tic leukemia (ALL). This hypothesis is mainly based on the similar ethnic background (Asian), morphology, immunophenotype, and genotype (lack of T-cell receptor gene rearrangements) of both entities. Moreover, EBV is detected in over 75% of aggressive NK-cell leukemia cases and near 100% in nasalNK/Tcelllymphoma [3,4]. Cytogenetic abnormalities were originally re- ported as being relatively similar in both entities with abnormalities in chromosomes 6, 7, 11, and 17 as the most frequently reported in addi- tion to complex karyotypic abnormalities [4-6]. Despite these similarities, extensive bone mar- row and peripheral blood involvement in a leu- kemic fashion as advanced stage of nasal type NK/Tcelllymphoma is extremely rare.
Case presentation: One patient with NK/T-celllymphoma, presented initially with a penile mass, is reported. The 58-year-old man who presented with progressive painless penile swelling underwent penectomy for penile tumor. Histologically, the glans and foreskin revealed neoplastic infiltration of medium-sized lymphoma cells expressing CD56, CD3, granzyme-B, and labeled for EBV-encoded RNA in situ hybridization. Findings were consistent with NK/T-celllymphoma. By detailed history, we learned that the patient had nasal obstruction for more than 10 years. Nasopharyngeal involvement was screened with PET-CT; ENKTL was diagnosed after a nasopharyngeal biopsy. The final diagnosis was primary nasalNK/T-celllymphoma, with metastasis to the penis. Additional sites of disease appeared soon afterward (adrenal gland, liver, spleen and lymph nodes). The patient died within 4 months. Conclusion: This study suggested that penile NK/T-celllymphoma tends to disseminate early and pursues an aggressive course. It is imperative to distinguish nasalNK/Tlymphoma from other types of tumors, because the prognosis and treatment differ significantly for secondary metastases.
Southeast Asian and Central/South American countries were 5.2 and 3%, respectively, as compared with just 0.3% in North American and European countries . The lymphoma is locally invasive. Because of angiodes- truction, the lymphoma destroys midline facial struc- tures, often manifesting as hard palate perforation (Fig. 1d) . Other facial structures may also be in- volved, including the orbit, salivary glands, and paranasal sinuses. In non-nasalNK/T-celllymphoma, commonly involved primary sites include the skin , gastrointes- tinal tract [35, 36], and testis . Occasional involve- ment of rare sites including the muscle  and uterus  had also been reported. NK/T-cell lymphomas are predominantly extranodal, and primary nodal presenta- tion is exceptionally rare . It must be noted that when NK/T-cell lymphomas appear to present primarily in non-nasal sites, F18 florodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) is needed to exclude an occult nasal primary (practically all NK/T-cell lymphomas are FDG-avid [41, 42]) (Fig. 2a, b). If nasal involvement is found, these “non-nasal” cases should be regarded as nasal lymphomas with systemic spread . Hence, a strict definition of non-nasalNK/T- celllymphoma requires exclusion of a nasal primary on PET/CT.
Until now, cell line samples have been used broadly in most types of cancer studies. For gene expression profiling, we designed a study to include both CT and CC samples, and tried to discover the common and different points between them. We found that CT and CC samples were quite different at the level of gene expression for both up and downregulated genes. The unsupervised clustering revealed even closer distance between CT and NC than that of CT and CC. As we selected study subjects which satisfied sufficient tumor cell contents, the difference could not be explained by normal cell contamination of tumor tissues. Due to the accumulated genetic alterations over division, the cancer cell lines may exhibit more prominent expression pattern far from primary tissue. Since we used the genes showing most variable expression patterns throughout samples for clustering analysis, these alterations specific for CC might affect greatly to the results. Although only some parts of DEGs were shared between the two groups, it seems meaningful that the DEGs included genes of JAK/ STAT pathway or chromatin modification, supporting our main findings derived from mutational profiles.
Normal glands of the mucosa were decreased; cells of the residual glands showed acidophilic degeneration in the cytoplasm, and numerous lymphocyte infiltrations were seen in the sub- epithelium (Figure 2A). Tumor cells varied in density and distribution; local tumor cells invaded glands and formed lymphatic epithelial lesions. Neoplastic cells showed similar small to intermediate size and shape, irregular nucle- ar contours, clear cytoplasm, and dispersed karyorrhexis, but lacked cell necrosis and apop- tosis (Figure 2B). Intercellular substance was loose and edematous, absent in lymphoid folli- cles, infiltrated with dense plasma cells and small lymphocytes, and some small blood ves- sels were dilated and congested (Figure 2C). Focally, the tumor cells exhibited an angiocen- tric growth pattern, but vascular wall damage and fibrinoid necrosis were not identified in these sections (Figure 2D). Immunohistoche- mical staining showed that the tumor cells were positive for cytoplasmic CD3ε (Figure 3A), CD56 (Figure 3B), and the cytotoxic molecules (granzyme B, TIA-1), but negative for cytokera- tin (pan), B cell markers (CD20 and Pax-5), S-100, Desmin, Chromogranin A, and Sy- naptophysin. CD4 and CD8 shows that a subset of cells were positive. EBER in situ hybridization (ISH) staining (Figure 3C) showed that nearly all neoplastic cells were positive; the Ki-67 (Figure 3D) labeling index was about 80%. Based on the histopathological and immunohistochemi- cal findings, we confirmed the pathological diagnosis of ENKTCL-NT.
For differential diagnosis, (i) “peripheral T-cell lymph- oma, not otherwise specified ” , (ii) “ extranodal NK/T-celllymphoma (nasal type)” and (iii) chronic active Epstein- Barr virus infection (CAEBV) were considered. As described above, the tumor had characteristics of both peripheral T-cell and NK/T-cell lymphomas. The find- ings of CD3 + CD45RO + CD56- could indicate peripheral T-celllymphoma. On the other hand, the findings of cytotoxicity-associated molecule TIA-1+, no TCR re- arrangement and EBV + could indicate NK/T-cell lymph- oma. The present case could not strictly be categorized into either. However, considering the findings of TIA-1+, EBER1+ and no TCR rearrangement, we finally diagnosed this lymphoma as extranodal NK/T-celllymphoma (nasal type). Recently, Miles et al. reported a case of CD56- negative extranodal NK/T-celllymphoma . In that case, neoplastic lymphoid cells expressed CD3, TIA-1 and EBER1 with an unusual lack of CD56. In addition, the patient had no typical symptoms of infectious mononucleosis-like illness, hypersensitivity to mosquito bites or other symptoms supporting CAEBV .
Relatively, ANKL is a more aggressive disease than ENKTL and often presents a more rapid clinical course despite the poor outcomes of both diseases . As previ- ously reported, most cases of ANKL were diagnosed from the presences of NK neoplastic cells in peripheral blood, bone marrow or tissue. However, a few ENKTL patients present with bone marrow involvement, but many ANKL patients can present with multiorgan in- volvement, including peripheral blood, bone marrow, live, and spleen, as well as destruction of the facial mid- line. In addition, the number of leukemia cells in the bone marrow and peripheral blood may fluctuate over a comparatively large range  which may result in a misdiagnosis. In addition, when the nose and nasophar- ynx are initially involved, it is much harder to confirm the type of disease, which may indicate the prognosis of the patient.
function (serum creatinine ≤ 1.5 mg/dL and creatinine clearance ≥ 50 mL/min), and hepatic function (total bilirubin ≤ 2 times the upper limit of normal and aspartate and alanine transaminase levels ≤ 3 times the upper limit of normal); (4) no previous or concomitant malignancies; and (5) a complete set of clinical information and follow- up data. Patients with aggressive NK-cell leukemia, negative EBV in situ hybridization, CNS involvement, pregnancy, or lactation were excluded. Based on the primary tumor site, the cancers were classified as upper aerodigestive tract NK/T-celllymphoma (UENKTL: primary tumors confined to the nasal cavity, nasopharynx, paranasal sinuses, tonsils, hypopharynx, and larynx) or extra-UENKTL (EUENKTL: primary tumors at all sites excluding nasal disease) . Primary tumors within the nasal cavity with secondary spread to other organs were regarded as UENKTL. This study design was approved by the SunYat-sen University Cancer Center Research Ethics Board. All of the patients agreed that their medical information could be used for medical research, and signed an informed consent during their first visit.
been widely used for both predicting prognosis and selecting therapeutic options in patients with aggressive non-Hodgkin’s lymphoma. However, its value has been challenged by nasal ENKTL because it has failed to predict prognosis in retrospective analyses [12, 13]. Recently, PIT has been carried out in other sub- types T-celllymphoma and its improved prog- nostic value were recognized [14-16]. However, these prognostic models are based primarily on pre-treatment clinical characteristics; the path- ological or molecular factors that may predict the prognosis of nasal ENKTL have not yet been well defined. Ki-67 proliferation rate was report- ed to be correlated with a shorter disease-free survival and OS (P < 0.05), while Ann Arbor stage and IPI failed to predict prognosis of the patients with nasal ENKTL . Recently, loss of the granzyme B protease inhibitor 9, cyclo- oxygenase-2 expression and decreased quan- tity of tumor-infiltrating FOXP3-positive regula- tory T-cells have been associated with poor prognosis of nasal or UAT-ENKTL [18-20]. Nasal ENKTL is associated with various histo- logic changes. According to the predominant lymphoma cells in the infiltrates, they could be classified into four histologic subtypes; small cell type, medium-sized cell type, large cell type, and pleomorphic cell type . The majori- ty consists of polymorphous infiltrations of small, medium, and large atypical lymphocytes with accompanying inflammatory cells, plasma cells, macrophages, and neutrophils. The asso- Figure 2. Kaplan-Meier curve of event-free survival and overall survival according to nuclear diameter of tumor cells (NDTC) group.
erythrocyte, supporting the diagnosis of a small celllymphoma . CD3 immunohistochemistry was used to classify the tumor as T-celllymphoma. Lymphoma caused by bovine leukaemia virus is B-celllymphoma , whereas SBL is more likely to be associated with T cells . B-celllymphoma is also possible with SBL . Sub- classification of αβ T-cell or γδ T-celllymphoma or nat- ural killer (NK)-celllymphoma was not done because appropriate immunohistochemistry was not available. However, bovine NK cells are CD3 negative . Electron microscopy revealed intracytoplasmatic electron-dense granules in a few cells, which were suggestive of cytotoxic granules; a γδ T-celllymphoma was therefore possible [14,15,24]. However, the tumour was not epitheliotropic and had no affinity to the nasal mucous membranes. A rim composed mainly of collagenous fibres separated the epithelial layer from the underlying lymphoma masses. Lymph nodes and other internal organs had no macro- scopic evidence of tumour invasion and histological exam- ination of both mandibular lymh nodes revealed no tumour cells. Immunohistochemical staining for CD3, CD79α and CD20 revealed regular distribution of lymph cells, and lymph node architecture was normal, pointing to an activated lymph node. The mitotic index is a good measurement per se for the classification of malignancy of many tumours including lymphoma. An index of greater than 20 per 400 x field indicates malignancy. Alternatively, the proportion of proliferating cells can also be estimated by immunohistochemical assay of Ki-67 antigen expres- sion, which has proven very useful in human oncology . Ki-67 is a highly conserved non-histone nuclear anti- gen protein involved in maintaining chromosomal stability during mitosis . In dogs with highly malignant T-celllymphoma, the Ki-67 index ranged from 50 to 70% . The Ki-67 index was 55% in the present case, which was in agreement with the high mitotic index. Nasal lymph- oma is very common in cats and is predominatly B-cell
were enrolled in this study. Moreover, no statistical asso- ciation was shown between LMP1 and LMP2A expres- sion and other clinical parameters, including age, Ann Arbor stage, LDH level, IPI or response to treatment. Furthermore, Kaplan-Meier survival analysis showed that positive B symptoms, single therapy strategy and high expression of LMP1 and LMP2A could independ- ently predict poor overall survival. These results are con- sistent with the regulatory effects of LMP1 and LMP2A on tumor cell growth, invasion, and metastasis reported in previous studies [14-17], and the poor prognosis of patients with high expression of LMP1 and LMP2A [3,29].
Extranodal natural killer/T-celllymphoma (nasal type, ENKTL) is a relatively rare type of malignant lymphoma that is highly malignant. 1 Nasal cavity-type ENKTL ori- ginates from the nasal cavity with a predilection for the nasal septum and inferior nasal concha. Common nasal diseases include nasal tumors, nasal obstruction and nose- bleeds. Along with the progression of diseases, patients present with nasal space-occupying lesions, extensive involvement with adjacent soft tissues, ulcers and bone destruction. 2–4 Extranasal-type ENKTL affects the skin, gastrointestinal tract and reproductive organs with diverse manifestations according to the different organs involved. A clinical trial is recommended for the treatment of NK/T-celllymphoma. The treatment for these patients mainly includes chemotherapy, radiotherapy or hemato- poietic stem-cell transplantation. Better ef ﬁ cacy for radio- therapy was observed in early stage but poor ef ﬁ cacy in the advanced stage. In recent years, checkpoint inhibitors have been explored as a novel therapeutic approach by enhancing antitumor immunity by blocking immune check points with antibodies, a pathway that has been shown to be increasingly important in ENKTL. PD-1/PD-L1 are responsible for this negative immune regulation and are the targets of the antitumor effect. 5,6 However, effective ﬁ rst-line treatment of NK/T-celllymphoma remains to be explored. In the earliest, anthracycline-containing che- motherapy regimens, such as CHOP, were the mainstay of advanced ENKTL treatment. However, as P-glycoprotein in lymphoma cells, which leads to drug ef ﬂ ux and resistance to treatment, these regimens yield poor outcomes. 7,8 To explore more effective chemotherapy regimens for ENKTL, a series of studies on ENKTL therapy have been carried out since 2009 in the Lymphoma Diagnosis and Treatment Center, Henan, China. The IC50 values of 30 types of chemotherapy agents (such as anthracycline, vincristine, breviscapine, dacarbazine, cisplatin, methotrexate, gemcitabine, colas- pase and pegaspargase) on the NK/T-celllymphomacell line SNK-6 were detected in vitro to identify the medica- tions with low IC50 values, high sensitivity, different action sites and no overlapping side effects. 9 The DDGP chemotherapy regimen alone (cisplatin, dexamethasone, gemcitabine and pegaspargase) was applied to treat advanced NK/T-celllymphoma. The clinical ef ﬁ cacy and safety of the DDGP regimen were evaluated. From August 2010 to May 2012, our center enrolled 12 newly-
Majority of reported cases of intravascular NK/T-celllymphoma showed NK-cell pheno- type and negative for monoclonal TCR rear- rangement suggested they were NK-cell lym- phoma . A few cases of the reported intra- vascular NK/T-celllymphoma may be cytotoxic T-celllymphoma, but they were not further con- firmed by TCR rearrangement study . To our knowledge, only 5 cases of intravascular cyto- toxic T-celllymphoma with sufficient phenotype studies have been reported so far (Table 1). In the present case, the neoplastic cells within the blood vessels were CD45+, CD3+, TIA-1+, Granzyme B+, EBER+, and CD56-, CD30-, ALK-, as well as positive for TCR monoclonal rear- rangement. These data supported the diagno- sis of intravascular cytotoxic T-celllymphoma. Intravascular cytotoxic T-celllymphoma or NK/T-celllymphoma should differentiate from other lymphoma including nasal type extranod- al NK/T-celllymphoma, aggressive NK-cell leu- kemia, intravascular anaplastic large cell lym- phoma. Nasal type extranodal NK/T-cell lym- phomas exhibit angiocentric and angiodestruc- tive growth pattern rather than intravascular growth. In addition, coagulative necrosis is very common in nasal type extranodal NK/T-celllymphoma . Although aggressive NK-cell leu- kemia often displays identical immunopheno- type as extranodal NK/T-celllymphoma or intravascular NK/T-celllymphoma, the former is commonly occur in young to middle-aged adults with a high frequency of bone marrow involvement . Moreover, TCRgγg genes are in germ-line configuration for NK-cell leukemia. The morphology and immune phenotype between intravascular anaplastic large celllymphoma and intravascular cytotoxic T-celllymphoma may be very similar, but the former are positive for CD30 [7, 16]. Another mimicker of IVL should be take into consideration for differential diagnosis is benign atypical intra- vascular CD30+ T-cell proliferation, which is characterized by accumulation of large CD30+ polyclonal T cells within lymphatic in close vicinity to ulceration or inflammatory skin disease. There is no association with Epstein- Barr virus infection for benign atypical in- travascular CD30+ T-cell proliferation . Some recent studies suggested that intravas- cular NK/T-celllymphoma, aggressive NK-cell leukemia and nasal type extranodal NK/T-celllymphoma were closely related diseases due to currently not classified as a separate subtype
Extranodal natural killer/Tcell (NK/Tcell) lymphoma, nasal type, is a rare non-Hodgkin lymphoma originating in the nasal cavity or in the paranasal sinuses. It is strongly associated with Epstein-Barr virus (EBV) infec- tion. Its prevalence is higher in countries in South-East Asia and in Central and South America than in Europe and in North America; it occurs in middle-aged persons and affects males more frequently than females [1-5]. Most cases arise from natural killer cells, only a few from cytotoxic T-cells [6,7].
Nasal and Nasal Type Natural Killer (Nk)/T Cell Lymphoma Immunophenotype and Epstein Barr Virus (Ebv) Association ORIGINAL ARTICLE Nasal and Nasal type Natural Killer (NK)/Y cell Lymphoma Immunophenot[.]
Extranodal NK/T-celllymphoma, nasal type (ENKL) is a subtype associated with Epstein-Barr virus (EBV) infection and commonly involves the upper respiratory tract, such as the nasal cavity, nasopharynx, and parana- sal sinuses . In previous reports, approximately 14– 23% of ENKLs occurred in extranasal sites: the skin, soft tissue, gastrointestinal tract, and testis [4–7]. Pulmonary involvement of ENKL (pulmonary ENKL) is extremely rare. Here, we report a young Japanese man with pulmonary ENKL who was successfully treated with intensive combination chemotherapy and cord blood transplantation (CBT).
Natural killer/Tcelllymphoma, nasal type, are histologi- cally characterized by angiocentricity and invasion of the blood vessels by lymphoma cells, resulting in ischemic necrosis; the neoplastic cells have a variable size and usually appear morphologically immature and the cyto- logical features are heterogeneous, with a variable mix- ture of inflammatory cells. Azurophilic granules are usually observed in the cytoplasm of the lymphoma cells using imprint smears . Aggressive NK-cell leukemia cells are larger than normal large granular lymphocytes and often have a pale or slightly basophilic cytoplasm with azurophilic granules and a nucleus with slightly im- mature chromatin and inconspicuous or distinct nucle- oli. As in NKTCL, necrosis, apoptosis, angioinvasion, and angiodestruction are common findings in tissue bi- opsies . Also frequent is hemophagocytosis, which re- sults from uncontrolled macrophage stimulation by inflammatory cytokines produced by the neoplastic cells and may result in the development of a hemophagocytic syndrome.
Not all patients with localized nasal ENKTL have a better treatment outcome than do those with advanced disease because some patients can develop early relapse, which has a dismal prognosis despite the initial presentation as localized ENKTL. By contrast, other patients may have a truly localized disease with a small tumor burden. There- fore, identification of patients at high risk of treatment failure may help in developing the risk-adapted treatment approach in patients with localized nasal ENKTL. Cur- rently, the prognostic index of natural killer lymphoma (PINK), which includes age > 60 years, stage III or IV disease, distant lymph node involvement, and nonnasal disease, is used as a prognostic model for patients with ENKTL . The PINK model is particularly useful in identifying those patients who should be treated for advanced disease. However, only a small proportion of patients with localized nasal ENKTL might belong to high risk according to the PINK model. Therefore, a modified PINK model that includes the EBV DNA titer in the blood at the time of diagnosis (PINK-E) may be more useful for identifying patients at risk of treatment failure among those with localized nasal ENKTL. The EBV DNA titer in blood has been suggested as a potential surrogate marker for disease activity because of its significant association with a high tumor burden and poor treatment outcomes [41–43]. Moreover, the presence of circulating EBV DNA at the end of treatment correlates with the risk of relapse, which suggests its potential as a marker of residual disease .