Bone marrow transplantation in lymphomatoid granulomatosis. Report of a case

Childhood lymphomatoid granulomatosis: a report of 2 cases and review of the literature

Lymphomatoid granulomatosis (LG) is a B-cell type lymphoproliferative disease. It mainly affects the lungs but may have extrapulmonary manifestations, especially in the central nervous system. The purpose of this study was to review the pediatric cases in the literature and add 2 new cases to the existing literature. A review of the literature was performed on children (0 to 18 years of age at diagnosis) with pathologically proven LG. We found 47 case reports, which, together with 2 new cases, were systematically analyzed. The median age was 12 years. The main symptoms were general, pulmonary, and neurological. Approximately one third of the patients were immunocompromised. High mortality rate was observed. Pediatric LG is a rare disease, which appears to be more frequently seen in immunocompromised patients, especially patients with leukemia. The disease has a high mortality rate; therefore, aggressive therapy according to a high-grade B-cell lymphoma protocol is justified.

Hematopoietic stem cell transplantation in patients with lymphomatoid granulomatosis: a European group for blood and marrow transplantation report

Lymphomatoid granulomatosis (LG) is a very rare, Epstein-Barr virus-associated lymphoproliferative disorder of B cells. Prognosis is poor, particularly after relapse and no curative treatment exists. We report the results of high-dose therapy and autologous stem cell transplantation (ASCT) or reduced-intensity conditioning and allogeneic stem cell transplantation (alloSCT) in patients with multiply relapsed LG. A European Group for Blood and Marrow Transplantation survey identified 10 patients who had received 9 ASCT and 4 alloSCT. All patients had active disease at the time of transplantation. With a median follow-up of 5.1 (range, 1.4 to 6.3) years, 6 patients are alive and disease-free. Two ASCT patients died of septicemia early after transplantation, and 1 committed suicide after being in continuous complete remission 19 months after ASCT. Another patient allografted 4 years after ASCT remained disease-free but died of severe graft-versus-host disease 3 months after alloSCT. High-dose therapy followed by ASCT and alloSCT are effective therapeutic options and should be considered in all patients with refractory and multiply relapsed LG.

Primary cerebral lymphomatoid granulomatosis: report of four cases and literature review

BACKGROUND

Lymphomatoid granulomatosis (LYG) is an angiocentric and angiodestructive lymphoreticular proliferation, which usually involves the lungs, but may also involve the central nervous system (CNS). Unique involvement of the CNS has been reported rarely. We report our experience with LYG confined to the brain and review the pertinent literature.

PATIENTS AND METHODS

From January 1995 to September 2007, we identified patients with isolated brain LYG through a search of the histopathology database of the Catholic University of Rome; medical and radiological data were analyzed. Immunophenotype, in situ hybridization analysis of EBV-encoded small RNAs (EBER ISH) and immunoglobulin rearrangement studies were performed on the pathological specimens.

RESULTS

Four patients with brain-LYG (male/female 1:1, mean age 44 years) underwent surgery in the study period. Subsequent therapy was tailored according to LYG grading. At the latest follow-up (range from 18 to 221 months), patient conditions had improved in all cases. EBER ISH was negative in all cases. Study of the IgH chain gene documented a monoclonal pattern in two cases.

CONCLUSIONS

CNS-LYG is a rare disease that should be considered in the differential diagnosis of both diffuse and space-occupying cerebral lesions. Primary cerebral LYG seems not to be associated with EBV and appears to have a better prognosis than systemic LYG with CNS localization, which is frequently EBV positive.

Prolonged remission of refractory lymphomatoid granulomatosis after autologous hemopoietic stem cell transplantation with post-transplantation maintenance interferon

Lymphomatoid granulomatosis (LYG) is a rare Epstein Barr virus (EBV)-associated lymphoproliferative disease. Even with combination chemotherapy, mortality is high. There is no standard therapy for relapsed or refractory disease. There is only one report in the literature of a complete remission with high-dose chemotherapy and autologous stem cell transplantation. This study presents the case of a patient with progressive LYG, who was successfully treated with autologous stem cell transplantation after conditioning with high-dose chemotherapy and total body irradiation. After transplantation, maintenance therapy with interferon alpha 2a was administered for 3.75 years. The patient remains well and in remission 8 years post-transplantation. This is the first report of a durable (>1 year) complete remission after high-dose chemotherapy and autologous stem cell transplantation in LYG. The role of high-dose chemotherapy and autologous stem cell transplantation in relapsed or refractory cases merits further evaluation. The exact place of interferon in treatment of LYG remains to be clarified but is promising.

Successful treatment of mediastinal lymphomatoid granulomatosis with rituximab monotherapy

Lymphomatoid granulomatosis is a rare Epstein-Barr virus (EBV)-positive-B-cell lymphoproliferative disorder. Treatment options include corticosteroids, antiviral therapy, interferon-alpha and chemotherapy. However, long-term prognosis is poor and no therapeutic standard has been established yet. In a 21-year-old woman, a biopsy of mediastinal mass revealed lymphomatoid granulomatosis. Combined therapy with valganciclovir and interferon-alpha proved ineffective. In view of the CD20 expression of the tumor cells, monotherapy with rituximab was intiated. After 3 months a complete remission was achieved. Rituximab was continued for another 6 months with subsequent consolidation radiotherapy. This is the first report of an enduring complete remission (20 months) of a non-CNS lymphomatoid granulomatosis treated with rituximab.

Lymphomatoid granulomatosis in a renal transplant patient

Lymphomatoid granulomatosis is a rare angiocentric and angiodestructive pulmonary angiitis considered as a variant of the lymphoproliferative disorder group. Patients with organ transplantation are at an increased risk for post-transplant lymphoproliferative disorders secondary to their immunosuppression. However, lymphomatoid granulomatosis has rarely been described in patients with renal transplantation. It often presents with severe pulmonary signs. We describe a case whose initial presentation was an isolated VIth nerve palsy. We review the radiological and pathological findings and discuss the etiopathogenesis and therapeutic options of this particular lymphoproliferative disorder. With careful and stepwise reduction in her immunosuppression, our patient showed a complete disappearance of her lymphomatoid granulomatosis, and she is clinically well more than 3 years after the diagnosis, with good kidney function.

Autologous hematopoietic stem cell transplantation for refractory lymphomatoid granulomatosis

Lymphomatoid granulomatosis (LG) is a rare lymphoproliferative disorder. There is no standard therapy for refractory patient. Here we present the case of a patient with LG of the lung and the brain who was refractory to polychemotherapy. An autologous hematopoietic stem cell transplantation was done and the patient achieved a complete remission. This represents the first case of high-dose chemotherapy with hematopoietic stem cell support in this disease.

Lymphomatoid granulomatosis in a 4-year-old boy

Lymphomatoid granulomatosis is a necrotizing angiocentric and angiodestructive infiltrative process involving primarily the lung, skin, central nervous system, and kidney. The incidence is highest in middle-aged men and is rare in children. We report a case of lymphomatoid granulomatosis involving both skin and lung in a 4-year-old boy. The disease progressed to peripheral T-cell lymphoma, which was unusual in light of recent evidence suggesting a B-cell origin in the majority of cases.

Lymphomatoid granulomatosis: evidence that some cases represent Epstein-Barr virus-associated B-cell lymphoma

Lymphomatoid granulomatosis is currently classified as part of a spectrum of angiocentric immunoproliferative lesions. These were initially thought to be of T-cell phenotype, but recent papers have shown that some cases are B-cell proliferations, sometimes associated with Epstein-Barr virus infection. We reviewed the clinicopathological features of 16 patients with pulmonary lymphomatoid granulomatosis, using immunohistochemistry to assess the phenotype of the infiltrate, the polymerase chain reaction to look for immunoglobulin heavy chain and T-cell receptor gene rearrangements, and in-situ-hybridization to look for Epstein-Barr virus infection. In seven of seven cases the atypical lymphoid population was of B-cell phenotype, with four cases showing evidence of either monoclonality or oligoclonality. All seven cases, including those that lacked unequivocal proof of malignancy, behaved aggressively. Epstein-Barr virus RNA was detected in four cases. We conclude that some cases of lymphomatoid granulomatosis are B-cell lymphomas, sometimes associated with Epstein-Barr virus infection.

Peripheral T-cell lymphoma in childhood: a report of five cases in Taiwan

We encountered five children with peripheral T-cell lymphoma (PTL) at National Taiwan University Hospital (NTUH) from 1985-1989. The patients were four boys and one girl, aged between 5 and 13 years. The duration of prediagnostic symptoms varied from 1 month to 5 years. All had pyrexia and lymphadenopathy; one had a prolonged history of granulomatosis with repeated infection. Four had hepatosplenomegaly. One patient presented with diffuse pulmonary infiltration and impending respiratory failure. All patients were negative for human T-cell leukemia virus (HTLV)-I antibody, and positive for HBsAg. Four patients who had EBV-viral capsid antigen (VCA) IgG and who were IgM tested were positive for EBV-VCA IgG, but only two had evidence of active EBV infection. Tumor cell markers were examined and showed the following phenotypes: all patients were CD2, CD3, and CD7 positive but CD19 and CD20 negative; three patients were CD4 positive and CD8 negative; the other two patients were CD4 negative and CD8 positive. Four patients died 2-7 months after diagnosis. The remaining patient received allogeneic bone marrow transplantation and has survived free of disease for more than 22 months after transplant. Our five cases reconfirm the high frequency of diagnostic delay, the heterogenous immunophenotypes, high mortality, and poor responsiveness to conventional therapy for PTL. Bone marrow transplantation in the early stage might be a possible cure of this disease.

Lymphomatoid granulomatosis

Lymphomatoid granulomatosis or angiocentric T-cell lymphoma is a systemic disease that affects multiple organs. The histopathologic findings include a characteristic infiltrate that is both angiocentric and angiodestructive. The prognosis is poor but may be improved by early recognition and aggressive chemotherapy. We report a case of cutaneous lymphomatoid granulomatosis and emphasize that dermatologists play an important role in the early diagnosis of this disease.

Pulmonary lymphomatoid granulomatosis in seven dogs (1976-1987)

Seven dogs with pulmonary lymphomatoid granulomatosis were reviewed. The disease occurred in six large-breed and one small-breed dogs. The dogs were five to 14 years old (mean, 8.4; median, 7), and four of seven dogs were males. Three dogs had been previously treated with adulticide therapy for canine dirofilariasis. Clinical histories included a progressive respiratory disease characterized by varying degrees of cough, dyspnea, exercise intolerance, and weight loss. Thoracic radiographic features included hilar lymphadenopathy, pulmonary masses of varying sizes, and mixed pulmonary patterns of lobar consolidation with ill-defined interstitial and alveolar pulmonary infiltrates. Cardiovascular changes compatible with chronic dirofilariasis were present in three dogs. The clinical course was usually progressive and fatal. The survival time ranged from six days to four years (mean, 12.5 mos; median, 3 mos). Gross and histologic features included mass lesions with areas of necrosis that replaced normal pulmonary architecture. Cytologically, these lesions were characterized by infiltration with pleomorphic, angioinvasive mononuclear cells that often resulted in vascular obliteration. The infiltrating cells resembled large lymphoid cells that possessed large hyperchromatic nuclei and small amounts of cytoplasm. Systemic lymphoid neoplasia with peripheral lymphadenopathy was diagnosed in two dogs. In both cases, lymph-node cytology was similar to the cellular infiltrates found in the lungs and consistent with a diagnosis of lymphomatoid granulomatosis. These features are compared with previously reported cases of canine lymphomatoid granulomatosis and those features identified in a similar disease described in man.

Lymphomatoid granulomatosis: two cases with skin involvement

Lymphomatoid granulomatosis is a systemic disease marked by a polymorphous cellular infiltrate that is both angiocentric and angiodestructive. The predominant organs of involvement are lungs, skin, central nervous system, and kidneys. I describe two cases of lymphomatoid granulomatosis in association with cutaneous manifestations, stressing to the dermatologist the importance of early recognition and diagnosis of this entity.

Sequential half-body irradiation in lymphomatoid granulomatosis. Report of a case and an immunohistologic study

A case is presented of a man with ulcerating skin nodules who was diagnosed by histologic and immunohistologic analysis of skin biopsy specimens as having lymphomatoid granulomatosis (LYG). Phenotypic studies showed the majority of the infiltrating cells to be activated CD4+ T-lymphocytes. The disease followed a rapidly progressive course and did not respond to treatment with cytotoxic chemotherapy. The patient developed life-threatening systemic symptoms and involvement of both upper and lower respiratory tracts. After treatment with sequential half-body irradiation he has been in complete remission for 3.5 years.

Necrotizing vasculitis with granulomatosis

Table 1 summarizes some of the differentiating characteristics among these diseases. Clinically, the differentiating features are that classic Wegener's granulomatosis involves both the upper and lower respiratory systems and kidneys. Renal involvement is the major cause of morbidity and mortality. Churg-Strauss syndrome has the distinguishing characteristics of an allergic asthmatic prodrome and a profound eosinophilia. It encompasses and destroy's tissue not only of the lungs but also most of the other organ systems in the body. A major cause of mortality is cardiac disease, which is not a feature of either of the other two diseases. Finally, lymphomatoid granulomatosis is seen predominantly in the lungs, skin, and central nervous system and is the only one of the three that is associated with the development of a lymphoma. Although there are definitive clinical differences of these entities, as mentioned above, it is the histopathologic features that can diagnostically separate the three. Wegener's granulomatosis is predominantly a necrotizing granulomatous infiltrate that has a polymorphous infiltrate of neutrophils, plasma cells, and histiocytes and is very distinct from the eosinophilic granulomas of CSS or the lymphocytic ones of LYG. Finally, all of the diseases respond differently to medications. Patients with Churg-Strauss syndrome for the most part respond well to high dosages of oral steroids and usually do not require therapy with immunosuppressive agents. Therapy with steroids alone is not adequate for the treatment of Wegener's granulomatosis, and the therapy is a combination of steroids with chemotherapeutic agents, cyclophosphamide being the agent of choice. The most difficult disease to treat in this review is LYG.(ABSTRACT TRUNCATED AT 250 WORDS)