Peripheral T/Natural killer-cell lymphoma involving the female genital tract: A clinicopathologic study of 5 cases

Anaplastic large cell lymphoma presenting as a mass in the uterine cervix: a case report

T-cell lymphoma is an extremely rare form of malignancy in the female genital tract. Most of the reported cases of lymphoma are B-cell lymphomas. A few cases of primary T-cell lymphomas involving the vagina or the vulva have been reported. We are reporting the first case of anaplastic large cell lymphoma (ALCL) presenting as a uterine cervical mass. The patient is a 24-year-old female who presented to the emergency room with a history of menorrhagia, night sweats and 40-pound weight loss. The diagnosis of ALCL was confirmed through immunohistochemical studies with strong CD30 and ALK expression. Fluorescent hybridization showed a rearrangement of the anaplastic lymphoma kinase (ALK) gene. Since ALCL may have a variable expression of T-cell antigens, the diagnosis may easily be missed when CD45 and/or CD3 is negative, and screening epithelial stains for carcinoma (e.g., p63 and EMA) are positive. CD30 must be performed to raise the consideration of ALCL when reniform nuclei are observed.

Disseminated Anaplastic Lymphoma Kinase (ALK)-Positive T-cell Lymphoma Involving the Uterus and Cervix: A Case Report

Primary or secondary non-Hodgkin lymphomas (NHLs) involving the female gynecologic tract are rare. T-cell subtypes are further rare and portend a worse prognosis. We present a case of a 23-year-old female presenting with a cervical mass accompanied by constitutional symptoms and abnormal vaginal bleeding. Immunohistochemistry studies revealed the presence of disseminated T-cell non-Hodgkin lymphoma that was anaplastic lymphoma kinase (ALK)-positive. The patient demonstrated a complete response to systemic chemotherapy initially and again after the relapse of the disease one year after diagnosis. To our knowledge, this is the first case of an ALK-positive T-cell lymphoma with secondary involvement of the uterus and cervix; all previously published cases of this histologic subtype in the gynecologic tract describe primary disease of the vagina. This case emphasizes the importance of immunohistochemistry studies inclusive of T-cell and B-cell markers when evaluating biopsies from cervical tumors to render the appropriate diagnosis and guide systemic therapy.

Primary uterine lymphoma: The Yokohama Cooperative Study Group for Hematology (YACHT) study

AIM

Primary malignant lymphomas arising from the female genital tract are very rare, with an incidence rate of 0.5%. Because of its rarity, its clinical characteristics, prognosis and optimal treatment are still unclear. Here, we retrospectively evaluated female patients with uterine lymphoma.

METHODS

Between January 2000 and October 2016, 4362 patients were newly diagnosed with malignant lymphoma by the participating institutions of YACHT. Among these 4362 patients, we retrospectively evaluated 14 adult patients with primary uterine lymphoma.

RESULTS

The median follow up time was 41 months. The median age at diagnosis was 68 years. Of 14 patients, 10 (72%) were diagnosed with diffuse large B-cell lymphoma. Seven patients presented with vaginal bleeding and three with abdominal pain. Eleven patients (79%) had advanced stages at diagnosis. Three patients (21%) had ovarian involvement and 2 (14%) had vaginal involvement. Induction chemotherapy regimens were R-CHOP in seven patients (50%), CHOP in three (21%) and other regimens in four (29%). Among 14 patients, 12 patients (86%) achieved a complete response and 2 (14%) experienced disease progression. Three patients (21%) showed relapse. Five patients (36%) died because of malignant lymphoma. The 3-year overall survival rate was 57.9%. Soluble interleukin-2 receptor levels > 5000 U/mL, anemia, a bulky mass and the presence of > 1 extranodal sites, B symptom at diagnosis were associated with a poor prognosis.

CONCLUSION

Female genital lymphoma is very rare, and further study of more cases is warranted.

Impact of the SCF signaling pathway on leukemia stem cell-mediated ATL initiation and progression in an HBZ transgenic mouse model

Adult T-cell leukemia (ATL) is a malignant disease caused by human T-lymphotropic virus type 1. In aggressive ATL, the response to chemotherapy is extremely poor. We hypothesized that this poor response is due to the existence of chemotherapy-resistant cells, such as leukemic stem cells. Previously, we successfully identified an ATL stem cell (ATLSC) candidate as the c-kit⁺/CD38⁻/CD71⁻ cells in an ATL mouse model using Tax transgenic mice. Here, with a new ATL mouse model using HBZ-transgenic mice, we further discovered that the functional ATLSC candidate, which commonly expresses c-kit, is drug-resistant and has the ability to initiate tumors and reconstitute lymphomatous cells. We characterized the ATLSCs as c-kit⁺/CD4⁻/CD8⁻ cells and found that they have a similar gene expression profile as T cell progenitors. Additionally, we found that AP-1 gene family members, including Junb, Jund, and Fosb, were up-regulated in the ATLSC fraction. The results of an in vitro assay showed that ATLSCs cultured with cytokines known to promote stem cell expansion, such as stem cell factor (SCF), showed highly proliferative activity and maintained their stem cell fraction. Inhibition of c-kit–SCF signaling with the neutralizing antibody ACK2 affected ATLSC self-renewal and proliferation. Experiments in Sl/Sld mice, which have a mutation in the membrane-bound c-kit ligand, found that ATL development was completely blocked in these mice. These results clearly suggest that the c-kit–SCF signal plays a key role in ATLSC self-renewal and in ATL initiation and disease progression.

Primary natural killer/T cell lymphoma of the cervix: case report and clinicopathological analysis

OBJECTIVE

To present pathological and molecular characterizations of a rare case that was diagnosed as nasal-type natural killer (NK)/T cell lymphoma primarily arising in the cervix.

CASE REPORT

An Asian woman was admitted to hospital with a hysteromyoma, and laparotomy was performed. A large tumor of the uterus was found, which was limited to the cervix. Pathological examination showed NK/T cell lymphoma, which was supported by histological and immunohistochemical studies and was confirmed by evidence of Epstein-Barr virus infection. Less commonly, this case concerned a cytotoxic T cell phenotype, as molecular studies showed evidence of a clonal T cell receptor γ chain gene rearrangement. Microscopically, prominent and extensive necrosis was the distinctive feature of this case, which reminded us of considering it as a tumor.

CONCLUSION

Primary NK/T lymphoma of the cervix is rare. Our experience in this case provided variable information on both pathological and molecular studies. This case may be of value in the differential diagnosis of lymphoid lesions and other small cell tumors of the cervix.

Sonographic appearance of uterine lymphoma: case report and review of the literature

Uterine lymphoma is rare and tends to be misdiagnosed due to lack of specific radiologic features. Few reports have been published on the sonographic characteristics of uterine lymphoma. We present a case report of uterine lymphoma manifested by a fast growing uterus and describe the sonographic findings.

Primary extranodal NK/T cell lymphoma, nasal-type of uterus with adenomyosis: a case report

Natural killer (NK)/T cell lymphoma of the female genital tract is extremely rare. We here report a case of ‘nasal type’ NK/T cell lymphoma arising in the uterus with adenomyosis in a 41-year-old woman with fever and hypogastralgia. The histologic analysis demonstrated a highly aggressive tumor with characteristic angiocentric/angiodestructive growth pattern and focal necrosis. The lymphoma cells displayed a CD3ϵ/CD56/TIA-1/granzyme-B/Perforin-positive and CD20/CD79a/CD4/CD8-negative immunophenotype and positive for Epstein-Barr virus by EBER in situ hybridization. Clinically, the disease was limited to the uterus at the initial diagnosis, but progressed rapidly. The patient died on day 54 after hysterectomy, irrespective of intensive chemotherapy.

Primary uterine NK-cell lymphoma, nasal-type: a unique malignancy of a prominent cell type of the endometrium

Natural killer (NK) cells host in the human endometrium with dedicated role in reproductive physiology. Interestingly, malignant transformation of these specialized cells has not been presented thus far. Here we report a primary endometrial NK-cell lymphoma of a 48 year-old patient presenting with irregular bleeding. The endometrial curetting showed a dense lymphomatous infiltrate demonstrating highly infiltrative aggressive features with characteristic angiocentric, partially angiodestructive growth pattern and accompanying focal necroses. The lymphoma cells displayed a CD3ε/CD56/TIA-1/granzyme-B-positive and CD5/CD4/CD8/TCRγδ-negative immunophenotype, proved to be positive for Epstein-Barr virus by EBER in situ hybridization, and revealed no clonal T-cell receptor gene rearrangement. The diagnosis of uterine extranodal NK-cell lymphoma, nasal-type was made. Clinically, the disease was limited to the uterus at diagnosis, but progressed rapidly, and the patient died within 5 months due disseminated lymphoma, irrespective of intensive chemotherapy. Genuine NK-cell lymphomas occurring in the uterus as primary site seem to be rare making the therapeutic decisions extremely complicated.

Primary lymphomas of the cervix and uterus: the University of Pennsylvania's experience and a review of the literature

Primary lymphomas of the cervix and uterus are rare with approximately 150 cases reported in the world literature to date. Appropriate diagnosis is often delayed until the post-operative setting as clinical and radiographic presentations are non-specific. Several sub-types of lymphoma arising primarily in the cervix or uterus have been reported with diffuse large B-Cell lymphoma (DLBCL) being the most frequent. Due to the low incidence of this disease, no randomized clinical trials exist to help guide treatment. This study reports the experience of four patients with primary lymphomas of the uterus and cervix that reflect the heterogeneity of cases reported in the literature to date. The patients had a mean age at diagnosis of 46 (range 35 - 56) and presented with abnormal uterine bleeding. One patient was diagnosed by total abdominal hysterectomy (TAH), two patients were diagnosed by cervical biopsy and one patient was diagnosed by endometrial biopsy. Three patients had DLBCL and one patient had marginal zone lymphoma (MZL). All patients had stage IIE disease. Of the patients with DLBCL, one received chemotherapy followed by TAH and two received TAH followed by chemotherapy. Two of these three patients remain disease-free post-initial therapy with the third now disease-free post-salvage therapy and autologous stem cell transplant. The patient with MZL was treated with TAH alone and remains disease-free. Based on the case series and a review of available literature, primary lymphomas of the uterus or cervix are rare and require an individualized approach to treatment. In general, patients with limited stage disease should be treated with localized and systemic therapy to optimize chances of cure.

A case of non-Hodgkin’s lymphoma of the ovary: Usefulness of18F-FDG PET for staging and assessment of the therapeutic response

Primary ovarian lymphoma as the initial manifestation is rare. A 27-year-old woman presented to our hospital with the symptoms of lower abdominal fullness and pollakisuria. CT scan and MRI revealed bilateral ovarian tumors, which showed heterogeneous masses. 18F-FDG PET revealed strong uptake by the abdominal masses, and the maximum standardized uptake value (SUVmax) was 12.5. Abnormal uptake was not shown by other regions. An exploratory laparotomy was performed. Histological findings revealed diffuse large B-cell lymphoma. The clinical stage was IV according to the Ann Arbor system. International prognostic index (IPI) was 3 (high-intermediate risk). Chemotherapy was administered consisting of three courses of an R-CHOP regimen, and 18F-FDG PET and CT scan revealed no signs of involvement 3 months after initiation of the chemotherapy. 18F-FDG PET was a useful method for staging and assessment of the therapeutic response in primary ovarian lymphoma.

Lymphoma of the female genital tract: current status

SUMMARY

: Primary lymphomas affecting the female reproductive system are uncommon but often pose a diagnostic challenge if their existence is not suspected. This article reviews the pathological and clinical features of lymphomas occurring in various sites in the female genital tract including the vulva, vagina, cervix, endometrium, fallopian tubes, and ovaries. Using the recent World Health Organization classification, the various types of lymphomas are identified as separate diseases and not as morphological variations of the same disease. The immunophenotypic and cytogenetics features of the major lymphomas are summarized. The incidence, presenting symptoms, gross and microscopic features, major differential diagnostic considerations, response to therapy, and expected outcome are discussed. Using published data on patient outcome, the International Federation of Obstetricians and Gynecologists and Ann Arbor staging systems are compared for their predictive value, and the difficulty in assigning primary and secondary status in extranodal lymphomas is emphasized. The observed differences in the behavior of some lymphomas in gynecological sites compared with their usual nodal location are presented. Finally, the possible etiology of these conditions is discussed in light of the emerging paradigm of mucosa-associated lymphoid tissue lymphomas.

Primary extranodal NK/T cell lymphoma ("nasal type") of the endometrium: report of an unusual case diagnosed at autopsy

Primary natural killer (NK)/T cell lymphoma of the female genital tract is extremely rare. We here report the case of a "nasal type" NK/T cell lymphoma arising in the uterus. The diagnosis was established only at autopsy.

Bilateral peripheral T-cell lymphoma of the fallopian tubes

BACKGROUND

Lymphoma of the female genital tract is rare, and usually involves the ovaries or the uterus. Most cases of fallopian tube lymphoma reflect disease arising in the ovaries. All previously reported cases of primary lymphoma of the fallopian tube were of B cell lineage.

CASE

A 51-year-old woman presented with systemic upset and a pelvic mass. At laparotomy, both fallopian tubes were inflamed and histological examination revealed peripheral T-cell lymphoma. At staging, she had IIB(E) disease, and she was treated with six cycles of CHOP-M chemotherapy.

CONCLUSION

Our case is unusual in that this is the first described case of peripheral T-cell lymphoma arising in the fallopian tubes and is moreover unusual because of the involvement of both fallopian tubes without involvement of other gynaecological organs. The clinical course was favourable with complete remission maintained for more than 5 years.

A case of primary mucosa-associated lymphoid tissue lymphoma of the vagina

We report the first case of primary mucosa-associated lymphoid tissue (MALT) lymphoma of the vagina, the diagnosis of which is supported by genetic and immunophenotypic studies. A 65-year-old, para 2 woman presented to our hospital in July 1997 with a history of prolonged vaginal discharge. Although cytologic examination suggested possible malignancy, a biopsy of the vaginal wall was diagnosed as chronic inflammation. In June 2000, she underwent gynecologic examination because of anuria. Excisional biopsy revealed subepithelial infiltration of atypical lymphoid cells that stained for CD20, CD79a, and BCL-2; stained weakly for IgM; and did not stain for CD3, CD5, CD7, CD10, CD56, CD23, and IgD, suggesting marginal zone B-cell lineage. Monoclonality was detected by Southern blot analysis, and this patient was finally diagnosed as having primary MALT lymphoma of the vagina. She received 3 cycles of chemotherapy (THP-COP) and concurrent radiation to the whole pelvis. The patient is alive and well 40 months after treatment. Because the vagina is one of the mucosa-associated tissues, MALT lymphoma, though rare, must be included in the differential diagnosis of the vaginal neoplasms.

Unique Collision of Hodgkin Lymphoma and Adenosquamous Carcinoma in the Uterine Cervix: Synchronous Malignant Neoplasms of the Cervix

To document the first reported synchronous occurrence of Hodgkin lymphoma and adenosquamous carcinoma involving the female genital tract. Review of cytologic, histologic, and immunohistochemical studies obtained from a 50-year-old, multiparous, postmenopausal, Hispanic female who had a left inguinal mass, bilateral lower extremity pain and numbness, fatigue, anorexia, a 20- to 30-pound weight loss, and a malodorous vaginal discharge at presentation is presented. Cervical squamous cell carcinoma was diagnosed by routine cytologic and histologic analysis. Hodgkin lymphoma subsequently was diagnosed in the inguinal lymph nodes by fine-needle aspiration biopsy and excisional biopsy before the patient underwent hysterectomy. In addition to invasive and in situ adenosquamous carcinoma of the uterine cervix, the hysterectomy specimen also contained previously unsuspected Hodgkin lymphoma. To our knowledge, this is the first reported case of adenosquamous carcinoma and Hodgkin lymphoma synchronously involving the female reproductive tract.

A case of malignant lymphoma of the ovary manifesting like an advanced ovarian cancer

BACKGROUND

In recent years, true primary ovarian lymphoma has been considered to carry a favorable prognosis, although most studies of supposedly primary ovarian lymphoma have reported a poor outcome.

CASE

A 47-year-old woman presented with signs and symptoms suggestive of an advanced ovarian cancer. Ultrasonography and magnetic resonance imaging revealed bilateral abdominal tumors, each measuring 10 cm in diameter, thickened omentum, and a large amount of ascitic fluid, but no enlarged lymph nodes. The diagnosis of malignant lymphoma was established from the biopsy specimen after exploratory laparotomy. Six years following chemotherapy, the patient is alive and disease free without additional surgery.

CONCLUSION

The prognosis of ovarian lymphoma was evaluated according to clinical stage, modality of onset, histologic type, and phenotype. It remains controversial whether this case can be considered truly primary ovarian lymphoma and not merely a localized initial manifestation of a generalized disease. But if this case of advanced ovarian lymphoma were not primary, it could still be managed successfully with chemotherapy appropriate for the specific histology.

Primary ovarian lymphoma: report of cases and review of literature

Primary female reproductive system lymphomas are distinctly uncommon. We report two cases with primary ovarian non Hodgkin's lymphoma (NHL) having unilateral involvement in one case while the other had bilateral ovarian involvement. Both cases initially presented with ovarian enlargement. The median size of the tumour was 5.8 x 5 cm2. Histologically, by using the WHO classification, one lesion was classified as diffuse small B cell phenotype of intermediate grade and the other as diffuse high grade, B cell phenotype. On the basis of staging studies and clinical follow up, we conclude that both of the neoplasms in the report arose in the ovary. Both of the patients are disease free at 24 months and 6 months of follow up respectively, following excision and chemotherapy. We conclude that that the complete remission and failure free survival of patients with ovarian NHL treated with appropriate treatment appear to be similar to that of patients with extranodal NHL.