Sinonasal lymphoma: a clinicopathologic analysis of 58 cases from the Massachusetts General Hospital

Nasal natural killer/T-cell lymphoma mimicking orbital cellulitis: A diagnostic dilemma

Nasal natural killer/T-cell lymphoma (NK/TCL) is a rare form of malignant non-Hodgkin lymphoma (NHL) with a far more rare involvement of orbit. The orbital involvement has a highly variable clinical presentation. Here, we report one such case of a 40-year-old male patient who presented with swelling in the right upper and lower eyelids with the diminution of vision for 12 days. He had a history of blocked nose for two months. Clinical examination and CT scan of the orbit and paranasal sinuses suggested a diagnosis of right orbital cellulitis with pansinusitis. A combination of intravenous antibiotics was started, and functional endoscopic sinus surgery was done. Histopathology was a suggestive of nasal NK/TCLl NHL. After proper staging, the patient was given chemotherapy and radiotherapy. There was a complete resolution of mass with no recurrence over a follow-up of 10 months.

Adult T-cell Leukemia/Lymphoma (ATL) in the Nasal and Paranasal Cavity: Four Cases Report

Adult T-cell leukemia/lymphoma (ATL) is a form of leukemia caused by the human T-cell leukemia virus type I (HTLV-1). Otolaryngologists often diagnose ATL based on cervical lymphadenopathy or Waldeyer ring lesions. However, there are few reports of ATL occurring in the nasal and paranasal cavity. Here, we report four such cases of ATL. Case 1: An 82-year-old man diagnosed with acute-type ATL with a tumor in the nasal cavity underwent 5 courses of THP-COP, but died after 36 months due to ATL. Case 2: A 62-year-old woman diagnosed with lymphoma-type ATL with a tumor in the frontal sinus was treated with 5 courses of VCAP-AMP-VECP, and has survived for more than 10 years. Case 3: A 64-year-old man diagnosed with lymphoma-type ATL with a tumor in the maxillary sinus underwent 8 courses of VCAP-AMP-VECP and 2 courses of mogamulizumab, but died after 34 months due to ATL. Case 4: A 52-year-old woman diagnosed with lymphoma-type ATL with tumors in both ethmoid sinuses received 2 courses of CHOP, 2 courses of DeVIC, radiotherapy (32 Gy) and 2 courses of mogamulizumab, but died after 9 months due to ATL.

Diffuse Large B-Cell Lymphoma of the Frontal Sinus: A Case Report

Diffuse large B-cell lymphoma (DLBCL) is the most common type of Non-Hodgkin Lymphoma (NHL). It often involves the gastrointestinal tract, head and neck, and skin, but virtually any tissue or organ can be affected. The primary NHL of the nasal cavity and paranasal sinuses are extremely rare, causing diagnostic and therapeutic difficulties. We present the case of a 49-year-old woman with a 4-week history of diplopia and right superior eyelid swelling. Clinical, radiological, and histological examination led to the diagnosis of DLBCL of the right frontal sinus with anterior invasion of subcutaneous soft tissues and posterior intracranial involvement of the frontal region. She underwent three cycles of MATRIX chemotherapy, three cycles of R-DA-EPOCH, and CAR-T therapy. Unfortunately, treatments were unsuccessful and the patient died 11 months after diagnosis. In conclusion, an early diagnosis of DLBCL of the frontal sinus is difficult as it is often confused with other nasal pathologies. This causes a delay in treatment.

A rare case of sphenoid sinus lymphoma

Malignancy of the sphenoid sinus is rare. Tumors may extend to adjacent anatomic structures before detection and may be easily missed. Outcomes are typically poor and vary by tumor type. Clinicians should maintain vigilance for neoplastic disease in patients presenting with headache and ocular/neurological complaints of the face/sinuses.

Sinonasal B-cell lymphomas: A nationwide cohort study, with an emphasis on the prognosis and the recurrence pattern of primary diffuse large B-cell lymphoma

Lymphomas of the nasal cavity and paranasal sinuses (NPS) are rare. Knowledge on sinonasal B‐cell lymphoma (SNBCL) primarily comes from case series or single‐center studies on small cohorts. We sought to determine the subtype distribution, clinical characteristics, disease behavior, and prognosis on a nationwide scale, with an emphasis on prognostic factors for the most common sinonasal lymphoma, primary sinonasal diffuse large B‐cell lymphoma (PSDLBCL). We collated all data from medical records and national databases on patients registered with SNBCL from 1980 through 2018 in the national pathology registry and collected all tissue samples for validation of diagnosis. We included 205 patients and found 10 different subtypes of lymphoma. Diffuse large B‐cell lymphoma (DLBCL) was the predominant subtype (80%). The incidence of SNBCL was 0.14/100,000 person‐years. The five‐year progression‐free survival (PFS) and overall survival rates for PSDLBCL were 50% and 56%, respectively. For PSDLBCL, Rituximab showed a statistically significant effect (Hazard Ratio 0.22, p < 0.001), whereas consolidative radiotherapy combined with immunochemotherapy was of limited value (PFS, p = 0.93). When treatment failure occurred, DLBCL showed a distinct pattern of recurrence/dissemination to the NPS, skin, breast, central nervous system (CNS), and/or testis. Collectively, DLBCL comprised a clear majority of SNBCLs, although nine other subtypes were represented. Data showed that immunochemotherapy increased survival for PSDLBCL and that the addition of radiotherapy did not benefit patients. Furthermore, treatment failure for sinonasal DLBCL showed a possible common pathogenesis with primary extranodal lymphomas of specific locations (e.g., CNS, skin, breast, and testis).

What Effect Does Epstein-Barr Virus Have on Extranodal Natural Killer/T-Cell Lymphoma Prognosis? A Review of 153 Reported Cases

The primary aim of this review is to identify the relationship between Epstein-Barr virus (EBV) and prognosis in extranodal natural killer/T-cell lymphoma (ENKTL). Additionally, a literature review of ENKTL was carried out. The investigators designed and implemented a 21-year literature review using the online databases PubMed and Google Scholar. The total number of cases analyzed was 153 (64 case reports; one comparative study; one systematic review). Information related to ENKTL from July 1999 to February 2021 was included in the study. Study variables included: patient demographics, tumor classification, screening modalities, tumor characteristics, symptomatology, treatment, and prognosis. The average age at diagnosis was 50.9 years (range: 4-90 years). Patients of Asian ethnicity were most commonly affected, and there was a 1.6:1 male to female ratio. ENKTL was most frequently detected in the head and neck region, and 53.1% of cases metastasized. Of all head and neck cases, the nose was the most affected location. Immunohistochemistry positivity included: EBV (32.0%), CD2 (96.6%), CD3ϵ (81.7%), CD43 (91.7%), CD56 (86.4%), Granzyme (97.1%), Perforin (90.9%), TIA-1 (97.8%), p53 (33.3%). The most frequently employed single treatment modality was chemotherapy alone, and 34.2% of patients expired within five years of diagnosis. The average follow-up period was 16.51 months (range: 0.25-66 months). EBV was significantly associated with metastatic ENKTL (χ² = 4.36; CV = 3.84; p = 0.037). We found no association between EBV and ENKTL prognosis (χ² = 17.2; CV = 21.0; p = 0.14).

Orbital Lymphoma Masquerading as Orbital Cellulitis

Background

Orbital lymphomas are primarily non-Hodgkin type and can originate from the eyelids, extraocular muscles, soft tissue orbital adnexa, conjunctiva, or lacrimal glands. Orbital malignancies often represent a diagnostic dilemma for clinicians given their varying and atypical presentations.

Objective

To report a case of orbital lymphoma mimicking orbital cellulitis.

Case

A 66-year-old male patient presented with sudden onset of painful proptosis with visual impairment in the left eye for 15 days. On ocular examination, best-corrected visual acuity was 6/12 in the right eye and 2/60 in the left eye, abaxial proptosis with hypertropia, swollen and erythematous eyelids, restricted extraocular movement in all cardinal position of gaze, conjunctival congestion with chemosis and tortuous vessels, sluggish pupillary reaction, and chorioretinal folds in the inferior quadrants. The case was diagnosed as left eye orbital cellulitis, and the patient was treated with broad-spectrum intravenous antibiotics and oral steroids. No clinically discernible response was noted despite 7 days of antibiotics and steroids. Contrast-enhanced computed tomography (CECT) orbit showed features suggestive of orbital lymphoma involving the ipsilateral maxillary and ethmoid sinuses. ENT consultation with diagnostic nasal endoscopy and biopsy was done. Histopathological reports showed features of non-Hodgkin lymphoma.

Conclusion

Orbital malignancies masquerading as orbital cellulitis can pose a diagnostic dilemma. A multidisciplinary approach involving ENT consultation, radiological investigation, and pathological sampling can help achieve a timely diagnosis and appropriate management.

Extranodal NK/T-cell lymphoma, nasal type without evidence of EBV infection

Extranodal natural killer/T cell lymphoma-nasal type (EN-NK/T-NT) is extremely rare in Western countries; however, it is the most common subtype of peripheral T cell lymphoma in China. Despite this, there are a limited number of clinicopathological research studies on Epstein-Barr virus (EBV)-negative EN-NK/T-NTs. EBV-negative EN-NK/T-NT is a rare disease type, which has not been fully investigated. If other diagnostic criteria are met, such as the lesions being located predominantly in the upper aerodigestive tract, the presence of angiocentricity or angioinvasion, necrosis and expression of NK/T-cell phenotype, EN-NK/T-NT may be diagnosed, even if EBV is negative. In the present study, 99 cases of EN-NK/T-NTs were analyzed retrospectively, among which seven cases were EBV-negative EN-NK/T-NTs and selected for further investigation. In addition, the present study reviewed previously published research into EN-NK/T-NT, highlighting that EBV-negative EN-NK/T-NT is rare and that its geographical distribution is mainly in countries in Asia, Central America and South America. Patients with EBV-negative EN-NK/T-NT were all of Chinese ethnicity, with a median age of 32 years and primarily female. Furthermore, these patients shared similar clinicopathological characteristics (such as the tumor occurring mainly in the upper aerodigestive tract, the presence of vascular destruction, necrosis and cytotoxic phenotypes) to patients with EBV-positive EN-NK/T-NT. Immunohistochemistry and molecular analysis results indicated that tumor cells were primarily of NK or cytotoxic T origin; however, EBV-encoded small RNAs were not detected in any of these cases. Among the immunochemistry markers, T-bet was statistical significantly different between EBV-positive and -negative cases. Fluorescence in situ hybridization was also performed in two EBV-negative cases, including one case with a co-deletion of 6q21 and PR/SET domain 1 genes. There was only available follow-up data in 3/5 patients who survived for 37–113 months (median, 40 months). As EN-NK/T-NT can be diagnosed, even when EBV is negative, awareness of this subtype may prevent misdiagnosis or delayed diagnosis.

Epstein - Barr virus positive T and NK-cell lymphoproliferations: Morphological features and differential diagnosis

The spectrum of Epstein-Barr virus (EBV)-positive T and NK-cell lymphoproliferations is broad and ranges from reactive self-limited disorders to neoplastic processes with a fulminant clinical course. EBV plays an important role promoting lymphomagenesis, although the precise mechanisms remain elusive. EBV-positive lymphoproliferative disorders (LPD) are more common in East Asia (China, Japan, Korea and Taiwan), and Latin America suggesting a strong genetic predisposition. The revised 2016 World Health Organization (WHO) lymphoma classification recognizes the following malignant NK- and T-cell lymphomas; extranodal NK/T-cell lymphoma, nasal type (ENKTCL), aggressive NK-cell leukemia (ANKL), and the provisional entity within the group of peripheral T-cell lymphoma, not otherwise specified (PTCL, NOS) "primary EBV-positive nodal T or NK cell lymphoma". Disorders presenting mainly in children and young adults include chronic active EBV infection (CAEBV) - systemic and cutaneous forms - which are not considered malignant disorders but were included in the WHO classification for the first time because of the differential diagnosis with other T- or NK-cell lymphomas. CAEBV, cutaneous form, includes hydroa vacciniforme-like LPD (HV-LPD) and severe mosquito bite allergy (SMBA). Finally, systemic EBV-positive T-cell lymphoma of childhood was recognized as lymphoma because of its fulminant clinical course. Given the shared pathogenesis of these disorders, overlapping features are common demanding a close clinical, morphological and molecular correlation for an accurate diagnosis. This review summarizes the clinical, histopathological and molecular features of EBV-associated T and NK-cell LPD, highlighting the main features that might aid in the differential diagnosis.

Clinicopathologic characteristics and novel biomarkers of aggressive B-cell lymphomas in the nasopharynx

BACKGROUND

The most common nasopharyngeal lymphoma in the United States are B-cell non-Hodgkin lymphomas (B-NHL). Relatively little is known about the clinicopathologic features of these cases. In this study, we characterize a bi-institutional cohort of aggressive B-NHL primary to the nasopharyngeal area. We compare and contrast EBV-positive versus EBV-negative cases and evaluate expression of SSTR2, CD30, and PD-L1, potential markers for targeted therapeutics.

METHODS AND RESULTS

We retrieved 53 cases of aggressive B-NHL from the two institutions. Staining was performed for in situ EBV (EBER), CD30, SSTR2 and PD-L1. The response to initial therapy, disease-free interval, and survival at two- and five-year following initial diagnosis were used as primary clinical outcome. Overall, 13 out of 53 cases (23%) were EBV positive. CD30 expression was more frequent in EBV-positive than in EBV-negative cases (4/6 vs 1/17). Seven of 14 (50%) cases tested demonstrated expression of PD-L1 within tumor cells; the two EBV-positive DLBCL tested showed substantial PD-L1 reactivity. Six of 15 (40%) cases tested were positive for SSTR2. The three EBV-positive patients with available outcome data died within one year of diagnosis; in contrast, the EBV-negative cases showed survival rate of 100% (8/8) and 83% (5/6) at two- and five-year follow-up, respectively.

DISCUSSION

The aggressive B-NHLs of the nasopharynx show differences between EBV-positive versus EBV-negative cases. The association of EBV-positive cases with expression of CD30 and PD-L1 may be particularly informative for targeted therapies. A significant number of cases expresses SSTR2, which could render them susceptible to somatostatin analogue and peptide receptor radionuclide therapies. Finally, our limited case series suggest that EBV negativity may be associated with a better prognosis.

Orbital lymphoma

Orbital lymphomas constitute 50-60% of ocular adnexal lymphomas. A total of 2211 cases of orbital lymphoma with a known subtype have been reported in the last 24 years (1994-2017). The vast majority of orbital lymphomas are of B-cell origin (97%), of which extranodal marginal zone B-cell lymphoma (EMZL) (59%) is the most common subtype, followed by diffuse large B-cell lymphoma (23%), follicular lymphoma (9%), and mantle cell lymphoma (5%). Orbital lymphoma is primarily a disease of the elderly. Gender distribution varies according to lymphoma subtype. However, extranodal marginal zone B-cell lymphoma (53%) and follicular lymphoma (75%) show a female predominance, whereas diffuse large B-cell lymphoma shows an even gender distribution. Mantle cell lymphoma has a striking male predominance of 80%. The histopathological subtype and the clinical stage of the disease are the best indicators of prognosis and patient outcome. Low-grade lymphomas such as extranodal marginal zone B-cell lymphoma and FL have a good prognosis, whereas high-grade lymphomas (diffuse large B-cell lymphoma and mantle cell lymphoma) are associated with a poor prognosis. When managing solitary low-grade lymphomas, radiotherapy is the treatment of choice. Chemotherapy, with or without radiotherapy, should be chosen for disseminated and high-grade lymphomas.

Diagnostic challenges in malignant tumors of nasal cavity and paranasal sinuses

Introduction:

Malignant tumors of sinonasal tract are extremely rare and comprise 3% of all head and neck malignant tumors. They constitute 0.2% of all invasive carcinomas. Sinonasal space is a small anatomical place, but is the site of origin for tumors with diverse histological features. Many of the tumors are similar to those that occur in various parts of the body and have overlapping histological features. A panel of immunohistochemical (IHC) markers is essential to diagnose these tumors. Most of the tumors arise in the maxillary sinus followed by ethmoid sinus. History and complete head and neck examination along with biopsy are mandatory for evaluating the disease.

Aim and Objectives:

To study the age-, sex- and site-wise incidence of different malignant lesions of the nasal cavity and paranasal sinuses. To subtype and classify the malignant tumors as per the WHO guidelines.

Materials and Methods:

Forty-seven cases of sinonasal tumors reported over a period of 3 years were retrieved from the archives of the department of pathology. The tissues were subjected to paraffin processing and stained with hematoxylin and eosin. IHC was done with a panel of markers, wherever necessary.

Results:

The present study included a total of 47 malignant lesions. Of which, 24 cases (51.06%) were squamous cell carcinomas (five cases each of well-differentiated SCC and moderately differentiated SCC and 14 cases of nonkeratinizing SCC). Five (10.63%) cases each were of neuroendocrine carcinoma and non-Hodgkin's lymphoma.

Conclusion:

Malignant neoplasms of sinonasal tract have overlapping clinical and pathological findings; establishing the correct diagnosis is difficult without using a panel of IHC markers.

Nasopharyngeal/Nasal Type T/NK Lymphomas: Analysis of 14 Cases and Review of the Literature

Aims and Background

Lymphoid malignancies expressing CD56 are rare and most occur in the nasal or nasopharyngeal region. They derive from natural killer ceils or from a small subset of T cells that have granular cytoplasm containing molecules that mediate cytotoxic activity: TIA-1, granzyme B and perforin. Both types are closely associated with Epstein-Barr virus.

Methods

We report the pathologic, immunophenotypic and molecular findings in 14 cases of nasopharyngeal/nasal type T/NK lymphomas.

Results

Clinically, all patients had localized disease and also had symptoms limited to the nose. The neoplastic cells were frequently pleomorphic, and angiocentric growth was common. Combined immunophenotypic and gene rearrangement analyses demonstrated that most of the cases were true NK cell tumors and were either CD56+ and CD3- or CD56+ and CD3+. Immunohistochemical study showed TIA-1 and granzyme B expression in all cases. By in situ hybridization, most of the cases were associated to Epstein-Barr virus, harboring type 1 virus, and polymerase chain reaction amplification across the 30 bp deletion showed high frequency of latent membrane protein-1-deleted variants.

Conclusions

The nasal type T/NK cell lymphoma shows distinctive clinicopathologic, immunophenotypic and molecular features. These results confirm the important role of Epstein-Barr virus as a local factor in their pathogenesis.

Cutaneous Hematolymphoid and Histiocytic Proliferations in Children

This article focuses on cutaneous hematopoietic neoplasms that are more likely to be encountered in the pediatric age-group and includes both lymphoproliferative and histiocytic disorders. The cutaneous hematologic disorders in children have a different epidemiologic profile to what is seen during adulthood. Although mycosis fungoides is the most frequent form of cutaneous lymphoma in adults, it is very rare in children. Because lymphoblastic leukemias and lymphomas are more frequent in the pediatric setting, cutaneous leukemic infiltrates are relatively common in this age-group. Similarly, histiocytic disorders are more common in children, particularly Langerhans cell histiocytosis and juvenile xanthogranuloma. Notably, the histiocytic disorders have undergone significant modifications on their nomenclature in the basis of the molecular characteristics that are present in them. A summary of the most frequent cutaneous hematopoietic disorders in children will be discussed further in this review.

Lymphoma of the nasal cavity and paranasal sinuses: A case series

BACKGROUND

Lymphomas of the sinonasal tract are a rare and heterogeneous subset of solid sinonasal neoplasms.

OBJECTIVE

To characterize, in this case series, presenting symptoms, treatment modalities, and outcomes for patients with sinonasal lymphoma within a single institution.

METHODS

Retrospective patient data were collected from an academic, oncologic center and entered into a repository designed to capture outcomes for sinonasal malignancies. Patient demographics, presenting symptoms, imaging findings, treatment modalities, and health status were retrospectively extrapolated and evaluated by using Kaplan-Meier estimations for survival probability.

RESULTS

Patients with sinonasal lymphoma with a mean follow-up of 50 months were identified (n = 18). Histologic diagnosis included the following: diffuse large B-cell lymphoma (n = 9), natural killer/T-cell lymphoma (n = 5), follicular lymphoma (n = 1), T-cell lymphoma (n = 1), and lymphoma-not otherwise specified (n = 2). The most frequent presenting symptoms were nasal obstruction (78%), facial pain (72%), facial swelling (50%), and nasal discharge (44%). Treatment before lymphoma diagnosis included antibiotics (83%), oral steroids (22%), decongestants (22%), and topical steroids (11%). Treatment regimens after diagnosis included both chemotherapy (94%) and chemoradiotherapy (56%). Survival rates by lymphoma subtype were 56% for B-cell lymphoma and 40% for natural killer/T-cell lymphoma. Overall, 2- and 5-year survival rates were 67% and 50%, respectively. The combination of chemotherapy and radiation resulted in significantly higher survival rates (p ≤ 0.001) than chemotherapy alone.

CONCLUSION

Sinonasal lymphomas are characterized by meager survival rates, which differ by histopathologic subtype. The diagnosis of sinonasal lymphoma is challenging because symptoms frequently parallel those of chronic rhinosinusitis. Increased awareness of these rare malignancies may improve detection and more timely treatment. Clinical trial registration NCT01332136.

Virus-associated neoplasms of the nasopharynx and sinonasal tract: diagnostic problems

A significant fraction of nasopharyngeal and sinonasal tumors are associated with Epstein-Barr virus (EBV) or human papillomavirus (HPV). Nasopharyngeal carcinoma (NPC) and extranodal NK/T-cell lymphoma harbor EBV in practically all cases, although a small proportion of cases of the former harbor HPV. Sinonasal inverted papillomas harbor HPV in about 25% of cases. Sinonasal squamous cell carcinomas harbor transcriptionally active HPV in about 20% of cases, and limited data suggest that this subset has a better prognosis than the HPV-negative subset. This review addresses the diagnostic issues of the EBV-associated tumors. Difficulties in diagnosis of NPC may be encountered when there are prominent crush artifacts, many admixed lymphoid cells masking the neoplastic cells, or numerous interspersed granulomas, whereas benign cellular components (epithelial crypts and germinal centers) and reactive lymphoid hyperplasia can potentially be mistaken for NPC. Immunostaining for pan-cytokeratin and/or in situ hybridization for EBER can help in confirming or refuting a diagnosis of NPC. The main diagnostic problem of extranodal NK/T-cell lymphoma is recognition of the neoplastic nature of those examples predominated by small cells or showing a mixture of cells. The identification of a destructive infiltrate (dense expansile infiltrate; angiocentric growth) and definite cytologic atypia (clear cells; many medium-sized cells) would favor a diagnosis of lymphoma, which can be supported by immunohistochemistry (most commonly CD3+, CD5-, CD56+) and in situ hybridization for EBER. In conclusion, among nasopharyngeal and sinonasal neoplasms, demonstration of EBV may aid in diagnosis, particularly NPC and extranodal NK/T-cell lymphoma. Demonstration of HPV does not have a role yet in diagnosis, although this may change in the future.

Cutaneous EBV-related lymphoproliferative disorders

This article will focus on the cutaneous lymphoproliferative disorders associated with EBV, with an emphasis on the upcoming changes in the revised 4th Edition of the WHO classification of tumors of the hematopoietic system, many of which deal with cutaneous disorders derived from NK-cells or T-cells. Extranodal NK/T-cell lymphoma usually presents in the upper aerodigestive tract, but can involve the skin secondarily. EBV-associated T- and NK-cell lymphoproliferative disorders (LPD) in the pediatric age group include the systemic diseases, chronic active EBV infection (CAEBV) and systemic EBV+ T-cell lymphoma of childhood. Hydroa vacciniforme (HV)-like LPD is a primarily cutaneous form of CAEBV and encompasses the lesions previously referred to as HV and HV-like lymphoma (HVLL). All the T/NK-cell-EBV-associated diseases occur with higher frequency in Asians, and indigenous populations from Central and South America and Mexico. Among the B-cell EBV-associated LPD two major changes have been introduced in the WHO. The previously designated EBV-positive diffuse large B-cell lymphoma (EBV-DLBCL) of the elderly, has been changed to EBV-DLBCL with 'not otherwise specified' as a modifier (NOS). A new addition to the WHO system is the more recently identified EBV+ mucocutaneous ulcer, which involves skin and mucosal-associated sites.

Spectrum of Radiological Manifestations in Lymphoproliferative Malignancies with Unusual Extra Nodal Soft Tissue Involvement

Lymphoproliferative malignancies constitute a wide spectrum of haematological malignancies and their prevalence is widely increasing. Non-Hodgkin lymphomas and Hodgkin disease, frequently involve extranodal soft tissue structures in the head and neck, thorax and abdomen. These malignancies may involve virtually any type of soft tissues to any extent; hence many different imaging manifestations are possible which may mimic other disorders. The imaging characteristics of extranodal lymphomatous soft tissue involvement are described and classified here according to the site of involvement in 6 cases (primary diseases with orbital, muscle, extra testicular, scalp, sinonasal and pachymeningeal/dural involvement). In majority of these cases at presentation we found a predominantly homogeneous soft tissue mass with mildly high attenuation on CT and a T2 intermediate signal on MRI at these sites without any manifestation of disease elsewhere but on follow-up two out of these six cases developed systemic disease elsewhere. Few consistent patterns were noticed on CT and MRI which might help to include lymphomas as an important differential diagnosis of soft tissue masses. Though a definitive diagnosis requires a biopsy (bone marrow, lymph node, or mass), and other laboratory tests, imaging primarily aims at staging of the disease and identification of new or recurrent disease.

Nasal dissemination of a single-clone IgH-rearranged conjunctival MALT lymphoma through the nasolacrimal duct: A case report

The aim of the present study was to report a rare case of single-clone, immunoglobulin heavy chain (IgH)-rearranged mucosa-associated lymphoid tissue (MALT) lymphoma in the conjunctiva, with nasal cavity dissemination through the nasolacrimal duct. A 24-year-old female was diagnosed with MALT lymphoma of the nasal cavity at the Department of Otolaryngology, Wan Fang Medical Center, Taipei Medical University (Tapei, Taiwan) in October 2008. A biopsy of the relapsing conjunctival lesion revealed a MALT lymphoma by pathological staining, while a single-clone, IgH-rearranged tumor lesion in the nasal cavity and conjunctiva was confirmed using continuous sinus computed tomography scans and polymerase chain reaction. Tumor lesions were negative for Helicobacter pylori and Chlamydia infection, but exhibited bilateral neck lymph node dissemination. A combination of radiation therapy (a total dosage of 46.8 Gray, in two phases covering the left lacrimal sac, nasal cavity and bilateral neck region) and topical ciprofloxacin plus steroid (0.3% ciprofloxacin 4 times a day and betamethasone eye ointment before sleep for 1 month) was provided as an effective therapeutic strategy, and no recurrence was found in the next 3 years. The nasolacrimal duct serves as a channel for conjunctival tumor spreading and is easily neglected. IgH-involved translocation in MALT lymphoma is a factor in the progression of the disease, and aggressive combination therapy is essential for a high-risk, disseminated IgH-rearranged MALT lymphoma.

Histological vascular invasion is a novel prognostic indicator in extranodal natural killer/T-cell lymphoma, nasal type

Extranodal natural killer (NK)/T-cell lymphoma, (ENKTL), nasal type, is an aggressive lymphoma with no validated prognostic parameters, to date. In the present study, vascular invasion by this tumor was retrospectively analyzed in 214 patients with untreated ENKTL to evaluate its association with clinical features, treatment response and prognosis. Histological vascular invasion by the tumor was confirmed in 32.7% of patients with ENKTL. The presence of vascular invasion significantly correlated with poor performance status, B symptoms, extranodal involved sites, advanced stage, elevated serum lactate dehydrogenase, D-dimer and cluster of differentiation 68⁺ tumor-associated macrophages. Upon treatment termination, the complete remission (CR) rate and overall response rate were significantly lower for the vascular invasion group compared with the non-vascular invasion group. Furthermore, vascular invasion resulted in significantly reduced 5-year progression-free survival (PFS; 21.8 vs. 60.1%) and overall survival (OS; 36.8 vs. 77.0%) rates. Using the multivariate Cox regression model, vascular invasion, stage III/IV and CR after chemotherapy were independent prognostic factors for OS and PFS. Thus, histological vascular invasion by the tumor affected the response to treatment, and was also an independent prognostic factor for OS and PFS in ENKTL, nasal type, suggesting a role for vascular invasion in disease progression.

Clinical findings of extranodal SNT lymphoid malignancies in a four-decade single-centre series

Sinonasally located lymphoid malignancies are rare lesions with first symptoms similar to other obstructive conditions. Additionally, they often coexist with nasal inflammation and mucosal necrosis. Therefore, time from the first symptoms to diagnosis tends to be long. Awareness and early diagnosis of this disease entity could improve treatment outcome. Altogether, 142 patients with sinonasal or nasopharyngeal (i.e. sinonasal tract, SNT) lymphoid malignancies, diagnosed and treated at the Helsinki University Hospital, during a 39-year period from 1975 to 2013, were retrospectively reviewed. There were 90 males (63 %) and 52 females (37 %) with a median age of 64 years (range 26-92). Eighty-four percent of the patients had primary diseases and 16 % had relapses of lymphoid malignancies primarily diagnosed at other locations. The mean duration of symptoms prior to diagnosis was 4.8 months (range 0.5-24). The most common histological entity was diffuse large B-cell lymphoma (43 %), followed by plasmacytoma (18 %). The most common location was nasopharynx (58 %) followed by nasal cavity (44 %) and paranasal sinuses (35 %). Sixty-nine percent of the lesions were at a single anatomic location of the sinonasal tract. Fifty-two percent of the cases were of Ann Arbor Stage I. Lymphoid malignancies form an important and diverse group in the differential diagnosis of SNT tumours. They most often present with general obstructive nasal symptoms due to tumour location. Most of them are primary lesions, highlighting the importance of an accurate diagnosis as early as possible.

Hematolymphoid Lesions of the Sinonasal Tract

Hematolymphoid neoplasms of the sinonasal tract are rare and the majority represents non-Hodgkin lymphomas. This review will focus on morphologic, immunophenotypic, and genetic characteristics of the most common types of non-Hodgkin lymphoma, namely diffuse large B cell lymphoma and extranodal natural killer/T-cell lymphoma, nasal type, but also include the discussion of less frequent other hematolymphoid entities, such as extranodal plasmacytomas and Rosai-Dorfman disease.

Sinonasal natural killer/T-cell lymphoma presenting as pyrexia of unknown origin with nasal symptoms

A 68-year-old Chinese man presented with an eight-month history of pyrexia of unknown origin and chronic sinusitis despite multiple courses of antibiotics. He underwent extensive investigations, including workups for infections, chronic granulomatous diseases and malignancy. Nasal biopsies were performed twice under local anaesthesia, but did not show any evidence of malignancy. Eventually, the patient was diagnosed with natural killer (NK)/T-cell lymphoma, nasal variant, based on histopathological findings from harvested deep tissue obtained via functional endoscopic sinus surgery. This study highlights that, for patients presenting with pyrexia of unknown origin and nasal symptoms, NK/T-cell lymphoma must be considered as a differential diagnosis. Generous amounts of tissue should be harvested under general anaesthesia rather than limited tissue under local anaesthesia, in order to facilitate and ensure a definitive diagnosis.

Sinonasal Lymphoma Presenting as a Probable Sanctuary Site for Relapsed B Acute Lymphoblastic Leukaemia: A Case Report and Review of the Literature

Sinonasal lymphoma is a non-Hodgkin lymphoma (NHL) representing 1.5% of all lymphomas. It presents as an unremitting ulceration with progressive destruction of midline sinonasal and surrounding structures. Poor prognosis warrants early treatment although diagnosis is challenging and frequently delayed. It is usually primary in origin and to our knowledge the sinonasal region has never been reported as a sanctuary site in leukaemia/lymphoma relapse. We present a unique case of B-cell ALL (acute lymphoblastic leukaemia) with late relapse to the nasal septum as a sinonasal lymphoblastic lymphoma and with genetic support for this as a sanctuary site.

Orbital presentation of a nasal midline destructive lesion in a young boy

Midline Destructive Lesions (MDL) are well known to cause nasal problems. There is a long differential diagnosis of such lesions. However, in the pediatric population, the 2 main diseases to be aware of are Non-Hodgkin's T-cell lymphoma and granulomatosis with polyangiitis (previously known as Wegener's granulomatosis). The authors present the report of a 15-year-old boy who presented with epiphora, chemosis, and limitation of left abduction. CT scan of his orbits suggested a destructive lesion of the ethmoid sinuses. His laboratory investigations revealed a positive ANCA. The patient underwent endoscopic sinus surgery, and this was characteristic for granulomatosis with polyangiitis. He was treated with systemic steroids and then maintained on cyclophosphamide, which controlled his disease activity. This case highlights the need for ophthalmologists to have a high index of suspicion for MDL and concomitant orbital disease.

Hematolymphoid lesions of the sinonasal tract

Various hematolymphoid lesions involve the sinonasal tract, including aggressive B, T, and NK-cell neoplasms; myeloid sarcoma; low-grade lymphomas; indolent T-lymphoblastic proliferations; and Rosai-Dorfman disease. Differentiating aggressive lymphomas from non-hematopoietic neoplasms such as poorly differentiated squamous cell carcinoma, olfactory neuroblastoma, or sinonasal undifferentiated carcinoma may pose diagnostic challenges. In addition, the necrosis, vascular damage, and inflammatory infiltrates that are associated with some hematolymphoid disorders can result in misdiagnosis as infectious, autoimmune, or inflammatory conditions. Here, we review hematolymphoid disorders involving the sinonasal tract including their key clinical and histopathologic features.

Burkitt lymphoma with initial clinical presentation due to infiltration of the central nervous system and eye orbits

Patient: Male, 17

Final Diagnosis: Burkitt lymphoma

Symptoms: Anisocoria, ipsilateral ptosis, opthalmoparesis, paresis

Medication: —

Clinical Procedure: —

Specialty: Oncology

Diffuse large B-cell lymphoma in the sphenoid sinus mimicking fibrous dysplasia in CT and MRI

We present a 70-year-old man with lymphoma who presented with a right eye movement disorder. CT examinations showed 'ground-glass' appearance extending around the right sphenoid sinus which suggested fibrous dysplasia. However, biopsy from the mass histologically proved it to be diffusing large B-cell lymphoma and positron emission tomography examinations revealed increased fluorodeoxyglucose (FDG) uptake around the right sphenoid bone and multiple spinal bones. After chemotherapy for lymphoma, abnormal FDG uptake disappeared from the body.

Sinonasal lymphoma: case series and review of the literature

BACKGROUND

Sinonasal lymphoma is a rare rhinologic entity. We present a case series and review the literature surrounding the diagnosis and management of this disease.

METHODS

A pathology database spanning 22 years at a tertiary care center was searched for a diagnosis of lymphoma in the paranasal sinuses or the nasal cavity. Seventeen cases were identified, and retrospective chart review was performed.

RESULTS

Maxillary and ethmoid sinuses were affected more frequently (n = 8 patients each) than sphenoid and frontal sinuses (n = 5 patients each). Histologically, the most common type was diffuse large B-cell lymphoma (53%, 9 patients), followed by extranodal natural killer/T-cell lymphoma (ENKL, 21%, 3 patients). Presenting symptoms included nasal obstruction and rhinorrhea (53%, 9 patients) and diplopia (18%, 3 patients); and radiographic imaging demonstrated a discrete mass (59%, 10 patients), sinus opacification (53%, 9 patients), and/or bony erosion (35%, 6 patients). Treatment included chemotherapy alone (71%, 12 patients), chemotherapy and radiation (6%, 1 patient), and radiation alone (6%, 1 patient). The 2-year and 5-year overall survival rates were 75% and 53%, respectively, whereas disease-free 2-year and 5-year survival rates were 70% and 49%, respectively.

CONCLUSION

Lymphoma of the nasal cavity and paranasal sinuses is extremely rare, may mimic benign processes, and may manifest either in an isolated fashion or in conjunction with systemic disease. B-cell lymphomas, a more favorable diagnosis, account for a majority of cases, whereas ENKL is associated with rapid disease progression and death. Chemotherapy and radiation are the main therapies. Histologic diagnosis is of paramount importance, and clinicians must remain cognizant of this entity to differentiate it from other sinonasal malignancies.

Diffuse large B-cell lymphoma of the sinonasal tract: analysis of survival in 852 cases

PURPOSE

Diffuse large B-cell lymphomas (DLBCLs) are rare tumors of the head and neck that often have non-specific presentations and significant morbidity and mortality. In this analysis we use a large cohort to compare the demographic and disease-specific parameters affecting survival and incidence of DLBCLs.

METHODS

The United States National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) registry was utilized to extract data regarding sinonasal diffuse large B-cell lymphoma between 1973 and 2009. A total of 852 cases of sinonasal DLBCLs were found. Presenting symptoms, demographics, disease specific survival, relative survival and survival by treatment modality were described for this rare tumor.

RESULTS

Overall disease specific survival (DSS) at 1-year was 84.7% and at 5 years was 68.0%. DSS was significantly lower for those not treated with radiation therapy, with 1- and 5-year survival rates of 77.3% and 62.5%, versus those treated with radiation therapy, with 1- and 5-year rates of 89.2% and 71.5% (p<0.05). Prognosis was significantly better for patients treated with radiation therapy (HR 0.6, p<0.05) while it was poorer for patients with involvement of multiple sinuses (HR 1.5, 1.8, p<0.05).

CONCLUSIONS

DLBCLs of the sinonasal tract are rare tumors of the head and neck. Survival is significantly improved for those treated with radiation therapy while the involvement of multiple sinuses is a negative prognostic indicator.

Pathogenesis and treatment of extranodal natural killer/T-cell lymphoma

Extranodal natural killer (NK)/T-cell lymphoma, nasal type (ENKL) is one of the uncommon subtypes of malignant lymphoma, and predominantly occurs in the nasal or paranasal areas and less frequently in the skin. Previously, its prognosis was poor due to the expression of P-glycoprotein, which actively exports several anticancer agents outside the lymphoma cells. However, in recent years, novel therapeutic approaches such as simultaneous chemoradiotherapy or l-asparaginase-based regimens including SMILE (steroid, methotrexate, ifosfamide, l-asparaginase, and etoposide) improved the response to therapy and survival of ENKL patients. Epstein-Barr virus (EBV) is present in lymphoma cells of almost all patients, accounting for the pathogenesis of ENKL. Fragmented EBV-DNA is released from tumor cells, and can be detected in the peripheral blood of patients. The EBV-DNA copy numbers are associated with tumor burden, and can predict the prognosis of ENKL, as well as the toxicity against chemotherapy. Based on this recent progress, ENKL is currently categorized as a lymphoma with intermediate prognosis, but the overall treatment results are not satisfactory. Further improvement of the prognosis of ENKL is therefore warranted, including the optimal use of hematopoietic stem cell transplantation (HSCT).

Extranodal natural killer/T-Cell lymphoma: A population-based comparison of sinonasal and extranasal disease

OBJECTIVES/HYPOTHESIS

Extranodal natural killer/T-cell Lymphoma (ENKTL) is a rare, aggressive malignancy that preferentially affects the paranasal region. This study analyzes the demographic, clinicopathologic, incidence, and survival characteristics of sinonasal ENKTL (SN-ENKTL) and extranasal ENKTL (EN-ENKTL) in a comparative fashion.

STUDY DESIGN

Retrospective analysis.

METHODS

The Surveillance, Epidemiology, and End Results database was queried; 528 cases were available for frequency and incidence analysis, and 473 for survival analysis. Data were examined according to age, gender, race, histology, the presence of systemic (or B) symptoms, treatment, and Ann Arbor stage.

RESULTS

Extranasal disease was a poor prognostic factor (hazard ratio [HR] = 1.69, 95% confidence interval [CI] = 1.30-2.19, P < .05). Patients with EN-ENKTL were older (mean 53.8 vs. 49.9 years, P < .05), most were male (72.5% vs. 59.8%, P < .05), and they were more likely to present with stage IIIE/IV disease (38.33% vs. 18.26%, P < .05). B symptoms were present in 38.41% of the EN-ENKTL group (vs. 22.86%, P < .05), and were a poor prognostic factor in this group only (HR = 1.6593, 95% CI = 1.05-2.62, P < .05). Radiation therapy demonstrated a survival advantage among both groups, especially in early stage disease.

CONCLUSIONS

SN-ENKTL carries a significantly better prognosis than EN-ENKTL, which presents at more advanced stages. Radiation therapy was associated with increased survival in both groups, especially in cases of localized disease.

LEVEL OF EVIDENCE

2b.

Unusual presentation of sporadic Burkitt's lymphoma originating from the nasal septum: a case report

INTRODUCTION

Burkitt's lymphoma is a highly aggressive, small, non-cleaved B-cell non-Hodgkin's lymphoma. In the sporadic form of the disease that occurs in non-endemic areas around the world, most commonly in developed countries, patients usually present with an abdominal mass that frequently involves the ileocecal region of the bowel; ocular or orbital involvement is rare. Primary disease of the sinuses is uncommon and, to the best of our knowledge, that of the anterior septum has never been described. We report the diagnosis and successful management of Burkitt's lymphoma originating from the nasal septum in a male patient.

CASE PRESENTATION

An otherwise healthy 78-year-old Caucasian man who did not smoke cigarettes was admitted to our Ear, Nose and Throat outpatient clinic with the complaint of nasal obstruction due to left-sided nasal septal thickening. Paranasal computerized tomography revealed a well-circumscribed solid mass originating from his anterior nasal septum and obstructing his airway. The final diagnosis of Burkitt's lymphoma was verified by immunohistochemical studies. Our patient had a good clinical outcome after chemoradiotherapy, with no problems reported to date in the second year of follow-up.

CONCLUSION

We provide what we believe to be the first report of a case of sporadic Burkitt's lymphoma involving the nasal septum, and describe the efficacy of first-line chemotherapy. Being an original case report with broader clinical impact across more than one area of medicine, this case presentation has the potential to significantly advance our understanding of Burkitt's lymphoma and we emphasize the need to include this disease in the differential diagnosis of patients presenting with a nasal septal mass.

Clinical value of metabolic tumor volume by PET/CT in extranodal natural killer/T cell lymphoma

This study investigated whether metabolic tumor volume (MTV) by PET/CT as indicator of extent of lymphoma burden would be a prognostic factor in stage I(E)/II(E) extranodal natural killer/T cell lymphoma (ENKTCL). Eighty patients with stage I(E)/II(E) ENKTCL in the upper aerodigestive tract underwent PET/CT at diagnosis were enrolled and 32 patients received upfront radiotherapy (RTx). MTV was measured on PET/CT images by the extranodal region above SUV, 2.5. Receiver operating curve analyses indicated that an MTV of 35.2 cm(3) was the ideal cut-off to distinguish between low and high MTV groups. Clinical outcomes were compared according to several prognostic factors (age, stage, high performance status [PS], high International Prognostic Index, elevated lactate dehydrogenase [LDH], local tumor invasiveness [LTI], high MTV and up-front RT). High PS, elevated LDH, LTI, high MTV and upfront RT were associated with survivals. In multivariate analysis, high MTV (PFS, HR=4.170, 95% CI=1.714-10.147, p=0.002; OS, HR=4.102, 95% CI=1.617-10.408, p=0.003) and up-front RT (PFS, HR=0.410, 95%CI=0.178-0.946, p=0.037; OS, HR=0.365, 95% CI=0.152-0.872, p=0.023) were significant independent prognostic factors. Upfront RTx and extent of tumor burden, as measured by the MTV, had significant prognostic value in patients with ENKTCL.

A patient with primary Burkitt's lymphoma of the postnasal space: case report

INTRODUCTION

Burkitt's lymphoma is a highly aggressive lymphoma. The endemic form is present with Epstein - Barr virus. The most common sites are the mandible, facial bones, kidneys, gastrointestinal tract, ovaries, breast and extra-nodal sites. We present the first reported case of a primary Burkitt's lymphoma of the postnasal space occurring in an elderly Caucasian male.

CASE PRESENTATION

A 72-year-old Caucasian male farmer presented with a 6-week history of a productive cough and a painless left sided cervical swelling. Examination of the neck revealed a 5 cm by 5 cm hard mass in the left anterior triangle. A CT scan of the head and neck showed a soft tissue swelling in the postnasal space. Histology of the postnasal space mass showed squamous mucosa infiltrated by a high grade lymphoma. Immunohistochemical staining and in situ hybridisation confirmed the tumour to be Epstein - Barr virus Ribonucleic acid negative suggesting this was a rare sporadic form of the tumour presenting in a location that is atypical for the clinical subtype and age of the patient.

CONCLUSION

This is the first reported case of sporadic Burkitt's lymphoma of the postnasal space of an elderly Caucasian male in the absence of Epstein - Barr virus or human immunodeficiency virus infection and further serves to illustrate the diversity of histological subtypes of malignancies that may develop at this concealed site.

Extranodal NK/T-cell lymphoma, nasal type, includes cases of natural killer cell and αβ, γδ, and αβ/γδ T-cell origin: a comprehensive clinicopathologic and phenotypic study

Extranodal NK/T-cell lymphoma (ENKTL), nasal type, may be of NK or T-cell origin; however, the proportion of T-ENKTLs and whether they are of αβ or γδ type remains uncertain. To elucidate the cell of origin and detailed phenotype of ENKTL and assess any clinicopathologic associations, 67 cases of ENKTL from Thailand were investigated, together with 5 γδ enteropathy-associated T-cell lymphomas (EATLs) for comparison. In all, 70% of the ENKTL were T-cell receptor (TCR) β,γ and, in cases tested, δ negative (presumptive NK origin); 5% were TCR γδ, 3% were TCR αβ, 1% were TCR αβ/γδ, and 21% were indeterminate. Out of 17 presumptive NK-ENKTLs tested, 3 had clonal TCR rearrangements. All cases were EBV and TIA-1; >85% were positive for CD3, CD2, granzyme B, pSTAT3, and Lsk/MATK; and all were CD16. Presumptive NK-ENKTLs had significantly more frequent CD56 (83% vs. 33%) and CXCL13 (59% vs. 0%) but less frequent PD-1 (0% vs. 40%) compared with T-ENKTLs. Of the NK-ENKTLs, 38% were Oct-2 compared with 0% of T-ENKTLs, and 54% were IRF4/MUM1 compared with 20% of T-ENKTLs. Only αβ T-ENKTLs were CD5. Intestinal ENKTLs were EBV and had significantly more frequent CD30, pSTAT3, and IRF4/MUM1 expression but less frequent CD16 compared with γδ EATL. Significant adverse prognostic indicators included a primary non-upper aerodigestive tract site, high stage, bone marrow involvement, International Prognostic Index ≥2, lack of radiotherapy, Ki67 >40%, and CD25 expression. The upper aerodigestive tract ENKTLs of T-cell origin compared with those of presumptive NK origin showed a trend for better survival. Thus, at least 11% of evaluable ENKTLs are of T-cell origin. Although T-ENKTLs have phenotypic and some possible clinical differences, they share many similarities with ENKTLs that lack TCR expression and are distinct from intestinal γδ EATL.

Extranodal non-hodgkin lymphomas of the oral cavity and maxillofacial region: a clinical study of 58 cases and review of the literature

PURPOSE

Approximately one third of non-Hodgkin lymphomas (NHLs) arise in tissues other than the lymph nodes. The purposes of this study are to evaluate the clinical outcome of NHLs of the oral cavity and maxillofacial region in a group of 58 patients who were diagnosed in our clinic and to discuss the clinical, histologic, and immunohistochemical features of these malignant neoplasms, as well as the prognosis.

MATERIALS AND METHODS

The study included 58 patients with extranodal NHLs of the oral cavity and maxillofacial region. There were 32 male and 26 female patients. The patients' ages ranged from 7 to 81 years. The most frequent sites of occurrence were the salivary glands (24 patients) and intraoral mucosa (21 patients). Other sites were the paranasal sinus (3 patients), Waldeyer ring (4 patients), bone of the jaws (3 patients), and orbit (3 patients). The histologic subtype was extranodal marginal zone lymphoma of the mucosa-associated lymphoid tissue (MALT) in 21 patients, diffuse large B-cell lymphoma (DLBCL) in 19, chronic lymphocytic leukemia in 10, mantle cell lymphoma in 4, follicular lymphoma in 2, Burkitt lymphoma/leukemia in 1, and B-cell acute lymphocytic leukemia (B-ALL) in 1. Of the DLBCL cases, 13 were stage IIE and 6 were stage IE. All the MALT lymphomas were stage IE.

RESULTS

The mean follow-up was 5 years after the initial diagnosis. A better prognosis was found in patients with MALT lymphomas (19 of 21 patients are alive) compared with those with DLBCLs (10 of 19 patients are alive).

CONCLUSIONS

MALT lymphomas have a more favorable outcome (about 90%) in comparison with DLBCLs. Careful examination of the oral cavity and neck by the maxillofacial surgeon is essential for the diagnosis and staging of lymphomas.

An algorithmic approach to the diagnosis of NK and T cell lymphomas

Lymphomas of natural killer (NK) and T cell lineages are uncommon disorders, although as a group they are more usually encountered in Asia compared to Western populations. In part due to their rarity, diagnosis and classification of T cell lymphomas often pose a challenge to clinicians and pathologists. Although there are morphological features that are characteristic of certain subtypes, correct classification of NK and T cell neoplasms relies heavily on the immunophenotype. With few exceptions, non-random genetic alterations such as translocations are less often seen in T cell neoplasms, adding to the diagnostic difficulty. Given these limitations, pathological diagnosis and classification of NK and T cell lymphomas are anything but straightforward. This paper attempts to present a practical algorithmic approach for the general pathologist who is confronted with these neoplasms.

Clinical behavior and treatment outcome of primary nasal diffuse large B-cell lymphoma

BACKGROUND

Nasal diffuse large B-cell lymphoma (DLBCL) is rare. The objective of this study was to evaluate the clinical features and treatment outcomes of patients with nasal DLBCL.

METHODS

Twenty-five patients were included in the study. All patients received combination chemotherapy with or without radiotherapy.

RESULTS

Patients with nasal DLBCL usually were older and were predominantly men with early stage disease, low frequency of B symptoms and elevated lactate dehydrogenase (LDH), good performance status, and a low-risk international prognostic index (IPI) score. The overall response rate after initial treatment was 76%, the 3-year overall survival (OS) rate for the whole group was 44%, and the median OS was 35 months. Performance status and IPI were significant prognostic factors for OS. For patients with IPI scores of 0 or 1, the 3-year OS rate was 54%, and the median OS was 52 months compared with 17% and 11 months, respectively, for patients with IPI scores of 2 or 3 (P = .033). The prognosis for patients who achieved a complete response (CR) was significantly better than that for patients who did not achieve a CR. Extranodal spread was the primary pattern of failure.

CONCLUSIONS

The current results indicated that primary nasal DLBCL appears to have distinct clinical features; its poor outcome and propensity for extranodal failure illustrate the need for innovative therapies.