Intravascular Large B-Cell Lymphoma

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS): contemporary advances and current controversies

Chronic lymphocytic inflammation with pontine perivascular enhancement responsive to steroids (CLIPPERS) is an inflammatory syndrome with characteristic clinical, radiological, and pathological features, and can be effectively treated with corticosteroid-based immunotherapies. The exact pathogenesis of CLIPPERS remains unclear, and specific diagnostic biomarkers are not available. According to the 2017 diagnostic criteria, probable CLIPPERS should be considered in middle-aged patients with subacute onset of pontocerebellar symptoms and typical punctuate and curvilinear gadolinium enhancement lesions ("salt-and-pepper" appearance) located in the hindbrain (especially pons) on magnetic resonance imaging. In addition, CLIPPERS-mimics, such as central nervous system (CNS) lymphoma, and several antibody-associated autoimmune CNS diseases (e.g., myelin oligodendrocyte glycoprotein antibody-associated disease, autoimmune glial fibrillary acidic protein astrocytopathy, and anti-N-methyl-D-aspartate receptor encephalitis), should be extensively excluded. The prerequisite for definite CLIPPERS is the perivascular T-cell-predominant inflammatory infiltration observed on pathological analysis. A biopsy is strongly suggested when clinical/radiological red flags are present. Most patients with CLIPPERS respond well to corticosteroids and have a good prognosis. Long-term low-dose corticosteroid maintenance therapy or corticosteroids coupled with immunosuppressants are recommended to prevent the recurrence of the syndrome. The potential progression of CLIPPERS to lymphoma has been suggested in some cases; therefore, at least 2-year clinical and radiological follow-up is essential. Here, we critically review the recent developments and provided an update on the clinical characteristics, diagnostic criteria, differential diagnoses, and therapeutic management of CLIPPERS. We also discuss the current controversies in this context that can be resolved in future research studies.

Cutaneous Intravascular Hematolymphoid Entities: A Review

Intravascular lymphomas are rare disease conditions that exhibit neoplastic lymphoid cells that are confined mainly to the lumens of small capillaries and medium-sized vessels. The majority of the intravascular lymphomas are of B-cell origin, but they can include NK/T-cell and CD30+ immunophenotypes. In the histologic differential diagnosis are benign proliferations such as intralymphatic histiocytosis and intravascular atypical CD30+ T-cell proliferation. In this review, we discuss the clinical, histopathologic, and molecular findings of intravascular B-cell lymphoma, intravascular NK/T-cell lymphoma, intralymphatic histiocytosis, and benign atypical intravascular CD30+ T-cell proliferation.

Differentiation Between Disseminated Carcinomatosis of the Bone Marrow From Urothelial Cancer and Intravascular Large B-cell Lymphoma: A Case Report

This case report describes a rare case of intravascular large B-cell lymphoma (IVLBCL), initially presenting with nonspecific symptoms of fever and fatigue, and tentatively diagnosed as disseminated carcinomatosis of the bone marrow originating from urothelial cancer in an 80-year-old woman. The patient's journey began with symptoms treated as common ailments and progressed through multiple differential diagnoses, including giant cell arteritis, TAFRO (thrombocytopenia, anasarca, fever, reticulin fibrosis, and organomegaly) syndrome, and disseminated carcinomatosis of the bone marrow originating from urothelial cancer due to the presence of systemic inflammation, anasarca, and elevated soluble interleukin 2 receptor levels, indicative of an intense immunological response. Despite initial treatments, her condition deteriorated, leading to further investigations that ultimately revealed the presence of malignant cells in the urine and bone marrow, confirming the diagnosis of IVLBCL. This case underscores the diagnostic challenges faced when elderly patients present with systemic inflammation and the critical need for thorough investigation beyond initial impressions. It highlights the importance of considering differentiation between disseminated carcinomatosis of the bone marrow and IVLBCL in the differential diagnosis of persistent inflammation, especially in cases where common causes have been excluded and the primary malignancy is not immediately apparent.

Intravascular Large B-cell Lymphoma Presenting as Pulmonary Ground-glass Nodules That Progressed Slowly over Several Months with No Overt Symptoms

A 74-year-old man with no overt symptoms was referred for a chest computed tomography (CT) that revealed multiple bilaterally pulmonary ground-glass nodules (GGNs) with subtle changes in size over eight months. Surgical lung biopsies were performed in the left upper lobe. A pathologic study confirmed the intravascular large B-cell lymphoma (IVLBCL). This lesion was a nodule-like cluster of atypical cells, meaning that it had been localized for several months. Pulmonary IVLBCL may form focal lesions presenting as GGN on chest CT and progress slowly without apparent symptoms.

Intravascular large B-cell lymphoma masquerading as stroke successfully treated with R-Hyper-CVAD

Intravascular large B cell lymphoma (IVLBCL) is exceedingly rare and difficult to diagnose. We describe a case of IVLBCL in a 56-year-old male which was identified after recurrent strokes. Right partial nephrectomy was then performed which demonstrated renal oncocytoma and IVLBCL. Chemotherapy was initiated with standard R-Hyper-CVAD which included intrathecal methotrexate and cytarabine. R-CHOP is largely considered the treatment of choice in IVLBCL, however low doses of chemotherapy in this regimen do not cross the blood brain barrier like in R-Hyper-CVAD. The patient achieved complete remission after completion of treatment and has remained in remission for 5 years after diagnosis.

A Case of Suspected T-cell Intravascular Lymphoma Mimicking Multiple Hepatic Abscesses and Adult-Onset Still's Disease

Diagnosing hyperferritinemia can be challenging due to the nonspecific nature of symptoms and various potential causes. This case report discusses the intricacies faced when diagnosing an elderly individual with hyperferritinemia, which eventually led to a specific diagnosis. An elderly patient presented with two months of fatigue, fever, and malaise, initially receiving several diagnoses. Despite some treatments, the patient's condition worsened, prompting further evaluation. Further investigation revealed a rare diagnosis. The progression of the disease led to the decision of palliative care. This case emphasizes the challenges in diagnosing elderly individuals and the importance of comprehensive follow-up and broad differential diagnosis. The need for a thorough investigation in the face of specific indicators is underscored. The patient's non-response to certain treatments required the consideration of less common conditions in the differential diagnosis. The case offers insights into addressing treatment suitability and making necessary adjustments. The situation underscores the need for careful evaluation, especially in unusual presentations, and the importance of timely conversations about care options. Lessons from this case assist healthcare professionals in understanding and managing intricate presentations in the elderly.

Diffuse large B-cell lymphoma in the course of systemic sarcoidosis: A case report and review of 30 Japanese patients with sarcoidosis-lymphoma syndrome

We report a patient with sarcoidosis who developed diffuse large B-cell lymphoma. A 71-year-old woman with persistent cough was diagnosed pathologically with sarcoidosis by resection of the right upper lung lobe with a nodule after an unsuccessful attempt of transbronchial needle aspiration for mediastinal lymphadenopathy. She was referred for an eye examination and found to have spotty retinal degeneration on the lower fundi of both eyes, together with residual macular edema and vitreous opacity in the left eye. At 76 years, she underwent cataract surgery and vitrectomy to gain a visual acuity of 0.6 in the left eye. At 77 years, she developed a cough and fever, and showed leukopenia and thrombocytopenia. Computed tomography showed multiple small nodular lesions in both lungs, and bilateral hilar, mediastinal, and hepatic lymphadenopathy. Fluorodeoxyglucose positron emission tomography demonstrated high uptake in the liver, spleen, pancreatic head, and lymph nodes. Bone marrow biopsy was intact, but liver biopsy revealed anomalous large lymphoid cells in the sinusoids which were positive for CD20 and showed a high Ki-67 index, leading to the diagnosis of diffuse large B-cell lymphoma. Chemotherapy with 8 courses of THP-COP (cyclophosphamide, pirarubicin, vincristine, and prednisolone) with rituximab, followed by intrathecal injection of methotrexate, cytarabine, and dexamethasone, resulted in complete remission. She maintained complete remission for 10 years until 88 years old at present. The literature review found 30 patients, including this case, who developed lymphoma in the course of sarcoidosis. A novel pathological diagnosis is required in the setting of acute symptomatic changes and novel lesions on imaging in patients with sarcoidosis.