Advances in the pathogenesis and therapeutic strategies of angioimmunoblastic T-cell lymphoma

Angioimmunoblastic T-cell lymphoma (AITL) is an aggressive subtype of peripheral T-cell lymphomas with its cell origin determined to be follicular helper T-cells. AITL is characterized by a prominent tumor microenvironment involving dysregulation of immune cells, signaling pathways, and extracellular matrix. Significant progress has been made in the molecular pathophysiology of AITL, including genetic mutations, immune metabolism, hematopoietic-derived microenvironment, and non-hematopoietic microenvironment cells. Early diagnosis, detection of severe complications, and timely effective treatment are crucial for managing AITL. Treatment typically involves various combination chemotherapies, but the prognosis is often poor, and relapsed and refractory AITL remains challenging, necessitating improved treatment strategies. Therefore, this article provides an overview of the pathogenesis and latest advances in the treatment of AITL, with a focus on potential therapeutic targets, novel treatment strategies, and emerging immunotherapeutic approaches.

Recent Advances in Diagnosis and Therapy of Angioimmunoblastic T Cell Lymphoma

Angioimmunoblastic T cell lymphoma (AITL) is a common subtype of mature peripheral T cell lymphoma (PTCL). As per the 2016 World Health Organization classification, AITL is now considered as a subtype of nodal T cell lymphoma with follicular helper T cells. The diagnosis is challenging and requires a constellation of clinical, laboratory and histopathological findings. Significant progress in the molecular pathophysiology of AITL has been achieved in the past two decades. Characteristic genomic features have been recognized that could provide a potential platform for better diagnosis and future prognostic models. Frontline therapy for AITL was mainly depending on chemotherapy and the management of relapsed or refractory AITL is still unsatisfactory with a very poor prognosis. Upfront transplantation offers better survival. Novel agents have been introduced recently with promising outcomes. Several clinical trials of combinations using novel agents are underway. Herein, we briefly review recent advances in AITL diagnosis and the evolving treatment landscape.

Outcomes and prognostic factors in angioimmunoblastic T-cell lymphoma: final report from the international T-cell Project

Angioimmunoblastic T-cell lymphoma (AITL) is a unique subtype of peripheral T-cell lymphoma (PTCL) with distinct clinicopathologic features and poor prognosis. We performed a subset analysis of 282 patients with AITL enrolled between 2006 and 2018 in the international prospective T-cell Project (NCT01142674). The primary and secondary end points were 5-year overall survival (OS) and progression-free survival (PFS), respectively. We analyzed the prognostic impact of clinical covariates and progression of disease within 24 months (POD24) and developed a novel prognostic score. The median age was 64 years, and 90% of patients had advanced-stage disease. Eighty-one percent received anthracycline-based regimens, and 13% underwent consolidative autologous stem cell transplant (ASCT) in first complete remission (CR1). Five-year OS and PFS estimates were 44% and 32%, respectively, with improved outcomes for patients who underwent ASCT in CR1. In multivariate analysis, age ≥60 years, Eastern Cooperative Oncology Group performance status >2, elevated C-reactive protein, and elevated β2 microglobulin were associated with inferior outcomes. A novel prognostic score (AITL score) combining these factors defined low-, intermediate-, and high-risk subgroups with 5-year OS estimates of 63%, 54%, and 21%, respectively, with greater discriminant power than established prognostic indices. Finally, POD24 was a powerful prognostic factor with 5-year OS of 63% for patients without POD24 compared with only 6% for patients with POD24 (P < .0001). These data will require validation in a prospective cohort of homogeneously treated patients. Optimal treatment of AITL continues to be an unmet need, and novel therapeutic approaches are required.

[Angioimmunoblastic T-cell lymphoma]

Angioimmunoblastic T-cell lymphoma (AITL) is a subtype of nodal peripheral T-cell lymphoma associated with aggressive clinical course that affects mostly the elderly. Clinical features at diagnosis are characterized by polyclonal hypergammaglobulinemia, B-symptoms, and advanced stage. It usually responds to anthracycline-based chemotherapy but eventually relapses with a median progression free survival of less than 2 years. High dose chemotherapy followed by autologous stem cell transplantation is an option for improving prognosis both in first-line and in relapsed or refractory settings. Several prospective clinical trials are evaluating the role of high dose chemotherapy as a consolidation in first-line treatment for T-cell lymphoma including AITL.

[Angioimmunoblastic T cell lymphoma complicated with endocapillary proliferative glomerulonephritis]

A 30-year-old female developed fever and multiple lymphadenopathy in September 2011. Her symptoms improved with antibiotic treatment. However, she again presented with fever and multiple lymphadenopathy in December 2011. In addition, she suffered from nephrotic syndrome with severe edema. She was therefore hospitalized to undergo detailed examinations. Renal biopsy revealed endocapillary proliferative glomerulonephritis. Since her renal function deteriorated rapidly, she was given steroid pulse therapy with methylprednisolone, followed by maintenance therapy with prednisolone. After treatment, her renal function improved but multiple lymphadenopathy persisted. Biopsy of a left axillary lymph node was then performed and revealed angioimmunoblastic T-cell lymphoma (AITL). She received CHOP therapy but showed no response. Therefore, she was given ESHAP therapy. A partial response was achieved and the nephrotic syndrome also resolved completely. We report this extremely rare case of renal dysfunction due to endocapillary proliferative glomerulonephritis complicated by AITL.

Clinicopathologic characteristics of angioimmunoblastic T-cell lymphoma: analysis of the international peripheral T-cell lymphoma project

PURPOSE

The International Peripheral T-Cell Lymphoma Project was undertaken to better understand the subtypes of T-cell and natural killer (NK) -cell lymphomas.

PATIENTS AND METHODS

Angioimmunoblastic T-cell lymphoma (AITL) was diagnosed according to the 2001 WHO criteria by a central review process consisting of panels of expert hematopathologists. Clinical, pathologic, immunophenotyping, treatment, and survival data were correlated.

RESULTS

Of 1,314 patients, 243 (18.5%) were diagnosed with AITL. At presentation, generalized lymphadenopathy was noted in 76% of patients, and 89% had stages III to IV disease. Skin rash was observed in 21% of patients. Hemolytic anemia and hypergammoglobulinemia occurred in 13% and 30% of patients, respectively. Five-year overall and failure-free survivals were 33% and 18%, respectively. At presentation, prognostic models were evaluated, including the standard International Prognostic Index, which comprised the following factors: age ≥ 60 years, stages III to IV disease, lactic dehydrogenase (LDH) > normal, extranodal sites (ENSs) > one, and performance status (PS) ≥ 2; the Prognostic Index for Peripheral T-Cell Lymphoma, comprising: age ≥ 60 years, PS ≥ 2, LDH > normal, and bone marrow involvement; and the alternative Prognostic Index for AITL (PIAI), comprising: age > 60 years, PS ≥ 2, ENSs > one, B symptoms, and platelet count < 150 × 10(9)/L. The simplified PIAI had a low-risk group (zero to one factors), with 5-year survival of 44%, and a high-risk group (two to five factors), with 5-year survival of 24% (P = .0065).

CONCLUSION

AITL is a rare clinicopathologic entity characterized by an aggressive course and dismal outcome with current therapies.

[Angioimmunoblastic T-cell lymphoma as a very poor-prognosis malignancy--a single centre experience]

BACKGROUND

Angioimmunoblastic T-lymphoma (AITL) is a poor prognosis malignancy. Because of relatively rare incidence and lack of publications in Czech, we decided to share our experience.

PATIENTS AND METHODS

Retrospective analysis of newly diagnosed AITL patients treated at our institution between 1/2000-12/2010.

RESULTS

Twelve patients with median age of 64 (43-82) years were analysed. Two patients over 80 years were treated with corticosteroids. Ten patients were treated with 6 cycles of CHOP-21 chemotherapy resulting in: 2/10 (20%) stable disease, 5/10 (50%) partial remission and 3/10 (30%) complete remission. The median EFS and OS of chemotherapy-treated patients were 8 and 10 months, resp. The EFS and OS were both significantly longer in patients who achieved complete remission within the first line of CHOP or autologous stem cells transplantation therapy: 43 vs 6 (p = 0.0052) and 46 vs 6 months (p = 0.0023), respectively. It was not possible to perform autologous transplantation in 4/7 (57%) patients in need for further reduction of the disease because of poor performance status or early progression of lymphoma and death during salvage chemotherapy.

CONCLUSION

AITL is a poor prognosis malignancy with a very high risk of early relapse after CHOP induction chemotherapy. In fit patients, autologous transplantation should be performed immediately after induction chemotherapy; information about availability of stem cells donor, both in the family or any available register, should be found during the induction treatment.

Cyclosporine A and reduced-intensity conditioning allogeneic stem cell transplantation for relapsed angioimmunoblastic T cell lymphoma with hemophagocytic syndrome

No standard therapeutic approaches have so far been established for the treatment of relapsed angioimmunoblastic T-cell lymphoma (AITL), a subtype of non-Hodgkin lymphoma. This case report describes an AITL patient who relapsed with hemophagocytic syndrome (HPS) two months after receiving high-dose chemotherapy (HDCT) supported by autologous peripheral blood stem cell transplantation (PBSCT). The patient was successfully treated with cyclosporine A (CsA) and subsequent allogeneic PBSCT with reduced intensity conditioning regimen (RIST). RIST may deserve consideration for treatment of AITL patients with severe complications such as HPS. Additionally, CsA could be a less-toxic therapeutic option for pre-RIST induction therapy against AITL.

[Clinical analysis of 12 patients with angioimmunoblastic T cell lymphoma]

To evaluate the clinical, pathological characters and prognosis of patients with angioimmunoblastic T cell lymphoma (AITL), the clinicopathologic features, immunophenotypes, therapy and survival rate of 12 AITL patients which were confirmed by pathologic examination were retrospectively studied. The results indicated that main symptom was observed as general lymphadenopathy, however, 9 patients had fever. The diagnosis of AITL was based on lymph-node biopsy. The histopathologic characteristics of AITL showed the damage of normal lymphnode structure, the proliferation of immunoblastic cells and arborescent super vascularization. All immunophenotypes were mature peripheral T-cellular. CVP regimen was the most common chemotherapy regimen used for patients. 58% patients have a good initial response to chemotherapy. 3-year survival was 25%, with median survival time of 25 months. In conclusion, most cases of AITL display an aggressive course, therefore, the disease progresses rapidly and has unfavorable prognosis, further studies are required to improve its therapy regimen.

[Epstein-Barr virus-related B-cell lymphoma of the skin which developed early after cord blood transplantation for angioimmunoblastic T-cell lymphoma]

We report here a rare case of EBV-related post-transplantation lymphoproliferative disorder (PTLD) localized to the skin. The patient was a 64-year-old man diagnosed with angioimmunoblastic T cell lymphoma (AITL). He underwent cord blood transplantation with a reduced intensity conditioning regimen during partial remission after chemotherapy. On day 70 after transplantation, subcutaneous tumors developed near the left scapula and in the left upper arm. Pathological examination of the skin tumor revealed that this tumor was composed of diffuse large centroblast-like cells, the majority of which were CD20 positive, CD 79a positive, CD30 positive and Epstein-Barr virus (EBV) latency-associated RNA (EBER) positive, and EBV-DNA was also detected in tumor cells. At that time, real-time polymerase chain reaction documented no evidence of the EBV genome in his blood. Chimerism analysis revealed that the tumor cells were derived from donor cells, which led to the diagnosis of EBV-related PTLD. For treatment, in addition to decreasing the dose of tacrolimus, we administered rituximab and local irradiation to skin lesions, which led to disappearance of the tumors followed by continued complete remission.

Evaluation and management of angioimmunoblastic T-cell lymphoma: a review of current approaches and future strategies

Angioimmunoblastic T-cell lymphoma (AITL) is a rare and complex lymphoproliferative disorder, clinically characterized by widespread lymphadenopathy, extranodal disease, immune-mediated hemolysis, and polyclonal hypergammaglobulinemia. Significant progress has been made in the understanding of AITL since its recognition as a clonal T-cell disorder with associated deregulation of B-cells and endothelial cells within a unique malignant microenvironment. However, as the responses to conventional chemotherapy have not been durable, prognosis with current treatment approaches has remained dismal. Here we review the clinical presentation, prognosis, and management of patients with AITL. We discuss recent developments in the understanding of the pathogenesis of AITL at a cellular and molecular level, including the implication of the follicular helper T-cell as the corresponding cell of origin, the roles of Epstein-Barr virus, B-cell deregulation, angiogenesis, and other signaling pathways in AITL, and the therapeutic implications of these findings. Finally, we discuss recent clinical trials and novel treatment approaches in the management of patients with AITL.

[Clinicopathological analysis of patients with angioimmunoblastic T-cell lymphoma (AILT)]

We retrospectively analyzed the clinical course and prognosis of 11 patients with angioimmunoblastic T-cell Lymphoma (AILT). Median patient age was 62 years old (range 39 to 85). All patients were in clinical stage III or IV. Clinical features included B symptoms, hepatosplenomegaly, skin rushes, pleural effusion, ascites and polyclonal hypergammaglobulinemia. The disease can be classified into three categories based on histological findings: 3 cases of AILT with hyperplastic germinal centers, 4 cases of typical AILT, and 4 cases of AILT with numerous clear cells. As the initial therapy, 10 patients received combination chemotherapy and only 1 patient received autologous peripheral blood stem cell transplantation. Seven patients achieved CR and 4 showed PD. The response rate was 63% and the median survival time was 20 months. One patient survived in CR for 122 months. Patients with AILT demonstrating hyperplastic germinal centers and no bone marrow infiltration were able to achieve long-term survival. The survival time of AILT demonstrated a wide range. It was thought that further consideration of the prognostic factors and stratification was required.

Prolonged survival of patients with angioimmunoblastic T-cell lymphoma after high-dose chemotherapy and autologous stem cell transplantation. The GELTAMO experience

OBJECTIVES

Angioimmunoblastic T-cell lymphoma (AIL) is a rare lymphoma with a poor prognosis and no standard treatment. Here, we report our experiences with 19 patients treated with high-dose chemotherapy and autologous stem cell transplantation (HDC/ASCT) within the GELTAMO co-operative group between 1992 and 2004.

METHODS

The median age at transplantation was 46 yr. Fifteen patients underwent the procedure as front-line therapy and four patients as salvage therapy. Most patients received peripheral stem cells (90%) coupled with BEAM or BEAC as conditioning regimen (79%).

RESULTS

A 79% of patients achieved complete response, 5% partial response and 16% failed the procedure. After a median follow-up of 25 months, eight patients died (seven of progressive disease and secondary neoplasia), while actuarial overall survival and progression-free survival at 3 yr was 60% and 55%. Prognostic factors associated with a poor outcome included bone marrow involvement, transplantation in refractory disease state, attributing more than one factor of the age-adjusted-International Prognostic Index, Pretransplant peripheral T-cell lymphoma (PTCL) Score or Prognostic Index for PTCL.

CONCLUSIONS

More than half of the patients with AIL that display unfavourable prognostic factors at diagnosis or relapse would be expected to be alive and disease-free after 3 yr when treated with HDC/ASCT. Patients who are transplanted in a refractory disease state do not benefit from this procedure.

Apoptosis in perforated cornea of a patient with graft-versus-host disease

CASE REPORT

Although ocular complications associated with graft-versus-host disease (GVHD) can include corneal dysfunction, corneal perforation is not common. We report the presence of apoptotic cells in a perforated cornea of a patient with GVHD. A 72-year-old man with the angioimmunoblastic type of malignant lymphoma developed chronic GVHD after allogeneic peripheral blood stem cell transplantation. Despite systemic and topical treatment, both corneas perforated, and penetrating keratoplasty with cataract extraction and intraocular lens implantation was performed on both eyes.

COMMENTS

The corneal button excised from the right eye was examined histologically and stained for apoptotic cells by TdT-mediated dUTP nick end labeling (TUNEL). This revealed thinning of the epithelial cell layer and stroma, with cells, including lymphocytes, infiltrating to the site of the perforation. Some of the epithelial cells and keratocytes were TUNEL positive. The presence of apoptotic cells in our case suggests that apoptosis may be involved in the perforation of the cornea in patients with GVHD.

Fulminant Epstein-Barr virus (EBV)-associated T-cell lymphoproliferative disorder with hemophagocytosis following autologous peripheral blood stem cell transplantation for relapsed angioimmunoblastic T-cell lymphoma

Post-transplant lymphoproliferative disorder (PTLD) is a complication that can develop after either solid-organ or hematopoietic stem cell transplantation (HSCT). T-cell PTLD is a rare disorder, especially following autologous HSCT. Here we report a case of T-cell PTLD which occurred after autologous peripheral blood stem cell transplantation (PBSCT) for relapsed angioimmunoblastic T-cell lymphoma (AILT). Three months after the transplant, the patient developed fever with elevated plasma Epstein-Barr virus (EBV)-PCR values. The patient subsequently developed pneumonitis, hepatomegaly and marked pancytopenia due to hemophagocytosis. The patient died of multi-organ failure, despite antiviral and steroid pulse therapy. Our post-mortem study confirmed the marked proliferation of EBV-infected T-cells that differed from the original AILT clone and macrophages/histiocytes were observed in the marrow, liver, lymph nodes and lungs. Phagocytosis was most evident in the bone marrow. The patient's AILT remained in complete remission. To the best of our knowledge, this is the first case of fulminant EBV-associated T-cell lymphoproliferative disorder (LPD) following autologous HSCT.

Treatment of a Patient with a Nodal Peripheral T-Cell Lymphoma (Angioimmunoblastic T-Cell Lymphoma) with a Human Monoclonal Antibody Against the CD4 Antigen (HuMax-CD4)

A patient with a CD4+ refractory peripheral T-cell lymphoma (PTL), subtype angioimmunoblastic T-cell lymphoma (AILD), was treated with a human monoclonal anti-CD4 antibody (HuMax-CD4) iv once weekly for 10 wk. Early during treatment all palpable enlarged lymph nodes disappeared. A decline of normal CD4+ T-cells in the blood mirrored the treatment effect. Shortly after stopping treatment the patient relapsed with new enlarged lymph nodes. This time no antitumor effect was seen when HuMax-CD4 treatment was reinstituted. No severe side effects were observed during the antibody treatment. This case report is the first describing that HuMax-CD4 has antilymphoma activity in PTL and is an interesting drug to study further in patients with CD4+ PTL.

T-cell large granular lymphocytic leukemia occurring after autologous peripheral blood stem cell transplantation

A 61-year-old man with angioimmunoblastic lymphoma in first complete remission underwent autologous peripheral blood stem cell transplantation. At 1 month post transplant, asymptomatic large granular lymphocytosis developed. The surface marker profile of the cells was CD3+CD8+CD56-CD57+. The disease course was chronic and indolent. The patient remains in complete remission from angioimmunoblastic lymphoma more than 6 months post transplant with persistent large granular lymphocytosis (lymphocyte count, 5-15 x 10(9)/l). Although post transplantation T-cell lymphoproliferative disorders have mostly occurred in allogeneic transplantation recipients and presented as aggressive lymphomas/leukemias, we suggest that chronic indolent T-cell large granular lymphocytic leukemia can occur after autologous stem cell transplantation.

Long-term disease-free survival in patients with angioimmunoblastic T-cell lymphoma after high-dose chemotherapy and autologous stem cell transplantation

BACKGROUND AND OBJECTIVES

Patients with angioimmunoblastic T-cell lymphoma (AIL) have a poor prognosis with conventional treatment.

DESIGN AND METHODS

We initiated an EBMT-based survey studying the impact of high-dose chemotherapy (HDCT) and autologous hematopoietic stem cell transplantation in patients with AIL. Data on 29 patients, who were transplanted between 1992 and 1998 in 16 transplant centers, were collected on standardized documentation forms.

RESULTS

The median age at transplantation was 53 years. HDCT was given as part of 1st-line therapy (N=14; 48%) or 2nd/3rd-line therapy (N=15; 52%). Regimens for the mobilization of peripheral blood stem cells (PBSC) included VIPE (N=7; 26%), DexaBEAM (N=6; 22%), CHOP-like regimens (N=6; 22%), other regimens (N=5; 19%) or alternatively growth factor alone (N=3; 11%). The median yield of PBSC was 3.8x106 CD34+cells/kg. Two patients received autologous bone marrow. The HDCT consisted of BEAM-type regimens in 16 patients, ICE-type regimens in 7, and other regimens in 6 patients. There was one treatment-related death. The rate of complete remissions increased from 45% before HDCT to 76% after HDCT. As of January 2003, after a median observation time of living patients of 5 years (range 2.5 to 10 years), 14 patients have died (13 from progressive disease), and 15 patients are alive. The probability of 5-year overall and event-free survival was 44% (95% CI, 22% to 66%) and 37% (95% CI, 17% to 57%), respectively. Long-term disease-free survival was observed in patients transplanted during 1st-line treatment as well as in the context of 2nd/3rd-line therapy.

INTERPRETATION AND CONCLUSIONS

There is evidence that AIL is susceptible to high-dose chemotherapy. HDCT and autologous stem cell transplantation should be considered in selected patients with AIL.

Successful rituximab treatment of an EBV-related lymphoproliferative disease arising after autologous transplantation for angioimmunoblastic T-cell lymphoma

Rituximab treatment of B-cell lymphoproliferative disease following transplantation is being evaluated. We describe an Epstein-Barr virus-related B-cell lymphoma that developed in a 55-year-old woman, one year after autologous transplantation for relapsing angioimmunoblastic T-cell lymphoma. Complete remission was achieved after four cycles of rituximab and reduced-dose CHOP. This case is discussed in the context of severe immunodepression. Monoclonal anti-CD20 antibodies might restore a balance between T-cell immunosurveillance and EBV proliferation in B-cells,

[Angioimmunoblastic T cell lymphoma (AITL) with autoimmune thrombocytopenia]

We present a case of angioimmunoblastic T cell lymphoma (AITL) with autoimmune thrombocytopenia. A 85-year-old man was admitted to our hospital with thrombocytopenia, generalized lymphadenopathy, pleural effusion, and splenomegaly in June 2000. Blood chemistry revealed hemoglobin and platelet counts of 8.8 g/dL and 26 x 10(9)/L, respectively. The level of platelet-associate-IgG was 2568.9 ng/10(7) cells. The direct Coombs test was positive. The level of serum IL-6 was 10.2 pg/ml. Megakaryocytes in the bone marrow increased. Lymph node biopsy showed diffuse proliferation of atypical lymphoid cells with a clear cytoplasm accompanied by plasma cells and small vessels. He was diagnosed as having AITL with autoimmune thrombocytopenia and hemolytic anemia. He received repeated platelet transfusion, and a limited effect of prednisolone therapy on his platelet count was observed. Combination chemotherapy lessened the extent of the lymphadenopathy and slightly elongated the interval of platelet transfusion. We next performed splenic irradiation and a slight increase in the platelet count was observed. He died of pneumonia in August 2000. Autoimmune thrombocytopenia associated with AITL is rare and the therapy containing prednisolone and chemotherapy is reported to be partly effective. Our case showed a minor response of autoimmune thrombocytopenia to splenic irradiation. Therapeutic intervention for hypersplenism should be considered if thrombocytopenia is not improved by chemotherapy alone.

Successful treatment of post-transplant lymphoproliferative disorder in autologous blood stem cell transplant recipients

We report three cases of post-transplant lymphoproliferative disorder (PTLD) in the context of autologous stem cell transplantation (ASCT) for multiple myeloma (MM) and non-Hodgkin's lymphoma. The first two cases received ASCT for MM, one with a CD34-selected autograft and the other with an unmanipulated autograft. Both these cases of PTLD achieved a complete response following treatment with IVIG, gancyclovir, solumedrol and interferon (IFN). The third case received ASCT with an unmanipulated autograft for relapsed angioimmunoblastic lymphoma. He also achieved a complete response but only after rituximab was added to IVIG, gancyclovir, solumedrol and IFN. None of these patients experienced a relapse of their PTLD with follow-up ranging from 1.5 to 5 years. These cases highlight the importance of considering PTLD in the differential diagnosis of lymphadenopathy and fever post ASCT. They also demonstrate the possibility of durable complete remission of post-ASCT PTLD following antiviral and immune modulating therapy.

Acute myocardial ischemia after high-dose therapy with BEAM regimen

We describe a case of acute myocardial ischemia following carmustine treatment during the BEAM regimen. Despite this, full completion of the autologous peripheral stem-cell transplant was possible.

Intravenous cyclosporine and tacrolimus caused anaphylaxis but oral cyclosporine capsules were tolerated in an allogeneic bone marrow transplant recipient

A Japanese female patient with angioimmunoblastic T cell lymphoma underwent allogeneic bone marrow transplantation (BMT) from her brother. Cyclosporine at a dose of 3 mg/kg was started by continuous infusion over 24 h on day -1 of BMT. Within a couple of minutes after the infusion was begun, she developed diffuse pruritic erythema on her whole body and tachycardia. The infusion was immediately stopped and corticosteroid was given, resulting in disappearance of the erythema gradually. She was then switched to intravenous tacrolimus. However, she suffered urticalial erythema again. Since polyoxyethylated castor oil, a solubilizer used in the injective formulation of both cyclosporine and tacrolimus, is considered to be responsible for the reaction, she was given oral capsules of cyclosporine (Sandimmun) in which polyoxyethylated castor oil was not contained. No further anaphylactic reaction was observed. The BM cells were successfully engrafted without causing severe GVHD. She was discharged on cyclosporine capsules without any further adverse effects. Anaphylaxis to intravenous cyclosporine and tacrolimus is a very rare but a serious complication. Our present case indicates that oral capsule of Sandimmun is a safe alternative to prevent GVHD in such a case of anaphylactic reaction against intravenous formulation.

High-dose chemotherapy and APSCT as a potential cure for relapsing hemolysing AILD

Angioimmunoblastic lymphadenopathy with dysproteinemia (or dysgammaglobulinemia) (AILD) is a lymphoproliferative disorder with cytogenetic and molecular abnormalities characteristic of malignant T-cell lymphoma (angioimmunoblastic T-cell lymphoma -- AITL). We report the clinical course of a 58-year-old male patient with unusually aggressive AILD, including severe hemolysis and Guillain-Barré syndrome, who entered complete remission after CHOP therapy, but had a full relapse after 2 months. At relapse, treatment with high-dose chemotherapy followed by autologous peripheral stem cell transplantation (APSCT) with CD34 selected cells was shown to be successful. The patient is alive and disease-free 3 years after diagnosis and 32 months after APSCT. Considering the poor prognosis of the majority of patients with AILD, intensive treatment followed by APSCT, may be a subject for further studies.

[Angioblastic lymphadenopathy--its course and prognosis]

INTRODUCTION

In recent years important advances have been made in the understanding of angioimmunoblastic lymphadenopathy since substantial controversy has been related to the name, course, prognosis and therapy of the disease. It was first recognized in the Kil Classification as a low risk T-cell lymphoma [5], and omitted from the most widely used Working Formulation for clinical purposes. According to the criteria of REAL (Revised European American Lymphoma), classification angioimmunoblastic lymphadenopathy (AILD) is one of peripheral postthymic T cell lymphomas that are an immunologically defined category of non-Hodgkin's lymphomas originating from the peripheral lymphatic tissues. Morphologically, AILD is characterized by partially or completely obliterated sinuses and frequent infiltration of the pericapsular tissue and substantial proliferation of epithelioid, postcapillary venules. Cytologically, polymorphous cellular infiltration with immunoblasts, transformed lymphoid cells, polyclonal plasma cells, eosinophils and epithelioid cells are found. Clinically, rapid occurrence of systemic symptoms in elderly individuals (sixth and seventh decades of life) with generalized lymphadenopathy, hepatosplenomegaly and cutaneous maculo-papulous or erythematous rash is noted. The patients are characterized with hyperimmune condition in the form of Coombs' positive haemolytic anaemia, polyclonal hypergamma-globulinaemia and liability to infections [8, 9]. In spite of numerous suggestions, therapeutic consensus has not been achieved, and the reported survival ranges from 1 to 30 months [10, 11]. Therefore, this information suggests an aggressive form of the disease with the 60% mortality rate.

METHODS

At the Institute of Haematology of the Clinical Centre of Serbia in Belgrade in the last five years, from 1993 through August 1998, nine patients were diagnosed with AILD according to the results of pathohistological examination of the extirpated peripheral lymph nodes and the correlation with clinical picture and relevant laboratory findings.

RESULTS

Clinical characteristics of nine patients in whom AILD was diagnosed after lymph node biopsy are given in Table 1. The group consisted of 6 men and 3 women, mean age 53. Eight patients were in advanced stage of the disease at the time of the diagnosis (III and IC CS), while the patient in II CS stage had a large tumorous mass (M+). All patients had initial systemic symptoms. Five of them developed fever with chills. Three patients had evidence of extranodal infiltration of the bone marrow. Infiltration of the liver was suspected in two patients according to aberrant hepatogram values, although pathohistological verification was not obtained. In one patient lung infiltration was histologically verified in addition to bone marrow and liver infiltration. All patients had peripheral lymphadenopathy, and most of them hepatosplenomegaly, as well. Three patients had the so called bulky form of the disease since the diameter of the largest tumour exceeded 10 cm. On admission, most were in poor overall condition, and only two were apparently healthy. Knowing that AILD is basically an immunoregulatory disease and that the described cases of association with systemic diseases of the connective tissue and some drugs were implied in the triggering of AILD, Table 2 shows important information obtained form histories of these patients. Namely, 7 of 9 patients had cutaneous changes suggestive of erythematous or maculopapular rash, while three had received corticosteroid therapy for months before AILD was diagnosed since toxoallergic exanthema had been incorrectly suspected. Three patients received gold sodium thiosulfate therapy for rheumatoid arthritis, while four had history of allergy to drugs and pollen. Table 3 shows laboratory results: anaemia was present in 8 of 9 patients, it was severe in three with haemoglobin values of 67 g/L, 72 g/L and 50 g/L, respectively. Five patients had haemolysis. A

Retropharyngeal lymphadenopathy in patients with nasopharyngeal carcinoma: a computed tomography-based study

BACKGROUND

The purpose of this study was to investigate the incidence and prognostic value of retropharyngeal lymphadenopathy in nasopharyngeal carcinoma patients using contrast enhanced computed tomography (CT).

METHODS

From January 1989 to December 1991, 364 patients with newly diagnosed nasopharyngeal carcinoma without distant metastasis had a baseline CT performed. All patients had radiotherapy as their primary treatment. Eighty-seven patients also received neoadjuvant chemotherapy for locally advanced disease. All patients with clinical N0 disease had prophylactic lymph node irradiation. The contrast enhanced CT given prior to all treatment was evaluated for the presence of retropharyngeal lymphadenopathy. Criteria for involved lymph nodes included a lymph node size of 10 mm or more, the presence of central necrosis within the lymph node, or the presence of a contrast enhancing rim.

RESULTS

The incidence of retropharyngeal lymphadenopathy was 29.1%. A higher incidence of retropharyngeal lymph node involvement was observed in Ho's T2/T3 disease compared with T1 disease, and a higher incidence was also found in patients with cervical lymph node disease compared with those with clinical N0 disease. No significant differences in relapse free survival rates, local control rates, lymph node control rates, or distant failure rates were observed between patients with or without retropharyngeal lymphadenopathy after adjusting for T and N classifications. In 134 patients with clinical N0 disease, retropharyngeal lymphadenopathy was found in 21 patients, whereas 113 had no evidence of retropharyngeal lymphadenopathy. However, no significant difference in treatment outcome was observed between the two groups.

CONCLUSIONS

Using CT imaging, the presence of retropharyngeal lymphadenopathy in patients with nasopharyngeal carcinoma does not appear to affect the prognosis. In patients with clinical N0 disease, the identification of retropharyngeal lymphadenopathy based only on CT imaging is not sufficient evidence for an N1 classification.

Significance of cytogenetic findings for the clinical outcome in patients with T-cell lymphoma of angioimmunoblastic lymphadenopathy type

PURPOSE

The aim of this study was to evaluate the significance of cytogenetic findings for the clinical outcome of patients with Angioimmunoblastic Lymphadenopathy (AILD)-Type T-cell lymphoma.

MATERIALS AND METHODS

In a retrospective analysis, the cytogenetic findings of 50 patients with AILD-type T-cell lymphoma were correlated with the frequency of spontaneous and therapy-induced remissions and with survival using the statistical methods of Kaplan and Meier and the model of Cox for multivariate analysis. Treatment was not uniform because the patients were treated in different hospitals during a period of 8 years and because a standard therapy has not yet been established.

RESULTS

The following cytogenetic findings were associated with a significantly lower incidence of therapy-induced remissions and a significantly shorter survival duration: presence of aberrant metaphases in unstimulated cultures (P = .04 for both parameters); clones with an additional X chromosome (P = .0001 and P = .03, respectively); structural aberrations of the short arm of chromosome 1, preferentially involving 1p31-32 (P < .001 and P = .04, respectively); and complex aberrant clones with more than four aberrations (P = .0003 and P = .005, respectively). Multivariate analysis showed that these cytogenetic findings had a significant influence on survival, but therapy modalities did not. Only the presence of complex aberrant clones was an independent prognostic factor. Trisomy 3 had no effect on survival, but patients without trisomy 5 (P = .08) tended to live longer.

CONCLUSION

This is the first study that seems to indicate that cytogenetic findings have prognostic significance in AILD-type T-cell lymphoma. These results must be proven in prospective studies of homogeneously treated patients.

Immunoblastic lymphadenopathy in a five-month-old girl: successful treatment with immunosuppressants

A five-month-old girl developed high fever, erythema, hepatosplenomegaly and generalized lymphadenopathy. Laboratory examinations revealed elevated peripheral leukocyte counts, C-reactive protein, lactate dehydrogenase and serum ferritin level. Pathologic examination of the lymph nodes revealed immunoblastic lymphadenopathy (IBL) on the basis of the complete effacement of the normal architecture, replacement by a diffuse infiltrate composed of immunoblasts, plasmacytoid cells and small lymphocytes, and an abortive proliferation of blood vessels. B-cells and T-cells were nearly equally mixed throughout the lymph nodes. No rearrangements of the B-cell immunoglobulin and T-cell receptor genes were detected. The patient was initially treated with alpha-interferon with dramatic efficacy. After relapse, however, the disease was well controlled with cyclosporin A (CyA) and subsequently with combination regimens of CyA, deoxyspagarin and azathioprine with fair success. An alternating regimen of 6-mercaptopurine, cyclophosphamide and methotrexate was then instituted which continued the complete remission for 12 months. The effects of immunosuppressants in the treatment of IBL merit investigation.

[Angioimmunoblastic lymphadenopathy with dysproteinemia: personal experience with 3 cases and review of the literature]

OBJECTIVE

We report personal experience on 3 cases of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD). We stress the prognostic and therapeutic aspects of this rare disease, that remain still unclear in recent literature.

DESIGN

We performed a retrospective study on 3 cases of AILD, with a mean follow-up of 32.6 months (range 30-36).

SETTING

Internal Medicine Unit.

PATIENTS

We observed three patients, 2 males and 1 female, with a mean age of 65 years (range 51-72), with AILD confirmed by histopathological exams and evidence of unfavorable prognostic features at the time of diagnosis.

INTERVENTIONS

2 patients received polychemotherapy with cyclophosphamide+prednisone; cyclophosphamide + vincristine + prednisone. One patient was treated with low doses of prednisone (25 mg/day).

MEASUREMENTS

We evaluated the degree of response (absent, partial, complete) an the time of survival (< 18 months or > 24 months).

RESULTS

Response to therapy was partial in all patients; 1 patient underwent a severe bone marrow depression. All patients were alive for more than 24 months.

CONCLUSIONS

The clinical course was independent of therapy (intensive or symptomatic) and prognostic criteria in all 3 patients. At present AILD is considered as a potentially malignant disease. Polychemotherapy must be used as a first choice treatment.

High-dose chemotherapy and autologous bone marrow transplantation in relapsing angioimmunoblastic lymphadenopathy with dysproteinemia (AILD)

Angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) or lymphogranulomatosis X is a lymphoproliferative disorder with a histological picture resembling that of reactive lesions but with frequent cytogenetic and molecular abnormalities characteristic of malignant T cell lymphoma. Clinically, the disease runs a fatal course in the majority of patients although occasional spontaneous remissions have been observed. Median survival approaches only 1 year even with the most effective treatment protocols implemented so far. Fewer than 20% of patients survive 5 years after diagnosis and cure seems exceedingly rare. High-dose chemotherapy (HDCT) followed by autologous bone marrow transplantation (ABMT) represents a promising new treatment modality for patients with advanced lymphoma conceivably including AILD. We report the first patient with relapsed AILD successfully treated by HDCT and ABMT. This 21-year-old male is alive and free of disease 27 months after ABMT with a Karnofsky score of 100%.

[IBL-type lymphadenopathy after infection of rubella virus]

A 52-year-old woman presented slight fever, diffuse papular skin rash and painful cervical lymph node swelling. Her lymph node swelling generally up to 3 cm in diameter, with petechiae on the lower legs and hepato-splenomegaly within a few weeks. ESR was 45 mm/h, Hb 10.0 g/dl, RBC 345 x 10(4)/microliter, WBC 22,600/microliter (atypical lymphocyte 47%), PLT 1.0 x 10(4)/microliter, GPT 91 U/L, gamma-globulin 34.3%, EBV-VCA x 2,560, EBNA x 20, and anti-rubella antibody x 512. The biopsied cervical lymph node showed histologic features of effacement of nodal architecture by an exuberant vascular proliferation accompanied with infiltration of the immunoblasts, and was diagnosed as immunoblastic lymphadenopathy (IBL)-type lymphadenopathy. The pulse therapy of methylprednisolone and high dose of gamma-globulin improved lymphadenopathy, thrombocytopenia and anemia. IBL-type lymphadenopathy after infection of rubella virus may be different from true IBL, but is important to discuss the pathogenesis of IBL.

[A remarkable effect of alpha-interferon in a case of angioimmunoblastic lymphadenopathy with dysproteinaemia (AILD) refractory to steroids and combination chemotherapies]

We experienced a remarkable effect of recombinant interferon alpha 2a (alpha-IFN) in a case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) which was refractory to steroids and combination chemotherapies. A 62 year-old woman was admitted because of high grade fever and extreme swelling of cervical lymph nodes. Poly-clonal hypergammaglobulinemia and plasma cell-like atypical lymphocytosis in the peripheral blood were demonstrated. Cervical lymph node biopsy disclosed histology of AILD. She initially responded well to prednisolone. Three months later, AILD relapsed in spite of prednisolone treatment. She received combination chemotherapies and responded well again. Seven months later, she became refractory to these combination chemotherapies. Consequently, we tried alpha-IFN (3 million units/day given intramuscularly). She became afebrile on the next day, and lymph nodes swelling gradually disappeared. She has been free from the disease for more than three months.

[Angioimmunoblastic lymphadenopathy with dysproteinemia]

Angioimmunoblastic lymphadenopathy with dysproteinemia. Angioimmunoblastic lymphadenopathy with dysproteinemia is a lymphomatous-like disease associated with typical anatomopathological features of the lymph nodes and severe dysproteinemia. The clinical course is variable. Acquired immunodeficiency, oral infections, neoplastic development are frequently present. The evolution of the disease is also variable; spontaneous resolution as well as lethal complications are possible. No specific therapy is available. There are conflicting opinions about the nosographic statement of angioimmunoblastic lymphadenopathy among benign lymphadenopathy and lymphomas.

Combined treatment of autoimmune MRL/Mp-lpr/lpr mice with cholera toxin plus irradiation. Combined treatment of autoimmune MRL/l mice

MRL/Mp-lpr/lpr (MRL/1) mice spontaneously develop autoimmune diseases like systemic lupus erythematosus (SLE) from 2 months of age, accompanied by massive lymphadenopathy. Such mice of 2 months of age were treated with 1 microgram cholera toxin (CT) every 7 days and/or with 400 rad of one-shot 60Co irradiation. CT treatment alone markedly improved nephritis as evaluated by proteinuria and moderately suppressed lymphadenopathy and anti-DNA antibody production, while irradiation alone prominently improved lymphadenopathy but showed little effect on both nephritis and anti-DNA antibody production. On the other hand, when mice were treated with the combination of CT plus irradiation, autoimmune nephritis as well as anti-DNA production and lymphadenopathy were almost completely inhibited. Taken together, each agent exerts the improvement effect at the different points from each other in an abnormal immunological circuit displayed in MRL/1 mice. This kind of combined treatment may be applicable to the clinical use for autoimmune diseases.

Angioimmunoblastic lymphadenopathy with dysproteinemia: report of a case in infancy with review of literature

A case of angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) in infancy is reported. The disease had a mild onset with generalized lymphadenopathy, hepatosplenomegaly, thrombocytopenia, polyclonal hypergammaglobulinemia, and T-cell deficiency. The AILD course lasted more than 100 months, alternating clinical remission to recurrent relapses. Hepatitis B viral infection suddenly evolving to hepatic failure was the cause of death. From a rapid survey of the present knowledge, the nosology, immunological features, and therapy of AILD are discussed and a possible presumptive pathogenetic pathway is proposed.

Effect of cyclophosphamide therapy on oncogene expression in angioimmunoblastic lymphadenopathy

The expression of four cellular oncogenes was studied by means of northern blot analysis of messenger RNA in peripheral-blood mononuclear cells from patients with angioimmunoblastic lymphadenopathy (AILD). On average, cells from patients with AILD and from those with systemic lupus erythematosus (SLE) expressed significantly more N-ras and significantly less c-fos mRNA than did cells from healthy controls. Expression of these cellular oncogenes was most abnormal in patients with the most severe disease. In contrast, increased levels of c-myc mRNA were found in patients with SLE but not in those with AILD. Administration of cyclophosphamide to patients with AILD was followed by return to normal of both N-ras and c-fos expression.

Angioimmunoblastic lymphadenopathy

Angioimmunoblastic lymphadenopathy often begins with constitutional symptoms, such as fever, malaise, and weight loss. Most patients have generalized lymphadenopathy, and about 40 per cent have skin lesions with maculopapular erythema, purpura, urticaria, or exfoliative erythroderma. Lymph-node biopsy specimens demonstrate the most characteristic histopathologic features: extensive effacement of lymph nodal architecture; a pleomorphic population of immunoblasts, plasma cells, lymphocytes, and eosinophils; interstitial deposits of eosinophilic material; and prominent vascular proliferation, with "arborization" of small vessels. The pathogenesis of angioimmunoblastic lymphadenopathy is still unknown, but its histopathologic features and laboratory findings strongly suggest that it is an immunologically mediated disorder. Some clinical and laboratory evidence supports the possibility that angioimmunoblastic lymphadenopathy is a benign reactive or proliferative process, whereas other studies suggest that it might be a malignant disease. In some patients, it can develop into immunoblastic sarcoma or other types of malignant lymphoma or leukemia. It is probably reasonable to consider angioimmunoblastic lymphadenopathy a prelymphomatous state of immunoblastic sarcoma.

Plasmapheresis in a patient with angioimmunoblastic lymphadenopathy. Improvement in clinical and immunologic abnormalities

A patient with steroid resistant, allergen related angioimmunoblastic lymphadenopathy underwent a course of six plasmaphereses during a three-week period. A 75% reduction in lymph node size along with the disappearance of her night sweats occurred. Immunologic abnormalities prior to plasmapheresis included the presence of elevated levels of circulating immune complexes, high levels of spontaneous mononuclear cell blastogenesis and abnormal mitogen responses to Conconavalin A and phytohemagglutinin. Following plasmapheresis there was a marked reduction in immune complex levels, and return of spontaneous blastogenesis and mitogen responses to normal levels. Mechanisms for the beneficial effect seen in this patient include removal of: (1) the antigenic stimulus; (2) antigen antibody complexes; and (3) other humoral factors which may modulate lymphocyte or macrophage function. Additional studies of plasmapheresis are warranted in selected patients with allergen related AIL.