Nasal Angiocentric Lymphoma With Hemophagocytic Syndrome

The Korea n J ourna l of Inte rnal Me dic ine Vol. 14, No. 2, J uly, 1999

N a s a l A n g io c e n t r ic Ly m p h o m a W it h He m o p h a g o c y t ic S y n d r o m e J i- Yo u n Ha n , M .D. , Eu n J o o S e o *, M .D. , Hi J e o n g Kw o n *, M . D. Ki O u k M in *, M .D. , J u n g S o o Kim **, J in Hy u n g Ka n g , M .D. Yo u n g S e o n Ho n g , M .D. , Ho o n- Ky o Kim , M . D. , Ky u n g S h ik Le e , M .D. De p a rt m e nt o f Int e rn a l M e d ic in e , Clin ic a l Pa t h o lo g y *, T h e Ca t h o lic U n iv e rs ity o f Ko re a Co lle g e o f M e d ic in e , Ca t h o lic Ca n c e r Ce nt e r, C lin ic a l R e s e a rc h La b o rat o ry o f S t . Pa u l 's Ho s p it a l **, S e o u l, Ko re a O bj e c t iv e s ：He m o p h ag o cy t ic s y n d ro m e ( HS ) is a f a t a l c o m p lic a t io n o f n a s a l a ng io c e n t ric ly m p h o m a (A L) a n d d if f ic u lt t o d is t in g u is h f ro m m a lig n a nt h is t io cy o s is . Ep s t e in - Ba rr v iru s ( E BV ) -a s s o c iat e d HS is f re q u e n t ly o b s e rv e d in ly m p h o m a o f T -c e ll lin e ag e a n d E BV is h ig h ly a s s o c ia t e d w it h n a s a l A L. Clin ic o p at h o lo g ic f e at u re s o f 1 0 n a s a l A Ls w it h HS w e re re v ie w e d t o d e t e rm in e t h e c lin ic a l s ig n if ic a n c e a n d t h e p a t h o g e n e t ic a s s o c ia t io n w it h E BV . M e t h o d s ： T e n p at ie nt s o f HS w e re id e nt if ie d f ro m a re t ro s p e ct iv e a n a ly s is o f 4 2 n a s a l A Ls d iag n o s e d f ro m 1 9 8 7 t o 1 9 9 6 . Im m u n o h is t o c h e m ic a l s t u d y a n d in s it u hy b rid iz at io n w e re p e rf o rm e d o n t h e p a ra f f in -e m b e d d e d t u m o r s p e c im e n s o b t a in e d f ro m 1 0 p at ie nt s . S e ro lo g ic s t u d y o f E BV -A b w a s p e rf o rm e d in 3 a v a ila b le p a t ie nt s . Re s u lt s ：Fiv e p a t ie nt s h a d HS a s in it ia l m a n if e s t at io n , 3 a t t h e t im e o f re la p s e a n d 2 d u ring t h e c lin ic a l re m is s io n o f A L. Fo u r p at ie nt s w e re t re a t e d by c o m b in a t io n c h e m o t h e ra p y ( CHO P) a n d o t h e rs h a d o n ly s u p p o rt iv e c a re . T h e m e d ia n s u rv iv a l o f a ll p a t ie nt s w it h HS w a s 4 . 1 m o nt h s ( ra n g e 2 d ay s -3 6 . 5 m o nt h s ) a n d a ll h a d f at a l o u t c o m e re g a rd le s s o f t h e t re at m e nt - m o d a lity . A ll c a s e s w e re p o s it iv e f o r UC HL 1 ( C D4 5 R O) a n d E BV by E BER in s it u hy b rid iza t io n . T h e d a t a o f s e ro lo g ic t e s t s in d ic at e d t h e a ct iv e E BV inf e ct io n . Co nc lu s io n s ：HS is a f a t a l c o m p lic a t io n o f n a s a l A L a n d h a s a h ig h a s s o c iat io n w it h E BV . Re a c t iv a t io n o f E BV m ay c o n t rib u t e t o HS a n d f u rt h e r in v e s t ig a t io n o f p re d ict iv e f a c t o rs a n d e f f e ct iv e t re at m e nt o f HS s h o u ld b e p u rs u e d in t h e f ut u re . ──────────────────────────────────────────────── Ke y W o rd ：A ng io c e nt ric ly m p h o m a , He m o p h a g o cy t ic s y n d ro m e , Ep s t e in - Ba rr v iru s

INT RO DUCT IO N Hemophagocytic syndrome (HS) is a systemic disease characterized by fever, pancytopenia, hepatosplenomegaly, lymphadenopathy, coagulopathy and histologically proliferation of histiocytes in the lymphoreticular system1 , 2 ) . It is usually associated with viral infection such as EBV, cytomegalovirus and adenovirus in the immunocompromised patients 3 , 4 ) . Recently, it has been reported that Address reprint requests to : Dr. Ji- Youn Han, 620-56 Jeonnong- Dong, Dongdaem un- Gu, S eoul 130- 022, Korea

EBV- associated HS is frequently observed in lymphoma of T- cell lineage and s hows fatal outcome 5 , 6 ) . It is difficult to distinguish HS from malignant histiocytosis (MH) and providing the suggestion of previously diagnosed MH may include HS in T- cell lymphoma. MH is a systemic malignancy derived from cells of the mononuclear phagocytic system and the essential diagnostic features include disseminated and progress ive proliferation of morphologically atypical histiocytes and presence of phagocytosis by these neoplastic cells. HS has the similar clinical manifestations, but the cytologic atypia in hemophagocytic cells is not present7 ) . Nasal angiocentric lymphoma(AL) has been classified as a peripheral T- cell

41

J.Y. HAN, E.J. SEO, H.J. KWON, K.O. MIN, J.S. KIM, J.H. KANG, Y.S. HONG, H.K. KIM, K.S. LEE

lymphoma, but recently classified as nasal or nasal type T/NK cell lymphoma and highly infected with EBV8 , 9 ) . MH- like HS does not infrequently occur in nasal AL and usually has a rapidly fatal course 8 ) . We recently experienced a patient with nasal AL in whom, as a terminal event, a syndrome mimicking MH developed. In this study, we retrospectively analyzed AL with HS which had initially been suspected of having MH to assess the clinical significances and the pathogenetic association with EBV, and that would help to change our concept of MH and distinguis h HS from MH.

MAT ER IA LS A ND MET HO DS - Patients From 1987 to 1996, a total of 42 patients admitted to Catholic Cancer Center were established to have nasal AL. Ten of 42 patients showed HS during the clinical course of AL. The diagnosis of HS was based on a combination of the following clinicopathologic features: fever and s plenomegaly, cytopenia of at least two hematopoietic series, and over 2% of hemophagocytic histiocytes in the bone marrow1 , 1 0 ) . All patients underwent computed tomography of PNS and abdomen, plain chest X- ray and bone marrow examinations; they were staged according to the Ann- Arbor system1 1 ) . The clinical and laboratory records were reviewed retrospectively. - Diagnos is of a ngioce ntric lymphoma The histopathologic diagnosis of AL was done by examination of paraffin- embedded tumor section with hemotoxylin- eosin stain. For immunophenotypical study, sections of the paraffin- embedded blocks were cut at 6 m thickness and stained with s pecific monoclonal antibodies by the avidinbiotin complex (ABC) peroxidase methods described previously1 2 ) . Mouse anti- human T- cell(CD45RO)(DAKO Carpinteria, CA) and Mouse anti- human B- cell(IgG2a)(DAKO Carpinteria, CA) were used for immunophenotyping of T and B lineage, respectively. - Association of a ngioce ntric lymphoma with EBV 1) S e rologic study of EBV-antibodies (Ab) Serologic tests of IgG and IgM Abs against EBV- viral capsid antigen (VCA), early antigen (EA) and Abs against

42

EBV nuclear antigens (EBNA) were performed in three available patients us ing the indirect immunofluorescence methods as previously described1 3 ) . 2) In s itu hybridization (IS H) The EBV RNA in situ hybridization studies were performed in 10 patients using biotinylated 26bp oligonucleotides (Research Genetics) complementary to the most abundant early RNA sequence in EBV infections. 6 m sections cut from paraffin block, placed on organos ilane pretreated glass slides, were deparaffinized, dehydrated, predigested with pepsin solution and hybridized for 30 min at a concentration of 0.5 g/ml of probe. After washing and blocking of endogenous peroxidase, detection was accomplished using streptavidin alkaline- phosphatase conjugate followed by development of signal with stable fast red TR/stable naphthol phosphate(Research Genetics) and counterstaining with hemotoxylin. A red color within the nucleus over background levels was considered as a positive reaction. A known EBV- positive neoplasm was a positive control and an EBV- negative lymphoid tissue was a negative control in each run. - S urviva l The duration of overall survival was from the date of diagnosis of AL to the date of death or last follow- up. S urvival duration from the diagnosis of HS was from the date of diagnosis to the date of death.

RES ULTS Patie nts' clinical features The basic clinical features and scheme of all patients were summarized in Table 1. There were 6 male and 4 female patients with median age of 43 years (range 23- 63 years). The initial clinical stage of lymphoma were stage I (2 cases), II (3 cases), III (3 cases) and IV (2 cases). Five patients had HS as initial manifestation, three at the time of relapse of lymphoma, and two during the clinical remission of lymphoma. Four patients were treated with CHOP (cyclophosphamide, doxorubicin, vincristine and prednisone) chemotherapy and six had only supportive care. All cases s howed rapidly fatal outcome and there was no significant difference depending on the methods of management. The median

NASAL ANGIOCENTRIC LYMPHOMA WITH HEMOPHA GOCYTIC S YNDR OME

survival time from the diagnosis of HS of all patients , supportively cared patients and patients with CHOP, was 18 days (range 2- 44 days), 18 days (range 2- 27 days), and 19.5 days (range 14- 44 days), respectively. The estimated median survival from the date of original diagnosis of AL was 4.1 months (range 2 days- 36.5 months).

DIS C US S IO N We recently experienced a patient with MH- like HS in nasal AL as a terminal event. HS has the similar clinical manifestations of MH and is difficult to distinguish from MH. Recently reassessment of patients previous ly diagnosed as having MH revealed that most cases were lymphoma of T- cell lineage or other, such as a

Ta ble 1. Patie nts ' c linic a l fe ature s

Patie nt No Age/Sex

Initia l CS

Prima ry Tx

Dx of HS

Duration from Tx of HS origina l Dx to HS(M)

Outcome

Surviva l from HS (D)

1

5 1/M

Ⅲ

No

at origina l Dx

0

s upportive

died

20

2

63/M

Ⅲ

No

at origina l Dx

0

CHOP

died

25

3

38/M

Ⅳ(skin)

No

at origina l Dx

0

s upportive

died

2

4

57/M

Ⅲ

No

at origina l Dx

0

s upportive

died

27

5

3 1/M

Ⅳ(BM)

No

at origina l Dx

0

s upportive

died

16

6

43/M

Ⅱ

XRT

at re lapse

19

CHOP

died

44

7

23/F

Ⅰ

XRT

at re lapse

36

CHOP

died

14

8

30/F

Ⅰ

XRT

at re lapse

9

CHOP

died

14

9

42/F

Ⅱ

CHOP

during re mission

7

s upportive

died

7

10

45F

Ⅱ

CHOP

during re mission

10

s upportive

died

21

CS：clinica l stage , Tx：treatme nt, BM：bone ma rrow, HS：he mophagocytic syndrome , Dx：diagnosis CHOP：cyclophospha mide , doxorubicin, vincristine , prednisone, XRT：radiation the rapy

Histopathologic features Polymorphic cellular composition was observed in six cases and the other 4 cases had relatively monomorphic compos ition. Angiocentricity was observed in 4 cases , and necrosis was in all cases. Immunophenotypical studies showed that all cases expressed T- cell phenotype. Representative histologic pictures of lymphoma and bone marrow of HS are shown in Fig. 1, 2, and 4, 5, respectively. Association of angiocentric lymphoma with EBV The serological tests in three available patients were as follows; positive anti- EBNA Ab, positive anti- VCA IgG Ab(titer over 1:640), and positive anti- EA IgG Ab(1:320), which indicated the active infection of EBV. In all cases, the EBV transcripts were seen in the nudei of the atypical cells by in situ EBER hybridization (Fig. 3).

Fig . 1. Medium- sized or la rge atypica l ce lls with pleomorphic features a nd a n occasiona l promine nt nucleolus(H & E sta in, X 200).

virusassociated HS 14 ) . Retrospective analysis in our center revealed that 11 of a total 16 patients (from 1987 to 1996), with MH previous ly diagnosed, were MH- like HS. Nine of 11 patients, initially suspected as MH, were caused by nasal AL(data not shown). 43


Fig . 2 . UCHL1(CD45RO) expression on atypica l lymphoid ce lls(Hae matoxylin counte rsta ining, X 100).

Fig . 4 . BM aspiration cytology shows increased histiocytes(a rrow) (Wright sta in, X 200).

Fig . 3 . Nuclea r sta ining of the atypica l lymphoid ce lls afte r EBER in situ hybridization(Haematoxylin countersta ining, X 200).

Fig . 5 . Histiocyte shows he mophagocytosis of normoblast & segme nted ne utrophil(wright sta in, X 400).

Nasal AL which has the histologic feature of angiocentricity has been classified as a peripheral T- cell lymphoma but, recently, it is proving that it may include true natural killer (NK) cell lineage8 , 9 ) . Although angiocentricity is common to these tumors, it is not universally seen and the term AL has proved confus ing. Therefore, it is proposed that the term nasal or nasal type T/NK cell lymphoma should replace AL as a choice 8 ) . In this study, we only used pan T- cell marker(CD45RO) to distinguish from B- cell and all showed T- cell phenotype and it did not perform NK- cell phenotying due to lack of fres h specimens. More phenotypical studies including immunophenotyping and T- cell receptor gene rearrangement would be needed to distinguis h the true T- cell lymphoma from NK- cell lymphoma. In this histologic study, necrosis and cellular polymorphism were a more common feature than 44

angiocenricity and monomorphism, respectively. HS was originally described in immunocompromised patients with viral infection3 ) . Among various infectious agents, herpes virus , especially EBV, has been frequently implicated in the pathogenesis of VAHS3 , 1 5 ) . EBV is a ubiquitous Herpes virus with tropis m for B- lymphocytes and oropharymgeal epithelium and has a strong association with endemic Burkitt's lymphoma, B- cell lymphoproliferative lesions in immunocompromised patients and nasopharyngeal carcinoma 13 , 1 6 ) . But recently, it appears that EBV has also been linked to about 40% of peripheral T- cell lymphoma and Hodgkin's disease 17 - 1 9 ) . EBV is also more regularly detected in more than 80 % of nasal AL and, in these tumors, virtually all tumor cells harbour the virus. In this study, the presence of EBV was detected in all cases, particularly in most of the atypical lymphoid cells by the in situ hybridization, and

NASAL ANGIOCENTRIC LYMPHOMA WITH HEMOPHA GOCYTIC S YNDR OME

the serologic test in three case indicated active infection. Although a causal relationship between EBV and AL is still undefined, the characteristic clinicopathologic features strongly s uggest that EBV may contribute to the lymphomagenesis and the biologic features of AL and in situ hybridization and serologic study would be helpful for diagnosis and prediction of AL with HS 8 , 1 3 ) . The mechanism of HS in AL is not fully understood yet, but it is thought to be caused by the cytokines, es pecially interferon- , tumor necrosis factor and interleukin- 1 released from EBV infected lymphocytes 2 0 , 2 1) . Further evaluation of the EBV- viral oncogenes and the microenvironment in HS would be needed to define the pathogenesis and the role of EBV in these tumors . HS contributes to the high mortality of AL and usually has rapidly fatal outcome 6 , 2 2 ) . It is difficult to predict HS in the course of nasal AL, but symptomatic recurrence and the histologic progression of the primary nasal lesion may be candidates. So, the repeated biopsy of the nasal lesion in symptomaticaly recurrent patients would be essential. In this study, most HS was developed in the active disease- status, but also even in the clinical remiss ion of two cases. We could not confirm the postmortem pathologic staging of all cases due to lack of the autopsy- specimen. However, Jaffe et al.7 ) had reported that malignant lymphoma with erythrophagocytosis simulating MH had prevalence of lymphoma- involvements in lymph nodes , spleen, liver, lung, skin and kidney and hepatosplenomegaly was a common feature in all cases of HS, even in the patients with clinical remission. Therefore, pathologic staging, including laparoscopic biopsy, would be needed for the exact staging of lymphoma with MH- like HS. There is no effective treatment for HS and, in literatural review, the combination of high- dose intravenous immunoglobulin and etoposide or high dose steroid were effective in some cases of HS 2 , 6 , 2 3 ) . Smith et al.2 4 ) described a young patient successfully treated with CHOP chemotherapy in the early phase of the clinical course. But, in this study, all patients showed as rapidly progressing into the fulminant course despite CHOP chemotherapy or palliative steroid pulse therapy. It seems that more aggressive treatment is needed in this condition and further investigation of the pathogenesis and biology of AL with HS should be pursued in order to improve the prognosis.

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