Hepatosplenic Gammadelta T-cell Lymphoma Research Articles

Targeting T-Cell Lymphoma Using CD70-Directed Cord Blood-Derived CAR-NK Cells

T-cell lymphomas (TCL) are a heterogenous group of non-Hodgkin lymphoma characterized by resistance to conventional therapies posing an urgent need for safe and effective therapies. CAR-NK cells have emerged as a promising “off-the-shelf” cancer immunotherapy and are especially attractive for the treatment of T-cell malignancies. This is especially the case given the challenge of targeting T cell malignancies with CAR T cells due to shared antigens across the therapeutic, normal and malignant T cells posing the risk of CAR T cell fratricide, T-cell aplasia, and contamination of the CAR T products with malignant T cells. We have developed an FDA-approved system for ex vivo NK cell expansion, which reliably generates clinically relevant doses of GMP-grade NK cells from a cord blood (CB) unit. We have used this platform to engineer NK cells to express a CAR targeting CD19 using GMP-grade retroviral vectors and demonstrated the safety and efficacy of this platform in the clinic. We now propose to expand this approach to target TCL. CD70, a surface ligand of CD27, is overexpressed in a variety of cancers, including TCL. Signaling mediated by CD70-CD27 is thought to induce proliferation of TCL cells via activation of the NF-κB pathway. Thus, CD70 is an attractive target for CAR NK-cell therapy against TCL. We analyzed the publicly available primary TCL dataset (GSE19069) including anaplastic large cell lymphoma (30 samples), angioimmunoblastic TCL (37 samples), peripheral TCL (PTCL; 50 samples), and adult T cell leukemia/lymphoma (13 samples) for CD70 expression. The majority of the samples expressed CD70 transcript with a variable level of expression ( Figure 1). Using flow cytometry, we screened a panel of TCL cell lines with diverse histologic, cytogenetic and molecular properties for the expression of CD70. We demonstrated positive CD70 expression on most of the TCL cell lines profiled encompassing anaplastic large cell lymphoma (ALK+: KAR299; ALK-: MAC2A; fusion gene NPM-ALK+: SU-DHL1 and SUP-M2), hepatosplenic gamma-delta TCL (DERL-7), Sezary syndrome (SS; H9 and HuT78), and PTCL NOS (OCI-LY12). The CD70 intensity was highest on MAC2A, HuT78, KAR299 and SUP-M2, intermediate to low on DERL-7 and H9, and negative on SU-DHL1 and OCI-LY12. We designed a novel retroviral vector targeting CD70 that: 1) encodes the CD70-targeting CAR gene based on the CD27 extracellular domain; 2) ectopically produces interleukin (IL)-15 to support NK cell proliferation; and 3) expresses the suicide gene inducible caspase 9 ( iC9) that can be pharmacologically activated to eliminate transduced cells in the event of toxicity. The construct will be referred to as CAR.70/IL-15. Non-transduced (NT) NK cells and NK cells transduced with a construct that leads to IL-15 production without a CAR (IL-15 NK cells) were used as controls. We demonstrated that CAR.70/IL-15 NK cells had a significantly enhanced cytotoxicity compared to NT- and IL-15 NK cells against the CD70+ cell lines while there was no difference in cytotoxicity between the NK cell conditions in the negative cell lines pointing to a CD70-targeted fashion of anti-TCL NK cell cytotoxicity. Moreover, CAR.70/IL-15 NK cells exhibited greater cytotoxicity against CD70+ cell lines in long-term cytotoxicity assays ( Figure 2). In a tumor rechallenge assay against KAR299 where fresh tumor cells were added every 3-4 days, CAR.70/IL-15 NK cells showed superior potency in continuous tumor control. In addition, CAR.70/IL-15 NK cells exhibited higher levels of degranulation (CD107a) and cytokine production (TNFα and INF-γ) when cocultured with CD70+ TCL cell lines, compared to NT and IL-15 NK cells. Furthermore, these CAR NK cells targeting CD70 outperformed CAR NK cells engineered to target CD19, which is an irrelevant target for TCL, further confirming the specific CD70-targeted activity of CAR.70/IL-15 NK cells. CyTOF immunophenotyping revealed that CAR.70/IL-15 NK cells are characterized by the increased expression of markers of cytotoxicity such as granzyme-b, perforin, TRAIL; and activating coreceptors/proliferation markers such as DNAM, CD25 and Ki67. Taken together, our findings validate CD70 as a promising target for TCL treatment using CAR NK cells. Our approach provides a solid foundation for the clinical translation of CD70-targeting CAR NK-cell therapy for patients with TCL.

Multiparameter Flowcytometry for Diagnosis and Subtyping of Mature Lymphocytic Neoplasms in Peripheral Blood and Bone Marrow: A Prospective Observational Study

Introduction: Multiparameter Flowcytometry (MFC) is a high throughput, quick, and practical technique for diagnoses of Chronic Lymphoproliferative Disorders (CLPDs). Indian CLPDs cases have distinct distribution and presentation than the developed world. Moreover, limited studies have confirmed the diagnostic utility of MFC in Indian CLPDs cases. Aim: To evaluate the diagnostic utility of MFC in peripheral blood and bone marrow aspirate of CLPDs cases. Materials and Methods: This was a single centre, prospective, observational study involving clinico-morphologically suspected or diagnosed 85 CLPDs cases. It was carried out in the Department of Pathology, Government Medical College and Hospital, Nagpur, Maharashtra, India, from January 2016 to November 2019. The patients were followed up for peripheral smear (PS) and Bone Marrow(BM) MFC and staging in nodal or extranodal Non-Hodgkin’s Lymphoma was done. Results: Clinico-morphological examination led to the diagnosis of 74 CLPD cases, while remaining 11 cases were strongly suspected. MFC immunophenotyping was contributory in diagnosing 74 CLPD cases which on further subtyping consisted of B-cell CLPD (N=70), and T-cell CLPD (N=3), while one case of B-NHL could not be subtyped. The most common B-cell CLPD included multiple myeloma (n=27), chronic lymphocytic leukemia (n=25), diffuse large B-cell lymphoma (n=7). T-cell CLPD included hepatosplenic gamma delta T-cell lymphoma (N=2) and adult T-cell lymphoma, follicular lymphoma (n=3), burkitt’s lymphoma (n=2), mantle cell lymphoma (n=2), prolymphocytic leukemia (n=2), splenic marginal zonal lymphoma (n=2), B Cell Non-Hodgkin’s Lymphoma (n=1). Finally, 11 suspected cases mostly comprised of reactive lymphocytosis (81.8%). Conclusion: MFC immunophenotyping led to diagnoses and determination of CLPD sub-class. It also resulted in rapid diagnoses of reactive hyperplasia and non-hematolymphoid malignancy which may mimic CLPD on morphology and hence, difficult to diagnose based on morphology alone.

Hepatosplenic Gamma Delta T-cell Lymphoma Presenting as Progressive Hepatosplenomegaly Highlighted during Pregnancy

Hepatosplenic T-cell lymphoma (HSGDTL) is a rare variant of T-cell lymphoma with few reported cases in literature. It usually presents with hepatosplenomegaly and constitutional symptoms, primarily in young to middle aged patients. The prognosis is generally poor, with maximum reported survival periods of 2-3 years. There is a link to immunodeficiency and some biological treatments. Liver biopsy with flow cytometry is required to confirm the diagnosis.

Silent T-cell receptor cutaneous T-cell lymphoma associated to a clonal plasma cell proliferation.

Within T-cell lymphomas (TCL) there are 2 entities expressing gamma-delta TCR: hepatosplenic gamma-delta T-cell lymphoma (HSGDTL) and the primary cutaneous gamma-delta T-cell lymphoma (PCGDTL). PCGDTL is a rare form of Tcell lymphoma with specific tropism for skin that have a dismal prognosis. Although even rarer, there have been reports of TCL with loss of expression of the TCR, which have been termed peripheral TCL TCR-silent type. We report the case of a cutaneous TCR-silent type lymphoma associated to a clonal plasma cell proliferation with an ominous outcome that led to a lot of discussion in its classification. Due to the aggressiveness of the disease and the scant evidence about therapy in this strange entity the outcome was fatal. We report a unique case of a TCR-silent cutaneous TCL with an exceptional histopathology, prolonged clinical evolution and a subsequent plasma cell clonal expansion.

Pretreatment Whole Blood Epstein-Barr Viremia Is a Prognostic Factor in Peripheral T-Cell Lymphoma

AbstractPeripheral T-cell lymphoma (PTCL) is the highly aggressive lymphoid malignancies, treatment outcome is very poor. There are increasing evidence about the role of Epstein-Barr virus (EBV) in PTCL. Because of its rarity, there was few studies about the prognostic factors incorporating EBV in PTCL.The aim of this study was to evaluate the role of EBV as prognostic factors in PTCL. We retrospectively reviewed the 174 PTCL patients (peripheral T-cell lymphoma, not otherwise specified; n=123, anaplastic large cell lymphoma; n=19, angioimmunoblastic T-cell lymphoma; n=26, enteropathy related T-cell lymphoma, n=5, hepatosplenic gammadelta T-cell lymphoma; n=1).Median age of the patients was 63 (20~94) years with 107 (61.5%) male patients. One-year OS and PFS was 55.5%, 37.5%, respectively. Stage 3 or 4 patients were 150 (86.2%). Bone marrow involvement were detected 73 (42.0%) patients among 163 available patients. For IPI scores, 29 (16.7%) patients were classified as low risk, 42 (24.1%) as low-intermediate risk, 57 (32.8%) as high-intermediate risk, and 46 (26.4%) as high risk. For PIT scores, 18 (11.1%) patients were classified in group 1, 41 (25.2%) in group 2, 58 (35.6%) in group 3, and 46 (28.2%) in group 4.Upfront autologous hematopoietic stem cell transplantation (n=17) improved OS and PFS (P=0.001 and P<0.001, respectively). In univariate analysis, poor performance status (ECOG ¡Ã2) (P <0.001 and P <0.001, respectively), low absolute lymphocyte counts (<1000/mm3) (P=0.022 and P=0.038, respectively), high ferritin (¡Ã1,000/mm3) (P =0.002 and P =0.002, respectively), EBV viremia in the whole blood (positive) (P=0.016 and P <0.001, respectively), low protein level (<6.3 g/dL) (P <0.001 and P <0.001, respectively) and low albumin level (<3.5 g/dL) (P =0.001 and P =0.001, respectively) were related with inferior OS and PFS. High international prognostic index (IPI) and prognostic index for PTCLu (PIT) were related with inferior OS and PFS (P<0.001, P=0.029 and P=0.019, P=0.278, respectively) (Figure 1A, 1B, 2A, 2B). In multivariate analysis, poor performance status, extranodal involvement more than one site and EBV viremia were related with OS and PFS in multivariate analysis. (P <0.001, P =0.024, P =0.001 and P =0.001, P=0.002, P=0.031, respectively).We made a new prognostic score model using statistically significant 3 variables in multivariate analysis: low, no adverse factors; intermediate, one factor; high, two or three factors. This model could identify three groups of patients for OS and PFS (Figure 3A,3B.)This study suggests that prognostic models including EBV for PTCL showed good risk classification. There will be need to investigate the mechanism of EBV and specific treatment strategy for EBV-related patients. These patients will be need to consider more effective therapeutic strategy to improve the poor survival in PTCL. [Display omitted] [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

A Case of Hepatosplenic Gamma-delta T Cell Lymphoma with Intravascular Lymphoma Like Features in a Young Male With Autoimmune Hepatitis

Hepatosplenic gamma delta T-cell lymphoma (HSGDTL) is a rare and aggressive hematologic malignancy that has been associated with long term use of immunosuppressive agents. Here we report a 22-year-old male on azathioprine and prednisone for autoimmune hepatitis who presented to hospital with abdominal pain, night sweats and 20lbs of weight loss. On exam he had hepatomegaly and splenomegaly but no lymphadenopathy. His initial lab tests were WBC 5.39 x 109/L, Hb 70 g/L, platelets 25 x 109/L, total bilirubin 74 μmol/L, AST 151 U/L, ALT 55 U/L and LDH 5932 U/L. He had marked hepatosplenomegaly without lymphadenopathy on abdominal CT scan. Bone marrow and liver biopsies confirmed the presence of HSGDTL. Unfortunately he did not respond to multiple cycles of chemotherapy and passed away. On autopsy he had multiorgan involvement of an intravascular lymphoma like (IVLL) T-cell population. There are no definitive risk factors for HSGDTL but an association with immunosuppressive agents has been well documented in renal transplant recipients and patients with inflammatory bowel disease (IBD). Specifically, the use of thiopurines for at least two years in young males with IBD has been linked to an increased risk of developing HSGDTL. To our knowledge, however, previous cases of HSGDTL in autoimmune hepatitis patients have been minimally reported in the literature. Unique to our case was the finding of an intravascular lymphoma like component on autopsy that was present in tissue samples from the patient's lungs, kidneys, heart, thyroid and testicles. As far as we know, a widespread multi-organ intravascular lymphoma in a HSGDTL patient is exceedingly rare. In fact we found only one other case in the literature. Therefore, it is difficult to assess the impact of this finding. It is possible the presence of intravascular lymphoma represents a subtype of HSGDTL and may provide insight into the aggressive nature of this disease. We must also consider an association between autoimmune hepatitis and HSGDTL with IVLL component independent of immunosuppressive therapy. However, future research into this little known and seldom reported malignancy will be required to fully appreciate these findings. Overall, we hope our case report will contribute to better understanding the association between T-cell lymphoma and long term use of immunosuppressive agents as well as identify new populations, specifically autoimmune hepatitis patients, who may be at risk of developing this deadly disease.Figure 1

Alemtuzumab As Pre-Conditioning Is Safe and Feasible in Patients with T-Cell Lymphoid Neoplasms Undergoing Allogeneic Stem Cell Transplantation

▪Background: In vivo T-cell depletion with Alemtuzumab reduces the incidence of acute and chronic graft-versus-host disease (GvHD) and graft failure, yet it results in an increase of opportunistic infections and delayed immune recovery. In addition, Alemtuzumab has considerable anti-lymphoma activity in T-cell neoplasms.We report on a pilot study analysing the safety and feasibility of Alemtuzumab as pre-conditioning prior to reduced intensity conditioning allogeneic stem cell transplantation (RIC-alloSCT) in patients diagnosed with T-cell non-Hodgkin lymphoma.Methods: Six consecutive patients diagnosed with a T-cell lymphoid malignancy underwent RIC-alloSCT from a HLA-identical sibling (n=5) or a matched unrelated donor (n=1). Diagnosis were Angioimmunoblastic T-cell lymphoma (n=3), hepato-splenic gamma-delta T-cell lymphoma (n=1), T/NK cavum lymphoma (n=2) and Sèzary Syndrome (n=1). All received unmanipulated peripheral blood stem cells; At transplantation 2 patients were in CR, and 4 in PR. Median number of prior regimens was 2 (range 2-5). Conditioning regimen included Fludarabine (5 x 30mg/m2) and Melphalan (2 x 70mg/m2) in all cases. GvHD prophylaxis comprised Cyclosporine A and Methotrexate.The pre-conditioning protocol consisted on 6 escalating doses of intravenous Alemtuzumab starting on day -28 (3 mg on day -28, 10 mg on day -26 followed by four doses of 30 mg on days -24 to -17) given 3 times a week (MWF) on an out-patient basis.Results: Five patients received all six doses of Alemtuzumab as planned whereas one patient received only four doses for logistic reasons related to donor availability. Acetaminophen, Hydrocortisone and Dexchlorpheniramine were administered as pre-medication in all cases with no severe infusional reaction observed. There were no delays in proceeding to SCT conditioning and patients develop no infectious complications during the Alemtuzumab - alloSCT interval.All patients engrafted with a median time to neutrophil engraftment of 23 days (range 14-27). Acute skin GvHD (grade I and III) was observed in 2 patients (33.3%), both obtaining a CR with topical and systemic corticosteroids respectively. Two patients developed mild ocular chronic GvHD (one after subsequent infusions of donor lymphocytes - DLI) but none has suffered from extensive chronic GvHD. No opportunistic infection was observed apart from CMV reactivation that developed in 3 out of 4 seropositive patients (no CMV disease was observed). All patients experienced delayed immune reconstitution (CD4 >200/ul) at a median of 321 days (range 229-518). All 4 patients in PR prior to alloSCT achieved a complete remission. Only one patient (diagnosed with Sèzary Syndrome) experienced a relapsed and responded to DLI. With a median follow-up of 42 months, all patients remain alive and in CR.Conclusions: Our preliminary results suggest that administration of Alemtuzumab prior to reduced intensity conditioning is feasible and safe. In addition to providing T-cell depletion, Alemtuzumab may improve the response rate in T-cell lymphoid malignancies without increasing the risk of infectious complications. These results require further validation in larger phase II studies. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Gamma-delta t-cell lymphomas.

Gamma-delta T-cell lymphomas are aggressive and rare diseases originating from gamma-delta lymphocytes. These cells, which naturally play a role in the innate, non-specific immune response, develop from thymic precursor in the bone marrow, lack the major histocompatibility complex restrictions and can be divided into two subpopulations: Vdelta1, mostly represented in the intestine, and Vdelta2, prevalently located in the skin, tonsils and lymph nodes. Chronic immunosuppression such as in solid organ transplanted subjects and prolonged antigenic exposure are probably the strongest risk factors for the triggering of lymphomagenesis. Two entities are recognised by the 2008 WHO Classification: hepatosplenic gamma-delta T-cell lymphoma (HSGDTL) and primary cutaneous gamma-delta T-cell lymphoma (PCGDTL). The former is more common among young males, presenting with B symptoms, splenomegaly and thrombocytopenia, usually with the absence of nodal involvement. Natural behaviour of HSGDTL is characterised by low response rates, poor treatment tolerability, common early progression of disease and disappointing survival figures. PCGDTL accounts for <1% of all primary cutaneous lymphomas, occurring in adults with relevant comorbidities. Cutaneous lesions may vary, but its clinical behaviour is usually aggressive and long-term survival is anecdotal. Available literature on gamma-delta T-cell lymphomas is fractioned, mostly consisting of case reports or small cumulative series. Therefore, clinical suspicion and diagnosis are usually delayed, and therapeutic management remains to be established. This review critically analyses available evidence on diagnosis, staging and behaviour of gamma-delta T-cell lymphomas, provides recommendations for therapeutic management in routine practice and discusses relevant unmet clinical needs for future studies.

Hepatosplenic gamma delta T-cell lymphoma in a boy with visceral leishmaniasis: a case report

IntroductionHepatosplenic gamma delta T-cell lymphoma is a rare peripheral T-cell lymphoma of cytotoxic T-cell origin with an aggressive clinical course. Chronic immunosuppression has been proposed as a possible pathogenetic mechanism. No association of hepatosplenic gamma delta T-cell lymphoma with visceral leishmaniasis has been described in the past. We describe a case of an adolescent boy with hepatosplenic gamma delta T-cell lymphoma with leukemic presentation, who was diagnosed to have visceral leishmaniasis, 9 months prior to presentation at our center. To the best of our knowledge this is the first report of hepatosplenic gamma delta T-cell lymphoma with a prior history of visceral leishmaniasis in the medical literature.Case presentationA 13-year-old Indian boy presented to the hematology out-patient department with a history of progressive abdominal distension of 9 months’ duration and low grade fever of 2 months’ duration. He was a known case of visceral leishmaniasis and was treated with some clinical improvement in the past. However, his symptoms recurred and he was diagnosed to have hepatosplenic gamma delta T-cell lymphoma at our center. Cytogenetic analysis showed characteristic karyotype of isochromosome 7.ConclusionsChronic antigen stimulation due to visceral leishmaniasis may have led to an expansion of gamma delta T cells in our patient, and immunophenotypic analysis of bone marrow aspirate and characteristic karyotype helped to achieve the diagnosis. The aim of this case report is to highlight the rare association of hepatosplenic T-cell lymphoma with visceral leishmaniasis.

Cytotoxic and Gamma-Delta Subtypes Of Peripheral T-Cell Lymphoma: A Single Center Experience

BackgroundPeripheral T-cell lymphomas (TCLs) are uncommon neoplasms. TCLs in which gamma-delta T-cell receptors are expressed are extremely aggressive and rare, accounting for less than 1% of lymphoid neoplasms. The two main types of CTLs recognized in the 2008 WHO classification of lymphoid neoplasms are hepatosplenic T-cell lymphoma (HSTL) and primary cutaneous gamma-delta T-cell lymphoma (PCGD-TCL). Although rare, these diseases are associated with an aggressive clinical course, refractoriness to conventional therapies, and poor prognosis. MethodsPatients with newly diagnosed cytotoxic or gamma-delta TCLs treated from 2005-2012 were retrospectively identified. Analyses included patient characteristics, clinical presentation, pathology, treatment and outcome. ResultsTwenty-two patients (11 cutaneous gamma-delta TCL, 5 primary cutaneous aggressive epidermotropic CD8+TCL, 4 hepatosplenic gamma-delta TCL, 2 cytotoxic TCL involving the intestine) were identified. Median age was 48 (range: 18-70), 12% (12/22) were male, and 54.5% (12) presented with B symptoms. Initial therapy included CHOP based chemotherapy in 6, denileukin difititox with CHOP in 5, and single agent denileukin diftitox in 4. One patient died with hemophagocytosis prior to initiation of chemotherapy. Fifteen of 21 pts responded to initial therapy but 10 of 15 required more than one regimen containing either etoposide or gemcitabine to achieve remission. The median number of regimens was 2 (range 0-4). In the salvage setting, two patients had partial responses with romidepsin, one had a PR with pralatrexate and one had a CR after pralatrexate salvage therapy. Thirteen patients underwent stem cell transplantation in first remission: autologous in 5 pts who had no donor, and allogeneic in 8 pts. At a median follow up of 3 years, 60% relapsed, and 14 (63%) are still alive. Of the patients who underwent transplant, one auto pt died from hemophagocytosis, 2 alloBMT patients died from acute GVHD, and 2 alloBMT pts died from disease progression. One alloBMT patient with cutaneous gamma delta TCL relapsed and responded to salvage therapy. ConclusionsCytotoxic and gamma-delta TCLs are rare diseases that have traditionally responded poorly to treatment. In our experience, many patients have a suboptimal response to CHOP alone and require additional therapy to achieve remission. We report a favorable outcome after stem cell transplantation and with implementation of novel agents. Advances in understanding biology and international collaborative efforts are required to improve outcome in these rare entities. Disclosures:Off Label Use:sorafenib in t cell nhl. Foss:merck: Research Funding; spectrum: Research Funding; eisai: Membership on an entity's Board of Directors or advisory committees; millenium: Honoraria, Membership on an entity's Board of Directors or advisory committees; celgene: Honoraria, Research Funding; seattle genetics: Research Funding.

Outcomes of Allogeneic Blood or Marrow Transplantation for Peripheral T-Cell Lymphoma.

Abstract 3084Peripheral T-cell lymphoma (PTCL) is characterized by high rates of chemoresistance and relapse. The role of allogeneic (allo) BMT remains to be defined. Treatment-associated toxicities and donor availability remain key concerns. We reviewed the outcomes of 44 consecutive, related donor allo BMTs for PTCL performed at Johns Hopkins Hospital from 1994–2011. Nodal (n=23), extranodal (n=14), leukemic/disseminated (n=3), and cutaneous (n=4) histologies were represented. This was a poor-risk cohort, with 60% receiving > 2 prior chemotherapy regimens, 50% having history of chemorefractory disease, and 25% having active disease at BMT. Patients receiving reduced-intensity conditioning (RIC) were significantly older (median 59 years, range 24–70) than patients receiving myeloablative conditioning (MAC; median 46 years, range 18–64), p=0.01; median age at RIC/haplo BMT was 60. Thirty patients received post-transplantation cyclophosphamide (PT/Cy) as part of their GVHD prophylaxis, including all RIC/HLA-haploidentical (haplo) BMTs (n=18), all RIC/HLA-matched BMTs (n=6), 3 of the 4 myeloablative conditioning (MAC)/haplo BMTs, and 3 of the 16 MAC/HLA-matched BMTs (where PT/Cy was the sole GVHD prophylaxis). With 3.9 years median follow-up for survivors (range 0.5–13.7 years), the estimated 3-year progression-free survival (PFS) and overall survival (OS) were both 37% (95% confidence interval (CI) 24–56% and 24–57%). In older patients (> 60, n=14), the estimated 2-year PFS and OS were 38% (CI 13–63%) and 45% (CI 20–73%); in patients < 60 (n=30), 2-year PFS and OS were 41% (95% CI 24–59%) and 43% (95% CI 25–61%). On unadjusted analysis, there was a tendency towards superior PFS for allo BMT in first remission versus beyond first remission, with an estimated 3-year PFS of 53% (95% CI 34–82%) versus 23% (95% CI 10–51%), p=0.08. Of the 15 patients who remain alive in sustained remission, ten received allo BMT in first remission; represented among these ten are especially poor-risk histologies, including adult T-cell leukemia/lymphoma, hepatosplenic gamma-delta T-cell lymphoma, and subcutaneous panniculitis-like gamma-delta T-cell lymphoma. With a median time to relapse of 3.2 months (interquartile range 1.8–8.8 months), the estimated 3-year cumulative incidence of relapse was 46% after MAC, 56% after RIC, and 50% after RIC/haplo BMT by competing risk analysis. Estimated 1-year non-relapse mortality was 10% for MAC, 8% for RIC, and 11% for RIC/haplo BMT. On competing risk analysis, cumulative incidences of acute grade II-IV GVHD and chronic GVHD were 16% and 19%, with no differences between matched and haplo donors. On unadjusted analysis, patients with acute grade II-IV or chronic GVHD had a 17% probability of relapse, compared to 66% in patients without GVHD, p=0.02. Allo BMT affords long-term survival for a subset of PTCL patients. This RIC/haplo platform substantially expands allo BMT options to most patients with PTCL, including those who are older and unable to tolerate high-dose conditioning. Allo-BMT may be appropriate in first remission in select high-risk cases. Disclosures:Symons:Busulfex: Research Funding.

Hepatobiliary and Pancreatic: Hepatosplenic gamma‐delta T‐cell lymphoma

Hepatosplenic gamma-delta (gd) T-cell lymphoma is a rare form of peripheral T-cell lymphoma that was first proposed as a distinct clinicopathologic entity in 1990. Common presenting symptoms include fever, weakness and abdominal pain. On examination, the liver and spleen are enlarged but there are no enlarged peripheral lymph nodes. Typical blood tests reveal anemia, leukopenia and thrombocytopenia but liver function tests are either normal or near-normal. Histological features are characterized by malignant T-cell proliferation in the sinusoids of the liver, sinuses and red pulp of the spleen and sinuses of the bone marrow. Immunophenotypic expressions include CD2 + , CD3 + , CD4 , CD5, CD7, CD16, CD56, TIA-1 + , TdT and granzyme B. The T-cell receptor—gd phenotype (TCRd1 + ) is positive while the T-cell receptor—ab phenotype (bF1) is negative. Thus far, responses to chemotherapeutic regimens have been poor and patients have a median survival of only 11‐16 months. Of interest to gastroenterologists are case reports of hepatosplenic gd T-cell lymphomas in patients with inflammatory bowel disease after treatment with monoclonal antibodies against tumor necrosis factor. Most of these patients have been young men receiving concomitant medication with azathioprine, 6-mercaptopurine or methotrexate. The patient illustrated below was a 46-year-old man who was admitted to hospital with upper abdominal distension and peripheral edema. Twelve months previously, he had been treated by splenectomy for splenomegaly and features of hypersplenism. An abdominal computed tomography scan showed a huge liver that extended into the pelvis. The liver had a heterogeneous appearance but no discrete nodules (Figure 1). Blood tests revealed mild anemia (hemoglobin 108 g/l), a mild elevation of the white cell count (13.4x10 9

DA-EPOCH Chemotherapy Is Highly Effective in ALK-Positive and ALK-Negative ALCL: Results of a Prospective Study of PTCL Subtypes in Adults

Abstract 1618 Background:Anaplastic large cell lymphoma (ALCL) is a distinct type of peripheral T-cell lymphoma (PTCL) characterized histologically, by large anaplastic lymphoid cells that are CD30 positive. There is biologic heterogeneity within ALCL: ALK (anaplastic lymphoma kinase) positive cases harbor a translocation usually involving chromosomes 2 and 5 resulting in over-expression of ALK (variant translocations also occur) whereas ALK negative cases do not. ALK positive ALCL is also clinically distinctive, with a younger age of onset and better treatment outcomes. In the recent International PTCL and Natural Killer (NK) T-Cell Lymphoma Study (Savage et al. Blood.2008: 111 (12)), the outcome for patients with ALK positive compared to ALK negative ALCL was significantly better (5-year failure-free survival (FFS) 60% versus 36%: p=0.15). Methods: We prospectively investigated the efficacy of 6 cycles of DA-EPOCH chemotherapy in newly diagnosed patients with both ALK positive and ALK negative ALCL and compared their outcome to other subtypes of PTCL. Results: Clinical characteristics of 38 enrolled patients are shown below. 22 patients had a diagnosis of ALCL and other diagnoses were PTCL-NOS (10), hepatosplenic gamma delta T-cell lymphoma (4), enteropathy associated T-cell lymphoma (1) and angioimmunoblastic T-cell lymphoma (1). Patients with ALK positive and ALK negative ALCL had similar characteristics. With a median potential follow-up time of 10.5 years, the 5 year progression-free survival (PFS) probability for ALK positive versus negative patients was 80% versus 71% (p=0.82); 5 year overall survival (OS) was 86% in both groups (p=0.95). For patients with other subtypes of PTCL, PFS and OS were 32% and 50% respectively, at 5-years. Conclusions: In contrast to other reports, patients with ALK negative ALCL had a very favorable outcome following DA-EPOCH chemotherapy that was no different from that of ALK positive cases. This regimen is highly effective in ALCL, independent of ALK expression. Accrual continues. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Histopathological audit of splenectomies received at a cancer hospital

There are few studies in the literature studying the yield of the diagnostic splenectomy in a suspicious lymphoma case. Moreover, their relevance is limited owing to low number of cases, the use of selection criteria, and the lack of modern ancillary studies. We present a histopathological review of splenectomy specimens referred as a case of lymphoma to our center. The medical charts and laboratory data on all patients of all splenectomy specimens between the years 2003 and 2008 were reviewed. Morphological and immunohistochemical features were analyzed and the lymphomas were sub-typed in accordance to 2008 WHO Classification of Hematolymphoid Neoplasms. Flow cytometry immunophenotyping available in few cases was correlated. A total of 46 cases studied included splenic marginal zone lymphoma (SMZL) (19 cases), splenic diffuse large B-cell lymphoma (DLBCL) (14 cases), splenic diffuse red pulp B-cell lymphoma (DRP) (five cases), follicular lymphoma (three cases), hairy cell leukemia (HCL) (two cases), HCL variant (HCLv) (1 case), 1 case of hepatosplenic gamma delta T-cell lymphoma (TCL), and 1 cases of TCL (not otherwise specified). Predominantly splenic lymphoma is a biologically heterogeneous entity, ranging from low-grade SMZL to high-grade DLBCLs. TCLs constituted only 4% of all our cases. DRP, HCL, and HCLv have similar diffuse red pulp patterns of splenic involvement and are differentiated based on flow cytometric immunophenotyping. We had a large number of splenic DLBCL and none of these involved bone marrow (BM), while all other lymphoma subtypes had BM involvement (stage IV disease). Morphological and immunophenotypic (immunohistochemistry and flow cytometry) features of BM and splenectomy specimen need to be correlated to differentiate these rare though similar-looking entities with overlapping features.

Outcomes In Allogeneic Hematopoietic Stem Cell Transplantation for Peripheral T-Cell Lymphoma: A Single Center's 12-Year Experience

AbstractAbstract 2360Peripheral T-cell lymphomas (PTCL) represent a rare and heterogeneous group of lymphoproliferative disorders characterized by poor prognosis. For relapsed and refractory disease, treatment options remain limited, and recent data has suggested that patients with PTCL beyond first remission (CR2/PR2+) do not benefit from autologous hematopoietic stem cell transplantation (HSCT) (Chen et al. Biol Blood Marrow Transplant. 2008; 14:741-747). The role of allogeneic HSCT in this patient population is not well defined, although several recently published retrospective analyses have shown promising results. We examined the outcomes of 27 patients with PTCL who underwent allogeneic HSCT for relapsed or primary refractory disease at Washington University between 1997–2008. PTCL subtypes in this cohort included PTCL not otherwise specified (NOS,n=9), anaplastic large cell lymphoma (ALCL,n=9), angioimmunoblastic T-cell lymphoma (AILT,n=5), hepatosplenic gamma-delta T-cell lymphoma (n=2), subcutaneous panniculitis-like T-cell lymphoma (n=1), and extra-nodal NK T-cell lymphoma (n=1). Among the patients with ALCL, 1 patient had anaplastic lymphoma kinase (ALK) negative ALCL; however, ALK status was unavailable for the other 8 patients in this group. Median age was 45 years (range 19–61) and 37% were female. 23 patients underwent myeloablative conditioning regimens with the majority receiving total body irradiation and cytoxan (74%). 4 patients received nonmyeloablative conditioning regimens consisting of fludarabine and anti-thymocyte globulin. 14 patients had HLA-identical related donors, 8 patients had HLA-identical unrelated donors, and the remaining 5 patients had unrelated mismatched donors. In general, patients were heavily pre-treated with an average of 3.3 chemotherapy regimens preceding allogeneic HSCT, and 7 patients (26%) had undergone prior autologous HSCT. 7 patients were transplanted at CR1/PR1, 14 patients at CR2/PR2+, and 6 patients had refractory disease at the time of transplant. Of the patients that were transplanted at CR1/PR1, 6 out of 7 were refractory to their first-line chemotherapy. 1-year, 3-year, and 5-year overall survival (OS) rates were 59%, 50%, and 50%, respectively. Corresponding progression free survival (PFS) rates were 56%, 51%, and 51%, and non-relapse mortality (NRM) rates were 15%, 15%, and 15%. Median OS was 27 months, and median follow-up time was 22 months. Univariate analysis demonstrated similar rates of OS (p=0.5), PFS (p=0.5), and NRM (p=0.8) between the CR1/PR1 and CR2/PR2+ subgroups, and a trend towards lower OS and PFS in patients with refractory disease at transplant. There was no statistical difference in OS (p=0.6), PFS (p=0.6), or NRM (p=0.6) between different PTCL histological subtypes, and no clear trend favoring any particular subtype. We conclude that allogeneic HSCT can provide durable remission and survival for patients with relapsed and refractory PTCL, with acceptable treatment-related mortality. Future prospective trials are needed to further define the role of allogeneic HSCT in this patient population. [Display omitted] [Display omitted] Disclosures:No relevant conflicts of interest to declare.

Retinal hemorrhages as a presenting sign in an adolescent patient with hepatosplenic gamma–delta T‐cell lymphoma

Hepatosplenic gamma-delta T-cell lymphoma is a very rare, aggressive form of peripheral lymphoma first recognized in 1990. Patients often present with organomegaly, anemia, adenopathy, and B symptoms. Rarely in the literature is a pediatric patient described with this subtype of peripheral T-cell lymphoma. Also, retinal hemorrhages have never been described as a presenting symptom of hepatosplenic gamma-delta T-cell lymphoma. We describe an adolescent patient with hepatosplenic gamma-delta T-cell lymphoma who presented with retinal hemorrhages, massive splenomegaly, bone marrow involvement, and B symptoms.

Hepatosplenic gamma-delta T-cell lymphoma: clinicopathological features and treatment

Background: Hepatosplenic T-cell lymphoma (HSTCL) is a rare peripheral T-cell lymphoma; treatment with standard anthracycline-containing chemotherapy regimens has been disappointing, and an optimal treatment strategy for this patient population has not yet been determined.Methods: We identified 15 cases of pathologically confirmed HSTCL in the institution's database. Clinical characteristics and treatment results were reviewed.Results: Complete responses (CRs) were achieved in 7 of 14 patients who received chemotherapy. Achievement of CR was followed by hematopoietic stem-cell transplantation in three patients. Median duration of CR was 8 months (range 2 to 32+ months) with four patients currently alive and in CR at 5, 8, 12, and 32 months, respectively. Median overall survival (OS) was 11 months (range 2 to 36+ months). Patients who achieved a CR had a median OS of 13 months, compared with 7.5 months in patients who did not achieve a CR. Risk factors associated with worse outcome included male gender, failure to achieve a CR, history of immunocompromise, and absence of a T-cell receptor gene rearrangement in the gamma chain.Conclusion: A better understanding of the pathophysiology of HSTCL and new therapeutic strategies are needed.

Hematologic abnormalities following renal transplantation

Recipients of renal allografts are surviving longer and, consequently, may experience a variety of complications related not only to the transplanted kidney, but also to the hematopoietic system. Common hematologic complications in the renal transplant patient include abnormalities of one cell line, such as post-transplantation erythrocytosis or anemia, that are often treatable with simple measures. Conversely, pathologies involving the leukocyte and platelet population often exist in the context of pancytopenia, which may be a manifestation of systemic infection (e.g., cytomegalovirus, human herpesvirus 8) or malignancy (post-transplantation lymphoproliferative disorders). Uncommon, but life-threatening, processes complicating renal transplantation include hepatosplenic gammadelta T-cell lymphoma and viral-induced hemophagocytic syndrome, both of which are associated with severe pancytopenia and, often, death. Since this patient population is often managed in a multidisciplinary fashion by nephrologists, infection specialists, transplant surgeons, hematologists, and internal medicine physicians, a succinct review of this topic is warranted.

Immunophenotypic Profile of Acute Leukemia: Critical Analysis and Insights Gained at a Tertiary Care Center in India

The purpose of this retrospective study, the largest series in our country, was to illustrate the spectrum of subtypes and the immunophenotypic features of cases referred as acute leukemia (AL). Morphological diagnosis was correlated with cytochemical stains, immunophenotyping, and molecular genetic studies including fluorescent in-situ hybridization (FISH) and polymerase chain reaction (PCR). Two thousand five hundred and eleven consecutive new referral cases of Acute Leukemia (AL) between January 1, 2003 and December 31, 2006 were evaluated based on WHO classification. It included 1464 cases (58.3%) of Acute Lymphoblastic Leukemia (ALL), 962 cases (38.3%) of Acute Myeloid Leukemia (AML), 45 cases (1.8%) of Chronic Myelogenous Leukemia in blast crisis (CMLBC), 37 cases (1.5%) of biphenotypic acute leukemia (BAL), 1 case of Triphenotypic AL and 2 cases of Acute Undifferentiated leukemia (AUL). Common subtypes of ALL were B-cell ALL (76%) which comprised of intermediate stage/CALLA positive (73%), early precursor/Pro BALL (3%). T-cell ALL constituted 24% (348 cases) of ALL. Common subtypes of AML included AMLM2 (27%), AMLM5 (15%), AMLM0 (12%), AMLM1 (12%), APML (11%), AML t(8;21) (9%). CMLBC included myeloid blast crisis (40 cases), lymphoid blast crisis (2 cases), and biphenotypic leukemia (3 cases). CD13 was most sensitive and CD117 most specific for determining myeloid lineage. An immunoprofile of CD34+, HLADR+, CD14+ and CD33− is unlikely to be APML. CD117 is not a sensitive marker for APML and shows negative to weak continuous expression on promyelocytes. CD19 was expressed in 45% of FAB AMLM2 with t(8;21)(q22;q22). At least five cases of hepatosplenic gamma delta T-cell lymphomas were misdiagnosed as T-ALL based on a minimal selective panel where blasts expressed surface CD3. These cases were correctly diagnosed at relapse. Overall incidence of AML in adults is low (53% only). T-ALL is common in adolescent males. We recommend at least ten antibodies mainly CD13, CD33, CD117, CD10, CD19, HLADR, CD7, CD5 (or CD2), CD45 and CD34 as a primary minimal panel for a case of AL. Tdt is invaluable in work-up of pediatric T-cell neoplasm, to differentiate T-ALL from hepatosplenic gamma delta T cell lymphoma. Only 8% cases required additional markers (including intracytoplasmic markers) in the secondary panel for a lineage assignment. cCD22 is more sensitive than cCD79a for B-cell lineage assignment. Drawbacks of this study included referral bias, no clinical correlation, and three color immunophenotyping with FSC/SSC gating. Our approach for immunophenotyping was semi directed, a primary minimal panel followed by additional antibodies, as and when required. Cytoplasmic lineage specific markers (used in additional panel) for a lineage assignment were required only in 8% cases (n=199). We used only 14–20 antibodies per case (mean = 16), a number much less then many other laboratories. WHO classification has made it mandatory to do FISH/PCR to diagnose various leukemias which otherwise could be diagnosed with reasonable accuracy based on morphology, cytochemistry and flow cytometry like CML, APML, AMLM4Eo etc. Significant number of our FAB AMLM2 and AMLM4E0 cases did not show associated translocations. Few patients were partially treated by referring physician (steroids, blood transfusion, heavy metals etc), a category not addressed in WHO classification. Cytogenetics made a major difference in therapeutic decision in 0.8% cases only. Though flow cytometry is extremely popular amongst hematopathology laboratories, cytogenetics is available at few selected centers in countries with limited resources.

Late Relapses Characterize Autologous Transplantation (ASCT) in First Complete Remission (CR) for Peripheral T-Cell Lymphoma (PTCL).

With the exception of ALK-positive anaplastic large cell lymphoma (ALCL), standard-dose chemotherapy is curative in a minority of patients (pts) with PTCL, and most pts have progressive disease less than 2 years from completing treatment. Several studies suggest that ASCT in 1st CR significantly improves the short-term outcome of pts with PTCL, but its long-term efficacy is not known. To address this, we assessed the outcome of sequential patients who underwent ASCT in 1st CR (n=15). Histologic subtypes were PTCL, unspecified, in 6 pts, angioimmunoblastic T-cell lymphoma in 5 pts, ALK-negative ALCL in 3 pts and hepatosplenic gamma delta T-cell lymphoma in 1 pt. Induction chemotherapy was CHOP (n=2) or CHOP-ICE hybrid (n=12) in 93% of pts. The age-adjusted IPI (AAIPI) was 2–3 in 9 of 14 assessable patients (64%), and 11 pts (73%) had stage III–IV disease. The conditioning regimen consisted of BEAM or CBV in 10 pts and TBI/Cy/VP-16 in 5 pts. All patients received peripheral blood progenitor cells for hematopoietic support. The median follow-up of all patients is 24 months (range 4.5–70). Five pts (33%) have progressed, with a median time to progression of 50 months (range 10–70). Four of the 5 pts who progressed did so more than 2 years from ASCT; they comprise 57% of patients with more than 2-years of follow-up. Four of 5 patients with progressive disease have died, with a median time from progression to death of 1 month (0.6–14.6). In this small series the AAIPI was not predictive of PFS or OS. While our results confirm the that ASCT in 1st CR significantly delays the time to progression, they suggest that it may not be curative in the majority of patients. If confirmed in ongoing larger prospective studies, this observation warrants trials of post-ASCT maintenance treatment and, for younger patients, trials of allogeneic transplantation in 1st CR or sequential ASCT followed by allogeneic transplantation. Figure Figure