Natural Killer Cell Tumor Research Articles

Aggressive mature natural killer cell neoplasms: report on a series of 12 European patients with emphasis on flow cytometry based immunophenotype and DNA content of neoplastic natural killer cells

We report 12 cases of aggressive natural killer (NK) cell neoplasms diagnosed in Portugal, with emphasis on flow cytometry. Ten patients had extranodal NK/T cell lymphoma, nasal type and two had aggressive NK cell leukemia, and seven were men and five were women, with a median age of 50 years. NK cells brightly expressed the CD56 adhesion molecule and CD94 lectin type killer receptor and had an activation-related HLA-DR+ CD45RA+ CD45RO+ immunophenotype, in most cases. In contrast, dim CD16 expression was found in a minor proportion of cases, whereas CD57 and the CD158a and CD158e1 killer immunoglobulin-like receptors were negative. One-third of cases showed a hyperploid DNA content and nearly all had a very high S-phase proliferative rate. The phenotypic features of the neoplastic NK cells would suggest that they represent the transformed counterpart of the CD56 + bright NK cells that circulate in normal blood.

Primary bone marrow natural killer/T-cell lymphoma/leukemia: a report of the two cases

Natural killer (NK) cell neoplasms are aggressive tumors and comprise aggressive NK cell leukemia (ANKL) and extranodal nature killer (NK)/T-cell lymphoma (ENKTL), nasal type. Here we report two cases of NK cell neoplasm localized in the bone marrow without peripheral blood involvement. Both patients presented with prolonged fever, anemia, and thrombocytopenia and were treated initially as infectious disease. Imaging studies revealed splenomegaly without any nodular lesion or lymphadenopathy. Bone marrow examination revealed extensive marrow involvement in both cases. Serum EBV viral loads at diagnosis of these two patients were at 130,000 and 60,000 copies/μL, respectively. Staging workup including nasal examination/biopsy was negative. Both patients passed away in a month. These tumors were diag-nostically challenging due to the unusual clinical presentation and absence of leukemic change, tumor mass or lymphadenopathy. Our cases demonstrate that lymphoma/leukemia should be considered in patients with fever of unknown origin and marrow aspiration/biopsy be performed. Early diagnosis and novel effective therapeutic regimens may benefit these patients. This case may be considered as ANKL in the aleukemic phase or ENKTL with marrow involvement/presentation. A diagnostic labeling of either ANKL or ENKTL might be arbitrary and only of personal preference, although molecular study might help with the differential diagnosis.

Aggressive Mature Natural Killer Cell Neoplasms: From EBV-Infection to Disease Etiopathogeny

Mature Natural Killer (NK) cell neoplasms are rare tumors with higher prevalence in Asia, Central and South America, which are related to Epstein Barr Virus (EBV) infection. Nature killer /T cell lymphoma, nasal type, presents as a localized or generalized destructive tumor, affecting the nose, the upper aero digestive tract or any organ or tissue, whereas aggressive NK-cell leukemia manifests as a systemic disease that preferentially affects the bone marrow, the spleen and the liver, and rapidly evolve to multiorgan failure resulting in death. Both NK-cell neoplasms arise as a consequence of the inability of the immune system to control EBV infection and of the transforming potential of multiple EBV gene products. Chronic active EBV infection and EBV-related lymphoproliferative disorders of NK-cells are predisposing conditions. The tumor NK-cells do express an EBV infection type II latency pattern, specific EBV-encoded latent membrane proteins and early region EBV RNAs being detected on lymphoma cells. The EBV encoded proteins and non-coding EBV RNAs and micro-RNAs expressed on the infected cells are involved in immune deregulation and play a crucial role in cell transformation and oncogenesis. This review addresses the mechanisms used by EBV to infect the cells and to evade the immune-surveillance as well as to induce cell survival and transformation, and characterizes the spectrum of the clinical manifestations associated with chronic EBV-infection and related T-and NK-lymphoproliferative disorders. Improving the knowledge in this subject will help to develop new therapeutic approaches for chronic EBV-infection and even prevention strategies for the aggressive NK-cell malignancies.

Aggressive Mature Natural Killer Cell Neoplasms: from Disease Biology to Disease Manifestations

Nature killer (NK)/T cell lymphoma, nasal type, and aggressive NK-cell leukemia are rare tumors with higher prevalence in Asia, Central and South America, which are etiologically related to the Epstein Barr virus (EBV). Proteins encoded by EBV genes and non-coding viral RNAs expressed on the infected cells are involved in immune deregulation and cell transformation and lymphomagenesis occur as a consequence of multiple oncogenic events. Complex chromosomal abnormalities are frequent and loss of chromosomes 6q, 11q, 13q, and 17p are recurrent aberrations. In accordance, many genes are differentially expressed, often due to gene deletion, mutation or methylation. These include, among others, tumor suppressor genes and oncogenes, as wells as genes involved in cell signal transducer pathways, cell survival and apoptosis, cell cycle, cell motility and cell adhesion, as well as in cell communication through cytokine networks. Consequently many biochemical pathways are affected in NK-cell neoplasms, which could contribute to cancer development and progression, as well as to disease manifestations. This review focuses on the molecular and biochemical mechanisms by which EBV induces NK-cell lymphomagenesis, disrupting genes and molecules involved in crucial biological processes. Improving the knowledge in this subject will help to better understand the disease biology and clinical manifestations and to develop new treatment approaches for the NK-cell malignancies.

Expression of the Activating Receptor, NKp46 (CD335), in Human Natural Killer and T-Cell Neoplasia

To evaluate the expression of CD335 (NKp46), an activation receptor that is selectively expressed on natural killer (NK) cells. We assessed CD335's potential utility as a diagnostic marker in 657 cases by flow cytometry and 410 cases by immunohistochemistry. We observed that CD335 was highly specific for NK cells in nonneoplastic tissues. Moreover, 61 (90%) of 68 of NK cell neoplasms demonstrated CD335 expression, whereas B-cell, myelomonocytic, and plasma cell neoplasms lacked expression. Notably, 16 (20%) of 82 mature T-cell neoplasms, particularly T-cell large granular lymphocytic leukemia, mycosis fungoides, and ALK+ anaplastic large cell lymphoma, aberrantly expressed CD335. Collectively, these data support the diagnostic utility of CD335 in evaluating hematopoietic malignancies and suggest that CD335 could be a useful target for selective immunotherapy in patients with mature NK and T-cell neoplasms.

Interferon-α Suppresses cAMP to Disarm Human Regulatory T Cells

IFN-α is an antineoplastic agent in the treatment of several solid and hematologic malignancies that exerts strong immune- and autoimmune-stimulating activity. However, the mechanisms of immune activation by IFN-α remain incompletely understood, particularly with regard to CD4(+)CD25(high)Foxp(+) regulatory T cells (Treg). Here, we show that IFN-α deactivates the suppressive function of human Treg by downregulating their intracellular cAMP level. IFN-α-mediated Treg inactivation increased CD4(+) effector T-cell activation and natural killer cell tumor cytotoxicity. Mechanistically, repression of cAMP in Treg was caused by IFN-α-induced MAP-ERK kinase (MEK)/extracellular signal-regulated kinase (ERK)-mediated phosphodiesterase 4 (PDE4) activation and accompanied by downregulation of IFN receptor (IFNAR)-2 and negative regulation of T-cell receptor signaling. IFN-α did not affect the anergic state, cytokine production, Foxp3 expression, or methylation state of the Treg-specific demethylated region (TSDR) within the FOXP3 locus associated with a stable imprinted phenotype of human Treg. Abrogated protection by IFN-α-treated Treg in a humanized mouse model of xenogeneic graft-versus-host disease confirmed IFN-α-dependent regulation of Treg activity in vivo. Collectively, the present study unravels Treg inactivation as a novel IFN-α activity that provides a conceivable explanation for the immune-promoting effect and induction of autoimmunity by IFN-α treatment in patients with cancer and suggests IFN-α for concomitant Treg blockade in the context of therapeutic vaccination against tumor antigens.

Intraperitoneal delivery of human natural killer cells for treatment of ovarian cancer in a mouse xenograft model

Background aimsThere is an urgent need for novel therapeutic strategies for relapsed ovarian cancer. Dramatic clinical anti-tumor effects have been observed with interleukin (IL)-2 activated natural killer (NK) cells; however, intravenous delivery of NK cells in patients with ovarian cancer has not been successful in ameliorating disease. We investigated in vivo engraftment of intraperitoneally (IP) delivered NK cells in an ovarian cancer xenograft model to determine if delivery mode can affect tumor cell killing and circumvent lack of NK cell expansion. MethodsAn ovarian cancer xenograft mouse model was established to evaluate efficacy of IP-delivered NK cells. Tumor burden was monitored by bioluminescent imaging of luciferase-expressing ovarian cancer cells. NK cell persistence, tumor burden and NK cell trafficking were evaluated. Transplanted NK cells were evaluated by flow cytometry and cytotoxicity assays. ResultsIP delivery of human NK cells plus cytokines led to high levels of circulating NK and was effective in clearing intraperitoneal ovarian cancer burden in xenografted mice. NK cells remained within the peritoneal cavity 54 days after injection and had markers of maturation. Additionally, surviving NK cells were able to kill ovarian cancer cells at a rate similar to pre-infusion levels, supporting that in vivo functionality of human NK cells can be maintained after IP infusion. ConclusionsIP delivery of NK cells leads to stable engraftment and antitumor response in an ovarian cancer xenograft model. These data support further pre-clinical and clinical evaluation of IP delivery of allogeneic NK cells in ovarian cancer.

Bevacizumab and cyclosphosphamide, doxorubicin, vincristine and prednisone in combination for patients with peripheral T-cell or natural killer cell neoplasms: an Eastern Cooperative Oncology Group study (E2404)

Peripheral T-cell lymphoma (PTCL) and natural killer (NK) cell lymphoma have poor survival with conventional cytotoxic chemotherapy. Because angiogenesis plays an important role in the biology of PTCL, a fully humanized anti-vascular endothelial growth factor (VEGF) antibody, bevacizumab (A), was studied in combination with standard cyclosphosphamide, doxorubicin, vincristine and prednisone (CHOP) chemotherapy (ACHOP) to evaluate its potential to improve outcome in these patients. Patients were treated with 6–8 cycles of ACHOP followed by eight doses of maintenance A (15 mg/kg every 21 days). Forty-six patients were enrolled on this phase 2 study from July 2006 through March 2009. Forty-four patients were evaluable for toxicity and 39 were evaluable for response, progression and survival. A total of 324 cycles (range: 2–16, median 7) were administered to 39 evaluable patients and only nine completed all planned treatment. The overall response rate was 90% with 19 (49%) complete response/complete response unconfirmed (CR/CRu) and 16 (41%) a partial response (PR). The 1-year progression-free survival (PFS) rate was 44% at a median follow-up of 3 years. The median PFS and overall survival (OS) rates were 7.7 and 22 months, respectively. Twenty-three patients died (21 from lymphoma, two while in remission). Grade 3 or 4 toxicities included febrile neutropenia (n = 8), anemia (n = 3), thrombocytopenia (n = 5), congestive heart failure (n = 4), venous thrombosis (n = 3), gastrointestinal hemorrhage/perforation (n = 2), infection (n = 8) and fatigue (n = 6). Despite a high overall response rate, the ACHOP regimen failed to result in durable remissions and was associated with significant toxicities. Studies of novel therapeutics are needed for this patient population, whose clinical outcome remains poor.

Aggressive mature natural killer cell neoplasms: from epidemiology to diagnosis.

Mature natural killer (NK) cell neoplasms are classified by the World Health Organization into NK/T cell lymphoma, nasal type (NKTCL), aggressive NK-cell leukemia (ANKCL) and chronic lymphoproliferative disorders of NK-cells, the latter being considered provisionally. NKTCL and ANKCL are rare diseases, with higher prevalence in Asia, Central and South America. Most NKTCL present extranodal, as a destructive tumor affecting the nose and upper aerodigestive tract (nasal NKTCL) or any organ or tissue (extranasal NKTCL) whereas ANKCL manifests as a systemic disease with multiorgan involvement and naturally evolutes to death in a few weeks. The histopathological hallmark of these aggressive NK-cell tumors is a polymorphic neoplastic infiltrate with angiocentricity, angiodestruction and tissue necrosis. The tumor cells have cytoplasmatic azurophilic granules and usually show a CD45+bright, CD2+, sCD3-, cytCD3epsilon+, CD56+bright, CD16−/+, cytotoxic granules molecules+ phenotype. T-cell receptor genes are in germ-line configuration. Epstein-Barr virus (EBV) -encoded membrane proteins and early region EBV RNA are usually detected on lymphoma cells, with a pattern suggestive of a latent viral infection type II. Complex chromosomal abnormalities are frequent and loss of chromosomes 6q, 11q, 13q, and 17p are recurrent aberrations. The rarity of the NK-cell tumors limits our ability to standardize the procedures for the diagnosis and clinical management and efforts should be made to encourage multi-institutional registries.

Conditional IFNAR1 ablation reveals distinct requirements of Type I IFN signaling for NK cell maturation and tumor surveillance

Mice with an impaired Type I interferon (IFN) signaling (IFNAR1- and IFNβ-deficient mice) display an increased susceptibility toward v-ABL-induced B-cell leukemia/lymphoma. The enhanced leukemogenesis in the absence of an intact Type I IFN signaling is caused by alterations within the tumor environment. Deletion of Ifnar1 in tumor cells (as obtained in Ifnar1f/f CD19-Cre mice) failed to impact on disease latency or type. In line with this observation, the initial transformation and proliferative capacity of tumor cells were unaltered irrespective of whether the cells expressed IFNAR1 or not. v-ABL-induced leukemogenesis is mainly subjected to natural killer (NK) cell-mediated tumor surveillance. Thus, we concentrated on NK cell functions in IFNAR1 deficient animals. Ifnar1-/- NK cells displayed maturation defects as well as an impaired cytolytic activity. When we deleted Ifnar1 selectively in mature NK cells (by crossing Ncr1-iCre mice to Ifnar1f/f animals), maturation was not altered. However, NK cells derived from Ifnar1f/f Ncr1-iCre mice showed a significant cytolytic defect in vitro against the hematopoietic cell lines YAC-1 and RMA-S, but not against the melanoma cell line B16F10. Interestingly, this defect was not related to an in vivo phenotype as v-ABL-induced leukemogenesis was unaltered in Ifnar1f/f Ncr1-iCre compared with Ifnar1f/f control mice. Moreover, the ability of Ifnar1f/f Ncr1-iCre NK cells to kill B16F10 melanoma cells was unaltered, both in vitro and in vivo. Our data reveal that despite the necessity for Type I IFN in NK cell maturation the expression of IFNAR1 on mature murine NK cells is not required for efficient tumor surveillance.

Flow cytometric immunophenotyping is of great value to diagnosis of natural killer cell neoplasms involving bone marrow and peripheral blood

Natural killer (NK) cell neoplasms are unusual disorders. In this study we compared results of flow cytometric immunophenotype (FCI) with cytomorphology, histopathology and clinical findings in a series of patients with NK cell neoplasms with peripheral blood and/or bone marrow involvement, and the FCI of neoplastic and normal NK cells were compared. Retrospective data and specimens (bone marrow aspiration or peripheral blood) from 71 cases of NK cell neoplasms were obtained. All patients have been demonstrated laboratory and clinical features consistent with NK cell neoplasms, and the subtypes were determined by integrated clinical estimation. Routine 4-color flow cytometry (FCM) using a NK/T cell related antibody panels was performed. NK cell neoplasms were divided into two major subtypes by FCI, namely malignant NK cell lymphoma, including extranodal nasal type NK cell lymphoma (ENKL, 11 cases) and aggressive NK cell lymphoma/leukemia (ANKL, 43 cases), and relative indolent chronic lymphoproliferative disorder of NK cell (CLPD-NK, 17 cases). The former exhibited stronger CD56-expressing, larger forward scatter (FSC) and more usually CD7- and CD16-missing. FCI of CLPD-NK was similar to normal NK cells, but CD56-expressing was abnormal, which was negative in five cases and partially or dimly expressed in eight cases. Cytomorphologic abnormal cells were found on bone marrow slides of 4 cases of ENKL and 30 cases of ANKL. Eight cases of ENKL were positive in bone marrow biopsies, and other three cases were negative. In 32 cases of ANKL which bone marrow biopsies were applied, 21 cases were positive in the first biopsies. Lymphocytosis was found only in six cases of CLPD-NK by cytomorphology, and biopsy pathology was not much useful for diagnosing CLPD-NK. These results suggest that FCM analysis of bone marrow and peripheral blood was superior to cytomorphology, bone marrow biopsy, and immunohistochemistry in sensitivity and early diagnosis for ANKL, stage III/IV ENKL and CLPD-NK. FCI could not only define abnormal NK cells but also determine the malignant classification. It is beneficial for clinical management and further study of NK cell neoplasms.

Lineage-specific growth inhibition of NK cell lines by FOXO3 in association with Akt activation status

FOXO3 and PRDM1 are located on 6q21, one of the most frequently deleted regions among natural killer (NK) cell neoplasms. We previously demonstrated that forced expression of each gene suppresses the proliferation of NK cell lines with the 6q deletion. In this study, the forced expression of FOXO3 or PRDM1 was performed in various cell lines to clarify these suppressive effects. Forced expression of PRDM1 suppressed the proliferation of not only NK cell lines, but also other broad lineage cell lines. On the other hand, forced expression of FOXO3 was only effective on NK cell lines. FOXO3 functions as a transcriptional factor when it is localized in nuclei. Akt is known to induce cytoplasmic localization of FOXO3 as a result of phosphorylation. Transduced FOXO3 was predominantly localized in nuclei of NK cell lines, while it was localized in the cytoplasm of all non-NK cell lines. NK cell lines showed significantly lower Akt activity compared to other lineage cell lines. The low Akt activity and nucleic localization of FOXO3 in NK cell neoplasms seemed to cause NK cell-specific suppression. These findings indicate the "functional lineage specificity" of FOXO3 and the possibility for NK cell-specific gene therapy with minimal unexpected effects.

Diverging trends in incidence and mortality, and improved survival of non-Hodgkin's lymphoma, in the Netherlands, 1989–2007

We studied progress in the fight against non-Hodgkin's lymphoma (NHL) in the Netherlands by describing the changes in incidence, treatment, relative survival, and mortality during 1989-2007. We included all adult patients with NHL [i.e. all mature B-, T-, and natural killer (NK) cell neoplasms, with the exception of plasma cell neoplasms], newly diagnosed in the period 1989-2007 and recorded in the Netherlands Cancer Registry (n=55 069). Regular mortality data were derived from Statistics Netherlands. Follow-up was completed up to 1 January 2009. Annual percentages of change in incidence, mortality, and relative survival were calculated. The incidence of indolent B-cell and T- and NK-cell neoplasms rose significantly (estimated annual percentage change=1.2% and 1.3%, respectively); incidence of aggressive B-cell neoplasms remained stable. Mortality due to NHL remained stable between 1989 and 2003, and has decreased since 2003. Five-year relative survival rates rose from 67% to 75%, and from 43% to 52%, respectively, for indolent and aggressive mature B-cell neoplasms, but 5-year survival remained stable at 48% for T- and NK-cell neoplasms. In the Netherlands, incidence of indolent mature B-cell and mature T- and NK-cell neoplasms has increased since 1989 but remained stable for aggressive neoplasms. Survival increased for all mature B-cell neoplasms, preceding a declining mortality and increased prevalence of NHL (17 597 on 1 January 2008).

Clinical and Experimental Features of Natural Killer Cell Leukemias in a Chinese Population: A Single Center Experience of 10 Years

Abstract 4892Leukemia of natural killer (NK) cell lineage is rare which affects Asian population preferentially. Here 10 Chinese patients with NK cell leukemia were retrospectively evaluated. Among them 7 man and 3 women, the middle age was 47 years (range 22–57 years). Aggressive NK cell leukemias were finally diagnosed in 7 patients, myeloid/NK cell precursor acute leukemias in 2 patients and NK-CLPD in 1 patient. Pronounced extramedullary involvements (breast mass, multiple subcutaneous nodes and eye rectus muscle mass) were the main manifestation in 2 myeloid/NK cell precursor acute leukemias and 1 aggressive NK-cell leukemia. Clonal cytogenetic abnormality (46, XX, 16P-) was only found in 1 myeloid/NK cell precursor acute leukemia patient. Epstein-Barr virus test was performed in 8 patients and 3 were Positive (all were aggressive NK-cell leukemias). The overall survival of 4 cases of aggressive NK-cell leukemias combined with hematophagocytic syndrome were less than 1.3 months. During following up, 8 patients died of disease, 1 NK-CLPD patient and 1 aggressive NK-cell leukemia patient treated by allo-BMT were still alive. The former NK-CLPD, who was in indolent course, survived 60+ months. The later patient was first diagnosed as NK-CLPD but with lymphoadenopathy and splenomegaly, the metabolic activity of spleen by F-18 FDG uptake was in normal range, lymph node pathology showed reactive change and PB EBV-DNA copy was negative, later hematophagocytic syndrome occurred and EBV-DNA copy became positive. The lymph node pathology were reexamined by FISH method and scattered EBV positive cells were found, so the exact diagnosis from beginning should be occult aggressive NK cell leukemia, soon matched sibling donor BMT was performed and the patient got complete remission and the EBV-DNA copy became negative and lived well for 10+ months. Natural killer cell neoplasms are rare and most in aggressive clinical course, novel therapeutic regimens including allogeneic bone marrow transplantation should be investigated to improve outcome of this disease. Disclosures:No relevant conflicts of interest to declare.

Short-term and long-term leptin exposure differentially affect human natural killer cell immune functions

Epidemiological studies have indicated that obesity is associated with a higher risk for certain cancers caused by elevated levels of adipocyte-derived hormones. Leptin, one such hormone produced by adipocytes, is a major regulator of metabolism and has also been shown to modulate immunity. However, its role in regulating human natural killer (NK) cell functions is largely unknown. Here, we show that the leptin receptor (Ob-R) is expressed on 5% of NK cells isolated from blood donors, as measured with flow cytometry, and expression of the signal-transducing long form of the leptin receptor Ob-Rb was confirmed with quantitative PCR. The Ob-R+ subpopulation displayed a lower expression of CD16, a cell surface receptor mediating antibody-dependent activation. Short-term stimulation with leptin increased IFNγ secretion, CD69 activation marker expression, and cytotoxic lysis of tumor cells; this was mediated by an improved conjugate forming between NK cells and tumor cells as well as higher expression of tumor necrosis factor-related apoptosis-inducing ligand. On the contrary, long-term incubation with leptin significantly impaired these NK cell immune functions and decreased cell proliferation. In addition, phosphorylation of Jak-2 after leptin stimulation was reduced in peripheral mononuclear blood cells from obese humans compared with normal-weight controls. NK cells represent an immune cell population that is crucial for an effective antitumor response. Here, we show that long-term exposure to leptin, similarly to the situation in obese individuals with elevated serum leptin levels, significantly impairs integral parts of NK cell immune functions, possibly linking leptin to increased cancer susceptibility in obesity.

Treatment Algorithms for Mature T-Cell and Natural Killer-Cell Neoplasms

Mature T-cell and natural killer (NK)-cell lymphomas are rare neoplasms, differing geographically in frequencies. T-cell lymphomas are more common in Asia than in western countries, and NK-cell lymphomas occur almost exclusively in Asia and South America. The rarity of these lymphomas means that treatment algorithms of T-cell and NK-cell lymphomas have not been well established. Angioimmunoblastic T-cell lymphoma, anaplastic large cell lymphoma and peripheral T-cell lymphoma, not otherwise specified, are the more commonly encountered T-cell lymphomas. Treatment with anthracycline-based regimens designed for aggressive B-cell lymphomas gives unsatisfactory results. Cutaneous T-cell lymphomas may remain indolent, but outcome is poor for advanced diseases. Novel therapies, including monoclonal antibodies, nucleoside analogs, histone deacetylase inhibitors and small molecules targeting cellular signaling pathways, are being explored alone or in combination with chemotherapy. High-dose chemotherapy with hematopoietic stem cell transplantation (HSCT) is recommended for high-risk cases. NK-cell lymphomas exhibit the multidrug resistance phenotype due to P-glycoprotein expression, so that anthracycline-based regimens are ineffective. Non-multidrug resistance-dependent regimens and L-asparaginase-based protocols have been shown to be highly active. Autologous HSCT is not routinely performed. The role of allogeneic HSCT is being examined.

State of the art in natural killer cell malignancies

The recently updated World Health Organization (WHO) classification of tumors of hematopoietic and lymphoid tissues, published in 2008, has made great advances in revising the disorders previously included in the pool of natural killer (NK) cell tumors. Although NK cell neoplasms represent a relatively rare group of diseases, accounting for <5% of all lymphoid neoplasms, they include very distinctive conditions both clinically and pathologically. This family of diseases includes the most indolent clinical forms, such as the provisional new entry of chronic lymphoproliferative disorder of NK cells (CLPD-NK) in the WHO classification, as well as one of the most fatal diseases recognized in medical oncology, aggressive NK cell leukemia (ANKL), which is characterized by a prognosis of weeks, or even days. In addition, some disorders previously identified as blastic NK cell lymphoma within the NK cell system have been more properly defined and included in the blastic plasmacytoid dentritic cell neoplasms, although rare cases of bona fide immature NK lymphoid tumors (now classified as NK cell lymphoblastic leukemia/lymphoma) have been reported in the literature. This paper focuses on recent concepts and progress in morphology, pathogenesis, clinicopathological features, treatment approaches, and outcomes of NK cell malignancies.

Guidelines for the management of mature T‐cell and NK‐cell neoplasms (excluding cutaneous T‐cell lymphoma)

The peripheral T-cell neoplasms are a biologically and clinically heterogeneous group of rare disorders that result from clonal proliferation of mature post-thymic lymphocytes. Natural killer (NK) cell neoplasms are included in this group. The World Health Organization classification of haemopoietic malignancies has divided this group of disorders into those with predominantly leukaemic (disseminated), nodal, extra-nodal or cutaneous presentation. They usually affect adults and are more commonly reported in males than in females. The median age at diagnosis is 61 years with a range of 17-90 years. Although some subtypes may follow a relatively benign protracted course most have an aggressive clinical behaviour and poor prognosis. Excluding anaplastic lymphoma kinase (ALK)-positive anaplastic large cell lymphoma (ALCL), which has a good outcome, 5-year survival for other nodal and extranodal T-cell lymphomas is about 30%. Most patients present with unfavourable international prognostic index scores (>3) and poor performance status. The rarity of these diseases and the lack of randomized trials mean that there is no consensus about optimal therapy for T- and NK-cell neoplasms and recommendations in this guideline are therefore based on small case series, phase II trials and expert opinion.

NK cell neoplasias

Neoplasms of natural killer (NK) cells are rare, and have not been well characterized until the past decade. In the new WHO classification of hematolymphoid tumors, three categories of NK cell neoplasms are recognized: Extranodal NK/T cell lymphoma, Aggressive NK cell leukemia, and Blastic NK cell lymphoma. Blastic NK cell lymphoma is morphologically and immunologically different from the first two categories, lacks EBV association, and there is little compelling evidence that it truly represents an NK cell neoplasm. In fact, recent studies suggest that this may be a neoplasm of probable precursor dendritic cells related to plasmacytoid monocytes (plasmacytoid dendritic cells). Since its lineage is still uncertain, this entity will not be discussed.

The Diagnosis and Management of Extranodal NK/T-Cell Lymphoma, Nasal-Type and Aggressive NK-Cell Leukemia

Natural killer (NK) cell lymphomas are rare malignancies. They are classified as extranodal NK/T-cell lymphoma, nasal type, and aggressive NK cell leukemia. NK cell neoplasms are prevalent in Asian and South American populations, but are extremely rare in the West. They can be classified clinically into nasal, non-nasal, and aggressive lymphoma/leukemia subtypes. For nasal NK cell lymphomas, combined chemotherapy and radiotherapy are indicated for stage I/II disease. Chemotherapy is the main treatment for stage III/IV nasal NK cell lymphomas, as well as the non-nasal and aggressive subtypes. Regimens containing drugs not affected by the P-glycoprotein, particularly in combination with L-asparaginase, have resulted in much improvement in treatment outcome for high-risk, refractory or relapsed patients. Autologous or allogeneic hematopoietic stem cell transplantation should be considered for selected patients. Epstein-Barr virus DNA load as a surrogate marker for prognostication, and clinical stratification of patients should be incorporated in clinical management algorithms.