Splenic Lymphoma Research Articles

Targeted next‐generation sequencing reveals molecular heterogeneity in non‐chronic lymphocytic leukemia clonal B‐cell lymphocytosis

Non-chronic lymphocytic leukemia (non-CLL) clonal B-cell lymphocytosis (CBL) encompasses a heterogeneous group of hematologic disorders that are still poorly understood. To shed light on their biological aspects, we retrospectively analyzed a highly selected series of 28 patients, who had a clonal B-cell population in the peripheral blood and in the bone marrow, without evidence of lymphoma. Extended targeted next-generation sequencing revealed wide molecular heterogeneity with MYD88 (14%), PDE4DIP (14%), BIRC3 (11%), CCND3 (11%), NOTCH1 (11%), and TNFAIP3 (11%) as the most mutated genes. Mutations of MYD88 were "nonclassic" in most cases. Although some genetic lesions were overlapping with indolent lymphomas, mainly splenic B-cell lymphomas of marginal zone origin and splenic diffuse red pulp small B-cell lymphoma, the genetic profile of our non-CLL CBL series seemed to suggest that various pathways could be involved in the pathogenesis of these disorders, not mirroring any specific lymphoma entity. These data better enlighten the molecular characteristics of non-CLL CBL; however, more efforts are needed in order to improve the diagnostic process, prognostication, and clinical management.

B-cell neoplasms and Hodgkin lymphoma in the spleen

B-cell lymphoma of spleen may be primary (most commonly splenic diffuse large B-cell lymphoma) or secondary (typically low-grade non-Hodgkin lymphoma). Depending on the specific lymphoma subtype, there may be a predominantly white pulp pattern of involvement, a predominantly red pulp pattern or a focal nodular pattern. Splenectomy is the ideal specimen for a multiparametric integrative diagnosis of splenic lymphoma, as it allows for a combined study of morphology, immunohistology, flow cytometry, cytogenetics, and molecular genetic techniques. This review article describes the clinicopathologic characteristics of all the relevant B-cell neoplasms that may be encountered in a splenic biopsy or a splenectomy specimen.

Establishment and characterization of a porcine B cell lymphoma cell line

The lack of available, well characterized, established, domestic porcine cell lines hinders the advancement of porcine cellular immunology. A case of multicentric lymphoma was diagnosed in a market weight pig at the time of slaughter. Affected lymph nodes and spleen were collected and used for single cell isolation and analysis. Cell lines were established by 3 rounds of limiting dilution from splenic and subiliac lymph node lymphomas. Surface marker staining identified the cells as CD21+, CD79a+, CD20+, PAX5+, and CD3− and cells were grown and easily passaged in cell culture. Transcriptome analysis was carried out to further characterize these rapidly proliferating cells validating the initial cytometric findings, confirming their identity as B cell lymphomas, and suggesting that they arose from germinal center centroblasts with aberrant control of BCL6 expression. Functional analysis identified the cells as being involved in cancer, cell movement, cell survival, and apoptosis. These new porcine B cell lymphoma cell lines will be a valuable resource for more in-depth cellular investigations into the porcine immune system and cancer, as well as providing a potential tool for the growth of lymphotropic viruses of pigs and humans.

Gastrosplenic Fistula and Coeliac Artery Occlusion

Gastrosplenic fistula (GSF) is a very rare complication of several disease processes and can lead to catastrophic bleeding, necessitating emergent treatment. Splenic or gastric lymphomas are the predominant causes, with trauma and gastric surgery also implicated in several case reports. We present a case of a gastrosplenic fistula resulting from occlusion of the coeliac artery. To our knowledge, this is the first reported case of a GSF resulting from severe intra-abdominal arterial disease. A 60-year-old male initially presented to the emergency department with epigastric pain. He had an extensive medical history, including dialysis-dependent end-stage renal failure, atrial fibrillation, coronary artery disease, and multiple previous abdominal surgeries. Investigation with CT angiography revealed calcified occlusion of the coeliac artery as well as extensive calcification throughout his aorta and arterial tree. A diagnosis of mesenteric angina was made, but due to his poor functional status, he was not suitable for surgical or transcatheter interventions. He was treated symptomatically, but a month later developed sudden worsening of his epigastric pain, followed by large volume haematemesis. CT angiography showed a GSF with extensive gastric necrosis. Due to his poor functional status and rapid deterioration, he opted for palliation and passed away two days later. It has been postulated that GSF develops from the invasion of malignant tissue from the stomach to the spleen or vice versa, and subsequent necrosis of this tissue results in fistula formation. This case demonstrates that the invasion of an adjacent organ may not be necessary; necrosis itself can cause erosion that ultimately results in fistula formation.

The prognostic significance of POD24 in 106 cases with splenic marginal lymphoma with bone marrow invasion

目的探讨24个月内疾病进展（POD24）对伴骨髓侵犯的脾边缘区淋巴瘤（SMZL）患者总生存的影响，比较POD24与非POD24患者的临床特征。方法回顾性分析2002年1月至2017年1月中国医学科学院血液病医院收治的有治疗指征且经过正规治疗的伴骨髓侵犯的SMZL患者，选取随访时间足以对POD24进行判断的患者（排除因非进展因素发生死亡的患者），进行预后评估及临床特征比较。结果共入组患者106例，中位年龄57（25～79）岁。①临床特征：全部患者均有骨髓侵犯和脾肿大，其中巨脾59.4％（63/106），肝大14.8％（15/101）；复杂核型22.7％（18/79），13q缺失5.1％（4/78），11q缺失1.3％（1/72），17p缺失2.5％（2/80），12号染色体三体（CEP12）7.5％（4/53）。②生存分析：单因素分析提示POD24、HGB<100 g/L以及CEP12为与总生存相关的不良预后因素；多因素分析提示仅POD24有独立预后意义［HR＝20.116（95％CI 2.226～181.820），P＝0.008］。③亚组分析：POD24患者较非POD24患者起病时纵隔淋巴结肿大的发生率（63.6％对18.9％，P＝0.005）及复杂核型发生率（50.0％对17.9％，P＝0.024）明显增高；腹腔淋巴结肿大、贫血、血小板减少、白蛋白下降以及乳酸脱氢酶增高的发生率在POD24患者中更高，与非POD24患者相比差异无统计学意义（P>0.05）。结论POD24为影响伴骨髓侵犯的SMZL患者总生存的独立预后不良因素，起病时伴纵隔淋巴结肿大及复杂核型的患者发生POD24比例更高。

Clinicopathological analysis of splenic red pulp low-grade B-cell lymphoma.

Primary splenic low-grade B-cell lymphoma of the red pulp comprises hairy cell leukemia (HCL) and splenic B-cell lymphoma/leukemia, unclassifiable (SPLL-U). SPLL-U is a rare disease that includes subtypes of a hairy cell leukemia-variant (HCL-v), splenic diffuse red pulp small B-cell lymphoma (SDRPL) and other types that are known as narrow sense SPLL-U (SPLL-U-NS). Notably, limited information is available regarding the BRAF mutation (V600E) and cyclin D3 expression in subtypes of SPLL-U. Therefore, we performed a pathological analysis of the BRAF mutation (V600E) and characterized pathological features of SPLL-U. We reviewed the pathological findings of 12 SPLL-U cases. The 12 cases considered included two cases of HCL-v, six cases of SPLL-U-NS and four undetermined cases. The BRAF mutation (V600E) was detected in three cases, which were all SPLL-U-NS. Cases with the BRAF mutation (V600E) have increased levels of CD103 expression and decreased cyclin D3 and cyclin D1 expression compared with cases that lacked the BRAF mutation. These findings suggest that the BRAF mutation might play a significant role in SPLL-U. Therefore, the significance of the BRAF mutation should be evaluated via genomic or transcriptional analyses of a large cohort of SPLL-U patients.

Epidemiology of Hairy Cell Leukemia (HCL) and HCL-Like Disorders

Hairy cell leukemia (HCL) is a very rare and well-defined entity that is characterized by the presence of hairy cells expressing the characteristic markers CD11c, CD25, CD103 and CD123 and in most cases by the presence of the BRAFV600E mutation. The incidence rate, directly adjusted to the 2000 United States standard population is estimated at 0.62 per 100 000 person-years (PA) in white men, 0.21 in black men, 0.20 in Asian men and 0.06 American Indian or Alaska native men. Based on the estimated 2019 leukemia incidence, of 61,780 in the United States, approximately 1,240 new HCL cases are expected per year, with only 60–75 new patients having a variant form of HCL each year. In France, the median age of patients at diagnosis is 63 years in men and 59 years in women. There is a strong male predominance, with a sex ratio of 5:1. HCL is a malignant disorder with a good prognosis, with a standardized average survival at 1 year and 5 years of 95% (95% CI: 91-97 for both). The etiology of HCL remains unknown. The risk of secondary cancers is high, especially that of another malignant hematologic disorder. This high risk justifies the need for prolonged hematological monitoring. HCL must be distinguished from other HCL-like disorders, including the variant form of HCL (HCL-V) or splenic diffuse red pulp lymphoma (SDRPL), warranting the development of international epidemiologic studies.

Primary Splenic Lymphoma with Hemophagocytic Syndrome : Report of a Case with Treatment and Diagnosis by Splenectomy

Primary Splenic Lymphoma with Hemophagocytic Syndrome : Report of a Case with Treatment and Diagnosis by Splenectomy

Splenectomy in Lymphoproliferative Disorders: A Single Eastern European Center Experience.

Background and Objectives: Hematological malignancies are usually systemic diseases of life-threatening impact, and frequently require prompt and energetic therapeutic intervention. Due to systemic involvement, the role of surgery is generally limited to diagnostic approaches, and it is very rarely employed as a therapeutic modality. Splenectomy represents an exception to this paradigm, being used both as a diagnostic and tumor debulking procedure, notably in splenic lymphomas. Materials and Methods: We investigated the role of splenectomy in a single center prospective study of splenectomy outcome in patients with splenic involvement in the course of lymphoproliferative disorders. In the present study, we included all patients treated in our department for lymphoid malignancies over a period of six years, who underwent splenectomy as a diagnostic or debulking procedure after referral and workup, or had been referred to our department after first being splenectomized and diagnosed with splenic lymphoma. Patient characteristics and treatment outcome were investigated. Results: We enrolled 54 patients, with 34 (63%) splenectomized patients: 12 splenectomies (22.2%) for diagnostic purposes and 22 (40.7%) for treatment. Special attention was given to the 28 (51.85%) patients diagnosed with splenic marginal zone lymphoma (SMZL), a subtype with a clear therapeutic indication for splenectomy. Average age of patients was 57.5 (±13.1) years with a higher prevalence of feminine gender (66.67%). Age above 60 years old (p = 0.0295), ECOG (Eastern Cooperative Oncology Group) > 2 (p = 0.0402) and B-signs (p nonsignificant (NS)) were most frequently found in SMZL patients. Anemia, and notably autoimmune anemia, was more frequent in SMZL versus other small-cell lymphomas and also in splenectomized patients, as was leukocytosis and lymphocytosis. Treatment of patients with lymphoproliferative disorders consisted of chemotherapy and/or splenectomy. Most SMZL patients received chemotherapy as first line treatment (61.5%) and had only partial response (57.7%). Second treatment line was splenectomy in 80% of patients who required treatment, followed by a 60% rate of complete response (CR). Splenectomy offered a higher complete response rate (twice as high than in non-splenectomized, regardless of histology type, p = NS), followed by a survival advantage (Overall Survival (OS)~64 versus 59 months, p = NS). Particularly, SMZL patients had a 4.8 times higher rate of CR than other non-Hodgkin lymphoma (NHL) patients (p = 0.04), a longer progression free survival (73 months vs. 31 months for other small-cell NHLs p = NS) and a 1.5fold lower death rate (p = NS). The procedure was rather safe, with a 38.5% frequency of adverse reactions, mostly minor and manageable. Conclusions: Our data suggest that splenectomy is an effective and safe therapeutic option in patients with lymphoid malignancies and splenic involvement, particularly splenic marginal zone lymphoma.

Güneydoğu Anadolu Bölgesindeki Non-Hodgkin Lenfoma Sınıflaması: 550 Hastanın İncelenmesi

Background: The distribution of non-Hodgkin lymphoma (NHL) subtypes differs around the world. In this study we aimed to evaluate the gender, age, subtypes, biopsy sites, nodal and extranodal residential area, and stage of disease in the patients with NHL admitted to our hospital between January 2005 and December 2014.Materials and Methods: The records of NHL patients admitted to our hospital between January 2005 and December 2014 were retrospectively reviewed Results: Among 550 patients, 335 patients (60.9%) were male, 215 patients (39.1%) were female. The average age of over all the patients was 56 years (15-95). The average age of women was 57 (15-88), the average age of men was 54 years (15-95). The histological subtypes of NHL patients were as follows: 447 patients (81.3%) B-cell lymphoma, 84 patients (15.2%) T / NK cell lymphoma, 19 patients (3.5%) unclassified subtype. NHL patients divided into subtypes according to 2001 and 2008 WHO (World Health Organization) Classification and histopathologic subtypes were as follow: Diffuse Large B Cell Lymphoma (DLBCL) 295 patients (53,63%), small lymphocytic lymphoma (SLL) 37 patients (6.7%), Extranodal marginal zone lymphoma (MALT type) 37 patients (6,75%), peripheral T-cell Lymphoma 27 patients (4.9%), mantle cell lymphoma 26 patients (4.72%), Nodal Marginal Zone B-Cell Lymphoma 7 patients (1,3%), follicular lymphoma in 12 patients (2.1%), Burkitt's lymphoma 7 patients (1.3%), Splenic marginal zone B-cell lymphoma 4 patients (0,7). The most common subtype of NHL was DLBCL 295 patients (53,63%). Follicular lymphomas are less common in our center. Extranodal involvement rate was 38,5% of patients. According to the distribution of the sites of extranodal NHLs, the vast majority of patients 43% had GI tract involvement. The most commonly affected GI sites were stomach (27,8%). In this study 22.9% of the patients were in Stage 1, 26.7% in Stage 2, 19.5% in Stage 3, 30.9% in Stage 4 according to Ann- Arbor classification. In conclusion, the characteristics of NHLs in our region show some differences from other sites of the world. Conclusions: The characteristics of NHL patients vary according to geographical differences. Present study has revealed the importance of geriatric assessment. NHL was observed frequently in men. Environmental risk factors have to research, epidemiologically. The most common subtype of NHL was DLBL. Follicular lymphomas are less common in our center. Improvement of national cancer registration system and multicenter large-scale studies reviewing the treatment protocols are needed to ensure the early diagnosis and therapy of NHL.

Discordant lymphoma: report of one case and review of literature

Objective To investigate the clinical characteristics, diagnosis, treatment and prognosis of discordant lymphoma. Methods The clinical data of one patient with discordant lymphoma at the PLA Strategic Support Force Characteristic Medical Center were retrospectively analyzed, and the related literatures were reviewed. Results The patient was treated for thrombocytopenia and the examination showed splenomegaly. After hormone treatment, the platelet rebounded and thrombocytopenia occurred during hormone reduction. Splenectomy was performed. Postoperative pathological diagnosis of splenic marginal lymphoma was made and observed. Axillary lymph node enlargement occurred nine months later. Pathological diagnosis of diffuse large B-cell lymphoma was made by using lymph node biopsy, and the disease condition was alleviated after immunotherapy combined with chemotherapy. Conclusions Discordant lymphoma is rare and shows no special clinical manifestations. Its diagnosis should rely on pathological examination. Immunotherapy combined with chemotherapy may be more effective. Key words: Lymphoma, B-cell, marginal zone; Lymphoma, large B-cell, diffuse; Discordant lymphoma; Pathogenesis; Diagnosis; Prognosis

Detailed Functional Characterization of Splenic Marginal Zone Lymphoma: Uncovering Links between the Epigenetic and the Signaling Machinery

Splenic marginal-zone lymphoma (SMZL) ontogeny and evolution is a complex process, involving, amongst others, (super)antigenic stimulation, molecular deregulation of genes involved in the physiological differentiation of splenic marginal zone B cells (e.g. NOTCH2 and KLF2), and epigenetic alterations leading to silencing of different tumor suppressor genes and overexpression of oncogenes, including the PRC2-complex (EZH2, EED, and SUZ12). However, despite important recent progress, advances in the fundamental understanding of SMZL have not yet been translated in improved patient management, highlighting the need for further molecular investigations. In this context, here we aimed at detailed characterization of: (i) epigenetic modifiers, particularly the histone methyltransferase EZH2, a marker of clinical aggressiveness and druggable target in lymphoma; (ii) immune signaling capacity of SMZL B cells; and, (iii) antigen reactivity profile of the SMZL clonotypic B Cell Receptor immunoglobulin (BcR IG). Quantification of EZH2 mRNA levels using quantitative Real-time PCR (n=26 SMZL patients) and protein levels using western blotting (WB) (n=14) revealed that EZH2 was expressed in all cases yet in a heterogeneous manner (2^-ΔCt range: 0.079-1.38; ΕΖΗ2+ cells: 3.11%-44.8%). Interestingly, higher proliferation rates (Ki67+ cells) were observed in cases with high EZH2 protein levels (n=4) compared to cases with low EZH2 (n=6) (FD=2.6; p&amp;lt;0.05). Stimulation of SMZL CD19+ B cells (n=8) through i) the BcR with anti-IgM ii) Toll-Like receptor 9 (TLR9) with CpG and iii) BcR/TLR for 60 minutes affected pBTK, pERK and pNF-kB levels as revealed by WB and flow cytometry (FCM). Although, great heterogeneity was observed in the responses between different cases, categorization of SMZL cases based on EZH2 levels showed that, at basal level, EZH2high cases expressed higher pBTK, pERK and pNF-κB compared to EZH2low cases (FC=2.4, FC=6,1, FC=12.7, respectively; p&amp;lt;0.05 for all comparisons). BcR and TLR9 activation and, especially, co-stimulation with anti-IgM/CpG induced the expression of pBTK, pERK and pNF-κB in EZH2low cases, while the opposite was observed in EZH2high cases. Moreover, stimulation through both the BcR and BcR/TLR9 for 24 hours could also induce EZH2 expression compared to the unstimulated control cells (FC=1.6; p&amp;lt;0.05 for both comparisons). To gain insight into the type of antigenic stimuli that could activate BcR signaling through the BcR we investigated the antigen binding profile of 10 SMZL clonotypic BcR IGs expressed as recombinant human IgM monoclonal antibodies (mAbs). Cases were representative of the most common IGHV genes in SMZL (IGHV1-2*04, IGHV4-34 and IGHV3-23). Reactivity (at 15 μg/ml) against various autoantigens was evaluated by ELISA. Five of 9 (56%), 4/7 (57%), 5/10 (50%), 2/9(22%), 2/9 (22%), 3/9 (33%), 3/8 (38%), 4/8 (50%) and 4 of 9 (44%) SMZL IgM mAbs displayed reactivity against native DNA, nuclear Hep-2 cell extract, actin, myosin, thyroglobulin, β-amyloid, carbonic anhydrase, F(ab')2 and the hapten trinitrophenyl respectively, with optical density (OD) values greater than the cut-off point. Moreover, 5/10 (50%) SMZL IgM mAbs recognized more than 2 antigens and were characterized as polyreactive. Each of these SMZL mAbs exhibited a distinct antigen polyreactivity profile, while heterogeneity was observed even amongst cases expressing the same gene or cases with similar IGHV gene mutational load. Recognition of epitopes on the surface of viable MEC1 B and HEK293 cells was assessed by FCΜ. Two of 3 and 5/11 mAbs bound to viable MEC1 B cells and HEK293 cells, respectively: binding to HEK293 cells was more pronounced for minimally mutated/unmutated versus mutated mAbs (p&amp;lt;0.05). Importantly, stimulation of SMZL CD19+ B cells with the SMZL BcR cognate antigens actin and myosin resulted in regulation of pERK/pPLCγ2 in 3/6 and 1/2 cases, respectively, as revealed by WB. Overall, SMZL cells can be activated by microenvironmental signals albeit in a different manner depending on EZH2 levels, highlighting links between the epigenetic and the signaling machinery with potential therapeutic implications. Moreover, the recognition of a wide range of autoantigens by the SMZL mAbs indicates that SMZL B cell clones may arise from polyreactive B cells, likely resident in the normal splenic marginal zone. Disclosures Stamatopoulos: Janssen: Honoraria, Research Funding; Abbvie: Honoraria, Research Funding.

Targeted Next Generation Sequencing Reveals Molecular Heterogeneity in Non-CLL Clonal B-Cell Lymphocytosis

Background. Non-chronic lymphocytic leukemia (non-CLL) clonal B-cell lymphocytosis (CBL) encompasses a heterogeneous group of hematologic disorders that are still poorly understood. The main purpose of this study was to explore the genomic landscape of non-CLL CBL, correlating the results with clinical, histological and immunogenetic features. Methods. We retrospectively analysed the disease characteristics in a highly selected series of 28 patients, who had a clonal lymphocytosis in peripheral blood (PB) and clonal lymphoid populations in the bone marrow (BM), without evidence of lymphadenopathy, splenomegaly, peripheral cytopenia or constitutional symptoms.In all patients the BM evaluation, comprising flow cytometry, histology and immunohistochemistry, was not able to classify the lymphoproliferative disorder in any of the WHO-defined entities. A diagnosis of CLL or a leukemic phase of mantle cell or follicular lymphoma was ruled out in each subject. Targeted next generation sequencing (NGS) was performed on DNA extracted from CD19+ BM or PB cells using a core panel of 138 genes frequently reported in mature B cell neoplasms.On the basis of the information retrieved from the KEGG and REACTOME databases, each mutated gene was assigned to a specific lymphoma-enriched pathway. Results: Clinical, flow cytometric and histological data are presented in Table 1.The median BM infiltration was 30% (range: 5-80%); the pattern of infiltration was interstitial or mixed (nodular and interstitial) in the majority of the cases; sinusoidal localization was noticed in 54% of cases. There was a borderline correlation between the extent of BM infiltration and the absolute number of PB clonal B cells count (Spearman's Rho: 0.38, p=0.05), that ranged from 851/mmc to 14508/mmc (median: 3604/mmc). With a median follow-up of 35.2 months (range: 6-125), only 1 patient developed disease progression to a B-cell lymphoma not otherwise specified (5-yrs CI of progression: 11.9%; 95%CI: 0.6%-40.7%). The sequence analysis of 138 genes revealed a total number of 74 somatic mutations in 51 genes. All the 28 cases displayed at least 1 mutation, with the number of mutations ranging from 1 to 7 (median 2). The most frequently mutated genes were MYD88 (14%), PDE4DIP (14%), BIRC3 (11%), CCND3 (11%), NOTCH1 (11%) and TNFAIP3 (11%) (fig.1).Notably, 3 out of 4 MYD88 variants were different from the classical p.L265P (p.M232T, p.V217F and p.L204F not previously described). Data on IGHV were available for 22 patients (79%) (Fig.2): VH gene repertoire was similar to that reported in non-CLL malignancies and no distinct stereotyped subset was found. Truly unmutated IGHV genes with 100% of germline identity were present in 3 cases (11%). The analysis of disease features according to mutated genes showed that MCwas more frequent in patients harbouring mutations in MYD88 (p=0.08) or TNFAIP3 (p=0.02); these patients had also a higher number of mast cells on BM histology than the wild type ones (p=0.02 and p=0.05, respectively). NOTCH1 mutated patients showed an absolute number of B-cell peripheral clonal lymphocytes higher than wild type cases (p=0.037). The most frequently involved pathways were NF-kB signalling (32%) and cell communication pathways (32%), followed by cell cycle (29%), chromatin organization (25%), transcriptional misregulation (21%), Toll-like receptor (TLR) signalling (18%) and NOTCH signalling pathways (14%) (Fig. 3).Patients with mutated chromatin organization pathway more often showed normal LDH levels compared with wild type cases (100% vs 40% p=0.01). Conclusions. We characterised non-CLL CBL, integrating BM histological features and IGHV data with an extended NGS panel. The mutational landscape was extremely heterogeneous, pointing out a wide spectrum of somatic mutations. Most of them have been already described in Waldenström's Macroglobulinemia and splenic B-cell lymphomas; of note, we found a new variant of MYD88 associated with an IgM MC and recurrent mutations of PDE4DIP, which have not been previously reported in indolent B-cell malignancies. Disclosures Varettoni: Janssen: Consultancy; Roche: Consultancy; ABBVIE: Other: travel expenses; Gilead: Other: travel expenses. Arcaini:Bayer, Celgene, Gilead Sciences, Roche, Sandoz, Janssen-Cilag, VERASTEM: Consultancy; Celgene: Speakers Bureau; Celgene, Roche, Janssen-Cilag, Gilead: Other: Travel expenses; Gilead Sciences: Research Funding.

Clonal B-Cell Lymphocytosis with Mariginal-Zone Features: Comparison with Overt Splenic Marginal-Zone Lymphomas in 77 Patients from a Monocentric Series

Diagnosis of non-CLL B Cell Chronic Lymphoproliferative Disorders (BCLPD), defined by the detection of peripheral blood (PB) B-Cell clone with flow cytometry (FC) Matutesscore≤3, is not an infrequent event in clinical daily practice. Only a portion of these cases may be actually classified according to the 2016 revision of WHO classification of lymphoid neoplasms, as in these cases a non-bone marrow (BM) tissue biopsy is rarely available due to "liquid-only disease" (BM, PB, splenomegaly) or difficult accessible sites. The two most likely diagnosis of BCLPD according to WHO 2016 are splenic marginal-zone lymphoma (SMZL) and monoclonal B Cell lymphocytosis (MBL) with non-CLL phenotype (CD19+, CD20+, SIg+, CD5-), sometimes reported as MZL-like, defined by monotypic clonal B lymphocytes (CBL) &lt;5 x 109/l. A recent study pointed out a similar outcome regardless CBL value exceeding or not this arbitrary cut-off in strictly defined cases (absence of cytopenias, splenomegaly and adenopathy) of clonal B cell lymphocytosis with marginal-zone features (CBL-MZ) and confirmed the really indolent behaviour of this entity (Xochelli, Blood 2014). On these bases we decided to retrospectively collect clinical, immunophenotypic, molecular features and outcome of all consecutive patients (pts) with CD5- CBL-MZ owing to the Department of Hematology of University of Insubria (Varese, Italy) from 2011 to 2019 and to compare them with overt SMZL cases. Excluding 5 SMZL pts who were splenectomized, all cases were diagnosed by means of non-BM tissue biopsy, namely BM histology and PB/BM FC, FISH and molecular studies, when appropriate, and complete laboratory and imaging staging procedures (CT scan or US). The primary objective of the study was time to progression (TTP) for CBL-MZ group. Secondary objectives were overall survival (OS), progression-free survival (PFS) for treated pts and evaluation of early progression &lt;24 months (Early POD) (Luminari, Blood 2019). Overall we collected complete data of 33 pts with CD5- CBL-MZ, and 44 with SMZL (Table 1). Focusing on CBL-MZ, FC immunophenotypic findings showed a B-Cell population with Matutes score 0 to 2 in all cases, uniform expression of B Cell antigens, namely CD19, CD20 strong, FMC7 (93%), SIg (intermediate/bright in 71%), while CD10 and CD5 were consistently negative. CD23 was expressed in 18%, CD38 in 9% and CD49b in 95%. BM sinusoidal infiltration pattern was detected in 50% of cases. TP53 mutation/deletion was detected in 4/16 pts (25%) while trisomy 12 and del13q in 1 pt each. Twenty pts presented with &lt;5000/mmc CBL (MBL-MZ) and 13 with ≥5000/mmc CBL. With a median follow-up of 1.8 years, 6 pts (18%) progressed (4 in SMZL, 1 NMZL and 1 SLL; Fig 2) with a median TTP of 1.7 yrs (range 0.3- 12.3), while the remaining 27 remained completely stable. Among 4 pts treated, 2 received Rituximab-based regimen, both achieving CR and 2 with Chlorambucil both experiencing progression. Overall, 5 pts died (2 for progressive lymphoma), with an estimated 5-yrs of 80%. Concerning prognostic factors, after adjusting by competing risk method, at univariate analysis age &gt;60 yrs, CBL &gt;5000/mmc and albumin &lt;3.5 g/dl, were associated to shorter TTP, while age &gt;60 yrs, Hb &lt;11 g/dl, ECOG PS ≥2 and albumin &lt;3.5 g/dl resulted predictive of worse OS (Table 2). By applying multivariate Cox regression model, only age &gt;60 yrs and CBL&gt;5000/mmc retained prognostic significance for TTP (p&lt;0.0001), while ECOG PS ≥2 and albumin &lt;3.5 g/dl remained independently associated with inferior OS (p&lt;0.0001). Considering the SMZL group, 34 pts underwent systemic treatment (rituximab-based in 32, including R-Bendamustine in 17). With a median follow-up time of 2.8 yrs, 9 pts progressed (4 of whom within 24 months from treatment initiation), with a median PFS 2.9 yrs, and 8 died (7 due to progression, including 3 DLBCL transformations) with an estimated 5-yrs OS of 79%. Notably, Early POD SMZL pts exhibited a significant increased risk of death (p&lt;0.0001, fig.2), while in CBL-MZ did not (p=0.4). In conclusion, CBL-MZ confirmed to be associated with indolent course and preferential evolution toward SMZL, of which it can be viewed as an initial phase or a precursor entity. In contrast with previous findings, the WHO 16 CBL cut-off defining MBL (5 x 109/l), together with advanced age, retained prognostic relevance for TTP. Finally, we confirmed for the first time in an independent series of SMZL the highly prognostic impact of Early POD24. Disclosures Passamonti: Roche: Consultancy; Janssen: Consultancy, Speakers Bureau; Celgene: Consultancy, Speakers Bureau; Novartis: Consultancy, Honoraria, Speakers Bureau.

Hairy cell leukemia: 2020 update on diagnosis, risk stratification, and treatment.

Hairy cell leukemia (HCL) and HCL-like disorders, including HCL variant (HCL-V) and splenic diffuse red pulp lymphoma (SDRPL), are a very heterogeneous group of mature lymphoid B-cell disorders. They are characterized by the identification of hairy cells, a specific genetic profile, a different clinical course and the need for appropriate treatment. Diagnosis of HCL is based on morphological evidence of hairy cells, an HCL immunologic score of three or four based on the CD11C, CD103, CD123, and CD25 expression. Also, the trephine biopsy which makes it possible to specify the degree of tumoral medullary infiltration and the presence of BRAF V600E somatic mutation. Progression of patients with HCL is based on a large splenomegaly, leukocytosis, a high number of hairy cells in the peripheral blood and the immunoglobulin heavy chain variable region gene mutational status. The VH4-34 positive HCL cases are associated with poor prognosis. Risk adapted therapy with purine nucleoside analogs (PNA) are indicated in symptomatic first line HCL patients. The use of PNA followed by rituximab represents an alternative option. Management of progressive or refractory disease is based on the use of BRAF inhibitors associated or not with MEK inhibitors, recombinant immunoconjugates targeting CD22 or BCR inhibitors.

2327 Not Just a Cyst: Rare Presentation of LUQ Pain

INTRODUCTION: Lymphangioma is a benign congenital malformation of the lymphatic system that is relatively common in juvenile population. Rarely, it can be seen in adults and majority of the cases are reported in the head and neck region (70-75%). Typically, these malformations are asymptomatic. In this report, we present a rare case of splenic lymphangioma presenting with severe, intractable abdominal pain. CASE DESCRIPTION/METHODS: A 50-year-old female presented with three-month history of progressive abdominal pain located below the left subcostal margin. Initial vital signs and lab work were unremarkable. Physical exam was significant for tenderness in the left upper abdominal quadrant. Computed tomography (CT) scan of abdomen with contrast revealed a hypointense lesion measuring up to 1.8 cm in the posterior aspect of the spleen. Subsequently, a hypo-enhancing splenic mass in the corresponding location was demonstrated in T1-weighted MRI images (Image 1A). The spleen was normal-sized and there were no liver lesions. A total splenectomy was performed with resolution of the pain during the hospitalization. Histopathological examination of the lesion revealed multiple cystic cavities containing pale eosinophilic fluid (Image 1B) resembling lymph, consistent with splenic lymphangioma. The cystic cavities were lined with elongated cells with bland nuclei and scant cytoplasm (Image 1C). Immunohistochemically, the lesion stained positive with CD31 (Image 1D). DISCUSSION: Clinical presentation of splenic lymphangioma varies depending on the spleen size with majority of the patients being asymptomatic. The diagnosis is usually made incidentally on routine imaging studies. Based on the clinical data and imaging results, our differential diagnosis included hemangioma, complex splenic cyst, lymphangioma, lymphoma, and pseudocysts. The splenic lymphangioma was diagnosed on microscopic examination following a splenectomy which was done to avoid any further complications such as; infection, rupture, hemorrhage and pleural effusions. The treatment modality of choice was complete surgical resection in this patient given relevant history. Other therapeutic modalities such as aspiration or drainage have not shown effective results in the literature. Despite the rarity, early recognition of these lesions is important as the delay in surgical intervention can result in complications.

Hemofilia adquirida A y B como manifestación inicial de linfoma no Hodgkin. Reporte de un caso y revisión de la literatura

La hemofilia adquirida es una complicación rara y potencialmente fatal en pacientes con neoplasias hematológicas (desórdenes linfoproliferativos) o tumores sólidos. Presentamos una paciente de 75 años de sexo femenino con antecedente de hipertensión arterial y anemia ferropénica que ingresa a urgencias por cuadro de dolor abdominal generalizado tipo cólico, asociado a episodios eméticos de contenido alimentario y deposiciones melénicas. Dentro de los estudios iniciales se encontraron: tiempos de coagulación prolongados, prueba de mezclas de aPTT con evidencia de anticoagulante circulante específico, factor IX, 0% y factor VIII, 0% con inhibidores de factor VIII y IX en 180 UB y 130 UB respectivamente. Se consideró que la paciente cursaba con hemofilia adquirida A y B con realización de estudios de extensión diagnosticándose linfoma no Hodgkin marginal esplénico.

Contrast Enhanced Ultrasound of Splenic Lymphoma Involvement Case presentation

The study present a case of splenic lymphoma in a middle-aged male, showing up with abdominal pain, weight loss and recurrent oral candidosis. Blood test revealed remarkable leukocytosis, anemia and thrombocytopenia. Abdominal ultrasound showed marked splenomegaly with multiple hyperechogenic lesions. Contrast enhanced ultrasound (CEUS), performed on the lower pole of the spleen, showed a lesion lightly hypoenhanced in the arterial time, with progressive washout and marked hypoenhancement in the late phase, raising the suspicion of a malignant pathology. MRI results were consistent with a high suspicion of splenic malignancy, a possible lymphoid infiltration. The peripheral blood smear revealed lymphocytosis with villous lymphocytes, a variant form of hairy cell leukaemia. Iliac crest bone marrow biopsy confirmed the diagnosis. Our aim behind highlighting the topic is to underline the role of CEUS in identifying a malignant lesion, promptly leading us to further hematological investigation.

Primary Splenic Lymphoma, a Rare yet Possible Diagnosis: A Case Report and Review of the Literature

Introduction: The spleen is subject to a variety of benign and malignant disorders, which can be manifested by nonspecific symptoms or signs. Hence, the diagnosis is often made based on radiological examinations and histopathological studies. Case Presentation: Herein we present a case report of a patient with pathologically approved primary splenic lymphoma (PSL). The patient was a 63-year-old woman presented with abdominal pain, predominantly in the left upper quadrant, since 1 month. Complete blood count (CBC) was normal except for mild anemia. Liver enzyme studies showed an elevated alkaline phosphatase level. Ultrasound (US) depicted a huge hypoechoic splenic mass and computed tomography (CT) confirmed the lesion to be a hypodense mass partially exophytic from the superior aspect of the spleen measuring up to 124 mm in size. The patient underwent a midline laparotomy and splenectomy and the spleen was sent for histopathological examination, which revealed high-grade B-cell lymphoma measuring 17 × 16 × 10 cm in size with capsular invasion and without any lymphovascular invasion. Conclusions: This case report highlights the importance of considering splenic lymphoma as a differential diagnosis, although rare, in a patient with abdominal pain and nonspecific clinical findings.

Leucémie à tricholeucocytes

Hairy cell leukemia (HCL) is a well-defined entity. Proliferation with hair cells, morphological aspects of hairy cells are easy to identify. Hairy cells express markers CD11c, CD25, CD103 and CD123. In 80% of cases, a BRAFV600E mutation is highlighted. In the absence of a BRAFV600E mutation, the differential diagnosis with other hair cell proliferations can be difficult, especially with the variant form of hairy leukemia, diffuse lymphoma of the red pulp of the spleen or splenic lymphoma of the marginal zone. Purine analogues (PNA) with or without anti-CD20 antibodies remain the first-line reference treatment. In case of relapse or resistance to PNA, BRAF inhibitors, with or without MEK inhibitors, are proposed in patients with the mutation. In the absence of BRAFV600E mutation, moxetumomab-pasudotox represents an interesting alternative. A multidisciplinary discussion is always necessary. In complex cases, expert advice is desirable.