Natural Killer-Like T-cell Lymphomas: Aggressive

Natural Killer-Like T-cell Lymphomas: Aggressive Lymphomas of
T-Large Granular Lymphocytes
By William
R. Macon,
Michael E. Williams, John P. Greer, Richard D. Hammer, Alan D. Glick, Robert D. Collins,
and John B. Cousar
Natural killer (NK)-like T cells are major histocompatibility
complex-unrestrictedcytotoxic T cellsthat are surfaceCD3positive, express NK-cell antigens,
and rearrangetheir T-cell
receptor. Most neoplasmsarising from this
T-cell subpopulation havebeena chronic lymphoproliierative disease referred t o as T-large granular lymphocyte (LGL) leukemia.
Only 10 NK-like T-cell lymphomas have been described in
detail previously; this study presents the clinicopathologic
features of six others and distinguishes these lymphomas
from T-LGL leukemia. All patients presented with B-symptoms and often had marked hepatosplenomegaly without
significant peripheral lymphadenopathy. Four ofthe six patients were immunosuppressed. All had CD3,CD8,CD56positive tumors, presumablyof hepatosplenic (n = 3). intestinal (n= l),
pulmonary (n = l),or nodal (n = 1) origin. Three
patients had lymphomatous bone marrow infiltrates, and
four had peripheral blood involvement by neoplastic large
lymphocytes, some of which had a blastic appearance or
resembled virocytes.Azurophilic granules, ultrastructurally
corresponding t o cytoplasmic densecore andlor double
density granules, were seen in all cases. T-cell d o n a l i was
shown in five tumors by Southern blot analysis, and three
had abnormal karyotypes. Two untreated patients died 20
days after presentation, and three patients who received
combination chemotherapy died within 5 months of presentation. One patient remains in complete remission 22
months after treatment. These findings suggest NK-like Tcell lymphomas are aggressive, are
clinicopathologicallydistinct fromT-LGL leukemia, and should be in the differential
diagnosis of extranodal T-cell lymphoproliferations, including those in immunosuppressed patients. Furthermore, the
LGL morphology,phenotype,
and tissue distribution of
some NK-like T-cell
lymphomas suggest they may arise from
thymic-independent T cells ofthe hepatic sinusoids andintestinal mucosa.
0 1996 by The American Society of Hematology.
N
T-LGL leukemia.'' Patients with this disorder generally have
a prolonged clinical course manifested by increased circulating CD57' T-LGLs, often with severe neutropenia, and occasionally have rheumatoid arthritis and mild to moderate
~plenornegaly.""~On the other hand, only 10 apparent NKlike T-cell lymphomas have been described in detail.I4-*'
Most of these present as aggressive CD56+ or CD57' hepatosplenic or intestinal tumors with variable nodal, cutaneous,
and peripheral blood involvement. A recent description of
three CD56+ aggressive variants of T-LGL leukemia may
represent NK-like T-cell lymphomas with
a
leukemic
phase."
In this report, we describe the clinical, morphologic, immunologic, karyotypic, and genotypic features of six NKlike T-cell lymphomas that distinguish these neoplasms as
a clinicopathologic entity distinct from T-LGL leukemia. We
also discuss the possibility that some of these NK-like Tcell lymphomas may arise from thymic-independent (extrathymically differentiated) T-cells.8,23
ATURAL KILLER (NK)-like T cells are phenotypically mature T cells that have a large granular lymphocyte (LGL)morphology,expressNK-cellantigens,andhave
properties similar to NK cells, such as cytotoxic activity in the
absence of major histocompatibility complex antigen presentation.'"TheseNK-likeTcells
are surfaceCD3-positiveand
rearrange their T-cell receptor, either a,5or y6, which distinguishes them fmm true NK cell^.'^ NK-like T cells comprise
lessthan 5% ofhumanperipheralblood
lymphocyte^,^^ and
are distributed in the intestinal mucosa, particularly within the
and in the hepatic sinusoids! Murine models also
show NK-like T cells in the spleen?,"
NK-like T-cell neoplasms are usually considered a chronic
lymphoproliferative disease, carrying the names Ty-lymphoproliferative disease, T-chronic lymphocytic leukemia,
lymphoproliferative disorder of granular lymphocytes, and
From theDepartment of Pathology, Division of Hematopathology,
and the Departments of Medicine and Pediatrics, Vanderbilt University Medical Center, Nashville, TN; and the Departments of Internal
Medicine and Pathology, University of Virginia Health Sciences
Center, Charlottesville, VA.
Submitted June 7, 1995; accepted August 22, 1995.
Supported in part by the Hematology Training Grant No. 5-T32DK-07186-19, National Institutes of Health, Bethesda, MD. W.R.M.
is an American Cancer Society Clinical Oncology Career Development Award recipient. This work was presented in part at the 84th
Annual Meeting of the United States and Canadian Division of the
International Academy of Pathology, Toronto, Canada, March 14,
1995.
Address reprint requests to William R. Macon, MD, Department
of Pathology, Medical Center North, C3321, Vanderbilt University,
Nashville, TN 37232-2561.
The publication costs of this article were defrayed in part by page
charge payment. This article must therefore be hereby marked
"advenisement" in accordance with 18 U.S.C. section 1734 solely to
indicate this fact.
0 1996 by The American Society of Hematology.
0006-4971/96/8704-0118$3.00/0
1474
MATERIALS AND METHODS
Patient population. Six patients with NK-like T-cell lymphomas, diagnosed at Vanderbilt University Medical Center (VUMC)
since 1989, were included in this study. Four patients received their
therapy at VUMC. Two others (patients 1 and 5 ) , whose pathology
materials were reviewed as Vanderbilt hematopathology consultation
cases, were hospitalized elsewhere; their clinical data were retrieved
through chart review and discussion with the referring pathologists.
Cytologic, histologic, and ultrastructural studies. Wright's
stained films or touch imprints were evaluated from peripheral blood
and aspirated bone marrow (patients 2 through 6 ) , pleural fluid (patient 5 ) and resected tumors (patients l and 6). Neoplastic lymphocytes in patient peripheral blood films were compared with those
from four patients with clonal T-LGL leukemia and from four patients known to have infectious mononucleosis. Differential counts
of 200 hematopoietic cells were performed on marrow aspirate films
for patients 2, 3, and 4.The morphological features on 4 pm thick,
hematoxylin and eosin-, periodic acid-Schiff (PAS)-, and methyl
green pyronin-stained sections of formalin- or B5-fixed, paraffinBlood, Vol 87, No 4 (February 15). 1996: pp 1474-1483
LYMPHOMAS NATURAL KILLER-LIKE T-CELL
1475
Table 1. Clinical Features of Patients Wkh NK-Like T-Cell Lymphomas
Patient
No.
of
AgeEex
Tumor
Findings
Hematologic
Presentation
Stage
Duodenum and
mesentery
Treatment
Outcome
IV
None
DOD 20 d after
presentation
1
64/M
Fever, abdominal pain, and
rectal bleeding
WBC = 17.9 X 103/pL (75%
PMN, 10% lymph), Hct =
29.2%. Plt = 333 X 1031
2*
32/M
Fever, night sweats, and
marked
hepatosplenomegaly
IV
Mega IV50
DNED 2 mo
after
presentation
3
9/F
Fever, lymphadenopathy,
and marked
hepatosplenomegaly;
pneumonia
Fever, night sweats, and
marked
hepatosplenomegaly
Spleen, marrow,
WBC = 2 x 103/pL (on
and blood
presentation), Hct =
32%. Pit = 8 X 1031~~;
WBC = 20.6 X 1 0 3 1 ~ ~
(postsplenectomy) (44%
PMN, 26% lymph)
WBC = 18.2 X 1 0 ~ (8%
1 ~ ~ Marrow and blood
TMN, 86% lymph), Hct =
30%.Plt = 285 X 103/pL
IV
MSK-NY-
CR x 22 mo
Marrow and blood
IV
PL
4t
5t
6t
16/M
62/M
64/M
Fever, shortness of breath,
pulmonary infiltrate,
pleural effusions, and
hepatosplenomegaly
Fever, night sweats,
shortness of breath,
mediastinal
lymphadenopathy, and
moderate sDlenomeaalv
- .
WBC = 6.0 X 1 0 3 1 ~
(5~
weeks preadmission)
(67% PMN, 17% lymph);
WBC = 26 x 103/pL(on
admission) (42% PMN,
44% lymph), Hct = 18%.
Plt = 82 X 103/p~
WBC = 3 X 1 0 3 1 (75%
~~
PMN,11% lymph), Hct
= 40.3%, Plt = 66 X lo3/
PL
WBC = 2.6 X 103/pL (86%
PMN,9% lymph), Hct =
31.6%, Plt = 172 X lo3/
1151
MSK-NY-II
DNED 3 mo
after
presentation
Lung, pulmonary
lymph node,
pericardium,
pleural fluid,
and blood
Mediastinal lymph
nodes
IV
None
DOD 20 d after
presentation
111
CHOP5*
DOD 5 mo after
presentation
4
Abbreviations: WBC, white blood cell count; PMN, neutrophils; lymph, lymphocytes; Hct, hematocrit; Plt, platelet count; DOD, died of disease;
DNED, died with no evidence of disease; CR, complete remission; PR, partial response.
* Immunosuppressed with azathioprine and prednisone for ulcerative colitis; Coombs‘-positive hemolyticanemia on presentation.
t Immunosuppressed with cyclosporin A, azathioprine and prednisone 4 years after renal (patient 4) or 7 and 15 months after cardiac (patients
5 and 6) transplantation.
embedded tissue were also reviewed for each patient. Electron microscopy was performed by standard methods to assess ultrastructural features of tumor cells in patients 1 through 5.
Immunologic studies. Several techniques were used in concert
for immunophenotypic analysis of tumor cells from each patient.
Cell surface antigens were detected by flow cytometryz4(FACScan;
Becton-Dickinson [BD], Mountainview, CA) of mononuclear cells
isolated from omental tumor (patient l), bone marrow (patients 2
and 4). peripheral blood (patient 3), pleural fluid (patient 5 ) , and
lymph node (patients 5 and 6). Immunoalkaline phosphatase (IAP)
studies using a labeled streptavidin-biotin system” (patients 3.4 and
5), and indirect immunofluorescence (IF)z6 (patients 1 through 4)
were performed on cytocentrifuge preparations of cells suspended
from the same tissues as those analyzed by flow cytometry (FACS).
Paraffin immunoperoxidase (PIP) studies were performed on 4 pm
sections of omental tumor (patient l), spleen (patient 2), bone marrow (patients 3 and 4), and lymph node (patients 5 and 6) using
either a manual three-stage indirect immunoperoxidase technique”
for monoclonal antibodies and an indirect peroxidase-antiperoxidase
procedure** for polyclonal antibodies, or an avidin-biotin complex
methodm with appropriate antigen retrieval using an automated immunostainer (Ventana 320 Automated Immunohistochemistry System, Ventana Medical Systems, Tuscon, M ) .
Antibodies directed against T-cell antigens, with vendor and technique indicated, included CD1 (OKT6, Ortho Diagnostics, Raritan,
NJ; FACS), CD2 (Leu-5,BD; FACS and IAP), CD3 (Leu-4, BD;
FACS and IAP or polyclonal CD3, DAKO, Carpenteria, CA; PIP),
CD4 (Leu-3, BD; FACSand IAP), CD5 (Leu-l, BD; FACS and
I A P or CD5, Novocastra Laboratories, Newcastle upon Tyne, United
Kingdom [obtained from Vector Laboratories, Burlingame, CA];
PIP), CD7 (Leu-9, BD; FACS and UP), CD8 (Leu-2, BD; FACS
and IAP), CD43 (Leu-22, BD or DF-TI, DAKO; PIP), CD45RO
(UCHLI, DAKO; PIP), and T-cell receptor beta chain WFl, T Cell
Diagnostics, Cambridge, MA; PIP). Antibodies directed against NKcell antigens included CDllb (Leu-15, BD; FACS and IAP), CD1 IC
(Leu-MS, BD, FACS and IAP), CD16 (Leu-11, BD; FACS and
IAP), CD56 (Leu-19, BD; FACS and IAP), and CD57 (Leu-7, BD;
FACS, IAP and PIP). Other antibodies used included those directed
at CD45 (HLe-l, BD; FACS or LCA, DAKO; PIP), CD10 (CALLA,
BD; FACS), CD15 (Leu-M1, BD; PIP), CD30 ( K - l , DAKO; FACS
or Ber-H2, DAKO; PIP), terminal deoxynucleotidyl transferase
(TdT, Supertechs, Bethesda, MD; IF), S-100 (DAKO; PIP), and
Epstein-Barr virus (EBV) latent membrane protein (LMP)(CSI -4,
DAKO; PIP).
Tumors were considered slightly positive when 20% to 39% of
the neoplastic cells marked with an individual antibody, moderately
MACON
'l
476
ET AL
fig l. Peripheralblood films from patients with NK-like T-cell
lymphomas, T-LGL leukemia, and infectious mononucleosis.
(A) Circulating tumor cells from
patient 2 were mostly large lymphocytes
with roundto oval nuclei having dispersed chromatin and prominent
nucleoli. Occasional neoplastic cells had
a blastic appearance(inset).
Azurophilic cytoplasmic granules were seen easily.
(B) Lymphocytes
from a patient with clonal T-LGL leukemia were smaller, and the
nuclei had dense chromatin
with l e s s d m i b l e nucleoli. Azurophilic
e
s
l from patient 3
granules were present. (C) Circulating tumor c
were often large lymphocytes
with a high nuclearcytoplasmicratio
and marked nuclear irregularity. Azurophilic granules were
scant in
these cells.(D) Wrocytes froma patient with infectious mononudeosis hada much smaller nuclaar:cytoplasmicratio and regular nuclear
profiles.
4
positivewhen 40% to 59% of theneoplastic cells marked, and
strongly positive when60% or more of the neoplasticcells marked.
Cytogenetic and molecular genetic studies. Karyotypic analysis
was performed on harvested cell suspensions from omental tumor
(patient 1) or bone marrow (patients 2,3, and 4). Metaphases fkom
20 cells in eachsamplewereevaluatedbyGiemsa
staining with
' ' F
I
b
A
C
'
1477
NATURAL KILLER-LIKET-CELL LYMPHOMAS
RESULTS
Clinical features. Table1summarizestheclinicalfeatures ofeach patient, including the principal hematologic
findings and histologically documented sites of tumor. All
patients presented with advanced stage disease (StageIII or
W )by the Ann Arborstagingsystem33andB-symptoms
(fever, night sweats, weight loss). Most patients also had
hepatosplenomegaly without significant peripheral lymphadenopathy and had an aggressive clinical course. Five patients were anemic, including patient 2 who presented with
a Coombs'-positive hemolytic anemia. Three patients had
an absolute lymphocytosis (range, 5,356 to 15,652/,uL) with
rapidly rising counts in patients 2 and 4. Patient 3 had an
absolute neutropenia that was associated with pneumonia.
Four patients were chronically immunosuppressed for longstanding ulcerative colitis (patient 2) or after solid organ
transplantation (patients 4, 5, and 6).
Morphologic features. Peripheral
bloodinvolvement
was extensive in patients 2, 3, and 4 and slight in patient 5.
Circulating tumor cells were mostly large lymphocytes with
abundant pale cytoplasm; fine to coarse
azuropldic granules
Fig 3. Bone marrow aspirate film and biopsy section from patient
with an NK-like T-cell lymphoma.(A) Tumor cells were easily found
in aspirate films from patient 2, including some exhibiting erythrophagocytosis. (B)Neoplastic cells were much more difficult to find
in tissue sections from this patient because of the accompanying
erythroid hyperplasia. Tumor cells
that phagocytosed nucleated red
blood cells helped identify the interstitial lymphomatous infiltrate
(arrows) (PAS stain).
trypsin pretreatment. Inadequate specimens precluded cytogenetic
analysis of tumor cells in patients 5 and 6 .
DNA for molecular genetic analysis was isolated from omental
tumor (patient l), bone marrow (patients 2 and 4), peripheral blood
6 )using
(patient 3), pleural fluid (patient5), and lymph node (patient
standard phenol-chloroform extraction. PurifiedDNA was digested
with the restriction endonucleases BumHI, EcoR1, and H i d U and
electrophoresedon agarose gels. TheDNA was transferred to nylon
membranes, and Southern blot analysis
was performed as previously
r e p ~ r t e d . ~Blots
. ~ ' were serially hybridized with probes for the Tcell receptor (TCR) beta-chain joining gene (JB) (Oncor, Gaithersburg, MD) in six patients, the TCR beta-chain constant gene (CB)
(Oncor) in one patient,theTCRgamma-chain
joining gene (JG)
(Oncor) in three patients, and the TCR delta-chain constant gene
(C,) (Dr Tak Mak, University
of Toronto, Toronto, Ontario, Canada)
in two patients. Probes for the immunoglobulin (Ig) heavy-chain
joining gene(JH) (Oncor) and Ig kappa light-chain joining gene
(JK)
(Oncor) were used in four and one patient, respectively. A c-myc
exon I probe (Dr Takis Papas, National Cancer Institute, Bethesda,
MD) wasalsousedforpatient
2?'." Rearrangementsindicating
clonality were identified by the presence of nongermline bands, as
compared with placental control DNA or with previously identified
positive and negative control DNA?*
Fig 4. Tissue sections from patient
with small bowellomental NKlike T-cell lymphoma
(PAS stains). (A) The lamina propria ofthe duodenum from patient
l is filled by lymphoma cells.
A lymphoepithelial
lesion is created by tumor cells that infiltrate a residual mucosal
gland (arrow). (B) Medium-size
tumor cells with dispersed chromatin
efface the omental fat. Numerous mitoses arealso evident.
1478
MACON ET AL
Fig 5. Electron m-aograph of
neoplastic cell fmm a patient with
an NK-likeT-cell lymphoma. Cytoplasmicgranulesin a tumor cell
from patient1 included somehble densityforms (arrows).
were seen in some neoplastic cells in all cases from films of
peripheral blood, marrow, or pleural fluid, or from touch
imprints of tumor (Fig 1A). The neoplastic cells in patients
2 and 4 had oval nuclei with dispersed chromatin and prominent nucleoli (Fig 1A); large cell size and a blastic appearance in some lymphocytes distinguished these neoplastic
cells from those in patients with T-LGL leukemia (Fig I B).
Some tumor cells in patients 3 and 5 resembled “atypical”
lymphocytes in patients with infectious mononucleosis; however, other neoplastic cells had increased nuclear to cytoplasmic ratios and markedly irregular nuclear profiles, which
distinguished them from virocytes (Fig IC and D). “Cloverleaf’ peripheral blood tumor cells in patient 3 (Fig 2A) and
markedly enlarged, dysplastic pleural fluid tumor cells in
patient 5 (Fig 2B) demonstrated the extreme variability of
nuclear shape and cell size.
Marrow involvement was more easily observed on films
thanin tissue sections. Differential counts on films from
patients 2, 3, and 4 showed tumor cells comprised 59%.
28%. and58% of marrowcells, respectively (Fig 3A). On the
other hand, sections showed only subtle interstitial lymphoid
infiltrates without focal lesions in hypercellular marrows
from each of these patients (Fig 3B). Furthermore, erythrophagocytosis by tumor cells was readily identifiedin marrow
films from patient 2, but was difficult to detect in splenic or
marrow sections (Fig 3).
The duodenal surface was ulcerated in patient I . Neoplastic lymphocytes filled the deeper lamina propria and
focally infiltrated residualmucosal
glands producing
“lymphoepithelial” lesions (Fig 4A). Lymphoma cells
in patient 1 and those that effaced the splenic architecture
in patient 2 were medium-size in sections (Fig 4B). Dys-
plastic large lymphocytes effaced pulmonary hilaror mediastinal nodes in patients 5 and 6. They also infiltrated
lung parenchyma, pleura, and pericardium
in patient 5.
Additionally,autopsy on patient 5 showedcongestive
hepatosplenomegaly (liver2,240 g and splten 630 g)
with erythrophagocytosis by histiocytes; no lymphoma
was identified in the liver or spleen.
Electronmicroscopy
demonstrated cytoplasmic dense
core and/or double density granules (Fig 5 ) in some tumor
cells from each patient studied. No parallel tubular arrays
were found in obviously neoplastic cells.
Immunologic features. Table 2 summari7~stheT-celland
NK-cell antigen expression of the tumor cells
in each patient.
Thecommonphenotypewas
CD2’, CD3+, CM-, CDS’,
CD56’, and CD57-, and there was variable expression of other
T-cell and NK-cell antigens.
The tumor cells were phenotypically
mature as therewasnoexpressionof
CDI, CD10 or TdT.
Tumors cells wereCD45+,and none expressed CD15 or S-100.
CD30 staining of tumor cells was seen only in patient 6. LMP
staining was seen in most tumor cells from patients 1, 5, and 6,
but was negative in patient 2.
Geneticfeatures. Karyotypic and genotypicdataare
shown in Table 3. Three of four patients studied had an
abnormal karyotype. A t(2; 17) was observed in two analyzed cells from patient 3. Isochromosome 7q was present
in I7 and 20 analyzed cells from patients 2 and 4, respectively. Patient 2 also had a t(8; 14) (q24;q24).T-cell clonality was demonstrated in five of six patients. No c-myc
rearrangement was identified for patient 2, suggesting the
possibility of a breakpoint 5‘ to the c-myc locus or of
point mutations within c-myc not detected with the exon
I probe.”
1479
NATURAL KILLER-LIKE T-CELL LYMPHOMAS
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DISCUSSION
We have described six T-cell lymphomas whose LGL
morphology, expression of CD3 and NK-cell antigens, and
ability to rearrange their T-cell receptor indicate an origin
from NK-like T cells. Ten other T-cell lymphomas with the
features of NK-like T-cell lymphomas have been reported
in detail (Table 4).14-*' Data from our series and the other
case reports suggest these lymphomas are a separate clinicopathologic entity that can be distinguished from T-LGL leukemia by multiparametric analysis. In this combined series,
NK-like T-cell lymphomas were aggressive as 93% presented with advanced stage disease and median survival was
less than 6 months. The median age was 48 years (range, 9
to 66 years); five patients (3 1%) were in the pediatric population. There was a 13:2 male:female ratio. Seventy-nine percent of patients presented with B-symptoms, and marked
hepatosplenomegaly was common (60%). These lymphomas
were usually extranodal (81%) and tended to be distributed
in the liver, spleen, and marrow (50%)or in the gastrointestinal tract (25%). Nodal or cutaneous involvement without
hepatosplenic or intestinal disease was unusual. A leukemic
phase was common (63%) and developed after splenectomy
in five of 10 patients. Peripheral white blood cell counts in
patients witha leukemic phase hadamedian of 18,000/
pL (range, 3,000 to 203,0OO/pL). Thrombocytopenia was
present in seven of 12 (58%)patients. A CD4- CD8+ phenotype was most common (n = 10) as compared with CD4+
CD8- (n = 2), CD4+ CD8' (n = 2) and CD4- CD8- (n =
2). CD56 was expressed on tumor cells in 11 of 12 (92%)
lymphomas studied for this antigen, whereas CD57 positivity
was observed in only four of 15 (27%) cases. Aberrant chromosomal analyses were found in five of six lymphomas
studied, and four of these had an i(7q).
Clinical implications dictate distinguishing leukemic
involvement by NK-like T-cell lymphomas from the more
indolent T-LGL leukemia. In comparison with T-LGL leukemia, patients with NK-like T-cell lymphomas are more likely
to be within the pediatric population, to present with Bsymptoms and marked hepatosplenomegaly, and to have
thrombocytopenia and a rapid increase in the number of
leukemic cells."-21 NK-likeT-cell lymphomas have less frequent neutropenia and infections. Leukemic cells of NK-like
T-cell lymphomas often exhibit marked nuclear pleomorphism or have a blastic appearance, the latter being rare in
chronic LGL leukemias.34 There is a greater tendency for
NK-like T-cell lymphomas to express CD56 rather than
CD57, whereas the opposite has been reported for T-LGL
leukemia." Parallel tubular arrays, frequently seen in ultrastructural studies of T-LGL
are apparently uncommon among NK-like T-cell lymphomas (seen in two of
11 cases studied). Cytogenetic abnormalities are common in
NK-like T-cell lymphomas, but not in T-LGL leukemia."
These differences between the two groups of neoplasms indicate that the recently reported cases of CD56+ aggressive
variant of T-LGL leukemia" may be NK-like T-cell lymphomas with a leukemic phase.
Several features seen in our series of NK-like T-cell
lymphomas may have biologic and clinical significance; in
MACON ET AL
1480
Table 3. Genetic Features of NK-Like T-cell Lymphomas
Genotype
Patient
No.
Karyotype
T-cell Receptor*
JE
1
2
3
4
5
6
46,XY
46,XY,i(7)(qlO),t(8;14)(q24;q24);add(13)~pl3~
46,XX,t(2;17)(q34;q21.3),add(l4)(q32)
46,XY,i(7)(q11.l),add12(pll.l)
GL
ND
ND
R
R
R
GL
R
R
CB
R
ND
ND ND
GL ND
ND
ND
JG
GLR
GL
ND
GL
ND
ND
Immunoglobulin*
CD
Del
ND
ND
ND
JH
GL
GL
GL
ND
ND
JK
ND
ND
ND
ND
ND
Abbreviations: R, rearranged; GL, germline; Del, deleted; ND, not done.
* See Materials and Methods for probe definition.
particular, CD56 (NCAM) expression, chromosomal abnormalities, immunosuppression, and EBV infection are noteworthy. NCAM, a neural cell adhesion molecule involved
in homotypic interactions, has been implicated in the extranodal dissemination of some peripheral T-cell lymphomas
(PTCLs), and its expression has been associated with an
aggressive clinical course.'y,36.37
However, some lymphomas
regarded as NCAM-positive PTCLs may be true NK-cell
lymphomas rather than NK-like T-cell lymphoma^.^^ Therefore, the term NK-like T-cell lymphoma might be best reserved for those lymphomas that express surface CD3 (or
framework determinants of the TCR) and NK-cell antigens,
particularly CD56, and have cytoplasmic granules by light
or electron microscopy. NK-like T-cell lymphomas that lack
surface CD3 or TCR framework determinants should exhibit
TCR gene rearrangements to distinguish them from true NKcell lymphomas.
Chromosomal abnormalities in NK-like T-cell lymphomas
may be of pathogenetic and prognostic significance. For instance, the erythrophagocytic T-cell lymphoma in patient 2
had a t(8; 14)(q24;q24), which may have juxtaposed the cmyc gene on 8q2438 and a transcriptionally active
(housekeeping) cytoskeletal protein gene such as that for aactinin located on 14q24.39Deregulation of c-myc, seen in
some T-cell neoplasms,mas well as possible alterations in the
quantity and cellular localization of cytoskeletal components
may have contributed to malignant tran~formation.4"~~
Furthermore, altered cytoskeletal proteins may have permitted
the phagocytosis of IgG-coated erythrocytes by the tumor
cells in this patient, a function not normally ascribed to T
cells. From a prognostic standpoint, total or partial trisomy
7q, as produced by i(7q) in patients 2 and 4and in two
others with an NK-like T-cell lymphoma20.21
and a high proportion of abnormal metaphases, also in patients 2 and 4,
are significantly more frequent in high-grade than in lowgrade F'[email protected]
The roles of immunosuppression and EBV infection in NKlike T-cell lymphomas are unclear. Four patients in our series
were chronically immunosuppressed, including three who had
receivedsolidorgantransplants.Therefore,NK-likeT-cell
lymphomas should be included in the differential diagnosis of
T-cell proliferations developing in immunosuppressed patients.
It is also interesting that two
of our posttransplant patients and
another with an intestinal NK-like T-cell lymphoma smng
had
LMPimmunopositivity in nearly all tumor cells, suggesting
they were EBV-as~ociated."~
However, it remains to be determined whether EBV is a pathogenetic,factor in the development
of NK-like T-cell lymphomas, orif infection of the tumorcells
occurs after clonal expansion.
Of further biologic interest is the observation that hepatosplenic and intestinal NK-like T-cell lymphomas not only
have cytological (LGL morphology) and immunological
(CD56+ or CD57+) features in common with thymic-independent T cells, but also have similar tissue distributions.n,z3,46-4~
NK-like T-cell lymphomas also may be of ap
or yS" types, as are extrathymically derived
Furthermore, thymic-independent T cells may be CD4CD8+, CD4' CDK, CD4+ CD8+, or CD4- CD8-n,2334y;
as
noted above, all four of these phenotypes have been observed
among NK-like T-cell lymphomas. Therefore, it is possible
that these lymphomas are derived from T-cell subpopulations
with extrathymic pathways of differentiation.
Finally, NK-like T-cell lymphomas should be considered
for all lymphomas of presumed hepatosplenic and intestinal
origin if patients present with B-symptoms and advanced stage
disease, includingaleukemicphase.Werecommend,in
agreement with Warzynskiet al,2' multiparametric analysis, as
described below, to facilitate recognition of these aggressive
lymphomas. Cytoplasmic granules may be demonstrated in
tumor cells usingRomanovsky's-typestainsonperipheral
blood, marrow, or other body fluid filmsor on touch imprints
of tumors. Electron microscopy may be used to detect granules not seen by light microscopy. Immunophenotypic analysis should include a broad panel of T-cell and NK-cell antigens (seeTable 2). Cytogenetic analysismay pinpoint patients
with especially poor prognosis, as well as identify specific
chromosomal abnormalities. T-cell receptor gene rearrangement studies are recommended to prove clonality in morphologically difficult lesions and to distinguishsome NK-like Tcell lymphomas from true NK-cell lymphomas.
NOTE ADDED IN PROOF
Dr Mohamed Elkhalifa, Director of Hematopathology,
University of South Alabama, Mobile, Alabama, has kindly
provided us data and patient materials on another NK-like
T-cell lymphoma since this manuscript was prepared. The
patient wasa 62-year-old female who presented with Bsymptoms, hepatosplenomegaly, abdominal pain, and slight
lymphadenopathy. Peripheral blood (WBC = 55 X 103/pL
with 80% lymphocytes, hematocrit = 31.6%, and platelets
LL
NATURAL KILLER-LIKE
Table 4. Clinkal Features of Reviourly Reported Patients With NK-Like T-cell Lymphomas
Reference
Age/Sex
Presentation
Known
Hematologic
Findings
Sites of Tumor
liver, marrow,
WBC = 18.7 x 103/pLSpleen,
(80% lymph), red
and blood
blood cells and
platelets "in normal
range"; developed
leukemic phase
postsplenectomy
Peripheral
stomach,
Spleen,
marrow,
521M Gastric mass and
and blood
lymphocytes = 10.8
splenomegaly
x 103/pL; developed
leukemic phase
postsplenectomy
NA
Lymph node
NA
NA
NA
Jejunum, ileum,
48/M Intestinal obstruction;
mesentery, and lungs
anorexia, weight loss,
asthenia, and night
sweats
Jejunum, lungs, and CSF
WBC = 9.5 x 103/pL
66/M Abdominal pain,
("intact differential"),
anorexia, and weight
loss
Hgb
= 13.5 g/dL, Plt =
350 X 103/p~
WBC = 11.0 x 103/pL Spleen, liver, lymph
39mn Fever, asthenia,
nodes, and blood
hepatosplenomegaly,
(80% lymph)
and
lymphadenopathy
NA
Skin
50/M Generalized
maculopapular rash
50F
12mn
Fever, asthenia, and
splenomegaly
Fever, petechiae, and
hepatosplenomegaly
WBC = 7.3 x 103/pL
Spleen, lymph nodes,
marrow, and blood
(on presentation),
Hgb = 13.8 g/dL, Plt
= 7 X 1031~~;
WBC =
203 X 1031p~ (90%
lymph)
(postsplenectomy)
lymph
WBC = 17.7 X 103/pLLiver,kidneys,
(postsplenectomy),
nodes, marrow, and
Hgb = 8.5g/dL, Plt =
blood
10 X 1 0 3 1 ~ ~
l8#J
Hepatosplenomegaly
20/M
Fever, anorexia, weight WBC = 2 x [email protected]/pL,
loss, massive
Hgb = 7 g/dL, Plt =
70 X 1031p~
hepatosplenomegaly,
and mild
lymphadenopathy
Spleen, liver, lymph
nodes, marrow, and
blood
Stage
Outcome
Treatment
No.
1V
"Aggressive
chemotherapy"
23
DOD
mo
after
presentation
IV
Prednisone and
undefined
chemotherapy
CR x 31 mo
14
NE
IV
NA
MACOP-BY
NA
DOD 5 mo after
presentation
15
16
IV
CHOP"
DOD 4 mo after
presentation
17
IV
None
NA
18
IE
Chlorambucil then
DOD
1
yr after
19
body
whole
presentation
irradiation
Prednisone
2.5 DOD
mo
after
presentation
IV
IV
IV
Cyclophosphamide, DOD 1.5 mo
prednisone, and
after
vincristine;
presentation
doxorubicin and
etoposide
Multiple
DOD 9 mo after
combination
presentation
chemotherapy
14
19
20
21
Abbreviations: WBC, white blood cell count; lymph, lymphocytes; Hgb, hemoglobin content; Plt, platelet count; NA, not available; NE, not
evaluable; CSF, cerebral spinal fluid; DOD, died of disease; CR, complete remission.
= 20 X 103/pL),bone marrow and a submental lymph node
were involved by lymphoma that was CD2+, CD3', CD4-,
CDY, CD7+, CD8-, CDllb+, CDllc-, CD16+, CD56',
CD57-, CD45RO', PFIC, and L W + . The T-cell receptor
betachain gene wasrearranged.There was anabnormal
karyotype, including an i(7q). The patient died two months
after
presentation
despite
combination
chemotherapy
(CHOP).
ACKNOWLEDGMENT
thank Drs ThomasHanes, Ritchie Clark,Daniel
Theauthors
Tench, and James Elrod for providing patient materials and clinical
data. We are grateful
for diagnostic molecular genetic interpretations
by DrCindyVnencak-Jones (VUMC), on patients 2 through 6,
and for her commentary andthatfrom Dr Brigitte Schlegelberger
(Department of Human Genetics,University of Kiel,Kiel, Germany). We also thankMargaretWhitefieldandPatriciaEnnisfor
technical assistance on Southern blots; Sandy Olson for technical
support in performing immunohistochemistry; Brent Weedman and
Fred Moms for photographic assistance; and Alva Wolfe for manuscript preparation.
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