EXTRAORDINARY CASE REPORT
Intravascular Natural Killer Cell Lymphoma Mimicking Mycosis Fungoides: A Case Report and Review of the Literature Niklas Gebauer, MD,* Ebba J. Nissen, MD,* Peter von den Driesch, Dr. Med,† Alfred C. Feller, Dr. Med,* and Hartmut Merz, Dr. Med*
Abstract: Intravascular lymphoma is a rare entity. Most cases constitute a variant of extranodal diffuse large B-cell lymphoma, and only 10% of the published cases are of T-cell or histiocytic origin. Even fewer cases of intravascular natural killer (NK) cell lymphoma have been reported. To date, only the intravascular lymphoma of B-cell linage is recognized as a distinct entity by the WHO Classification. Here, we report the clinical, morphological, immunohistochemical, and molecular findings of a 72-year-old male patient with intravascular NK-cell lymphoma of the skin who initially presented with red skin efflorescences suspicious of mycosis fungoides. A skin biopsy revealed large cell infiltrates of NK/T-cell phenotype (CD3e+, CD42, CD82, CD56+, and TIA-1+), which were localized strictly intravascularly and which were positive for Epstein–Barr virus nucleic acid EBER (Epstein–Barr virusencoded small RNA). Molecular studies revealed a germline configuration for the T-cell receptor consistent with the possibility of an NK-cell origin. At the beginning, the disease appeared to be limited to the skin with no sign of bone marrow involvement or leukemic dissemination. Chemotherapy was initiated; however, the patient subsequently developed meningiosis lymphomatosa with recurrent epileptic episodes and bone marrow infiltration with pancytopenia 7 months after primary admission. Finally, the patient passed away in a septic shock. Key Words: intravascular lymphoma, natural killer cell lymphoma, mycosis fungoides (Am J Dermatopathol 2014;36:e100–e104)
INTRODUCTION
Intravascular lymphoma (IVL) is a rare entity, first described as systematized endotheliomatosis or malignant angioendotheliomatosis by Pfleger and Tappeiner1 in 1959 and was believed to be a malignant proliferation of From the *Department of Pathology, Reference Center for Lymph Node Pathology and Hematopathology, University Hospital of SchleswigHolstein, Luebeck, Germany; and †Department of Dermatology and Allergology, Center for Skin Diseases, Bad Cannstatt, Germany. The authors declare no conflicts of interest. Reprints: Niklas Gebauer, MD, Department of Pathology, Reference Center for Lymph Node Pathology and Hematopathology, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany (e-mail: [email protected]). © 2014 Lippincott Williams & Wilkins
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endothelial linage. Later, immunohistochemical and molecular studies revealed the neoplasm to be of lymphoid origin.2 The clinical presentation of the disease is highly variable but most common skin lesions and neurological manifestations including dementia and focal symptoms are observed. Multiple organs may be involved resulting in a variety of clinical presentations including nephrotic syndrome, pyrexia, hypertension, and hematologic abnormalities such as cytopenia and disseminated intravascular coagulation. Classical B-symptoms are rarely present at the time of diagnosis. IVL is an extremely aggressive lymphoma with variable, but mostly limited response to chemotherapy. It is hypothesized that the overall poor prognosis is slightly more favorable in patients whose manifestations are limited to the skin at primary presentation.3–5 The majority of cases are classified as a rare variant of extranodal diffuse large B-cell lymphoma according to the WHO classification.6 Only about 10% of cases of IVL were found to be of T-cell or histiocytic origin. To date, only 7 cases of intravascular natural killer (NK) cell lymphoma have been reported. In 5 of the 7 cases, T-cell receptor (TCR) status was proven to be in germline configuration.5,7–10 Here, we report the clinical, morphological, immunohistochemical, and molecular findings of a 72-year-old male patient with intravascular NK-cell lymphoma (IVNKL) of the skin with secondary involvement of central nervous system (CNS) and bone marrow. Because this is a very rare disease, we discuss our case in the setting of the findings of all other previously published cases including the relevant differential diagnosis of such cutaneous lymphoproliferative disorders.
CASE REPORT A 72-year-old male patient presented with a short history of red plaque-like nonpruritic skin efflorescences, clinically suspicious of mycosis fungoides on the trunk and all 4 extremities, but without further clinical symptoms of relevance (Fig. 1). A biopsy of the erythematous plaques displayed features of IVL, which was subsequently classified as IVNKL employing immunohistochemical and molecular methods. Histologically, the skin biopsy showed dilated vessels with microthrombi and signs of organization as well as recanalization with a dense intravascular infiltrate composed of medium-sized irregular blast-like cells with hyperchromatic nuclei and prominent nucleoli. Numerous small blood vessels of the upper corium were involved (Figs. 2A, B). However, the infiltrates showed no sign of epidermotropism. Am J Dermatopathol Volume 36, Number 5, May 2014
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FIGURE 1. Gross picture. Multiple erythematous plaques on the trunk mimicking the clinical presentation of mycosis fungoides.
Intravascular Natural Killer Cell Lymphoma Immunohistochemical studies were performed on formalinfixed paraffin-embedded sections according to a standard 3-step immunoperoxidase technique using the automated TechMate system (DAKO, Glostrup, Denmark) and the BrightVision Kit (ImmunoLogic, Duiven, The Netherlands). A panel of primary antibodies against CD3e, CD4, CD8, CD20, CD30, CD31, CD34, CD56, CD123, CD138, T-cell intracellular antigen (TIA-1), MIB-1 (Ki-67), Pankeratin, and myeloperoxidase (MPO) was evaluated. The tumor cells were positive for CD3e, CD56, MIB-1 (70%), and TIA-1 and they were negative for CD4, CD8, CD20, CD30, CD34, MPO, and Pankeratin (Figs. 2C–F). Primary antibodies, pretreatments, and dilutions are briefly summarized in Table 3. TCRg gene rearrangement studies revealed a polyclonal T-cell population. In addition, Epstein–Barr virus (EBV) could be detected by means of in situ hybridization for EBER as described earlier.11,12 Flow cytometric analysis of the peripheral blood was performed to elucidate a potential leukemic component of the disease using antibodies against CD1a, CD3, CD4, CD5, CD7, CD10, CD16, CD19, CD20, CD22, CD23, CD26, CD30, CD34,
FIGURE 2. Dilated vessels with microthrombi and signs of organization as well as recanalization with a dense intravascular infiltrate composed of medium-sized irregular blast-like cells with hyperchromatic nuclei and prominent nucleoli. Involvement of most of the numerous small blood vessels of the upper corium and no sign of epidermotropism. By means of immunohistochemistry and chromogen in situ hybridization, the infiltrates are characterized as NK/ T-cells (D) with a highly elevated proliferation rate (E) and positivity for Epstein–Barr virus-encoded small RNA (F). Immunohistochemistry was performed using BrightVision Ultimate kit from Thermo Fisher, Hamburg, Germany, following the manufacturer’s protocol. HE (·40) (A), HE (·200) (B), Giemsa (·400) (C), CD56 (·400) (D), MIB-1 (·400) (E), EBER (·200) (F). 2014 Lippincott Williams & Wilkins
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TABLE 1. Reported Cases of IVNKL (Clinical Features) Case No.
Case
Age/Sex
Clinical Sites of Involvement
1
Santucci et al7
54/M
2
Wu et al8
41/M
3
Wu et al8
47/F
4
Kuo et al9
71/F
5 6
Song et al10 Nakamichi et al13
40/F 23/F
Erythematous plaques on trunk and thighs Erythematous plaques on lower extremities CNS, bone marrow, kidneys, ovaries, cervix Erythematous nodules and patches on trunk and extremities Dissem. erythematous skin lesions Erythematous plaques on abdomen
Therapy
7
Cerroni et al14
63/M
8
Presented here
72/M
Red-violaceous plaques on trunk and extremities Skin, secondary involvement of bone marrow and CNS
CD38, CD45, CD56, CD57, and CD117 with no signs of leukemic blast cells. Further clinical investigations including complete blood count, bone marrow aspirate/biopsy revealed no signs of extracutaneous involvement. The patient’s medical history was significant for type II diabetes mellitus, gastro-oesophageal reflux disease because of a hiatal hernia, coronary heart disease, myocardial infarction with subsequent aortocoronary bypass, severe peripheral artery occlusive disease, gallstones, and malignant melanoma 10 years in the past. The patient received 3 cycles of chlorambucil/urbasone according to the Knospe regimen but was readmitted only 6 months after primary admission now presenting with altered mental status and recurrent epileptic episodes. A spinal tap test was highly suspicious of meningiosis lymphomatosa and a peripheral blood count revealed pancytopenia. Subsequently, a bone marrow biopsy was performed and revealed dense medullary infiltrates of the IVNKL composing about 40% of the overall cellularity. In the following days, the physical and mental status of the patient deteriorated rapidly despite anticonvulsive treatment with levetriacetam, tentamen and dexamethasone, as well as intrathecal application of methotrexate. The patient died in septic shock only 7 months after primary admission.
CHOP CHOP and SCT Treatment unclear No treatment
Outcome Skin lesions in remission. Died of CNS involvement 17 months after diagnosis Alive and event-free at 1 yr Died 15 days after primary admission despite treatment Alive 5 months after diagnosis
CODOX-M/IVAC CHOP, M-AraC, related SCT 3 cycles of CHOP
Alive and event free at 7 mo Died of aGVHD 9 months after diagnosis
3 cycles of chlorambucil + urbasone
Died of sepsis due to pancytopenia 7 months after diagnosis
Died 6 months after diagnosis
DISCUSSION IVL is a rare entity. Most reported cases are of B-cell linage; rare published cases display a histiocytic or T-cell phenotype. Less than 10 cases of IVL of NK-cell origin have been published.7–10,13,14 However, not all cases reported as T-cell IVL were studied in extent for NK-cell markers and TCR gene rearrangements. Thus, IVL of T- or NK-cell type may have been slightly underdiagnosed in the past.15 The clinical features of IVNKL seem to be in accordance with those found in classical IVL as they appear to be highly variable: The clinical presentation is mainly determined by the site of involvement. CNS and bone marrow manifestations were observed frequently. Selected clinical and pathological features of previously published cases of IVNKL are summarized in Tables 1 and 2. Extranodal NK/T-cell lymphoma is an important differential diagnosis to IVL and shows similarities and overlap at the level of cytology, spreading, and immunohistochemical phenotype. This is a rare entity in Europe but can more
TABLE 2. Reported Cases of IVNKL (Immunohistochemical and Molecular Features) Case No. 1 2 3 4 5 6 7 8
Immunophenotype Positive CD3e, CD30, CD56, grB, MIB-1 (100%) CD3e, CD2, CD7, CD43, CD56, TIA-1, perforin, Bcl-2 CD3e, CD2, CD7, CD56, TIA-1, grB CD3e, CD56, TIA-1, MIB-1 (99%) CD3, CD45, CD56, TIA-1, grB, MIB-1 (100%) CD3e, CD56, TIA-1 CD3e, CD2, CD45, CD56, TIA-1 CD3e, CD56, MIB-1 (70%), TIA-1
Negative
EBER
TCR
CD4, CD8, CD57, CD68, Bcl-2, LMP-1 CD20, CD5, CD4, CD8, CD30, lysozyme, MPO, Pankeratin CD4, CD5, CD8, CD20, CD57 CD4, CD5, CD8, CD10, CD20, CD30, Bcl-6, LMP-1 CD4, CD8, CD20, CD29 CD20, CD79a, CD45RO CD4, CD8, CD20 CD4, CD8, CD20, CD29, CD30, CD34, CD54, MPO, Pankeratin
+ + 2 + + + + +
Not done Polyclonal Polyclonal Polyclonal Polyclonal Not done Polyclonal Polyclonal
EBER, in situ hybridization for Epstein–Barr virus-encoded small RNA; TCR, T-cell receptor gene rearrangement studies with polymerase chain reaction and subsequent capillary gel electrophoresis; grB, granzyme B.
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Intravascular Natural Killer Cell Lymphoma
TABLE 3. Primary Antibodies, Pretreatments, and Dilutions for Immunohistochemical Investigations Antibody CD3 CD3e CD4 CD8 CD20 CD30 CD31 CD34 CD56 CD123 CD138 TIA-1 Granzyme B Perphorin MPO MIB-1
Manufacturer
Clone
Lab Vision SCbio Lab Vision Lab Vision DAKO DAKO DAKO Cell Marque DAKO BD Biocarta Immunotech DAKO Novo DAKO DAKO
SP7 145-2C11 4B12 BC/1A5 L26 Ber-H2 JC70A QB End/10 123C3.5 9F5 BC/B44 TIA GrB7 5B10 Poly MIB-1
Pretreatment*
Dilution
ST ST ST ST
(pH: 9, 0) (pH: 9, 0) (pH: 9, 0) (pH: 9, 0) MW ST (pH: 9, 0) ST (pH: 9, 0) ST (pH: 9, 0) ST (pH: 8, 0) ST (pH: 6, 1) MW PC (pH: 6, 0) ST (pH: 9, 0) ST (pH: 9, 0) PC (pH: 6, 0) PC (pH: 6, 0)
1:100 1:100 1:50 1:100 1:50 1:50 1:40 1:100 1:50 1:50 1:100 1:50 1:50 1:25 1:600 1:500
Antibodies and preparations: Immunohistochemical studies were performed on formalin-fixed paraffin-embedded sections according to a standard, 3-step immunoperoxidase technique using the automated TechMate system (DAKO) and the BrightVision Kit (ImmunoLogic) according to the manufacturer’s instructions. *Pretreatment with PC, pressure cooker; ST, steamer; MW, microwave.
regularly be found in Asia as well as central and south America.16–18 Extranodal NK/T-cell lymphoma shows predominance for adults and male sex. Most common sites of involvement are the upper aerodigestive tract, skin, soft tissue, and the gastrointestinal tract.19 Intravascular dissemination in not a hallmark of this disease. The diagnosis of IVNKL is established in a multistep process integrating morphological, immunohistochemical, and molecular investigations. The infiltrate’s peculiar limitation to the vascular lumina can be demonstrated by CD34 immunostaining. Subsequently, the neoplastic cells are further characterized by means of immunoperoxidase studies of CD3e, CD20, CD56, TIA-1, and MPO. Proliferative activity of the disease is measured by Ki-67 expression (MIB-1). The neoplasm reported here expressed cytotoxic granules but was negative for the T-cell antigens CD3 and CD8. Moreover, the germline configuration of the TCR, positivity for CD56 and TIA-1, and association with EBV strongly indicates the lymphoma to be of NK-cell lineage. By means of in situ hybridization, we were able to demonstrate the presence of EBV nucleic acid although this appears not to be essential in establishing the diagnosis. The frequent association between IVNKL and EBV, however, underlines the potential parallels between this rare entity, NK/T-cell lymphoma of nasal-type, and IVLTCL, whereas in contrast to this EBV is rarely found in IVL of B-cell linage.15,20 To elucidate the mechanism behind the strictly intravascular distribution of tumor cells in IVL numerous proteins associated with diapedesis including CD11a, CD18, CD29, CD44, and CD54 have been investigated.21 Loss or malfunction of both beta-1-integrin (CD29) and ICAM-1 (CD54) was shown to promote the angiotropic character in IVL of B-cell lineage.22 A similar mechanism in the pathogenesis of IVNKL can be hypothesized. 2014 Lippincott Williams & Wilkins
Nevertheless, the underlying pathomechanisms for the development of the characteristic phenotype and dissemination have still to be elucidated. The clinical course of IVNKL as it is depicted in both the literature and the case presented here appears to be even more aggressive than in classical B-cell IVL. Most patients with IVL died in less than a year after the diagnosis was established.23 It was hypothesized that a limited stage of disease at diagnosis correlates with better outcome and better response to chemotherapy.8 Unfortunately, no standard treatment protocol for IVNKL has so far been established. Most patients were treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). Many of the patients showed only a partial and short-term response. It is a matter of debate, whether the patients benefit from such a treatment in terms of overall and/or event-free survival or quality of life.7,8,13,14 In conclusion, comparative clinical and pathological studies of extranodal nasal/nasal-type NK/T-cell lymphoma, intravascular T-cell lymphoma, and IVNKL in face of their morphological and molecular similarities and differences remain a goal for further studies. Furthermore, information about clinical presentation, manifestations, therapy, and outcome needs to be collected and reviewed systematically to improve our understanding of this extremely rare variant of extranodal non-Hodgkin’s Lymphoma and to evaluate the necessity to establish IVNKL as a distinct entity. REFERENCES 1. Pfleger L, Tappeiner J. On the recognition of systematized endotheliomatosis of the cutaneous blood vessels (reticuloendotheliosis)? [Article in German]. Hautarzt. 1959;10:359–363. 2. Sheibani K, Battifora H, Winberg CD, et al. Further evidence that “malignant angioendotheliomatosis” is an angiotropic large-cell lymphoma. N Engl J Med. 1986;314:943–948.
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3. Chang A, Zic JA, Boyd AS. Intravascular large cell lymphoma: a patient with asymptomatic purpuric patches and a chronic clinical course. J Am Acad Dermatol. 1998;39:318–321. 4. DiGiuseppe JA, Nelson WG, Seifter EJ, et al. Intravascular lymphomatosis: a clinicopathologic study of 10 cases and assessment of response to chemotherapy. J Clin Oncol. 1994;12:2573–2579. 5. Gleason BC, Brinster NK, Granter SR, et al. Intravascular cytotoxic T-cell lymphoma: a case report and review of the literature. J Am Acad Dermatol. 2008;58:290–294. 6. Swerdlow SH. WHO Classification of Tumors of Haematopoetic and Lymphoid Tissues. 4th ed. WHO, International Agency for Research on Cancer; 2008. 7. Santucci M, Pimpinelli N, Massi D, et al. Cytotoxic/natural killer cell cutaneous lymphomas. Report of EORTC cutaneous lymphoma task force workshop. Cancer. 2003;97:610–627. 8. Wu H, Said JW, Ames ED, et al. First reported cases of intravascular large cell lymphoma of the NK cell type: clinical, histologic, immunophenotypic, and molecular features. Am J Clin Pathol. 2005;123: 603–611. 9. Kuo TT, Chen MJ, Kuo MC. Cutaneous intravascular NK-cell lymphoma: report of a rare variant associated with Epstein-Barr virus. Am J Surg Pathol. 2006;30:1197–1201. 10. Song DE, Lee MW, Ryu MH, et al. Intravascular large cell lymphoma of the natural killer cell type. J Clin Oncol. 2007;25:1279–1282. 11. Howe JG, Steitz JA. Localization of Epstein-Barr virus-encoded small RNAs by in situ hybridization. Proc Natl Acad Sci U S A. 1986;83:9006– 9010. 12. van Dongen JJ, Langerak AW, Bruggemann M, et al. Design and standardization of PCR primers and protocols for detection of clonal immunoglobulin and T-cell receptor gene recombinations in suspect lymphoproliferations: report of the BIOMED-2 concerted action BMH4-CT98-3936. Leukemia. 2003;17:2257–2317.
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Am J Dermatopathol Volume 36, Number 5, May 2014 13. Nakamichi N, Fukuhara S, Aozasa K, et al. NK-cell intravascular lymphomatosis–a mini-review. Eur J Haematol. 2008;81:1–7. 14. Cerroni L, Massone C, Kutzner H, et al. Intravascular large T-cell or NK-cell lymphoma: a rare variant of intravascular large cell lymphoma with frequent cytotoxic phenotype and association with Epstein-Barr virus infection. Am J Surg Pathol. 2008;32:891–898. 15. Au WY, Shek WH, Nicholls J, et al. T-cell intravascular lymphomatosis (angiotropic large cell lymphoma): association with Epstein-Barr viral infection. Histopathology. 1997;31:563–567. 16. Quintanilla-Martinez L, Franklin JL, Guerrero I, et al. Histological and immunophenotypic profile of nasal NK/T cell lymphomas from Peru: high prevalence of p53 overexpression. Hum Pathol. 1999;30:849–855. 17. Lymphoma Study Group of Japanese Pathologists. The world health organization classification of malignant lymphomas in japan: incidence of recently recognized entities. Lymphoma study group of Japanese pathologists. Pathol Int. 2000;50:696–702. 18. Chan JK. Natural killer cell neoplasms. Anat Pathol. 1998;3:77–145. 19. Kwong YL, Chan AC, Liang R, et al. CD56+ NK lymphomas: clinicopathological features and prognosis. Br J Haematol. 1997;97:821–829. 20. Hsiao CH, Su IJ, Hsieh SW, et al. Epstein-Barr virus-associated intravascular lymphomatosis within Kaposi’s sarcoma in an AIDS patient. Am J Surg Pathol. 1999;23:482–487. 21. Ferry JA, Harris NL, Picker LJ, et al. Intravascular lymphomatosis (malignant angioendotheliomatosis). A B-cell neoplasm expressing surface homing receptors. Mod Pathol. 1988;1:444–452. 22. Ponzoni M, Arrigoni G, Gould VE, et al. Lack of CD 29 (beta1 integrin) and CD 54 (ICAM-1) adhesion molecules in intravascular lymphomatosis. Hum Pathol. 2000;31:220–226. 23. Ferreri AJ, Campo E, Seymour JF, et al. Intravascular lymphoma: clinical presentation, natural history, management and prognostic factors in a series of 38 cases, with special emphasis on the “cutaneous variant”. Br J Haematol. 2004;127:173–183.
2014 Lippincott Williams & Wilkins
Intravascular Natural Killer Cell Lymphoma Mimicking Mycosis Fungoides: A Case Report and Review of the Literature Niklas Gebauer, MD,* Ebba J. Nissen, MD,* Peter von den Driesch, Dr. Med,† Alfred C. Feller, Dr. Med,* and Hartmut Merz, Dr. Med*
Abstract: Intravascular lymphoma is a rare entity. Most cases constitute a variant of extranodal diffuse large B-cell lymphoma, and only 10% of the published cases are of T-cell or histiocytic origin. Even fewer cases of intravascular natural killer (NK) cell lymphoma have been reported. To date, only the intravascular lymphoma of B-cell linage is recognized as a distinct entity by the WHO Classification. Here, we report the clinical, morphological, immunohistochemical, and molecular findings of a 72-year-old male patient with intravascular NK-cell lymphoma of the skin who initially presented with red skin efflorescences suspicious of mycosis fungoides. A skin biopsy revealed large cell infiltrates of NK/T-cell phenotype (CD3e+, CD42, CD82, CD56+, and TIA-1+), which were localized strictly intravascularly and which were positive for Epstein–Barr virus nucleic acid EBER (Epstein–Barr virusencoded small RNA). Molecular studies revealed a germline configuration for the T-cell receptor consistent with the possibility of an NK-cell origin. At the beginning, the disease appeared to be limited to the skin with no sign of bone marrow involvement or leukemic dissemination. Chemotherapy was initiated; however, the patient subsequently developed meningiosis lymphomatosa with recurrent epileptic episodes and bone marrow infiltration with pancytopenia 7 months after primary admission. Finally, the patient passed away in a septic shock. Key Words: intravascular lymphoma, natural killer cell lymphoma, mycosis fungoides (Am J Dermatopathol 2014;36:e100–e104)
INTRODUCTION
Intravascular lymphoma (IVL) is a rare entity, first described as systematized endotheliomatosis or malignant angioendotheliomatosis by Pfleger and Tappeiner1 in 1959 and was believed to be a malignant proliferation of From the *Department of Pathology, Reference Center for Lymph Node Pathology and Hematopathology, University Hospital of SchleswigHolstein, Luebeck, Germany; and †Department of Dermatology and Allergology, Center for Skin Diseases, Bad Cannstatt, Germany. The authors declare no conflicts of interest. Reprints: Niklas Gebauer, MD, Department of Pathology, Reference Center for Lymph Node Pathology and Hematopathology, University Hospital of Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538 Luebeck, Germany (e-mail: [email protected]). © 2014 Lippincott Williams & Wilkins
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endothelial linage. Later, immunohistochemical and molecular studies revealed the neoplasm to be of lymphoid origin.2 The clinical presentation of the disease is highly variable but most common skin lesions and neurological manifestations including dementia and focal symptoms are observed. Multiple organs may be involved resulting in a variety of clinical presentations including nephrotic syndrome, pyrexia, hypertension, and hematologic abnormalities such as cytopenia and disseminated intravascular coagulation. Classical B-symptoms are rarely present at the time of diagnosis. IVL is an extremely aggressive lymphoma with variable, but mostly limited response to chemotherapy. It is hypothesized that the overall poor prognosis is slightly more favorable in patients whose manifestations are limited to the skin at primary presentation.3–5 The majority of cases are classified as a rare variant of extranodal diffuse large B-cell lymphoma according to the WHO classification.6 Only about 10% of cases of IVL were found to be of T-cell or histiocytic origin. To date, only 7 cases of intravascular natural killer (NK) cell lymphoma have been reported. In 5 of the 7 cases, T-cell receptor (TCR) status was proven to be in germline configuration.5,7–10 Here, we report the clinical, morphological, immunohistochemical, and molecular findings of a 72-year-old male patient with intravascular NK-cell lymphoma (IVNKL) of the skin with secondary involvement of central nervous system (CNS) and bone marrow. Because this is a very rare disease, we discuss our case in the setting of the findings of all other previously published cases including the relevant differential diagnosis of such cutaneous lymphoproliferative disorders.
CASE REPORT A 72-year-old male patient presented with a short history of red plaque-like nonpruritic skin efflorescences, clinically suspicious of mycosis fungoides on the trunk and all 4 extremities, but without further clinical symptoms of relevance (Fig. 1). A biopsy of the erythematous plaques displayed features of IVL, which was subsequently classified as IVNKL employing immunohistochemical and molecular methods. Histologically, the skin biopsy showed dilated vessels with microthrombi and signs of organization as well as recanalization with a dense intravascular infiltrate composed of medium-sized irregular blast-like cells with hyperchromatic nuclei and prominent nucleoli. Numerous small blood vessels of the upper corium were involved (Figs. 2A, B). However, the infiltrates showed no sign of epidermotropism. Am J Dermatopathol Volume 36, Number 5, May 2014
Am J Dermatopathol Volume 36, Number 5, May 2014
FIGURE 1. Gross picture. Multiple erythematous plaques on the trunk mimicking the clinical presentation of mycosis fungoides.
Intravascular Natural Killer Cell Lymphoma Immunohistochemical studies were performed on formalinfixed paraffin-embedded sections according to a standard 3-step immunoperoxidase technique using the automated TechMate system (DAKO, Glostrup, Denmark) and the BrightVision Kit (ImmunoLogic, Duiven, The Netherlands). A panel of primary antibodies against CD3e, CD4, CD8, CD20, CD30, CD31, CD34, CD56, CD123, CD138, T-cell intracellular antigen (TIA-1), MIB-1 (Ki-67), Pankeratin, and myeloperoxidase (MPO) was evaluated. The tumor cells were positive for CD3e, CD56, MIB-1 (70%), and TIA-1 and they were negative for CD4, CD8, CD20, CD30, CD34, MPO, and Pankeratin (Figs. 2C–F). Primary antibodies, pretreatments, and dilutions are briefly summarized in Table 3. TCRg gene rearrangement studies revealed a polyclonal T-cell population. In addition, Epstein–Barr virus (EBV) could be detected by means of in situ hybridization for EBER as described earlier.11,12 Flow cytometric analysis of the peripheral blood was performed to elucidate a potential leukemic component of the disease using antibodies against CD1a, CD3, CD4, CD5, CD7, CD10, CD16, CD19, CD20, CD22, CD23, CD26, CD30, CD34,
FIGURE 2. Dilated vessels with microthrombi and signs of organization as well as recanalization with a dense intravascular infiltrate composed of medium-sized irregular blast-like cells with hyperchromatic nuclei and prominent nucleoli. Involvement of most of the numerous small blood vessels of the upper corium and no sign of epidermotropism. By means of immunohistochemistry and chromogen in situ hybridization, the infiltrates are characterized as NK/ T-cells (D) with a highly elevated proliferation rate (E) and positivity for Epstein–Barr virus-encoded small RNA (F). Immunohistochemistry was performed using BrightVision Ultimate kit from Thermo Fisher, Hamburg, Germany, following the manufacturer’s protocol. HE (·40) (A), HE (·200) (B), Giemsa (·400) (C), CD56 (·400) (D), MIB-1 (·400) (E), EBER (·200) (F). 2014 Lippincott Williams & Wilkins
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TABLE 1. Reported Cases of IVNKL (Clinical Features) Case No.
Case
Age/Sex
Clinical Sites of Involvement
1
Santucci et al7
54/M
2
Wu et al8
41/M
3
Wu et al8
47/F
4
Kuo et al9
71/F
5 6
Song et al10 Nakamichi et al13
40/F 23/F
Erythematous plaques on trunk and thighs Erythematous plaques on lower extremities CNS, bone marrow, kidneys, ovaries, cervix Erythematous nodules and patches on trunk and extremities Dissem. erythematous skin lesions Erythematous plaques on abdomen
Therapy
7
Cerroni et al14
63/M
8
Presented here
72/M
Red-violaceous plaques on trunk and extremities Skin, secondary involvement of bone marrow and CNS
CD38, CD45, CD56, CD57, and CD117 with no signs of leukemic blast cells. Further clinical investigations including complete blood count, bone marrow aspirate/biopsy revealed no signs of extracutaneous involvement. The patient’s medical history was significant for type II diabetes mellitus, gastro-oesophageal reflux disease because of a hiatal hernia, coronary heart disease, myocardial infarction with subsequent aortocoronary bypass, severe peripheral artery occlusive disease, gallstones, and malignant melanoma 10 years in the past. The patient received 3 cycles of chlorambucil/urbasone according to the Knospe regimen but was readmitted only 6 months after primary admission now presenting with altered mental status and recurrent epileptic episodes. A spinal tap test was highly suspicious of meningiosis lymphomatosa and a peripheral blood count revealed pancytopenia. Subsequently, a bone marrow biopsy was performed and revealed dense medullary infiltrates of the IVNKL composing about 40% of the overall cellularity. In the following days, the physical and mental status of the patient deteriorated rapidly despite anticonvulsive treatment with levetriacetam, tentamen and dexamethasone, as well as intrathecal application of methotrexate. The patient died in septic shock only 7 months after primary admission.
CHOP CHOP and SCT Treatment unclear No treatment
Outcome Skin lesions in remission. Died of CNS involvement 17 months after diagnosis Alive and event-free at 1 yr Died 15 days after primary admission despite treatment Alive 5 months after diagnosis
CODOX-M/IVAC CHOP, M-AraC, related SCT 3 cycles of CHOP
Alive and event free at 7 mo Died of aGVHD 9 months after diagnosis
3 cycles of chlorambucil + urbasone
Died of sepsis due to pancytopenia 7 months after diagnosis
Died 6 months after diagnosis
DISCUSSION IVL is a rare entity. Most reported cases are of B-cell linage; rare published cases display a histiocytic or T-cell phenotype. Less than 10 cases of IVL of NK-cell origin have been published.7–10,13,14 However, not all cases reported as T-cell IVL were studied in extent for NK-cell markers and TCR gene rearrangements. Thus, IVL of T- or NK-cell type may have been slightly underdiagnosed in the past.15 The clinical features of IVNKL seem to be in accordance with those found in classical IVL as they appear to be highly variable: The clinical presentation is mainly determined by the site of involvement. CNS and bone marrow manifestations were observed frequently. Selected clinical and pathological features of previously published cases of IVNKL are summarized in Tables 1 and 2. Extranodal NK/T-cell lymphoma is an important differential diagnosis to IVL and shows similarities and overlap at the level of cytology, spreading, and immunohistochemical phenotype. This is a rare entity in Europe but can more
TABLE 2. Reported Cases of IVNKL (Immunohistochemical and Molecular Features) Case No. 1 2 3 4 5 6 7 8
Immunophenotype Positive CD3e, CD30, CD56, grB, MIB-1 (100%) CD3e, CD2, CD7, CD43, CD56, TIA-1, perforin, Bcl-2 CD3e, CD2, CD7, CD56, TIA-1, grB CD3e, CD56, TIA-1, MIB-1 (99%) CD3, CD45, CD56, TIA-1, grB, MIB-1 (100%) CD3e, CD56, TIA-1 CD3e, CD2, CD45, CD56, TIA-1 CD3e, CD56, MIB-1 (70%), TIA-1
Negative
EBER
TCR
CD4, CD8, CD57, CD68, Bcl-2, LMP-1 CD20, CD5, CD4, CD8, CD30, lysozyme, MPO, Pankeratin CD4, CD5, CD8, CD20, CD57 CD4, CD5, CD8, CD10, CD20, CD30, Bcl-6, LMP-1 CD4, CD8, CD20, CD29 CD20, CD79a, CD45RO CD4, CD8, CD20 CD4, CD8, CD20, CD29, CD30, CD34, CD54, MPO, Pankeratin
+ + 2 + + + + +
Not done Polyclonal Polyclonal Polyclonal Polyclonal Not done Polyclonal Polyclonal
EBER, in situ hybridization for Epstein–Barr virus-encoded small RNA; TCR, T-cell receptor gene rearrangement studies with polymerase chain reaction and subsequent capillary gel electrophoresis; grB, granzyme B.
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Am J Dermatopathol Volume 36, Number 5, May 2014
Intravascular Natural Killer Cell Lymphoma
TABLE 3. Primary Antibodies, Pretreatments, and Dilutions for Immunohistochemical Investigations Antibody CD3 CD3e CD4 CD8 CD20 CD30 CD31 CD34 CD56 CD123 CD138 TIA-1 Granzyme B Perphorin MPO MIB-1
Manufacturer
Clone
Lab Vision SCbio Lab Vision Lab Vision DAKO DAKO DAKO Cell Marque DAKO BD Biocarta Immunotech DAKO Novo DAKO DAKO
SP7 145-2C11 4B12 BC/1A5 L26 Ber-H2 JC70A QB End/10 123C3.5 9F5 BC/B44 TIA GrB7 5B10 Poly MIB-1
Pretreatment*
Dilution
ST ST ST ST
(pH: 9, 0) (pH: 9, 0) (pH: 9, 0) (pH: 9, 0) MW ST (pH: 9, 0) ST (pH: 9, 0) ST (pH: 9, 0) ST (pH: 8, 0) ST (pH: 6, 1) MW PC (pH: 6, 0) ST (pH: 9, 0) ST (pH: 9, 0) PC (pH: 6, 0) PC (pH: 6, 0)
1:100 1:100 1:50 1:100 1:50 1:50 1:40 1:100 1:50 1:50 1:100 1:50 1:50 1:25 1:600 1:500
Antibodies and preparations: Immunohistochemical studies were performed on formalin-fixed paraffin-embedded sections according to a standard, 3-step immunoperoxidase technique using the automated TechMate system (DAKO) and the BrightVision Kit (ImmunoLogic) according to the manufacturer’s instructions. *Pretreatment with PC, pressure cooker; ST, steamer; MW, microwave.
regularly be found in Asia as well as central and south America.16–18 Extranodal NK/T-cell lymphoma shows predominance for adults and male sex. Most common sites of involvement are the upper aerodigestive tract, skin, soft tissue, and the gastrointestinal tract.19 Intravascular dissemination in not a hallmark of this disease. The diagnosis of IVNKL is established in a multistep process integrating morphological, immunohistochemical, and molecular investigations. The infiltrate’s peculiar limitation to the vascular lumina can be demonstrated by CD34 immunostaining. Subsequently, the neoplastic cells are further characterized by means of immunoperoxidase studies of CD3e, CD20, CD56, TIA-1, and MPO. Proliferative activity of the disease is measured by Ki-67 expression (MIB-1). The neoplasm reported here expressed cytotoxic granules but was negative for the T-cell antigens CD3 and CD8. Moreover, the germline configuration of the TCR, positivity for CD56 and TIA-1, and association with EBV strongly indicates the lymphoma to be of NK-cell lineage. By means of in situ hybridization, we were able to demonstrate the presence of EBV nucleic acid although this appears not to be essential in establishing the diagnosis. The frequent association between IVNKL and EBV, however, underlines the potential parallels between this rare entity, NK/T-cell lymphoma of nasal-type, and IVLTCL, whereas in contrast to this EBV is rarely found in IVL of B-cell linage.15,20 To elucidate the mechanism behind the strictly intravascular distribution of tumor cells in IVL numerous proteins associated with diapedesis including CD11a, CD18, CD29, CD44, and CD54 have been investigated.21 Loss or malfunction of both beta-1-integrin (CD29) and ICAM-1 (CD54) was shown to promote the angiotropic character in IVL of B-cell lineage.22 A similar mechanism in the pathogenesis of IVNKL can be hypothesized. 2014 Lippincott Williams & Wilkins
Nevertheless, the underlying pathomechanisms for the development of the characteristic phenotype and dissemination have still to be elucidated. The clinical course of IVNKL as it is depicted in both the literature and the case presented here appears to be even more aggressive than in classical B-cell IVL. Most patients with IVL died in less than a year after the diagnosis was established.23 It was hypothesized that a limited stage of disease at diagnosis correlates with better outcome and better response to chemotherapy.8 Unfortunately, no standard treatment protocol for IVNKL has so far been established. Most patients were treated with cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP). Many of the patients showed only a partial and short-term response. It is a matter of debate, whether the patients benefit from such a treatment in terms of overall and/or event-free survival or quality of life.7,8,13,14 In conclusion, comparative clinical and pathological studies of extranodal nasal/nasal-type NK/T-cell lymphoma, intravascular T-cell lymphoma, and IVNKL in face of their morphological and molecular similarities and differences remain a goal for further studies. Furthermore, information about clinical presentation, manifestations, therapy, and outcome needs to be collected and reviewed systematically to improve our understanding of this extremely rare variant of extranodal non-Hodgkin’s Lymphoma and to evaluate the necessity to establish IVNKL as a distinct entity. REFERENCES 1. Pfleger L, Tappeiner J. On the recognition of systematized endotheliomatosis of the cutaneous blood vessels (reticuloendotheliosis)? [Article in German]. Hautarzt. 1959;10:359–363. 2. Sheibani K, Battifora H, Winberg CD, et al. Further evidence that “malignant angioendotheliomatosis” is an angiotropic large-cell lymphoma. N Engl J Med. 1986;314:943–948.
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3. Chang A, Zic JA, Boyd AS. Intravascular large cell lymphoma: a patient with asymptomatic purpuric patches and a chronic clinical course. J Am Acad Dermatol. 1998;39:318–321. 4. DiGiuseppe JA, Nelson WG, Seifter EJ, et al. Intravascular lymphomatosis: a clinicopathologic study of 10 cases and assessment of response to chemotherapy. J Clin Oncol. 1994;12:2573–2579. 5. Gleason BC, Brinster NK, Granter SR, et al. Intravascular cytotoxic T-cell lymphoma: a case report and review of the literature. J Am Acad Dermatol. 2008;58:290–294. 6. Swerdlow SH. WHO Classification of Tumors of Haematopoetic and Lymphoid Tissues. 4th ed. WHO, International Agency for Research on Cancer; 2008. 7. Santucci M, Pimpinelli N, Massi D, et al. Cytotoxic/natural killer cell cutaneous lymphomas. Report of EORTC cutaneous lymphoma task force workshop. Cancer. 2003;97:610–627. 8. Wu H, Said JW, Ames ED, et al. First reported cases of intravascular large cell lymphoma of the NK cell type: clinical, histologic, immunophenotypic, and molecular features. Am J Clin Pathol. 2005;123: 603–611. 9. Kuo TT, Chen MJ, Kuo MC. Cutaneous intravascular NK-cell lymphoma: report of a rare variant associated with Epstein-Barr virus. Am J Surg Pathol. 2006;30:1197–1201. 10. Song DE, Lee MW, Ryu MH, et al. Intravascular large cell lymphoma of the natural killer cell type. J Clin Oncol. 2007;25:1279–1282. 11. Howe JG, Steitz JA. Localization of Epstein-Barr virus-encoded small RNAs by in situ hybridization. Proc Natl Acad Sci U S A. 1986;83:9006– 9010. 12. van Dongen JJ, Langerak AW, Bruggemann M, et al. Design and standardization of PCR primers and protocols for detection of clonal immunoglobulin and T-cell receptor gene recombinations in suspect lymphoproliferations: report of the BIOMED-2 concerted action BMH4-CT98-3936. Leukemia. 2003;17:2257–2317.
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Am J Dermatopathol Volume 36, Number 5, May 2014 13. Nakamichi N, Fukuhara S, Aozasa K, et al. NK-cell intravascular lymphomatosis–a mini-review. Eur J Haematol. 2008;81:1–7. 14. Cerroni L, Massone C, Kutzner H, et al. Intravascular large T-cell or NK-cell lymphoma: a rare variant of intravascular large cell lymphoma with frequent cytotoxic phenotype and association with Epstein-Barr virus infection. Am J Surg Pathol. 2008;32:891–898. 15. Au WY, Shek WH, Nicholls J, et al. T-cell intravascular lymphomatosis (angiotropic large cell lymphoma): association with Epstein-Barr viral infection. Histopathology. 1997;31:563–567. 16. Quintanilla-Martinez L, Franklin JL, Guerrero I, et al. Histological and immunophenotypic profile of nasal NK/T cell lymphomas from Peru: high prevalence of p53 overexpression. Hum Pathol. 1999;30:849–855. 17. Lymphoma Study Group of Japanese Pathologists. The world health organization classification of malignant lymphomas in japan: incidence of recently recognized entities. Lymphoma study group of Japanese pathologists. Pathol Int. 2000;50:696–702. 18. Chan JK. Natural killer cell neoplasms. Anat Pathol. 1998;3:77–145. 19. Kwong YL, Chan AC, Liang R, et al. CD56+ NK lymphomas: clinicopathological features and prognosis. Br J Haematol. 1997;97:821–829. 20. Hsiao CH, Su IJ, Hsieh SW, et al. Epstein-Barr virus-associated intravascular lymphomatosis within Kaposi’s sarcoma in an AIDS patient. Am J Surg Pathol. 1999;23:482–487. 21. Ferry JA, Harris NL, Picker LJ, et al. Intravascular lymphomatosis (malignant angioendotheliomatosis). A B-cell neoplasm expressing surface homing receptors. Mod Pathol. 1988;1:444–452. 22. Ponzoni M, Arrigoni G, Gould VE, et al. Lack of CD 29 (beta1 integrin) and CD 54 (ICAM-1) adhesion molecules in intravascular lymphomatosis. Hum Pathol. 2000;31:220–226. 23. Ferreri AJ, Campo E, Seymour JF, et al. Intravascular lymphoma: clinical presentation, natural history, management and prognostic factors in a series of 38 cases, with special emphasis on the “cutaneous variant”. Br J Haematol. 2004;127:173–183.
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